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Archivos de Prevención de Riesgos Laborales

On-line version ISSN 1578-2549

Arch Prev Riesgos Labor vol.25 n.2 Barcelona Apr./Jun. 2022  Epub July 15, 2022

https://dx.doi.org/10.12961/aprl.2022.25.02.03 

Original Articles

Sickness absence, medical and workplace conditions during pregnancy in a cohort of healthcare workers

Ausencia por enfermedad, condiciones médicas y de trabajo durante el embarazo en una cohorte de profesionales sanitarias

Rocío Villar-Vinuesa (orcid: 0000-0002-1890-4441)1  2  3  , Consol Serra (orcid: 0000-0001-8337-8356)1  2  3  , Laura Serra (orcid: 0000-0002-8835-6890)3  4  , Fernando G Benavides (orcid: 0000-0003-0747-2660)2  3 

1Occupational Health Service, Parc de Salut Mar, Barcelona, Spain

2Center for Research in Occupational Health, IMIM-Hospital del Mar Medical Research Institute/University Pompeu Fabra, Barcelona, Spain

3CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain

4Research Group on Statistics, Econometrics and Health (GRECS), University of Girona, Girona, Spain

Abstract

Objectives:

To assess the association between sickness absence (SA) trajectories by medical diagnoses and exposure to occupational risk factors during pregnancy.

Methods:

SA trajectories were identified in a cohort of 367 pregnant workers from a healthcare institution (period 2010-2014), based on most frequent diagnosis using sequence analysis. Trajectory 1 included SA episodes due mainly to musculoskeletal disorders (58.86%), trajectory 2 included SA episodes due to pregnancy-related disorders (25.07%) and trajectory 3 included absences mainly covered by pregnancy-related occupational risk benefits (POR) and few SA episodes (16.08%). Exposure to occupational risk factors was assessed by experts and their association with trajectories was analysed using logistic regression. Relative risks (RR) and their 95% confidence intervals (95%CI) were adjusted for age, type of contract and work shift.

Results:

Trajectory 1 was negatively associated with exposure to safety and ergonomic risks (RR=0.56, 95%CI=0.35-0.90; RR=0.50, 95%CI=0.33-0.77, respectively) and with the highest global risk index (RR=0.68, 95%CI=0.49-0.96). Trajectory 3 was associated with safety and ergonomic risks (RR=2.75, 95%CI=1.59-4.75; RR=3.64, 95%CI=2.18-6.06, respectively) and with the highest global risk index (RR=2.69, 95%CI=1.43-5.01). Nursing aides and nurses had a higher probability of belonging to trajectory 3 (RR 5.58, 95%CI=2.09-14.95 and RR 5.00, 95%CI 2.18-6.06, respectively).

Conclusions:

Pregnancy-related and musculoskeletal disorders are the most frequent sickness absence diagnosis during pregnancy. Low levels of occupational risk factors exposure were related to absences from work covered mainly by sickness absence. Current social benefits seem to be used as a complementary way to balance work and health during pregnancy.

Keywords: pregnancy; sickness; sickness absence; occupational risk factors; medical diagnosis; pregnancy occupational risk benefit; working condition; cohort study

Resumen

Objetivo:

Evaluar la asociación entre trayectorias de ausencia por enfermedad (SA) según diagnóstico y exposición a factores de riesgo laborales durante el embarazo.

Métodos:

Estudio de cohortes (367 trabajadoras sanitarias embarazadas). Se identificaron trayectorias de ausencia por enfermedad según los diagnósticos más frecuentes mediante análisis de secuencias (2010-2014). La trayectoria 1 incluía SA principalmente por trastornos musculoesqueléticos (58,86%), la 2 por trastornos relacionados con el embarazo (25,07%) y la 3 incluía ausencias por la prestación por riesgo durante el embarazo (POR) y pocas SA (16,08%). La exposición a factores de riesgo laborales fue evaluada por expertos y se analizó la asociación con las trayectorias mediante regresión logística. Los riesgos relativos (RR) y sus intervalos de confianza (IC95%) se ajustaron por edad, contrato y turno.

Resultados:

La trayectoria 1 se asoció negativamente con la exposición a riesgos de seguridad y ergonómicos (RR=0,56, IC95%=0,35-0,90; RR=0,50, IC95%=0,33-0,77) y con índice de riesgo global más bajo (RR=0,68, IC95%=0,49-0,96). La tercera se asoció a riesgos de seguridad y ergonómicos (RR=2,75, IC 95 %=1,59-4,75; RR=3,64, IC 95 %=2,18-6,06) y con el riesgo más alto (RR=2,69, 95 % IC=1,43-5,01). El personal de enfermería tuvo mayor probabilidad de pertenecer a la trayectoria 3 (RR 5,58, IC95%=2,09-14,95 y RR 5,00, IC95% 2,18-6,06).

Conclusiones:

Los trastornos musculoesqueléticos y por trastornos relacionados con el embarazo son los grupos diagnósticos de SA más frecuentes. Bajos niveles de exposición a riesgos laborales se relacionaron con ausencias cubiertas principalmente por SA. Las prestaciones sociales parecen utilizarse complementariamente para equilibrar el trabajo y la salud.

Palabras clave: embarazo; enfermedad; ausencia por enfermedad; factores de riesgo laborales; diagnóstico médico; prestación por riesgo durante el embarazo; condiciones de trabajo; estudio de cohorte

Introduction

Pregnant women undergo important anatomical, physiological and psychological changes that often challenge job demands, especially at the end of pregnancy1,2. The transition from active work to maternity license after delivery depends on a delicate balance where many factors intervene, both work and non-work related3,4. In Spain, as in other countries with a consolidated social protection benefits scheme5, two optional types of social benefits have been developed to protect pregnant women and their foetus’s health. These benefits are aimed at guaranteeing the continuity of women’s labour relationship and to cover their salary if absences from work due to health issues are needed. One of them is the sickness absence (SA) benefit, applied when the absence is due to a health problem not related to working conditions. The other one is the pregnancy occupational risk (POR) benefit, available in only a few countries6,7 and applied when absence from work is needed to prevent exposure during pregnancy to occupational risk factors that cannot be avoided by job adjustments or other measures.

Sick leave among pregnant workers is a frequently discussed issue as their SA rates are usually high8,9. According to previous studies, three out of four pregnant women had at least one episode of SA10,11,12. Other studies have tried to identify predictors of SA during pregnancy and factors that could increase the probability of returning to work after a SA episode, such as job adjustments, among others13,14. Some studies have pointed out that there are not clear medical explanations for this phenomenon15,16,17. However, health related problems such as musculoskeletal pain before18 or related to pregnancy19, overweight20, and other factors including sedentary lifestyle21, tobacco, alcohol or other drugs consumption 22,23,24, women’s "double burden"17 and attitudes towards SA25 have been associated with SA during pregnancy. Furthermore, despite SA is a specific benefit to cope ill-health non-work related, exposure to some occupational risk factors, such as heavy load handling, forced postures or high psychosocial demands, have shown a significant influence on SA in workers during pregnancy 26,27 28 29.

In line with this situation, the study about sickness absence diagnoses and occupational risk factors influences on pregnant workers disability are needed to help women to stay at work in a sustainable, healthy and productive way.

Our hypothesis was that absences due to SA are not influenced by exposure to occupational risk factors but to factors not related to work, mainly to the pregnancy itself. The aim of the present analysis was to assess the association between SA and POR benefit according to information on medical diagnoses and exposure to occupational risk factors in a cohort of pregnant healthcare workers.

Methods

Study population

We selected 367 pregnancies with at least one episode of SA from a cohort of 428 women who worked at a public university hospital, Parc de Salut Mar (PSMAR), (3,841 workers including 74.6% women, 67% of them between 21 and 50 years old) and who started a pregnancy between 2010 and 2014. Among the 61 excluded women, 56 took only the POR benefit without any SA episode and 5 worked during the whole pregnancy. For each pregnant woman, we had a daily employment status record, where they could alternate three different statuses: active work, absences due to SA and absences due to POR. There were 68 pregnant workers (18.53%) who took both POR benefit and SA during the whole pregnancy.

Assessment of health conditions and exposure to occupational risk factors and covariates

The health status of each pregnant worker in relation to her workplace was assessed by an occupational physician. Furthermore, an occupational health safety specialist carried out the workplace risk assessment collecting detailed information about job tasks, equipment, use of personal protection equipment and other existing preventive measures. This risk assessment evaluated six types of risks: biological, chemical, physical, ergonomic, psychosocial and safety. All this information was summarised and a proposal of preventive measures to avoid or reduce exposure was reported. Risks were classified into trivial, tolerable, moderate, substantial or intolerable, taking into account the probability of exposure and its potential consequences on health30. The methodology applied in this study reproduces the one used in a previously published work over the same cohort31. These risk categories were grouped into a dichotomous variable (yes/no), being "yes" when the risk assessment report had qualified them as substantial or intolerable, and "no" for moderate, tolerable or trivial. In addition, each level of risk exposure was scored from 1 to 3: trivial and tolerable risks (one); moderate (two); and substantial and intolerable (three). A global risk exposure index was developed as the sum of the scores for each risk. The risk exposure index was grouped into tertiles: 6-9 (low risk), 10-11 (medium risk) and 12-18 (high risk).

Finally, the occupational physician, in coordination with the worker’s manager, established the conclusion considering the risk assessment report, the feasibility of job adjustments and the pregnant woman individual characteristics. When there was a risk (qualified as substantial or intolerable) that could not be eliminated or adjustments be implemented, POR benefit was managed with the Occupational Health Insurance Company.

Medical diagnoses of each SA episode were collected from the medical records of each worker and coded according to ICD-10. Maternal age (≤30, 31-35, ≥36), occupation (administrative/technical support, nursing aide, nurse, physician), type of contract (temporary, permanent), working shift (morning, afternoon, split-shift, night, others), and weekly work hours (<30, 30-35, 36-40) were also recorded.

Analysis

Firstly, we calculated the frequency of SA episodes and their percentages, the total duration and median duration (MD) and cumulative days of absence (DA) for each ICD-10 major diagnostic categories and grouping specific diagnosis codes. Secondly, using sequence analysis, we identified three trajectories of SA episodes in combination with active work and POR benefit episodes, and SA major diagnostic categories. The final number of trajectories was based on the dendrogram, a tree diagram that illustrates the arrangement of the clusters produced by hierarchical clustering and informs about how data are grouped together indicating the distance between them32. For each SA trajectory we calculated the frequency, the percentage of the total accumulated days of absence (AD), and the median duration (MD) of SA and POR according to occupational risk factors, age and other workplace variables. We conducted a χ2 test to assess statistical differences among trajectories and these variables.

Finally, the crude and adjusted relative risks (RR) and their 95% confidence intervals (CI 95%) were estimated to assess the association between each trajectory and exposure to occupational risk factors using logistic regression models with a robust variance. To calculate the RR for each occupational risk factor we considered those not exposed to that same risk factor (although exposure to the other risk factors could be present) as the reference category. Furthermore, for the global risk exposure index we considered the lowest tertile value as the reference category. A sensitivity analysis to confirm the relationship between exposure to occupational ergonomic risks and belonging to SA trajectory 1 and SA trajectory 2 by occupational categories was carried out. The statistical software RStudio and STATA 13 were used.

Confidentiality of personal data was preserved by anonymization of all processed information. The research project was evaluated and approved by the ethics committee of the hospital.

Results

A total of 655 episodes of SA were recorded among the 367 included pregnant workers, amounting a total of 28,313 AD and a median duration of 19 days (Table 1). The most frequent medical diagnosis group was health problems related to pregnancy (232 episodes, 35.4%), including mainly excessive vomiting (71 episodes, 2,641 AD), risk of abortive outcome (62 episodes, 3,644 AD) and risk related to delivery (39 episodes, 2,524 AD), accounting for a total of 12,039 AD (42.5%). The second most frequent group was musculoskeletal disorders (199 episodes, 30.4%), being low back pain the leading cause (178 episodes, 9,906 AD).

Table 1. Sickness absence (SA) episodes (N=655) during pregnancy, absence days (AD) and median duration (MD) by major diagnostic categories and diagnosis codes (ICD-10) among the sample of the pregnant workers cohort with at least one SA episode (N=367), Parc de Salut Mar 2010 - 2014 

ICD-10 DIAGNOSTIC GROUP N (%) AD (%) MD
O00-O9A PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 232 (35.42) 12039 (42.52) 22
O09.0, O20.0, O20.9 Risk of abortive outcome / haemorrhage in early pregnancy 62 (9.47) 3644 (12.87) 25
O60-O75 Complications of labour and delivery 39 (5.95) 2524 (8.91) 49
O21 Excessive vomiting in pregnancy 71 (10.84) 2641 (9.33) 6
O16.9, O26.5, Z39.9 Other health problems related to pregnancy 60 (9.16) 3230 (11.41) 18
M00-M99 DISEASES OF THE MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE 199 (30.38) 10471 (36.98) 45
M54.3-M54.5 Low back pain 178 (27.18) 9906 (34.99) 48
M25.5, M53.9, M54.2, M54.9, M75.0, M77.0, M79.1 Other health problems related to musculoskeletal system 21 (3.21) 565 (2.00) 12
J00-J99 DISEASES OF THE RESPIRATORY SYSTEM 70 (10.69) 450 (1.59) 3
J02.9 Acute pharyngitis 42 (6.41) 286 (1.01) 3
J03.9, J11.1, J20.9, J32.9, J45.9 Other health problems related to respiratory system 28 (4.27) 164 (0.58) 5
R00-R99 SYMPTOMS, SIGNS AND ABNORMAL CLINICAL ANB LABORATORY FINDINGS NECa 58 (8.85) 1993 (7.04) 7
R53.1, R53.8 Malaise and fatigue 17 (2.60) 1097 (3.87) 54
R00.0, R10.9, R19.7, R50.9, R60.0 Other symptoms or signs NECa 41 (6.26) 896 (3.16) 4
Z00-Z99 FACTORS INFLUENCING HEALTH STATUS AND CONTACT WITH HEALTH SERVICESb 24 (3.66) 736 (2.60) 7
F01-F99 MENTAL AND BEHAVIOURAL DISORDERS 16 (2.44) 862 (3.04) 32
K00-K95 DISEASES OF THE DIGESTIVE SYSTEM 14 (2.14) 261 (0.92) 4
N00-N99 DISEASES OF THE GENITOURINARY SYSTEM 7 (1.07) 206 (0.73) 21
- OTHER GROUPS* 16 (2.44) 527 (1.86) 5
- MISSING/UNREGISTERED 19 (2.90) 768 (2.71) 28
TOTAL 655 (100.00) 28313 (100.00) 19

a NEC: Not Elsewhere Classified; b Includes persons encountering health services in circumstances related to reproduction; * Includes: diseases of the nervous system, infectious and parasitic diseases, circulatory system diseases, eye and adnexa diseases, injury, poisoning and other external causes, ear and mastoid diseases and skin and subcutaneous tissue diseases.

SA trajectories are shown in Figure 1. Trajectory 1 includes women with SA due to musculoskeletal medical diagnoses as the main cause of absence from work, whereas women in trajectory 2 were absent from work because of SA due to pregnancy-related disorders. POR was the main cause of work absence in those women included in trajectory 3, combined with some SA mainly due to pregnancy-related medical diagnoses.

Figure 1. Sickness absence (SA) trajectories among a cohort of pregnant workers with at least one sickness absence episode during pregnancy (N=367), 2010-2014 

Most women are fitted in trajectory 1, where 216 pregnant workers (58.9%) accounting for 14,942 days of SA (389 episodes) with a median duration of SA episodes of 15 days. Trajectory 2 included 92 pregnant workers (25.1%), with 12,414 days of SA (171 episodes) and a median duration of 24 days. There were only 59 women (16.1%) in trajectory 3 accounting for 6,403 days of absence due to POR (58 episodes) and only 957 days of SA (95 episodes), with a median duration of 112 and 4 days, respectively. Active work accounted for 75%, 48% and 55% of pregnancies time in trajectory 1, 2 and 3, respectively (Table 2).

Almost half of pregnancies in trajectory 3 (47.5%) had the highest score (12 to 18) of exposure to occupational risk factors. Conversely, this percentage was 22.7% and 33.7% for pregnancies in trajectories 1 and 2, respectively, and more than 40% of these women showed a low level of exposure to occupational risk factors (6 to 9). Statistically significant differences were observed between the three trajectories for the occupational risk score, occupation and working shift (Table 2).

Table 2. Description of sickness absence (SA) trajectories accordin to risk exposure, age and workplace variables among the sample of pregnant workers cohort with at least one SA episode (N=367), Parc de Salut Mar 2010 - 2014 

PREGNANCIES TRAJECTORY 1 ACTIVE WORK / MUSCULOSKELETAL DISORDERS TRAJECTORY 2 ACTIVE WORK / SA PREGNANCY-RELATED DIAGNOSES TRAJECTORY 3 ACTIVE WORK / PREGNANCY OCCUPATIONAL RISK BENEFIT
N (%) N (%) EPa ADb MDc N (%) EP AD MD N (%) SA EP AD SA MD SA PORd EP AD POR MD POR pχ2
Risk factor exposure
Biological 167 (45.50) 88 (40.74) 142 6984 16 48 (52.17) 88 5911 29 28 (47.46) 39 374 3 28 3102 113 -
Physical 10 (2.72) 5 (2.31) 9 521 7 1 (1.09) 1 204 204 4 (6.78) 8 57 5 4 374 98
Chemical 25 (6.81) 12 (5.56) 15 588 15 9 (9.78) 13 1456 77 4 (6.78) 6 40 4 4 407 100
Safety 54 (14.71) 19 (8.80) 44 2383 13 16 (17.39) 21 1377 36 19 (32.20) 27 181 3 19 2076 114
Ergonomic 73 (19.89) 24 (11.11) 53 1877 11 21 (22.83) 43 2802 12 28 (47.46) 39 374 3 28 3102 113
Psychosocial 95 (25.89) 52 (24.07) 85 3469 23 22 (23.91) 43 2768 24 21 (35.59) 32 287 3 21 2348 114
Non exposed 126 (34.33) 94 (43.52) 161 5337 17 27 (29.35) 50 3780 29 5 (8.47) 11 114 3 4 510 132
Risk level exposure
6 - 9 161 (43.87) 107 (49.54) 189 6366 16 37 (40.22) 76 5252 15 15 (25.42) 29 406 6 14 1567 123
10 - 11 98 (26.70) 60 (27.78) 111 4767 15 24 (26.09) 39 2999 33 16 (27.12) 24 173 5 16 1809 108 0.003
12 - 18 108 (29.43) 49 (22.69) 89 3809 13 31 (33.70) 56 4163 24 28 (47.46) 42 378 4 28 3027 110
Maternal age (years)
≤ 30 71 (19.35) 42 (19.44) 76 3733 16 20 (21.74) 48 2144 8 9 (15.25) 15 220 7 9 958 107
31 - 35 174 (47.41) 95 (43.98) 174 6692 17 41 (44.57) 77 5660 24 38 (64.41) 62 486 4 38 4243 114 0.068
≥ 36 122 (33.24) 79 (36.57) 139 4517 13 31 (33.70) 46 4610 50 12 (20.34) 18 251 4 11 1202 110
Occupation
Physician 97 (26.43) 74 (34.26) 114 3263 21 18 (19.57) 33 2005 22 5 (8.47) 10 144 9 5 470 94
Administrative and technical support 76 (20.71) 58 (26.85) 111 3426 14 16 (17.39) 39 2190 9 2 (3.39) 2 14 7 2 160 80 0.000
Nursing aide 66 (17.98) 28 (12.96) 70 3298 12 19 (20.65) 29 2995 68 19 (32.20) 36 543 6 18 2012 113
Nurse 128 (34.88) 56 (25.93) 94 4955 14 39 (42.39) 70 5224 29 33 (55.93) 47 256 3 33 3761 112
Type of contract
Temporary 126 (34.33) 83 (38.43) 142 4691 14 28 (30.43) 57 2630 16 15 (25.42) 25 299 6 14 1418 103 0.116
Permanent 241 (65.67) 133 (61.57) 247 10251 16 64 (69.57) 114 5592 25 44 (74.58) 70 658 4 44 4985 114
Shift work
Morning 102 (27.79) 54 (25.00) 101 4240 15 35 (38.04) 57 4487 33 13 (22.03) 24 121 5 13 1453 108
Afternoon 80 (21.80) 34 (15.74) 74 3476 9 23 (25.00) 37 3359 57 23 (38.98) 37 373 4 22 2405 111 0.000
Split-shift 154 (41.96) 116 (53.70) 193 5963 21 25 (27.17) 57 3179 16 13 (22.03) 18 239 7 13 1298 108
Night and others* 31 (8.45) 12 (5.56) 21 1263 38 9 (9.78) 20 1389 29 10 (16.95) 16 224 4 10 1247 120
Weekly work hours
36-40 246 (67.03) 147 (68.06) 261 9201 21 60 (65.22) 126 8236 17 39 (66.10) 63 611 3 39 4260 108
30-35 59 (16.08) 32 (14.81) 65 2649 9 15 (16.30) 18 2018 58 12 (20.34) 20 121 6 12 1375 119 0.826
<30 62 (16.89) 37 (17.13) 63 3092 15 17 (18.48) 27 2160 44 8 (13.56) 12 225 8 7 768 116
Total 367 (100,00) 216 (58.86) 389 14942 15 92 (25.07) 171 12414 24 59 (16.08) 95 957 4 58 6403 112

aEP: Episodes; bAD: days of absence; cMD: median duration; dPOR: pregnancy occupational risk; *includes weekend shift.

The association between exposure to occupational risk factors and each trajectory separately is shown in Table 3. Pregnant workers in trajectory 1 had a negative association with safety and ergonomic risk factors (RR 0.56, 95% CI 0.35-0.90; RR 0.50, 95% CI 0.33-0.77, respectively), and with the highest global risk exposure index (score 12 to 18) (RR 0.68, 95% CI 0.49-0.96). Trajectory 3 was associated with safety (RR 2.75, 95% CI 1.59-4.75) and ergonomic risks (RR 3.64, 95% CI 2.18-6.06). The highest score of occupational risk factors exposure (score 12 to 18) was associated with trajectory 3 (RR 2.69, 95% CI 1.43-5.01). Trajectory 2 did not show any association with exposure to risk factors at work nor with any exposure score.

Table 3. Relative risk of the three clusters by risk exposure, age and workplace variables of the subsample of workers with at least one NWSA episode (N=367) of the pregnant workers cohort (N= 428), Parc de Salut Mar 2010 - 2014 

TRAJECTORY 1 ACTIVE WORK / MUSCULOSKELETAL DISORDERS TRAJECTORY 2 ACTIVE WORK / SA PREGNANCY-RELATED TRAJECTORY 3 ACTIVE WORK / PREGNANCY OCCUPATIONAL RISK BENEFIT
cRRa (CI 95%)b cRR (CI 95%) cRR (CI 95%)
Risk factor exposurec
Biological 0.82 (0.63-1.08) 1.31 (0.87-1.97) 1.33 (0.79-2.21)
Physical 0.85 (0.35-2.05) 0.39 (0.05-2.82) 2.6 (0.94-7.16)
Chemical 0.80 (0.45-1.44) 1.48 (0.75-2.95) 0.99 (0.36-2.75)
Safety 0.56 (0.35-0.90) 1.22 (0.71-2.09) 2.75 (1.59-4.75)
Ergonomic 0.50 (0.33-0.77) 1.19 (0.73-1.94) 3.64 (2.18-6.06)
Psychosocial 0.91 (0.66-1.24) 0.9 (0.56-1.45) 1.58 (0.93-2.70)
Non exposed 1.47 (1.13-1.93) 0.79 (0.51-1.24) 0.18 (0.07-0.44)
Risk level exposure
6 - 9 1 1 1
10 - 11 0.93 (0.68-1.26) 0.97 (0.58-1.62) 1.59 (0.79-3.22)
12 - 18 0.68 (0.49-0.96) 1.2 (0.75-1.94) 2.69 (1.43-5.01)
Maternal age (years)
≤ 30 1 1 1
31 - 35 0.92 (0.64-1.33) 0.84 (0.49-1.43) 1.72 (0.83-3.56)
≥ 36 1.09 (0.75-1.59) 0.9 (0.51-1.58) 0.78 (0.33-1.84)
Occupation
Physician 1 1 1
Administrative and technical support 1,00 (0.71-1.41) 1.13 (0.58-2.22) 0.51 (0.10-2.63)
Nursing aide 0.55 (0.36-0.86) 1.55 (0.81-2.96) 5.58 (2.09-14.95)
Nurse 0.57 (0.41-0.81) 1.64 (0.94-2.87) 5,00 (1.95-12.81)
Type of contract
Temporary 1 1 1
Permanent 0.84 (0.64-1.10) 1.19 (0.77-1.86) 1.53 (0.85-2.76)
Shift work
Morning 1 1 1
Afternoon 0.8 (0.52-1.23) 0.84 (0.49-1.42) 2.26 (1.14-4.45)
Split-shift 1.42 (1.03-1.97) 0.47 (0.28-0.79) 0.66 (0.31-1.43)
Night and others* 0.73 (0.39-1.36) 0.85 (0.41-1.76) 2.53 (1.11-5.78)
Weekly work hours
36-40 1 1 1
30-35 0.91 (0.62-1.33) 1.04 (0.59-1.83) 1.28 (0.67-2.45)
<30 0.99 (0.70-1.43) 1.12 (0.66-1.93) 0.81 (0.38-1.74)

a cRR: Crude Relative Risk; b CI 95 %: Confidence interval 95%; c cRR: calculated taking non-exposed as the reference category; *includes weekend shift.

Regarding occupation and taking physicians as the reference category, nursing aides and nurses had a higher probability of belonging to trajectory 3 (RR 5.58, 95% CI 2.09-14.95 and RR 5.00, 95% CI 1.95-12.81, respectively) and less likely than physicians to belong to trajectory 1 (RR 0.55, 95% CI 0.36-0.86; RR 0.57, 95% CI 0.41-0.81, respectively). Split-shift, compared to morning shift, was associated with trajectory 1 (RR 1.42, 95% CI 1.03-1.97) and negatively associated with trajectory 2 (RR 0.47, 95% CI 0.28-0.79), and both the afternoon and the night shifts were associated with trajectory 3 (RR 2.26, 95% CI 1.14-4.45; RR 2.53, 95% CI 1.11-5.78, respectively). No differences were observed for maternal age, type of contract and number of weekly work hours.

After adjusting for maternal age, type of contract and working shift, most associations there are some changes (Table 4). In particular, trajectory 1 was negatively associated with exposure to safety (RR=0.67, 95% CI 0.46-0.97), ergonomic (RR=0.59, 95% CI 0.42-0.82) and psychosocial (RR=0.77, 95% CI 0.62-0.95) risks. Trajectory 2 did not show any association, except for exposure to psychosocial risks (RR=2.56, 95% CI 1.47-4.46).

Table 4. Risk of belonging to one of the sickness absence (SA) trajectories according to risk exposure among the sample of the pregnant workers cohort with at least one NWSA episode (N=367), Parc de Salut Mar 2010 - 2014 

TRAJECTORY 1 ACTIVE WORK / MUSCULOSKELETAL DISORDERS TRAJECTORY 2 ACTIVE WORK / SA PREGNANCY-RELATED TRAJECTORY 3 ACTIVE WORK / PREGNANCY OCCUPATIONAL RISK BENEFIT
aRRa (CI 95%)b aRR (IC 95%) aRR (IC 95%)
Risk factor exposurec
Biological 0.92 (0.76-1.12) 1.25 (0.83-1.89) 2.36 (1.54-3.61)
Physical 0.82 (0.44-1.54) 0.38 (0.05-2.69) 3.27 (1.58-6.77)
Chemical 0.78 (0.51-1.17) 1.75 (0.96-3.19) 0.84 (0.32-2.19)
Safety 0.67 (0.46-0.97) 1.08 (0.68-1.73) 1.83 (1.16-2.88)
Ergonomic 0.59 (0.42-0.82) 1.1 (0.71-1.71) 2.36 (1.54-3.61)
Psychosocial 0.77 (0.62-0.95) 2.56 (1.47-4.46) 2.56 (1.47-4.46)
Non exposed 1.32 (1.40-1.59) 0.83 (0.52-1.31) 0.29 (0.10-0.81)
Risk level
6 - 9 1 1 1
10 - 11 1.04 (0.85-1.27) 0.89 (0.54-1.45) 1.14 (0.58-2.24)
12 - 18 0.73 (0.57-0.94) 1.11 (0.69-1.77) 2.16 (1.19-3.92)

a aRR: Adjusted Relative Risk for age and workplace variables; b CI 95%: Confidence Interval 95%; c aRR: calculated taking non-exposed as the reference category.

The stratified analysis by occupation (Table 5) showed that for physicians trajectory 2 was significantly associated with exposure to chemical and safety risks (RR=3.40, 95% CI 1.39-8.34 and RR=2.59, 95% CI 1.03-6.49, respectively); for nursing aides trajectory 3 was significantly associated with exposure to ergonomic risks (RR=6.15, 95% CI 1.99-19.03); and for nurses trajectory 3 was significantly associated with exposure to physical (RR=3.10, 95% CI 1.11-8.66), safety (RR=1.99, 95% CI 1.12-3.54), ergonomic (RR=1.79, 95% CI 1.03-3.11) and psychosocial risks (RR=3.19, 95% CI 1.58-6.43).

Table 5. Risk of beloging to Sickness Absence Trajectories (SAT) according to risk exposure by occupatiion among the sample of the pregnant workers cohort with at least one sickness absence (SA) episode (N=367), Parc de Salut Mar 2010-2014 

PHYSICIAN ADMINISTRATIVE AND TECHNICAL SUPPORT
SAT1 ACTIVE WORK / SA MUSCULOSKELETAL DISORDERS SAT2 ACTIVE WORK / SA RELATED TO PREGNANCY SAT3 ACTIVE WORK / PREGNANCY OCCUPATIONAL RISK BENEFIT SAT1 ACTIVE WORK / SA MUSCULOSKELETAL DISORDERS SAT2 ACTIVE WORK / SA RELATED TO PREGNANCY SAT3 ACTIVE WORK / PREGNANCY OCCUPATIONAL RISK BENEFIT
aRRa (95% CI)b aRR (95% CI) aRR (95% CI) aRR (95% CI) aRR (95% CI) aRR (95% CI)
Risk factor exposurec
Biological 0.95 (0.77 - 1.18) 0.97 (0.42- 2.22) 2.65 (0.31 - 22.89) 0.69 (0.14 - 3.34) 2.33 (0.25 - 21.70) - -
Physical 0.75 (0.37 - 1.54) 1.26 (0.18 - 8.68) 5.02 (0.65 - 38.51) - - - - - -
Chemical 0.54 (0.27 - 1.10) 3.40 (1.39 - 8.34) 2.28 (0.28 - 18.43) 0.88 (0.48 - 1.59) - - - -
Safety 0.73 (0.40 - 1.34) 2.59 (1.03 - 6.49) - - 0.41 (0.07 - 2.38) 1.42 (0.36 - 5.63) - -
Ergonomic 1.03 (0.72 - 1.47) 1.22 (0.34 - 4.44) - - 0.64 (0.29 - 1.43) 1.53 (0.41 - 5.75) 5.10 (0.27 - 94.55)
Psychosocial 0.86 (0.70 - 1.07) 1.16 (0.49 - 2.73) - - 0.67 (0.18 - 2.47) 2.90 (0.54 - 15.49) - -
Global risk index
6 - 9 1 1 1 1 1 1
10 - 11 0.99 (0.76 - 1.26) 1.14 (0.34 - 4.02) 0.84 (0.44 - 1.60) 0.68 (0.36 - 1.26) 1.91 (0.50 - 7.33) 5.10 (0.27 - 94.55)
12 - 18 0.78 (0.59 - 1.04) 1.43 (0.46 - 4.46) - - 1.65 (0.17 - 2.33) - - 0.13 (0.01 - 1.36)
NURSING AIDE NURSE
SAT1 ACTIVE WORK / SA MUSCULOSKELETAL DISORDERS SAT2 ACTIVE WORK / SA RELATED TO PREGNANCY SAT3 ACTIVE WORK / PREGNANCY OCCUPATIONAL RISK BENEFIT SAT1 ACTIVE WORK / SA MUSCULOSKELETAL DISORDERS SAT2 ACTIVE WORK / SA RELATED TO PREGNANCY SAT3 ACTIVE WORK / PREGNANCY OCCUPATIONAL RISK BENEFIT
aRR (95% CI) aRR (95% CI) aRR (95% CI) aRR (95% CI) aRR (95% CI) aRR (95% CI)
Risk factor exposure
Biological 1.15 (0.67 - 1.98) 1.24 (0.55 - 2.75) 0.59 (0.25 - 1.39) 1.00 (0.66 - 1.51) 1.28 (0.67 - 2.44) 0.72 (0.38 - 1.36)
Physical - - - - 2.22 (0.77 - 6.37) 0.91 (0.33 - 2.50) - - 3.10 (1.11 - 8.66)
Chemical 1.50 (0.61 - 3.68) 1.40 (0.44 - 4.41) - - 1.00 (0.44 - 2.26) 1.21 (0.44 - 3.35) 0.71 (0.26 - 1.91)
Safety 0.93 (0.48 - 1.81) 0.71 (0.27 - 1.90) 1.45 (0.65 - 3.19) 0.59 (0.31 - 1.13) 0.96 (0.51 - 1.82) 1.99 (1.12 - 3.54)
Ergonomic 0.14 (0.02 - 1.00) 0.62 (0.21 - 1.81) 6.15 (1.99 - 19.03) 0.65 (0.40 - 1.07) 1.02 (0.58 - 1.80) 1.79 (1.03 - 3.11)
Psychosocial 0.46 (0.13 - 1.63) 1.44 (0.37 - 5.52) 1.59 (0.46 - 5.57) 0.53 (0.25 - 1.14) 0.63 (0.32 - 2.90) 3.19 (1.58 - 6.43)
Global risk index
6 - 9 1 1 1 1 1 1
10 - 11 1.40 (0.82 - 2.40) 0.52 (0.17 - 1.62) 0.91 (0.33 - 2.49) 1.11 (0.66 - 2.19) 1.06 (0.48 - 2.31) 0.87 (0.37 - 2.02)
12 - 18 0.64 (0.22 - 1.89) 0.70 (0.26 - 1.86) 2.03 (0.85 - 4.85) 0.80 (0.44 - 1.60) 1.25 (0.56 - 2.78) 1.13 (0.53 - 2.44)

aaRR: relative risk adjusted for age, type of contract and shift work; b 95% CI: 95% confidence interval; caRR: calculated taking non-exposed as the reference category.

Discussion

Pregnancy-related health problems and musculoskeletal disorders represented up to 80% of absence days due to SA in our cohort of pregnant women, being low back pain, excessive vomiting and risk of abortive outcome the most frequent particular medical diagnoses and showing a negative or no association with exposure to occupational risk factors, respectively. Logically, we also found that women who were highly exposed to occupational risk factors, mainly biological, ergonomic, safety, hygiene and/or psychosocial, had absences from work covered predominantly by POR benefit, with one or more previous SA episodes mainly attributed to pregnancy-related medical conditions early in the pregnancy.

Our results could be explained because the POR benefit was correctly used to prevent health problems that could be caused or aggravated by adverse working conditions, such as musculoskeletal disorders in women exposed to high exposure to ergonomic risk factors. These patterns were confirmed after adjusting by age, occupation, type of contract and working shift. Those women belonging to the trajectory with SA episodes caused mainly by musculoskeletal disorders where not associated to ergonomic and psicosocial risk factors, as it would be expected. A hypothesis is that these SA episodes due to musculoskeletal disorders could be directly consequence of the pregnancy or/and non-work ergonomic risk factors. No previous study has to our knowledge included this information.

An important result from our study is that absences from work covered by SA during pregnancy were not associated to exposure to occupational risk factors. However, for physicians, we found an association between exposure to chemical and safety risks with the SA trajectory with episodes due to health problems related to pregnancy. A possible explanation to these findings is that working conditions may play a role in worsening symptoms or diseases related to pregnancy.

The frequency of SA shown in our cohort (85%) was higher in comparison with other previous studies, where reported SA during pregnancy varies from 29% to 72%33,34,35. A possible explanation may be due to differences in SA definition since some authors only consider SA episodes as those lasting more than one week or just consider those that occur only in certain weeks of pregnancy. We have registered all episodes from the first day and during the whole pregnancy period.

The main medical diagnosis of SA were pregnancy-related health problems, which confirms their important role contributing to the observed increase of SA during female reproductive age36. Previous studies had also shown that other diagnosis such as pelvic girdle pain and fatigue/sleep problems as the main reasons of SA11,37. Musculoskeletal complaints contributed substantially to SA during pregnancy in our study, being the second most frequent cause of absences from work. In fact, this is similar to the frequency of musculoskeletal disorders in the whole working population, for both men and women38,39. As reported in several studies11,40-42, low back pain was the most frequent reason of SA in our sample.

Another important implication from our results is the importance of the two current social benefits in Spain to cope with imbalances between work and health during pregnancy. On the one side, SA benefit is mainly used when pregnant workers suffer from health problems mainly related to pregnancy and/or other no-work related risk factors; on the other, POR benefit is applied when they are exposed to occupational risks before health effects occur. Our results show the suitable complementarity of the two benefits, and suggest that SA seems to be used also as a complementary way to assess the balance between work demands and physiologic changes.

This study has several strengths. First, it is based on a detailed follow-up throughout pregnancy with a precise daily register of active work and absences by SA, with or without POR. In addition, for each pregnancy we obtained detailed information on medical diagnoses of all SA from medical and SA records and a comprehensive occupational risk assessment. However, the interpretation of our results should be done with caution because of some limitations. The main one is related to the sample size and the characteristics of the study population, reducing the external validation of our results. Our sample corresponds to pregnant workers of a public university hospital who maintained their full salary during either of the two benefits as a result of an agreement with the unions. There is a need to reproduce the study in other companies with difference SA benefits schemes (usually only 70% for salary in SA benefits unless otherwise complemented, and 100% for POR benefits in Spain). In addition, most pregnant workers (76%) included in our study had a permanent contract. Nonetheless, we did not observe any differences of the magnitude of the association by type of contract in our sample. In any case, it would be interesting to analyse the same trajectories in companies of other sizes and different workforces and sectors, and with a higher proportion of temporary contracts.

In summary, a provisional conclusion is that current social benefits seem to be adequate for protecting pregnant workers from exposure to occupational risk factors, and to cope with imbalances between working conditions, health-related problems and pregnancy. Nevertheless, a great majority of pregnant women in our cohort had absences covered by SA benefit, some of them before initiating the POR benefit towards the third trimester of pregnancy. A great majority of women in our cohort had absences covered by SA benefit that could not be caused by pregnancy itself, but also, as we have seen, to working conditions43. Maybe a better management of occupational risk assessment and information provided to pregnant workers, stressing the need of POR benefit when occupational exposures are high, could reduce episodes of SA. Further research therefore needs to focus on the effects of working conditions improvement and the role of specialized preventive interventions that may help pregnant workers to ensure an adequate balance between motherhood and active work.

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Received: December 30, 2021; Accepted: March 22, 2022; pub: April 15, 2022

Correspondencia · Corresponding Author Rocío Villar Vinuesa rvillar@psmar.cat

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