Work as a social risk factor in pregnancy: A systematic review of screening practices related to working conditions and family leave among pregnant adults.

BACKGROUND: Paid family leave and working conditions are components of employment quality-a key social determinant of health across the life course, particularly during pregnancy. Increased research on prenatal social risk screening has not extended to employment quality. The objective of this systematic review was to identify prenatal screening practices and interventions in health care settings that address employment and working conditions as social risk factors among pregnant adults and to describe their properties and key findings. METHOD: We searched MEDLINE, PsychINFO, SocINDEX, EMBASE, and the SIREN Evidence and Resource Library for studies published through February 14, 2022. We selected multiple search terms related to four domains: (1) employment or working conditions; (2) screening; (3) health care settings; and (4) pregnancy or maternal health. RESULTS: Of the 2317 unique titles and abstracts that were potentially relevant, eight articles met all inclusion criteria and focused on pregnant populations. The content of identified screening practices varied substantially, highlighting the multiple ways employment is conceptualized as a potential risk factor. Few studies included multidimensional measures of employment to assess working conditions, which may be particularly relevant during pregnancy. CONCLUSIONS: Our review suggests that screening for employment as a social risk factor does not regularly occur in prenatal care. Although pragmatic properties of the screening tools we assessed are promising, tools seldom examine the multidimensional nature of work. Understanding the principal intent of screening for employment prenatally could provide greater opportunity to collect and interpret contextual factors that influence how both providers and patients respond to social risk.

Racial and Ethnic Inequities in Paid Family and Medical Leave: United States, 2011 and 2017-2018.

Objectives. To examine racial and ethnic inequities in paid family and medical leave (PFML) access and the extent to which these inequities are mediated by employment characteristics. Methods. We used data from the 2011 and 2017-2018 American Time Use Survey in the United States to describe paid leave access by race/ethnicity. We present unadjusted models, models stratified by policy-targetable employment characteristics, and adjusted regression models. Results. We found that 54.4% of non-Hispanic White workers reported access to PFML in 2017-2018 but that access was significantly lower among Asian, Black, and Hispanic workers. Inequities were strongest among private-sector and nonunionized workers. Leave access improved slightly between 2011 and 2017-2018, but the inequity patterns were unchanged. Conclusions. We observed large and significant racial and ethnic inequities in access to PFML that were only weakly mediated by job characteristics. PFML has a range of health benefits for workers and their families, but access remains limited and inequitable. Public Health Implications. Our findings suggest that broad PFML mandates (such as those in other high-income countries) may be needed to substantially narrow racial and ethnic gaps in paid leave access. (Am J Public Health. 2022;112(7):1050-1058. https://doi.org/10.2105/AJPH.2022.306825).

Inequities in paid parental leave across industry and occupational class: Drivers and simulated policy remedies.

Introduction: Paid family leave (PFL) has the potential to reduce persistent health disparities. This study aims to characterize differences in access to paid leave by industry sector and occupational class. Methods: The Bay Area Parental Leave Survey of Mothers included respondents 18 years of age or older who worked in the San Francisco Bay Area and gave birth from 2016 to 2017. Using linear probability models, we examined differences in five separate measures of PFL by industry sector and occupational class. We extended our regression analysis to simulate the full pay equivalent (FPE) weeks of leave that would have been taken under hypothetical scenarios of increased uptake and wage replacement rates. Results: Our study included 806 women in private for-profit or non-profit jobs. In fully adjusted models, blue-collar workers were 10.9% less likely to take 12 weeks of paid parental leave versus white-collar workers (95% CI: -25.9, 4.1). Respondents were 19.2% less likely receive 100% of their regular pay if they worked in education and health services (-29.1, -9.3) and 17.0% less likely if they worked in leisure and hospitality (-29.5, -4.4) versus respondents in professional and financial services. Respondents in leisure and hospitality reported 1.6 fewer FPE weeks of leave versus respondents in professional and financial services (-2.73, -0.42) and blue-collar respondents reported an average of 1.5 fewer FPE weeks versus white-collar workers (-2.66, -0.42). In our simulation analysis, when we manipulated rates of uptake for paid leave, the disparities in FPE by industry sector and occupational class were eliminated. Conclusion: We observed substantial inequities in access to paid leave by industry sector and occupational class. These findings underscore the potential importance of universal PFL programs with universal benefits to reduce clear inequities that persist within the labor market today.

Racial/Ethnic Inequities in Paid Parental Leave Access.

Purpose: Severe racial inequities in maternal and infant health in the United States are caused by the many forms of systemic racism. One manifestation of systemic racism that has received little attention is access to paid parental leave. The aim of this article is to characterize racial/ethnic inequities in access to paid leave after the birth of a child. Methods: We analyzed data on women who were employed during pregnancy (n=908) from the Bay Area Parental Leave Study of Mothers, a survey of mothers who gave birth in the San Francisco Bay Area in 2016-2017. We examined differences in access to government- and employer-paid leave, the duration of leave taken, and the percent of usual pay received while on leave. To explore these differences, we further examined knowledge of paid leave benefits and sources of information. Results: Non-Hispanic (NH) black and Hispanic women had significantly less access to paid leave through their employers or through government programs than their NH white and Asian counterparts. Relative to white women, Asian, Hispanic, and black women received 0.9 (p<0.05), 2.0 (p<0.01), and 3.6 (p<0.01) fewer weeks, respectively, of full-pay equivalent pay during their parental leaves. Despite inequitable access to paid leave, the duration of parental leave taken did not differ by race/ethnicity. Conclusions: Inequitable access to paid parental leave through both employers and government programs exacerbates racial inequities at birth. This form of structural racism could be addressed by policies expanding access to paid leave.

The association of paid medical and caregiving leave with the economic security and wellbeing of service sector workers.

BACKGROUND: Service-sector workers in the U.S. face extremely limited access to paid family and medical leave, but little research has examined the consequences for worker wellbeing. Our objective was to determine whether paid leave was associated with improved economic security and wellbeing for workers who needed leave for their own serious health condition or to care for a seriously ill loved one. METHODS: We analyzed data collected in 2020 by the Shift Project from 11,689 hourly service-sector workers across the US. We estimated the impact of taking paid leave on economic insecurity and wellbeing relative to taking unpaid leave, no leave, or not experiencing a need to take leave. RESULTS: Twenty percent of workers needed medical or caregiving leave in the reference period. Workers who took paid leave reported significantly less difficulty making ends meet, less hunger and utility payment hardship, and better sleep quality than those who had similar serious health or caregiving needs but did not take paid leave. CONCLUSIONS: Access to paid leave enables front line workers to take needed leave from work while maintaining their financial security and wellbeing.

Among Low-Income Women In San Francisco, Low Awareness Of Paid Parental Leave Benefits Inhibits Take-Up.

Paid family leave policies have the potential to reduce health disparities, yet access to paid leave remains limited and unevenly distributed in the United States. Using California administrative claims data, we examined the impact of the San Francisco Paid Parental Leave Ordinance, the first in the US to provide parental leave with full pay. We found that the law increased parental leave uptake in San Francisco by 13 percent among fathers, but there was little change in leave among mothers. Data from a survey of mothers suggest that the limited impact may be partly a result of low understanding of benefits. Lower-income mothers reported even less knowledge of their maternity leave benefits than other mothers, and fewer than 2 percent of lower-income mothers had accurate information about the policy. The San Francisco policy also excludes small employers, which further limits its reach among low-income workers. A simpler universal policy may be more effective in expanding parental leave among vulnerable workers.

The tipping point: could increasing the subminimum wage reduce poverty-related antenatal stressors in U.S. women?

PURPOSE: Tipped workers, primarily women of reproductive-age, can be paid a "subminimum wage" 71% lower than the federal minimum wage, contributing to economic hardship. Poverty-related antenatal stress has deleterious health effects for women and their children. The purpose of this study was to investigate the effects of increasing the state-level subminimum wage (currently $2.13 per hour) on poverty-related antenatal stress for women in the United States. METHODS: Utilizing a difference-in-differences approach comparing state wage policies over time, we estimated the impact of increases in the subminimum wage on poverty-related antenatal stress using data from 35 states participating in the Pregnancy Risk Assessment Monitoring System between 2004 and 2014, linked to state-level wage laws, census, and antipoverty policy data. RESULTS: The effect of increasing the subminimum wage on poverty-related stress differed by year and sociodemographics. Wage increases in 2014 were associated with the largest decreases in stress for unmarried women of color with less than a college degree, a population that we estimated would have experienced a 19.7% reduction in stress from 2004 to 2014 if subminimum wage was equivalent to the federal minimum wage. CONCLUSIONS: Increasing the subminimum wage can reduce poverty-related stress and may be a potential intervention for reducing poor health outcomes.

Effects of citizenship status, Latino ethnicity, and household language on health insurance coverage for U.S. adolescents, 2007-2016.

OBJECTIVE/STUDY QUESTION: To examine changes in uninsurance rates among U.S. adolescents ages 12-17 and assess whether trends over time differed by citizenship status, Latino ethnicity, and household language. DATA SOURCES/STUDY SETTING: 2007-2016 National Health Insurance Survey (NHIS). STUDY DESIGN: Multivariable logistic regression and postestimation marginal effects were used to assess changes in the current uninsured rate. Logistic regression models were used to determine significant trends over time for each demographic group and compare them to trends in the broader adolescent population. Marginal effects were employed to calculate adjusted outcome probabilities for each year. PRINCIPAL FINDINGS: Across all 12- to 17-year-olds, the unadjusted uninsured rate dropped significantly between 2007 and 2016, from 10.2 percent to 6.0 percent. For noncitizen youth, the probability of being uninsured increased from 26.6 percent in 2007 to 28.4 percent in 2016, after controlling for covariates. Latino youth and those in Spanish-speaking households saw declines in their adjusted uninsurance rate that was proportional to non-Latino and English-speaking youth. CONCLUSIONS: Most adolescents saw significant improvements in health insurance coverage between 2007 and 2016; however, disparities remain among Spanish-speaking and Latino adolescents and no improvements were seen among noncitizen youth. This suggests a need for equity-focused eligibility, outreach, and enrollment policies that expand insurance options for these populations.

Employee Experiences with a Newly Adopted Paid Parental Leave Policy: Equity Considerations for Policy Implementation.

Purpose: Paid parental leave (PPL) policies offer immense opportunity to enhance health equity by providing financial stability to workers and promoting the health of families in the United States. Working in partnership with a local county government, which recently adopted a paid leave policy, we engaged in a qualitative substudy to enhance our understanding of how workers perceived and experienced the policy across levels of the socioecological framework. Methods: Working in partnership with Multnomah County, a large public-sector employer in Portland, OR that recently adopted a PPL policy, we collected qualitative data through focus groups with employees. Data were transcribed, coded, and analyzed thematically. Results: We conducted seven focus groups with county employees (N=35) in the fall of 2017. Three major themes emerged from the focus group data: intersectional inequities, disparities by department, and uneven benefits. Conclusions: Our findings highlight the inequities of experience with the PPL policy across employees at individual, organization, and environmental levels. These findings offer insight and guidance for entities considering the adoption and implementation of such policies to consider concrete steps to enhance equity of access and experience.

Analyzing Policies Through a DOHaD Lens: What Can We Learn?

Social, health, and environmental policies are critical tools for providing the conditions needed for healthy populations. However, current policy analyses fall short of capturing their full potential impacts across the life course and from generation to generation. We argue that the field of Developmental Origins of Health and Disease (DOHaD), a conceptual and research framework positing that early life experiences significantly affect health trajectories across the lifespan and into future generations, provides an important lens through which to analyze social policies. To illustrate this point, we synthesized evidence related to policies from three domains-family leave, nutrition, and housing-to examine the health implications for multiple generations. We selected these policy domains because they represent increasing distance from a reproductive health focus, each with a growing evidence base to support a potential impact on pregnant women and their offspring. Each of these examples represents an opportunity to extend our understanding of policy impact using a DOHaD lens, taking into account the potential life course and intergenerational effects that have previously been overlooked.

Laboring Until Labor: The Prevalence and Correlates of Antenatal Maternity Leave in the United States.

Introduction Most women in the U.S. are employed during pregnancy and work until the month of childbirth. For many, working throughout pregnancy poses little threat to their health; however, women experiencing difficult pregnancies and/or working in strenuous or inflexible jobs may benefit from taking time from work as they approach childbirth, but almost no empirical evidence examines antenatal leave (ANL). Methods Using a national survey of English-speaking women, this paper offers the first national description of ANL and examines state policy predictors of uptake. Results Thirty-seven percent of employed women worked until the week their baby was due. After controlling for characteristics of women and their jobs, living in a state with any or multiple leave laws increased the probability of ANL by 14 and 23% points, respectively. Women living in states with multiple leave laws stopped work almost 2 weeks earlier than women in states without a policy. Discussion Paid leave policies currently being considered at the federal, state, and local levels should consider the potential impact on antenatal leave, in addition to postnatal leave, and how they influence population health.

Stroke-attributable death among older persons during the great recession.

Epidemiological evidence indicates an elevated risk for stroke among stressed persons, in general, and among individuals who have lost their job, in particular. We, therefore, tested the hypothesis that stroke accounted for a larger fraction of deaths during the Great Recession than expected from other deaths and from trends, cycles, and other forms of autocorrelation. Based on vital statistics death data from California spanning 132 months from January 2000 through December 2010, we found support for the hypothesis. These findings appear attributable to non-Hispanic white men, who experienced a 5% increase in their monthly odds of stroke-attributable death. Total mortality in this group, however, did not increase. Findings suggest that 879 deaths among older white men shifted from other causes to stroke during the 36 months following the start of the Great Recession. We infer the Great Recession may have affected social, biologic, and behavioral risk factors that altered the life histories of older white men in ways that shifted mortality risk toward stroke.

Twins less frequent than expected among male births in risk averse populations.

Male twin gestations exhibit higher incidence of fetal morbidity and mortality than singleton gestations. From an evolutionary perspective, the relatively high rates of infant and child mortality among male twins born into threatening environments reduce the fitness of these gestations, making them more vulnerable to fetal loss. Women do not perceive choosing to spontaneously abort gestations although the outcome may result from estimates, made without awareness, of the risks of continuing a pregnancy. Here, we examine whether the non-conscious decisional biology of gestation can be linked to conscious risk aversion. We test this speculation by measuring the association between household surveys in Sweden that gauge financial risk aversion in the population and the frequency of twins among live male births. We used time-series regression methods to estimate our suspected associations and Box-Jenkins modeling to ensure that autocorrelation did not confound the estimation or reduce its efficiency. We found, consistent with theory, that financial risk aversion in the population correlates inversely with the odds of a twin among Swedish males born two months later. The odds of a twin among males fell by approximately 3.5% two months after unexpectedly great risk aversion in the population. This work implies that shocks that affect population risk aversion carry implications for fetal loss in vulnerable twin pregnancies.

Work-family balance after childbirth: the association between employer-offered leave characteristics and maternity leave duration.

Early return to work after childbirth has been increasing among working mothers in the US. We assessed the relationship between access to employer-offered maternity leave (EOML) (both paid and unpaid) and uptake and duration of maternity leave following childbirth in a socio-economically diverse sample of full-time working women. We focus on California, a state that has long provided more generous maternity leave benefits than those offered by federal maternity leave policies through the State Disability Insurance program. The sample included 691 mothers who gave birth in Southern California in 2002-2003. Using weighted logistic regression, we examined the EOML-maternity leave duration relationship, controlling for whether the leave was paid, as well as other occupational, personality and health-related covariates. Compared with mothers who were offered more than 12 weeks of maternity leave, mothers with <6 weeks of EOML and those offered 6-12 weeks had five times higher odds of returning to work within 12 weeks; those offered no leave had six times higher odds of an early return. These relationships were similar after controlling for whether the leave was paid and after controlling for other occupational and health characteristics. Access to and duration of employer-offered maternity leave significantly determine timing of return to work following childbirth, potentially affecting work-family balance. Policy makers should recognize the pivotal role of employers in offering job security during and after maternity leave and consider widening the eligibility criteria of the Family and Medical Leave Act.