What is the Right Level of Sick Leave among Pregnant Women?

“…the adjustment of work life to pregnant women, including paid sick leave when indicated, may result in a total positive outcome for both the individual and society.”

Pregnancy is a normal part of life and not a disease. However, more women now participate in paid work than ever before, and pregnancy-related symptoms may influence a woman's ability to work. This poses new challenges to the work place when an employee gets pregnant. A recent study of 2918 pregnant women in Norway found that three out of four women had taken sick leave for at least 1 week during their pregnancies [1]. The median duration of sick leave was 8 weeks, with 50% of women needing between 4 and 16 weeks away from work [1]. What do these numbers reflect? Is the rate of sick leave during pregnancy too high, or too low?

Is there increased morbidity among pregnant women? Norway has a healthy population with very low infant and maternal mortality [2], thus it is not probable that Norwegian women have more complicated pregnancies than women in other countries. One of the main reasons women gave for sick leave was pelvic girdle pain. The awareness of this symptom is increasing in Scandinavian countries among healthcare providers and women, and one of the condition's main risk factors is a strenuous working condition [3]. Pelvic girdle pain leads to disability and sleep problems during pregnancy [4]. More women are engaged in paid work in Scandinavia, and this may explain both a higher prevalence of pelvic girdle pain and the increased demand for sick leave in this population.

Do pregnant women nowadays have less tolerance of normal pregnancy-related symptoms? Expectations among peers may influence whether some women take sick leave or not, similar to studies of disability pension, where the likelihood of receiving permanent disability pension seems to be influenced by the rate of people receiving disability pension in the neighbourhood [5]. Social conditions and attitudes may, therefore, explain some of the increase in sick leave among pregnant women [6]. Sleep and fatigue are common reasons given for taking sick leave. Women sleep poorly during the last trimester in pregnancy [4], and many women experience that being pregnant while working demands more energy than expected [7]. These factors – that is, poorer sleep and lack of energy – may be difficult to combine with a hectic work pace.

Not only has a woman's participation in the work place changed, but also the working conditions and demands for effectiveness and productivity have changed. With the demand for more effective work places, workers are expected to perform at 100% capacity. Women who are able to control their own work pace have less sick leave, both in manual and non-manual jobs [8]. Pregnant women may need more breaks, lighter workloads, more flexible or shorter work schedules, less overtime, possibilities to sit instead of stand and should not lift heavy objects. Women who report adjustments at their workplace have a shorter duration of sick leave [1,9]. When colleagues have already stretched their work capacity, there will be no room for such adjustments to pregnancy. In the current welfare system in Norway, payment during sick leave is totally refunded by the state. Thus, it may be economically beneficial for the employer in the short run to replace a pregnant woman with a nonpregnant temporary worker. However, this means the (temporary) loss of a qualified employee and hiring a less-experienced worker. The cost of replacing a competent pregnant woman with a new employee who requires training may be higher than keeping the woman at work with necessary adjustments to accommodate her pregnant condition.

Are the doctors and midwives nowadays more cautious? Medical and obstetrical knowledge have developed, as have the demands for safe pregnancies and deliveries, along with possible legal actions taken against healthcare providers in case of pregnancy-related injuries and/or deaths. This may lead to the preventive prescription of sick leave for women with high-risk pregnancies, such as having a multiple birth, hypertension or previous miscarriage, among others. We also now know more about what conditions are harmful for the mother and baby, such as working night shifts, working in situations where there is a risk of violence or working in environments with pollution or radiation. Too much focus on decreasing sick leave during pregnancy may lead to some employed women continuing to work despite ill health during pregnancy. This may, in turn, lead to an increased risk for both infants and mothers, and a slower postpartum recovery [10]. Thus, for some pregnant women, increased sick leave may be desirable.

“Sleep and fatigue are common reasons given for taking sick leave.”

Is this high prevalence a result of a too good welfare system? Working conditions and compensation for sick leave vary widely among countries [101]. In Norway, the current social welfare benefit allows workers up to 52 weeks of 100% paid sick leave if they have a medical condition demanding it. Social benefits in the society or economic agreement with the employer may influence whether a pregnant woman obtains sick leave [11]. However, there may also be negative consequences of sick leave. These can include loss of interesting work opportunities and promotions, and fewer salary increases. Using sick leave instead of work place adjustments or maternity leave will also result in fewer weeks to use if another serious health problem or accident occurs within the same year. For women in temporary employment, sick leave may result in her contract not being renewed, and employers may also be reluctant to employ women who may become pregnant.

Previously, prescribing sick leave for normal, pregnancy-related complaints in Norway was not allowed, with the paradoxical effect that it was easier to receive sick leave for low back pain for nonpregnant women than for pregnant women. Many women, therefore, left working life when they had children, and this may still be the case in many countries. As more women participate in the workforce, an increased proportion of women may be needing sick leave during pregnancy [12]. Many policy makers are concerned about the declining fertility rate in European countries. The Nordic countries, with their generous welfare benefits connected to childbirth and childcare, have a higher fertility rate than countries farther south in Europe. A healthy and balanced work–family policy, as seen in the Scandinavian countries, may therefore not prevent a country from being highly competitive economically [13]. Considering the total benefits for society, the adjustment of work life to pregnant women, including paid sick leave when indicated, may result in a total positive outcome for both the individual and society.