My Obstetrician Got However Me Fired : How work notes can be I am - PowerPoint PPT Presentation

6/15/2017 I have no financial disclosures My Obstetrician Got However…… Me Fired : How work notes can be I am not a lawyer nor a Human harmful… Resources expert and how to make them better Rebecca Jackson, MD, Obstetrics, Gynecology and Reproductive Sciences Zuckerberg San Francisco General Hospital University of California, San Francisco Department of Obstetrics, Department of Obstetrics, Gynecology & Reproductive Gynecology & Reproductive Sciences Sciences 2 Partners (and resources) Familiar request? • Joan Hastings JD • Liz Morris JD • www.pregnantatwork.org • Sharon Terman JD • Julia Parish JD • Jenna Gerry JD www.legalaidatwork.org Department of Obstetrics, Department of Obstetrics, Gynecology & Reproductive Gynecology & Reproductive Sciences Sciences 4 1

6/15/2017 Young vs UPS Young vs UPS Preview • Why we should care • Is it safe for women to work in pregnancy? • The minimum we need to know about leave and accommodations • How to write a work modification or leave letter to protect our patients’ jobs and pay Department of Obstetrics, Department of Obstetrics, Gynecology & Reproductive Gynecology & Reproductive Sciences Sciences 6 US Working Mothers It still happens. Employers…. • 67% of first time mothers work, most work • Fire women when they divulge pregnancy full-time, over 80% work well into the 3 rd • Decide what a pregnant woman should and trimester, ¾ return to work within 6 months shouldn’t do at work (“shouldn’t you be at home (EEOC) growing your baby?!) • 40% of mothers are the primary • Hold pregnant women to higher standards— breadwinners for families they are forced to “prove” themselves (Glynn, S.J. Center for American Progress 2012) capable • Juggling work, pregnancy, motherhood is • Tell them they can’t have time off to go to stressful. Worse is losing a job just as you prenatal appointments are about to start/enlarge your family • Force them out on leave rather than making • The US lacks social supports and social simple accommodations protection to buffer against stresses Department of Obstetrics, Department of Obstetrics, Gynecology & Reproductive Gynecology & Reproductive EEOC cases Sciences Sciences 2

6/15/2017 US lacks a paid national maternity leave Work accommodations for pregnancy policy • The Family Medical Leave Act (FMLA) • In a national survey of working guarantees unpaid job protected leave for pregnant women, more than half felt up to 12 weeks they needed a change in their job • Restricted to: duties or schedule – Women who have worked for an employer • ~40% of them never requested an for at least 1250 hours/year accommodation – Employer must have at least 50 employees • Of those who did, at least 13% were denied. • Only 60% of US workers are covered by FMLA Department of Obstetrics, Department of Obstetrics, Gynecology & Reproductive Gynecology & Reproductive Sciences Sciences Declercq ER, J Perinat Educ 2014 9 Safety of working during Is it safe to work while pregnant? pregnancy • Early studies focused on concerns around workplace exposures and teratogens for the fetus • More recent evidence examines associations between certain working conditions and SAB, PTB, and other ob outcomes . – Evidence low quality: observational studies, mostly retrospective, many do not control for confounders, often assess for occupational exposure AFTER delivery (recall bias) – Work types are inconsistently defined making comparison between studies difficult, many studies include only first trimester employment • Bottom line: Use caution when interpreting—results Department of Obstetrics, Department of Obstetrics, could be due to bias/confounding especially for odds Gynecology & Reproductive Gynecology & Reproductive Sciences Sciences ratios <1.5-2.0) 11 12 3

6/15/2017 Preterm delivery and work What does ACOG say? • Being employed (vs not) doesn’t increase risk • Not much • For physically demanding work, most prospective • Guidelines for Perinatal Care (7th edition): studies show no increased risk of PTD but a few do • Multiple meta-analyses: – Slight to modest increased risk with some work conditions (OR from 1.1-1.4): prolonged standing, heavy and repetitive lifting, physical exertion, work>40h, stand>4 hr, shift work (van Beukering, 2014, Palmer, 2013) – Higher quality studies had lower OR’s • OR <1.5 likely due to bias and confounding Department of Obstetrics, Department of Obstetrics, Gynecology & Reproductive Gynecology & Reproductive Sciences Sciences 13 14 Other guidelines about work in What does UpToDate say? pregnancy? While many women work while pregnant without any interference from • pregnancy-related changes, problems of nausea and vomiting, pain, and fatigue can negatively impact a woman's work performance. Despite data limitations, American Medical Association Council working while pregnant generally does not appear to negatively impact maternal on Scientific Affairs. Effects of or fetal health. However, the physical demands of the woman's job should be pregnancy on work performance. considered on a case-by-case basis, especially in women at higher risk of JAMA 1984 ;251:1995-7. preterm delivery or who have medical or obstetrical disorders that are unstable or associated with impaired placental perfusion (eg, preeclampsia, fetal growth restriction). (See 'Impact' above.) • To date, the available evidence does not justify imposing mandatory restrictions to working hours, shift work, lifting, standing, and physical work during pregnancy. Challenges to writing such guidelines include the lack of data demonstrating a clear cut-off at which work is detrimental to the health of most women and fetuses as well as the reality that some women must continue working while pregnant for economic reasons, regardless of medical advice. Department of Obstetrics, Department of Obstetrics, Any guidelines must also balance the data suggesting that some level of Gynecology & Reproductive Gynecology & Reproductive Sciences Sciences physical activity while pregnant is healthy. (See 'Work characteristics' above.) 15 4

6/15/2017 Reference What about lifting? • Regardless of its association with PTB, physically demanding work is associated with low back pain and musculoskeletal disorders that are exacerbated by pregnancy • Proposed guidelines for lifting McDonald, AJOG, 2013 – Use an NIOSH “lifting equation” to determine recommended weight limit (RWL)= the load healthy workers can lift up to 8 hrs per day without LBP – For non-pregnancy, max RWL=51 lbs in ideal lift (2 hands, close to body, no twisting, starting lift at 28- 52 inches off the floor) – As the distance between the load and the worker Department of Obstetrics, Department of Obstetrics, increases (eg in pregnancy), the RWL decreases Gynecology & Reproductive Gynecology & Reproductive Sciences Sciences McDonald, AJOG, 2013 Reference: Take-away on lifting- The limits might be less than we think…. WORK NOTES • Infrequent lifting – Early pregnancy: 36 lbs 26 36 – After 20 wks: 26 lbs • Less than 1 hour of lifting per day: – Early pregnancy: 30 lbs 22 30 – After 20 wks: 22 lbs • >1 hour of lifting per day: – Early pregnancy: 18 lbs 18 13 – After 20 wks: 13 lbs Department of Obstetrics, Department of Obstetrics, Gynecology & Reproductive Gynecology & Reproductive Sciences Sciences 19 20 5