1. Physical strain: pregnancy outcome and fertility Marja-Liisa Lindbohm Finnish Institute of Occupational Health

2. Potential effects of physical strain Pronounced physical exertion may alter hormonal balance alter hormonal balance increase intraabdominal pressure increase intraabdominal pressure decrease uterine blood flow decrease uterine blood flow affect nutritional status affect nutritional status

3. Measures of physical work load in occupational reproductive studies Single factors Single factors  Heavy lifting and load carrying  Prolonged standing and/or walking  Bending and reaching Integrated measures Integrated measures  Energy expenditure, work intensity  Biomechanical load  Fatigue score Surrogate measures: job title, work duties Surrogate measures: job title, work duties

4. Working conditions and risk of preterm birth: a meta-analysis (Mozurkewich et al 2000) Exposure No. studies Pooled odds ratio 95% CI Standing  3 hours/day 141.26 1.13 – 1.40 Physically demanding work 211.22 1.16 – 1.29 Long working hours (  40 h/w or  8 h/d) 101.03 0.92 – 1.16 High cumulative work fatigue score 61.63 1.33 – 1.98

5. Physically demanding work and adverse pregnancy outcome (Mozurkewich et al 2000) Pregnancy outcome No. studies Pooled odds ratio 95% CI Small for gestational age 101.37 1.30 – 1.44 Hypertension or preeclampsia 41.60 1.30 – 1.96

6. Standing, lifting and having small-for- gestational-age infant (Fortier et al 1995) Exposure Number of women Adjusted odds ratio 95% CI Standing < 3 21601.00. 3 – 5 hours 3 – 5 hours8881.13 0.83 – 1.55  6 hours  6 hours13421.42 1.02 – 1.95 Lifting, none 25001.00. 1 – 9 kg 1 – 9 kg8761.03 0.77 – 1.38  10 kg  10 kg5781.03 0.71 – 1.51

7. Lifting, hectic work pace and pre-eclampsia (Wergeland et al 1997) ExposureNumber Adjusted OR 95% CI Lifting 10-20 kg >20 times weekly >20 times weekly2792.0 1.2 – 3.2 10 - 20 times daily 10 - 20 times daily3071.7 1.1 – 2.7 >20 times daily >20 times daily1961.4 0.8 – 2.6 Hectic work pace Not daily Not daily19921.5 0.8 – 2.9 Daily < half the time Daily < half the time5132.1 1.0 – 4.2 Daily > half the time Daily > half the time4432.5 1.2 – 4.9

8. Prolonged standing and spontaneous abortion Inconsistent results on the effects of standing at work on the risk of spontaneous abortion Inconsistent results on the effects of standing at work on the risk of spontaneous abortion In two studies an increased risk for standing at work >8 hours/day was observed, but only in women who had a history of previous fetal loss In two studies an increased risk for standing at work >8 hours/day was observed, but only in women who had a history of previous fetal loss Cervical incompetence or other anatomical abnormalities or weakness may predispose these women to the effects of standing Cervical incompetence or other anatomical abnormalities or weakness may predispose these women to the effects of standing

9. Job strain and fertility (Hjollund et al 1998 and 2004) A follow-up study on couples trying to become pregnant A follow-up study on couples trying to become pregnant Job strain, defined as high job demands and low job control, had no substantial detrimental effect on fertility among women Job strain, defined as high job demands and low job control, had no substantial detrimental effect on fertility among women Analysis restricted to couples with no suspected competitive causes of reduced fertility showed reduced fertility in women with high-strain jobs Analysis restricted to couples with no suspected competitive causes of reduced fertility showed reduced fertility in women with high-strain jobs No association found between any semen characteristics or sexual hormones and job strain No association found between any semen characteristics or sexual hormones and job strain

10. Recommendations Pregnant workers should avoid extremely heavy physical exertion (close to the individual's maximum capacity) in early pregnancy Pregnant workers should avoid extremely heavy physical exertion (close to the individual's maximum capacity) in early pregnancy During second and third trimester, it is wise to reduce the physical work load and ensure that there are enough rest periods During second and third trimester, it is wise to reduce the physical work load and ensure that there are enough rest periods Continuous standing or walking during the whole workday should be avoided, at least in late pregnancy Continuous standing or walking during the whole workday should be avoided, at least in late pregnancy Ahlborg, J Occup Environ Med 1995;37:943

11. EU guidelines on movements and postures ( COM(2000) 466 final/2) Pregnant workers should not be exposed to manual handling involving risk of injury manual handling involving risk of injury awkward movements and postures, especially in confined spaces awkward movements and postures, especially in confined spaces work at heights work at heights long periods spent handling loads, or standing or sitting without regular exercise or movement to maintain healthy circulation long periods spent handling loads, or standing or sitting without regular exercise or movement to maintain healthy circulation

12. Guidelines on lifting weights (Denmark) ( AT-anvisning Nr. 4.0.0.2, 1998) Manual handling of heavy loads may pose a risk to pregnancy Manual handling of heavy loads may pose a risk to pregnancy If the load weights more than 10-12 kg there should be a break between each lift and the total of lifted weights should not exceed 1000 kg during a day If the load weights more than 10-12 kg there should be a break between each lift and the total of lifted weights should not exceed 1000 kg during a day From the beginning of the 7th month of pregnancy the weight of the lifted loads should be halved because of increasing lifting distance From the beginning of the 7th month of pregnancy the weight of the lifted loads should be halved because of increasing lifting distance

13. Shift work and spontaneous abortion among midwives (Axelsson et al 1996) ExposurePreg-nancies Adjusted OR 95% CI Always day 4221.0 Always night 2861.6 1.0 – 2.8 Two shift 6381.2 0.7 – 1.8 Three shift 3711.5 0.9 – 2.6 Late spontaneous abortion: Always night 2853.3 1.1 – 9.9

14. Shift or night work and preterm birth: a meta-analysis (Mozurkewich et al 2000) Six studies published in 1987 – 1998 Six studies published in 1987 – 1998 Pooled odds ratio 1.24 (95% CI 1.06 – 1.46) Pooled odds ratio 1.24 (95% CI 1.06 – 1.46) Analysis of three high-quality studies revealed also a weak association (OR 1.21, 95% CI 1.00 – 1.47) Analysis of three high-quality studies revealed also a weak association (OR 1.21, 95% CI 1.00 – 1.47) Conclusion: shift and night work may increase the risk of preterm birth Conclusion: shift and night work may increase the risk of preterm birth

15. Shift work and fetal growth retardation Inconsistent results on the effects of shift work Inconsistent results on the effects of shift work Elevated risk of giving birth to SGA babies among mothers in shift work (Nurminen et al 1989) Elevated risk of giving birth to SGA babies among mothers in shift work (Nurminen et al 1989) Elevated risk of having a baby with low birth weight (<2500 g) among midwives in night work (Bodin et al 1999) Elevated risk of having a baby with low birth weight (<2500 g) among midwives in night work (Bodin et al 1999) No excess of fetal growth retardation related to shift work or to evening or night work only (Fortier et al 1995) No excess of fetal growth retardation related to shift work or to evening or night work only (Fortier et al 1995)

16. Council Directive 92/85/EEC: night work Member States shall take necessary measures to ensure that a worker is not obliged to perform night work during her pregnancy and for a period following childbirth Member States shall take necessary measures to ensure that a worker is not obliged to perform night work during her pregnancy and for a period following childbirth A medical certificate stating that this is necessary for the safety or health of the worker is needed A medical certificate stating that this is necessary for the safety or health of the worker is needed Measures must entail the possibility of Measures must entail the possibility of  transfer to daytime work  or leave from work or extension of maternity leave where such a transfer is not feasible

17. EU Guidelines on fatigue and working hours ( COM(2000) 466 final/2) Because of increasing tiredness, some pregnant women may not be able to work irregular or late shifts, night work or overtime Because of increasing tiredness, some pregnant women may not be able to work irregular or late shifts, night work or overtime Not all women are affected in the same way; the risks vary with the type of work and the individual Not all women are affected in the same way; the risks vary with the type of work and the individual It may be necessary to adjust working hours temporarily, including the timing and frequency of rest breaks, and to change shift patterns and duration to avoid risks It may be necessary to adjust working hours temporarily, including the timing and frequency of rest breaks, and to change shift patterns and duration to avoid risks

18. Noise and adverse pregnancy outcome Noise may increase maternal catecholamine secretion, which may further stimulate or retard uterine contractions and affect uteroplacental blood flow Noise may increase maternal catecholamine secretion, which may further stimulate or retard uterine contractions and affect uteroplacental blood flow Noise exposure of  85dBL has been associated with fetal growth retardation Noise exposure of  85dBL has been associated with fetal growth retardation An excess of hormonal disturbances, infertility and spontaneous abortion also reported An excess of hormonal disturbances, infertility and spontaneous abortion also reported EU Guidelines: pregnant workers should not be exposed to noise levels exceeding national limit values EU Guidelines: pregnant workers should not be exposed to noise levels exceeding national limit values

19. EU Guidelines on some physical agents ( COM(2000) 466 final/2) Pregnant workers should not be exposed to prolonged excessive heat or cold be exposed to prolonged excessive heat or cold work in a high-pressure atmosphere or dive work in a high-pressure atmosphere or dive be exposed to unpleasant vibration of the entire body, particularly at low frequencies be exposed to unpleasant vibration of the entire body, particularly at low frequencies be exposed to work entailing shaking, shocks or where jolts or blows are delivered to the lower body be exposed to work entailing shaking, shocks or where jolts or blows are delivered to the lower body

20. References on physical strain, shift work and reproductive health Mozurkewich EL, Luke B, Avni M, Wolf FM. Working conditions and adverse pregnancy outcome: a meta- analysis. Obstet Gynecol 2000;95:623-635. Mozurkewich EL, Luke B, Avni M, Wolf FM. Working conditions and adverse pregnancy outcome: a meta- analysis. Obstet Gynecol 2000;95:623-635. Nurminen T. Shift work and reproductive health. Scand J Work Environ Health 1998;24:28-34. Nurminen T. Shift work and reproductive health. Scand J Work Environ Health 1998;24:28-34. Ahlborg G. Physical work load and pregnancy outcome. J Occup Environ Med 1995;37:941-944. Ahlborg G. Physical work load and pregnancy outcome. J Occup Environ Med 1995;37:941-944.