Background
Authoritative information on occupational reproductive hazards is scarce and complex because exposure levels vary, multiple exposures may be present, and the reproductive toxicity of many agents remains unknown. For these reasons, women’s health providers may find it challenging to effectively address workplace reproductive health issues with their patients who are pregnant, breast-feeding, or considering pregnancy. Reproductive epidemiologists at the Centers for Disease Control and Prevention National Institute for Occupational Safety and Health answered >200 public requests for occupational reproductive health information during 2009 through 2013. The most frequent occupations represented were health care (41%) and laboratory work (18%). The most common requests for exposure information concerned solvents (14%), anesthetic gases (10%), formaldehyde (7%), infectious agents in laboratories (7%) or health care settings (7%), and physical agents (14%), including ionizing radiation (6%). Information for developing workplace policies or guidelines was sought by 12% of the requestors. Occupational exposure effects on breast-feeding were an increasing concern among working women. Based on information developed in response to these requestors, information is provided for discussing workplace exposures with patients, assessing potential workplace reproductive hazards, and helping patients determine the best options for safe work in pregnancy. Appendices provide resources to address specific occupational exposures, employee groups, personal protective equipment, breast-feeding, and workplace regulations regarding work and pregnancy. These tools can help identify those most at risk of occupational reproductive hazards and improve workers’ reproductive health. The information can also be used to inform research priorities and assist the development of workplace reproductive health policies.
Related editorial, page 555
The problem
Women’s health providers may find it challenging to effectively address workplace reproductive health issues with their working patients who are pregnant, breast-feeding, or considering pregnancy.
A solution
Information and resources are provided for counseling patients about their workplace and reproductive health.
Overview
Communicating reproductive risks to workers is complex for women’s health providers. Only about 4000 of the 84,000 chemicals in the workplace have been evaluated for reproductive toxicity, and >2000 new chemicals are introduced annually. Besides chemicals and physical agents, reproductive hazards include physical demands (eg, heavy lifting, prolonged standing) and circadian disruption from night or rotating work schedules. The need for vigilance about hazardous occupational exposures continues after birth since some workplace chemicals can pass into breast milk or be carried home on a worker’s skin, hair, clothes, and shoes, where a child can be exposed. A purposeful response to these issues requires a framework for thinking about occupational exposures and reproductive health.
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Timing, type, and dose of exposure will influence adverse reproductive outcomes. In general, first-trimester exposures can result in miscarriage or structural anomalies. Second- and third-trimester pregnancy exposures may lead to functional impairments, small for gestational age, or preterm delivery.
- •
The developing fetus may be vulnerable to health effects at lower chemical concentrations than its mother. Susceptibility to workplace hazards varies throughout pregnancy due both to changes in maternal physiology and the fetus’ developmental stage. Neither of these is reflected in most existing workplace regulations and occupational exposure limits.
- •
The true scope of occupational reproductive health is not limited to pregnancy. Although this Call to Action is focused primarily on resources for counseling pregnant workers, preconceptional planning, breast-feeding, and male workers’ reproductive health also depend on appropriate counseling, action, and policy. Reproductive toxicants’ impact extends across the life course for both men and women–as was the case with men who sustained infertility from their occupational exposure to dibromochloropropane before it was banned.
- •
Very few chemicals used in the workplace are adequately tested for safe use during pregnancy. Exposure limits, respiratory guidelines, and personal protective equipment (PPE) guidelines issued by occupational health agencies were developed for healthy adult workers, not a developing fetus. Even when extensive reproductive and developmental toxicity testing data are available, they are rarely incorporated into workplace regulations. For example, California reviewed its Proposition 65 list of chemicals known to the state of California to cause reproductive or developmental toxicity. The 31 workplace chemicals in this category have been extensively evaluated, and are likely a significant underestimate of the actual number of reproductive/developmental toxicants in the workplace. Of the 31 known workplace reproductive/developmental toxicants, 5 (16%) had no permissible exposure limit in California, and 14 (45%) were regulated under occupational exposure limits not explicitly based on reproductive/developmental effects.
- •
The same agents may be occupational or environmental exposures. Although environmental exposure to an agent may be more common, occupational exposures to the same agent are usually higher. Hobbies and the home environment may also be sources of exposure.
Women’s health providers may struggle to effectively address occupational issues with their patients. A recent survey of obstetricians reported barriers to counseling women about prenatal environmental and occupational exposures: uncertainty about risks, the number of potential exposures, and the ability of their patients to take action to reduce risk. Further, there is no single resource for information on occupational reproductive health hazards. One potential source of counseling might be Teratology Information Services across the United States; but in a 2008 survey, occupational topics only accounted for 6% of their counseling time. Occupational counseling services have identified a demand for occupational reproductive counseling and the need to increase resource information for women’s health providers. The American Congress of Obstetrics and Gynecology (ACOG) and the American Society for Reproductive Medicine (ASRM) recently issued a joint Committee Opinion on the role of reproductive health professionals in the prevention of exposure to environmental and occupational toxic chemicals. Last year, the International Federation of Gynecology and Obstetrics (FIGO) issued a global call to action on preventing exposure to toxic environmental and occupational chemicals. Twelve additional global health professional societies have endorsed the FIGO opinion. Recommendations included improving public policy to prevent toxic exposures and engaging reproductive health professionals in the process, ultimately improving patient health. As part of that process, it is clear that women’s health providers should ask their patients about workplace exposures.
One resource available to women’s health providers and workers is CDC-INFO, the national contact center that launched in 2005. CDC-INFO delivers health information to consumers, health care professionals, and public health partners who call, mail, or e-mail their inquiries about disease prevention and health promotion ( http://www.cdc.gov/cdc-info/index.html ). Because occupational reproductive queries often describe unique or complex combinations of workplace exposures, they are routed to occupational reproductive epidemiologists at the National Institute for Occupational Safety and Health (NIOSH) who can provide individualized responses.
Our goal is to share the resources we developed for these CDC-INFO queries with women’s health providers to help them engage effectively with their patients, identify those most at risk, and improve workers’ reproductive health. This information may also inform research priorities and assist the development of workplace reproductive health policies.
CDC-INFO occupational reproductive queries
We collected information about CDC-INFO queries answered by the NIOSH Industrywide Studies Branch reproductive epidemiologists during calendar years 2009 through 2013. Responses were developed by subject matter experts in reproductive occupational health after consulting the scientific literature, reproductive databases, and other experts as required. Advice was provided based on the existing literature and incorporated uncertainties about reproductive hazards and actions employers could take to reduce potential risks.
As has been the case with similar services, women’s reproductive health issues constitute the majority of queries received. Although occupational exposures of male partners may also contribute to adverse pregnancy outcomes or impaired fertility, and other working adults in a pregnant woman’s household may be a source of workplace take-home exposures, the importance of these exposures appears to be overlooked in most of the queries we have received. Consistent with assessment by Frazier and Jones of occupational reproductive queries in 2000, 2 groups were still underrepresented: only 1 query was about male fertility, and 1 query was preconceptional.
Requestors, requestor occupations, and question content for the 217 CDC-INFO queries are described in the Figure . Requests were primarily (54%) from pregnant workers, but also from persons contacting us on behalf of pregnant workers: employers (16%), family or coworkers (9%), health care providers (6%), and public health agencies (5%). A small proportion of requests (5%) were for information about workplace exposures and a previously experienced adverse reproductive outcome.
The most frequent occupations of interest to requestors ( Figure ) were health care occupations (41%) and laboratory work (18%). The most frequent occupations in the composite “other” category were teachers (3%), beauticians/nail technicians (3%), other service workers (2%), law enforcement/firefighters (2%), and air crew or other airline workers (1%). Requestors most commonly asked about specific occupational exposures, but information about workplace policies or assistance developing guidelines was sought by 12% of requestors. The most common requests for information were for potential occupational exposure to solvents (14%), anesthetic gases (10%), formaldehyde (7%), infectious agents in laboratory environments (7%) or health care settings (7%), and physical agents (total 14%) including ionizing radiation (6%). Of the requests, 16% were about specific chemicals or drugs, including 6% about chemotherapy. Only 5 women contacted us regarding effects of occupational exposures on current breast-feeding as their primary concern. However, over the 5-year period examined, breast-feeding as a query topic (usually a secondary concern) increased from 2-13% of all queries.
A solution
Information and resources are provided for counseling patients about their workplace and reproductive health.
Overview
Communicating reproductive risks to workers is complex for women’s health providers. Only about 4000 of the 84,000 chemicals in the workplace have been evaluated for reproductive toxicity, and >2000 new chemicals are introduced annually. Besides chemicals and physical agents, reproductive hazards include physical demands (eg, heavy lifting, prolonged standing) and circadian disruption from night or rotating work schedules. The need for vigilance about hazardous occupational exposures continues after birth since some workplace chemicals can pass into breast milk or be carried home on a worker’s skin, hair, clothes, and shoes, where a child can be exposed. A purposeful response to these issues requires a framework for thinking about occupational exposures and reproductive health.
- •
Timing, type, and dose of exposure will influence adverse reproductive outcomes. In general, first-trimester exposures can result in miscarriage or structural anomalies. Second- and third-trimester pregnancy exposures may lead to functional impairments, small for gestational age, or preterm delivery.
- •
The developing fetus may be vulnerable to health effects at lower chemical concentrations than its mother. Susceptibility to workplace hazards varies throughout pregnancy due both to changes in maternal physiology and the fetus’ developmental stage. Neither of these is reflected in most existing workplace regulations and occupational exposure limits.
- •
The true scope of occupational reproductive health is not limited to pregnancy. Although this Call to Action is focused primarily on resources for counseling pregnant workers, preconceptional planning, breast-feeding, and male workers’ reproductive health also depend on appropriate counseling, action, and policy. Reproductive toxicants’ impact extends across the life course for both men and women–as was the case with men who sustained infertility from their occupational exposure to dibromochloropropane before it was banned.
- •
Very few chemicals used in the workplace are adequately tested for safe use during pregnancy. Exposure limits, respiratory guidelines, and personal protective equipment (PPE) guidelines issued by occupational health agencies were developed for healthy adult workers, not a developing fetus. Even when extensive reproductive and developmental toxicity testing data are available, they are rarely incorporated into workplace regulations. For example, California reviewed its Proposition 65 list of chemicals known to the state of California to cause reproductive or developmental toxicity. The 31 workplace chemicals in this category have been extensively evaluated, and are likely a significant underestimate of the actual number of reproductive/developmental toxicants in the workplace. Of the 31 known workplace reproductive/developmental toxicants, 5 (16%) had no permissible exposure limit in California, and 14 (45%) were regulated under occupational exposure limits not explicitly based on reproductive/developmental effects.
- •
The same agents may be occupational or environmental exposures. Although environmental exposure to an agent may be more common, occupational exposures to the same agent are usually higher. Hobbies and the home environment may also be sources of exposure.
Women’s health providers may struggle to effectively address occupational issues with their patients. A recent survey of obstetricians reported barriers to counseling women about prenatal environmental and occupational exposures: uncertainty about risks, the number of potential exposures, and the ability of their patients to take action to reduce risk. Further, there is no single resource for information on occupational reproductive health hazards. One potential source of counseling might be Teratology Information Services across the United States; but in a 2008 survey, occupational topics only accounted for 6% of their counseling time. Occupational counseling services have identified a demand for occupational reproductive counseling and the need to increase resource information for women’s health providers. The American Congress of Obstetrics and Gynecology (ACOG) and the American Society for Reproductive Medicine (ASRM) recently issued a joint Committee Opinion on the role of reproductive health professionals in the prevention of exposure to environmental and occupational toxic chemicals. Last year, the International Federation of Gynecology and Obstetrics (FIGO) issued a global call to action on preventing exposure to toxic environmental and occupational chemicals. Twelve additional global health professional societies have endorsed the FIGO opinion. Recommendations included improving public policy to prevent toxic exposures and engaging reproductive health professionals in the process, ultimately improving patient health. As part of that process, it is clear that women’s health providers should ask their patients about workplace exposures.
One resource available to women’s health providers and workers is CDC-INFO, the national contact center that launched in 2005. CDC-INFO delivers health information to consumers, health care professionals, and public health partners who call, mail, or e-mail their inquiries about disease prevention and health promotion ( http://www.cdc.gov/cdc-info/index.html ). Because occupational reproductive queries often describe unique or complex combinations of workplace exposures, they are routed to occupational reproductive epidemiologists at the National Institute for Occupational Safety and Health (NIOSH) who can provide individualized responses.
Our goal is to share the resources we developed for these CDC-INFO queries with women’s health providers to help them engage effectively with their patients, identify those most at risk, and improve workers’ reproductive health. This information may also inform research priorities and assist the development of workplace reproductive health policies.
CDC-INFO occupational reproductive queries
We collected information about CDC-INFO queries answered by the NIOSH Industrywide Studies Branch reproductive epidemiologists during calendar years 2009 through 2013. Responses were developed by subject matter experts in reproductive occupational health after consulting the scientific literature, reproductive databases, and other experts as required. Advice was provided based on the existing literature and incorporated uncertainties about reproductive hazards and actions employers could take to reduce potential risks.
As has been the case with similar services, women’s reproductive health issues constitute the majority of queries received. Although occupational exposures of male partners may also contribute to adverse pregnancy outcomes or impaired fertility, and other working adults in a pregnant woman’s household may be a source of workplace take-home exposures, the importance of these exposures appears to be overlooked in most of the queries we have received. Consistent with assessment by Frazier and Jones of occupational reproductive queries in 2000, 2 groups were still underrepresented: only 1 query was about male fertility, and 1 query was preconceptional.
Requestors, requestor occupations, and question content for the 217 CDC-INFO queries are described in the Figure . Requests were primarily (54%) from pregnant workers, but also from persons contacting us on behalf of pregnant workers: employers (16%), family or coworkers (9%), health care providers (6%), and public health agencies (5%). A small proportion of requests (5%) were for information about workplace exposures and a previously experienced adverse reproductive outcome.
