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Call to Action ajog.

org

“Will my work affect my pregnancy?”


Resources for anticipating and
answering patients’ questions
Barbara Grajewski, PhD; Carissa M. Rocheleau, PhD; Christina C. Lawson, PhD;
Candice Y. Johnson, PhD

The problem
Women’s health providers may find it BACKGROUND: Authoritative information on occupational reproductive hazards is scarce
challenging to effectively address work- and complex because exposure levels vary, multiple exposures may be present, and the
place reproductive health issues with reproductive toxicity of many agents remains unknown. For these reasons, women’s
their working patients who are pregnant, health providers may find it challenging to effectively address workplace reproductive
breast-feeding, or considering pregnancy. health issues with their patients who are pregnant, breast-feeding, or considering
pregnancy. Reproductive epidemiologists at the Centers for Disease Control and Pre-
A solution vention National Institute for Occupational Safety and Health answered >200 public
Information and resources are provided requests for occupational reproductive health information during 2009 through 2013.
for counseling patients about their The most frequent occupations represented were health care (41%) and laboratory work
workplace and reproductive health. (18%). The most common requests for exposure information concerned solvents (14%),
anesthetic gases (10%), formaldehyde (7%), infectious agents in laboratories (7%) or
Overview health care settings (7%), and physical agents (14%), including ionizing radiation (6%).
Communicating reproductive risks to Information for developing workplace policies or guidelines was sought by 12% of the
workers is complex for women’s health requestors. Occupational exposure effects on breast-feeding were an increasing concern
providers. Only about 4000 of the 84,000 among working women. Based on information developed in response to these re-
chemicals in the workplace have been questors, information is provided for discussing workplace exposures with patients,
evaluated for reproductive toxicity, and assessing potential workplace reproductive hazards, and helping patients determine the
>2000 new chemicals are introduced best options for safe work in pregnancy. Appendices provide resources to address
annually.1 Besides chemicals and phys- specific occupational exposures, employee groups, personal protective equipment,
ical agents,2-4 reproductive hazards breast-feeding, and workplace regulations regarding work and pregnancy. These tools
include physical demands (eg, heavy can help identify those most at risk of occupational reproductive hazards and improve
lifting, prolonged standing)5 and circa- workers’ reproductive health. The information can also be used to inform research
dian disruption from night or rotating priorities and assist the development of workplace reproductive health policies.
work schedules.6,7 The need for vigilance
about hazardous occupational exposures Key words: occupational safety and health, pregnancy, reproductive health
continues after birth since some

From the Industrywide Studies Branch, National Institute for Occupational Safety and Health,
workplace chemicals can pass into breast
Cincinnati, OH (all authors), and Epidemic Intelligence Service, Centers for Disease Control and milk or be carried home on a worker’s
Prevention, Atlanta, GA (Dr Johnson). skin, hair, clothes, and shoes, where a
Received Nov. 24, 2015; revised March 2, 2016; accepted March 7, 2016. child can be exposed.8 A purposeful
Dr Grajewski retired from the National Institute for Occupational Safety and Health as of Dec. 1, 2015. response to these issues requires a
This work was part of the Intramural Research Program of the National Institute for Occupational framework for thinking about occupa-
Safety and Health (NIOSH). The findings and conclusions in this report are those of the author(s) and tional exposures and reproductive
do not necessarily represent the views of NIOSH. Mention of any company or product does not health.
constitute endorsement by NIOSH. In addition, citations to World Wide Web sites external to NIOSH
do not constitute NIOSH endorsement of the sponsoring organizations or their programs or
 Timing, type, and dose of exposure will
products. Furthermore, NIOSH is not responsible for the content of these World Wide Web sites. The
authors report no conflict of interest. influence adverse reproductive out-
Selected findings presented at the 27th annual meeting of the Society for Pediatric and Perinatal
comes. In general, first-trimester
Epidemiologic Research, Seattle, WA, June 23-24, 2014. exposures can result in miscarriage
Corresponding author: Barbara Grajewski, PhD. bgrajewski1@gmail.com or structural anomalies. Second- and
0002-9378/$36.00  Published by Elsevier Inc.  http://dx.doi.org/10.1016/j.ajog.2016.03.005
third-trimester pregnancy exposures
may lead to functional impairments,
Related editorial, page 555 small for gestational age, or preterm
delivery.

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 The developing fetus may be vulnerable  The same agents may be occupational CDC-INFO, the national contact center
to health effects at lower chemical con- or environmental exposures. Although that launched in 2005.18 CDC-INFO
centrations than its mother. Suscepti- environmental exposure to an agent delivers health information to con-
bility to workplace hazards varies may be more common, occupational sumers, health care professionals, and
throughout pregnancy due both to exposures to the same agent are usu- public health partners who call, mail, or
changes in maternal physiology and ally higher. Hobbies and the home e-mail their inquiries about disease
the fetus’ developmental stage. environment may also be sources of prevention and health promotion
Neither of these is reflected in most exposure. (http://www.cdc.gov/cdc-info/index.
existing workplace regulations and html). Because occupational reproduc-
occupational exposure limits. Women’s health providers may strug- tive queries often describe unique or
 The true scope of occupational repro- gle to effectively address occupational complex combinations of workplace
ductive health is not limited to preg- issues with their patients. A recent survey exposures, they are routed to occupa-
nancy. Although this Call to Action is of obstetricians reported barriers to tional reproductive epidemiologists at
focused primarily on resources for counseling women about prenatal envi- the National Institute for Occupational
counseling pregnant workers, pre- ronmental and occupational exposures: Safety and Health (NIOSH) who can
conceptional planning, breast- uncertainty about risks, the number of provide individualized responses.
feeding, and male workers’ repro- potential exposures, and the ability of Our goal is to share the resources we
ductive health also depend on their patients to take action to reduce developed for these CDC-INFO queries
appropriate counseling, action, and risk.12 Further, there is no single with women’s health providers to help
policy. Reproductive toxicants’ resource for information on occupa- them engage effectively with their pa-
impact extends across the life course9 tional reproductive health hazards. One tients, identify those most at risk, and
for both men and womeneas was the potential source of counseling might be improve workers’ reproductive health.
case with men who sustained infer- Teratology Information Services across This information may also inform
tility from their occupational expo- the United States; but in a 2008 survey, research priorities and assist the devel-
sure to dibromochloropropane before occupational topics only accounted for opment of workplace reproductive
it was banned.10 6% of their counseling time.13 Occupa- health policies.
 Very few chemicals used in the work- tional counseling services14-16 have
place are adequately tested for safe use identified a demand for occupational CDC-INFO occupational reproductive
during pregnancy. Exposure limits, reproductive counseling and the need to queries
respiratory guidelines, and personal increase resource information for We collected information about CDC-
protective equipment (PPE) guide- women’s health providers. The Amer- INFO queries answered by the NIOSH
lines issued by occupational health ican Congress of Obstetrics and Gyne- Industrywide Studies Branch reproduc-
agencies were developed for healthy cology (ACOG) and the American tive epidemiologists during calendar
adult workers, not a developing Society for Reproductive Medicine years 2009 through 2013. Responses
fetus. Even when extensive repro- (ASRM) recently issued a joint Com- were developed by subject matter experts
ductive and developmental toxicity mittee Opinion on the role of repro- in reproductive occupational health
testing data are available, they are ductive health professionals in the after consulting the scientific literature,
rarely incorporated into workplace prevention of exposure to environ- reproductive databases, and other ex-
regulations. For example, California mental and occupational toxic chem- perts as required. Advice was provided
reviewed its Proposition 65 list of icals.9 Last year, the International based on the existing literature and
chemicals known to the state of Federation of Gynecology and Obstetrics incorporated uncertainties about repro-
California to cause reproductive or (FIGO) issued a global call to action on ductive hazards and actions employers
developmental toxicity. The 31 preventing exposure to toxic environ- could take to reduce potential risks.
workplace chemicals in this category mental and occupational chemicals.17 As has been the case with similar ser-
have been extensively evaluated, and Twelve additional global health profes- vices,14 women’s reproductive health is-
are likely a significant underestimate sional societies have endorsed the FIGO sues constitute the majority of queries
of the actual number of reproduc- opinion. Recommendations included received. Although occupational expo-
tive/developmental toxicants in the improving public policy to prevent toxic sures of male partners may also
workplace. Of the 31 known work- exposures and engaging reproductive contribute to adverse pregnancy out-
place reproductive/developmental health professionals in the process, ulti- comes or impaired fertility,19 and other
toxicants, 5 (16%) had no permis- mately improving patient health. As part working adults in a pregnant woman’s
sible exposure limit in California, of that process, it is clear that women’s household may be a source of workplace
and 14 (45%) were regulated under health providers should ask their pa- take-home exposures,20 the importance
occupational exposure limits not tients about workplace exposures. of these exposures appears to be over-
explicitly based on reproductive/ One resource available to women’s looked in most of the queries we have
developmental effects.11 health providers and workers is received. Consistent with assessment by

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ajog.org Call to Action

FIGURE
Occupational reproductive queries 2009 through 2013

(A) Requestors, (B) requestor occupations, and (C) question content are described for 217 Centers for Disease Control and Prevention-INFO queries
answered by occupational reproductive epidemiologists in Industrywide Studies Branch, National Institute for Occupational Safety and Health.
HCP, health care practitioner; PH, public health; Retrospective, query concerning adverse reproductive outcome that occurred previously.
Grajewski. “Will my work affect my pregnancy?” Am J Obstet Gynecol 2016.

Frazier and Jones14 of occupational previously experienced adverse repro- for information were for potential
reproductive queries in 2000, 2 groups ductive outcome. occupational exposure to solvents
were still underrepresented: only 1 query The most frequent occupations of (14%), anesthetic gases (10%), formal-
was about male fertility, and 1 query was interest to requestors (Figure) were dehyde (7%), infectious agents in labo-
preconceptional. health care occupations (41%) and lab- ratory environments (7%) or health care
Requestors, requestor occupations, oratory work (18%). The most frequent settings (7%), and physical agents (total
and question content for the 217 CDC- occupations in the composite “other” 14%) including ionizing radiation (6%).
INFO queries are described in the category were teachers (3%), beauti- Of the requests, 16% were about specific
Figure. Requests were primarily (54%) cians/nail technicians (3%), other ser- chemicals or drugs, including 6% about
from pregnant workers, but also from vice workers (2%), law enforcement/ chemotherapy. Only 5 women contacted
persons contacting us on behalf of firefighters (2%), and air crew or other us regarding effects of occupational
pregnant workers: employers (16%), airline workers (1%). Requestors most exposures on current breast-feeding as
family or coworkers (9%), health care commonly asked about specific occupa- their primary concern. However, over
providers (6%), and public health tional exposures, but information about the 5-year period examined, breast-
agencies (5%). A small proportion of workplace policies or assistance devel- feeding as a query topic (usually a sec-
requests (5%) were for information oping guidelines was sought by 12% of ondary concern) increased from 2-13%
about workplace exposures and a requestors. The most common requests of all queries.

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Information and Resources for  [For chemicals] “What form are the with engineering controls (eg, ventila-
Women’s Health Providers chemicals in: dust, vapor, liquid, gas?” tion) to provide a safe working envi-
Information and resource overview  “How much time do you spend using ronment for workers. Where this is not
The information and resources provided each thing that you are concerned feasible, use of PPE, including respira-
for counseling patients about their about in your workplace?” tors, may be an option. If neither hazard
workplace and reproductive health  “Do you use any personal protective elimination nor PPE are feasible, a
consist of information for women’s equipment (PPE) or other safety worker may wish to consider avoiding
health providers (below) and 2 appen- equipment when performing your hazardous duties preconceptionally or
dices. Appendix A summarizes strategies job?” during pregnancy or breast-feeding. In
and resources for 19 specific workplace  Ask about shiftwork and physical this section, we provide general infor-
exposures developed from responses to work factors (eg, prolonged standing, mation to consider about PPE and
CDC-INFO requestors. Information on heavy lifting), common exposures temporary reassignment.
PPE was included in most responses. associated with adverse reproductive
Appendix B provides information re- outcomes in some studies.5-7,21,22 Appropriate PPE may include gloves, eye
sources for additional inquiries, specific  Toxicants can be brought home by the protection, protective clothing, and respi-
employee groups and reproductive haz- worker or other family member on ratory protection. Gloves can prevent
ards, policy, PPE, and breast-feeding. work shoes, clothing, and other items. dermal absorption, but only if the right
Some of this material is also relevant to Anyone in the home or car can be material and thickness of glove is used. If
preconceptional planning and men’s exposed, including the worker, preg- splashing is likely, eye goggles and gowns
reproductive health. nant women, and children/infants. should be worn (see Appendix B “Addi-
Ask about this source of possible tional Resources on Occupational
Step 1: Talking about workplace exposure. Reproductive Health”). Respirators may
exposures with patients be the most challenging PPE question
This set of initial questions can generate Step 2: Determining which exposures for pregnant workers, and should be
useful information about workplace need to be addressed recommended only after careful evalua-
exposures: As mentioned above, the employer’s tion of the patient and exposure, sum-
Safety Data Sheets may not indicate marized below.
 “What do you do in your job? What reproductive hazards. Alternate data
does your department or group do or sources, such as New Jersey’s Right to Respirators may increase breathing resis-
make?” Know Hazardous Substance Fact tance. The OSHA respirator medical
 “What are you concerned about in Sheets (http://web.doh.state.nj.us/ questionnaire does not ask about preg-
your workplace? Any information on rtkhsfs/indexfs.aspx) are a good nancy, and pregnancy is not an exclusion
product name, actual chemical name, resource that specifically lists reproduc- for respiratory protection. But under 29
or work condition would be helpful.” tive hazards and ways to reduce exposure Code of Federal Regulations 1910.134 of
B A patient may self-evaluate a for many chemicals, including appro- the Occupational Safety and Health Act,
hazard on the basis of its smell. priate PPE. Reproductive hazards found fitness for respirator use must be deter-
Smell is not a good guide to in select occupations can be found on mined by a physician any time a worker’s
toxicity: harmful levels of chem- NIOSH work and pregnancy World health condition changes. Health con-
icals cannot always be smelled, Wide Web site (http://www.cdc.gov/ dition (including increased oxygen de-
and much less hazardous chem- niosh/topics/repro/pregnancy.html). If mand and decreased lung capacity) may
icals can have an odor. the patient’s workplace is unusual and/or change frequently throughout preg-
B Workers have a legal right to know involves multiple potential exposures, nancy. While some women are able
about hazardous exposures in CDC-INFO is available for consultation. to safely wear their usual respirator
their workplaceebut will not All workers have the right to a safe and throughout pregnancy, some might find
necessarily know if they are healthy workplace,23 and to know what it more difficult to breathe while wearing
exposed to reproductive toxicants. their workplace exposures are. Speaking a respirator and need to switch to a
Under OSHA’s Hazard Commu- with the patient’s employer and asking respirator with less breathing resistance.
nication Standard, workers have a about safer alternatives may also be Recent NIOSH research suggests that the
right to be informed of chemical useful. effects of wearing an N95 respirator for
hazards in their workplace an hour are the same for healthy preg-
through container labels, Safety Step 3: Determining actions to be nant and nonpregnant women; that fetal
Data Sheets (formerly called recommended for specific workplace heart rate is not affected under these
Material Safety Data Sheets), and reproductive hazards conditions; and that pregnant women
training. However, Safety Data Providing a safe work environment whose pregnancy weight gains are within
Sheets are not required to report should follow a hierarchy: workplace the Institute of Medicine guidelines
reproductive hazards. hazards should be eliminated or reduced should not need additional respirator fit

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ajog.org Call to Action

testing.24-26 Another possible option is a recommended accommodation was not CDC-INFO may be likely to have above-
loose-fitting powered air-purifying reasonable). Jackson et al29 provide a average health-seeking behaviors, higher
respirator, which does not make it current commentary on this issue. education, and the basic knowledge that
harder to breathe. A safety officer or certain exposures can harm their devel-
vendor can identify the correct powered Next steps oping baby. During pregnancy and after
air-purifying respirator cartridges and The information we have compiled ad- delivery, women actively seek credible
advise on proper storage and service life. dresses some of the most common health information.35 Pregnant women
workplace exposures women’s health of lower socioeconomic status turn to
Charcoal masks, paper masks, and surgical providers might encounter when coun- health care professionals as their most
masks do not protect against many seling their patients. A long list of gaps frequently consulted source of health
chemicals or infectious agents. Workers exists, headed by the need for reliable information.36 Women’s health pro-
should contact their health care pro- toxicity data so that exposure standards viders who have been unaware of the
vider, employer, or safety officer to (and related engineering controls) can need to assess workplace reproductive
choose the correct respiratory be developed in the context of repro- hazards for pregnant patients are also
protection. ductive and developmental toxicity, and not likely to have been aware of avail-
employers, workers, and women’s health able resources (including CDC-INFO)
Prevent take-home exposures. Prevention providers can make informed decisions. to get relevant information for their
may include leaving work clothing at Breast-feeding mothers need authorita- patients. We hope that these resources
work, showering before leaving work, tive information on the probable effects for women’s health providers will help
washing work clothes separately from of their infant’s exposure to occupational to reach a much broader range of
the rest of the family’s clothes, and not chemical exposures via breast milk. For working pregnant women, and ulti-
wearing work clothes or shoes inside the many medications and some other ex- mately impact working women’s and
home or car. posures, pharmacokinetic and maternal/ men’s reproductive health across their
child factors needed to assess impact on life courses. -
If the patient cannot be adequately pro- breast-feeding have been summarized30
tected from a reproductive toxicant by and guidance has been compiled.31,32 ACKNOWLEDGMENT
engineering controls or PPE, consider Organizations that counsel women and We are grateful to the requestors who provided
temporary reassignment. The US Equal their health care providers (eg, Mother- the basis of this report; Kathy Connick for liter-
Employment Opportunity Commission ToBaby33) have assessed some occupa- ature searches; Sharon Lavigne (Mother-
(EEOC) issued Updated Enforcement tional exposures, but evaluation of ToBaby, Connecticut) for breast-feeding
information; Jeri Anderson for ionizing radiation
Guidance on Pregnancy Discrimina- specific workplace chemicals remains
information; and Kaori Fujishiro for helpful com-
tion and Related Issues in July 2014.27 infrequent34 and requires estimates of ments on the manuscript.
Notably, if an employer provides light- occupational exposure levels, the con-
duty assignments to employees with in- centrations of chemicals in breast milk,
juries, they also have to extend the light- and assessment of possible toxicity to an REFERENCES
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