Systematic Review of Interventions Targeting Sickness (Case Study)
By Dr. Pernille Pedersen
Pregnant women may experience bodily changes as disabling and they consequently may be on sick leave from work.1–3 Sickness absence due to pregnancy may be higher than necessary from a health perspective4–6 and it is argued that pregnancy is being medicalised.7 The duration of sickness absence may be reduced by interventions aiming at work maintenance for pregnant women, thus, it is of importance to explore such interventions conducted in healthcare settings and workplaces.
In Scandinavia, the rate of sickness absence among pregnant women is high compared with non-pregnant women.7–12 Thus, the average sickness absence is 8.5 days per year for all Danish employees13 compared with 48 days among pregnant women.14 In Norway, three out of four pregnant women were absent due to sickness for a median duration of 8 weeks.15 The average sickness absence during pregnancy has increased over the last decades.10 16–18
According to the literature, the main reasons for sickness absence during pregnancy are health related, for example, nausea/vomiting, fatigue, sleep disturbances, bleeding, pelvic pain and low back pain.12 15 19–21 Especially low back pain is frequent and increases the rate of sickness absence during pregnancy.22 Low back pain may also have impact on future work ability if rehabilitation is insufficient as the rate of relapse is high.
General and health-related risk factors for sickness absence include multiparity, age, educational level, use of reproductive therapy, back pain, maternal weight and smoking habits.11 16 17 24–28 Physical activity on the other hand is associated with a lower risk of absence from work during pregnancy,24 25 maybe because it reduce pain and disability.22 Moreover, high maternal weight is a risk factor for low back pelvic pain.24 Thus, there seems to be a pathway from high maternal weight through low level of physical activity to sick leave during pregnancy. Pregnant women are therefore recommended to continue physical activity by healthcare professionals.29 Work-related risk factors include previous sickness absence, low job control, lifting, night or shift work,7 working in standing position and high job strain.30 However, except for high levels of exposure, such as working in night shift, >40 hours/week, lifting >100 kg/day, standing >6 hours/day, recent reviews do not provide strong evidence for mandatory restrictions of occupational factors, as risk of miscarriage and low birth weight are only moderately elevated.31–33 Thus, there is no reason to believe that common workplace exposures constitute a high risk for pregnant women.29
Moreover, job adjustment has been found to reduce sickness absence, but only few pregnant women obtain the needed adjustment.28 34
Sickness certificates may be needed if adjustments are not possible, for example, in hazardous jobs involving chemical procedures or biological risks. However, studies found that only 0.5%–5% of sickness certificates related to possible teratogenic effects.21 35
Sickness certificates are issued based on health-related reasons. However, medical explanations may not be the main reason for sickness absence during pregnancy. A study found that three out of four pregnant women on sickness absence rated their health as good or excellent.36 Moreover, comparison of sick-listed to not sick-listed pregnant women has not shown differences in either mode of delivery or birth weight.18 36 Thus, sickness absence may be a complex social phenomenon due to changes in attitudes towards the naturally occurring pregnancy discomforts as well as inexpedient coping strategies among pregnant women.19 20 37–39 Physicians might find it difficult to establish a medical diagnosis to support a sickness certificate and find themselves in a dilemma between being the woman’s confidante and preventing unnecessary sickness absence.4–6 Legislation and compensation rules vary across countries resulting in different rates of sickness absence.40 Thus, associations are found between higher social benefits and higher rates of sickness absence registered during pregnancy.36 37
Sickness absence during pregnancy has consequences for both the pregnant women and society. At the individual level, the consequences are loss of possibilities for a salary increase and promotions, and it may result in a contract not being renewed.41 Moreover, long-term sickness absence is a predictor for future sickness absence and for receiving disability pension 8 years after child birth.25 For workplaces and society, sickness absence results in considerable costs due to reduced productivity; pregnancy-related sickness absence constituted around 4000 full-time positions corresponding to an annual cost of Kr1.4 billion.14 Moreover, employers may become reluctant to employing women of childbearing age.21 41
A literature review exploring pregnancy at workplaces recommends an improvement of the workplace conditions, for example, social support and a proactive approach.33 In order to sustain the ability to work for pregnant women recommendations are made to support a healthy work environment by eliminating risks and hazards.42 43 Several current laws within the USA, Canada, the UK and the European Union (EU) are in force to delineate the rights of pregnant women.33 However, an initial search found only few interventions conducted in healthcare settings to reduce sickness absence; the studies were of low quality and results were inconclusive.44 45 The literature illustrates the potential for preventive initiatives in both healthcare settings and workplaces among pregnant women.
A search in the databases PROSPERO, PubMed, the Cochrane Library and the JBI Database of Systematic Reviews and Implementation Reports did not result in retrieving any systematic reviews or protocols on sickness absence among pregnant women. A Cochrane review was found on interventions preventing low back and pelvic pain, and whether treatments decreased the rate of sickness absence, but it focused on randomised controlled trials (RCTs) in prenatal care only.22
Thus, conducting this systematic review is an important contribution to the scientific literature in order to evaluate the effectiveness of interventions to reduce sickness absence in pregnant women in either healthcare settings or workplaces.
Results from this systematic review may contribute to developing an evidence-based intervention by integrating factors, processes and stakeholders relevant for preventive initiatives among pregnant women.
A total of nine studies were quality assessed and of these, four were excluded due to insufficient methodological quality. Five RCTs conducted in healthcare settings in Sweden and Norway were included. Due to heterogeneity, meta-analysis was not performed.
Two RCTs examined complementary and alternative medicine and three RCTs the effect of physical exercise. In general, the frequency of women on sickness absence was lower in the intervention groups than the control groups, however, only among pregnant women who participated in a 12-week exercise programme, the frequency was significantly lower (22% vs 30%, p=0.04).