A Longitudinal Analysis of Total Workload and Women’s
Health after Childbirth
AcademyHealth, Annual Research Meeting, June 30, 2009
Informing
g Health Policyy through
g a Gender Lens
Pat McGovern, PhD, Professor
University of Minnesota
Research Team
Pat McGovern, PhD, Professor & PI (1)
Rada Dagher
Dagher, PhD,
PhD Assistant Professor ((2))
Heidi Roeber-Rice, MD, Occupational & Environmental
Medicine Residency Program Director (3)
Dwenda Gjerdingen, MD, Professor (4)
Bryan Dowd, PhD, Professor (5)
L ri Uk
Laurie
Ukestad,
t d MS
MS, Pr
Project
j t Manager
M n r (1)
Ulf Lundberg, PhD, Professor (6)
(1) Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis, USA
(2) College of Public Health and Health Professions,University of Florida, Gainsville, USA
(3) Midwest Center for Occupational Health & Safety, School of Public Health, University of Minnesota, Minneapolis, USA
(4) Department of Family & Community Medicine, School of Medicine, University of Minnesota, Minneapolis, USA
(5) Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, USA
(6) Department of Psychology, University of Stockholm, Stockholm, Sweden
Why Should We Care?

Social trends of women working
outside the home unlikely to change



Economics
Education & smaller family size
Social fulfillment

Implications for health & quality of
life for mothers & their families

E l
Employers
ffocused
d on productivity
d i i &
health care costs

The Obamas ?
catalystfaith.files.wordpress.com/2009
Mothers’ Labor Force Participation,
p
, 2007
007
Age of
Children
Total
Mothers
Married
Mothers
Single
Mothers
U d 1
Under
year
51 4%
51.4%
52 8%
52.8%
48%
BLS,, 2008. Employment
p y
Characteristics of Families in 2007
US Labor Force Participation (LFP) Rates
& Mothers of Infants
Timing of return to work after childbirth among
first time mothers employed
p y during
g pregnancy:
p g
y
 4.7 % at 1 month
 60% att 3 months
th
 82% at 12 months
Johnson, TD. 2007. Maternity Leave & Employment Patterns: 20012001-2003. Current Population Reports, PP-70
70--113. US
Census Bureau, Washington DC.
What is the Postpartum ?

Traditional Medical Perspective
Approximately 4 to 6 weeks after childbirth
 Involution of the uterus
 Typically involves one medical visit

Uterus after childbirth
Uterus 6 wks after childbirth
What is the Postpartum ?

There are many minor to moderate
discomforts that may last for weeks to
months after childbirth


Fatigue, breast soreness, CC-section or
episiotomy discomforts, constipation or
hemorrhoids, uterine cramps, sexual concerns &
respiratory symptoms
There are serious problems (e.g., postpartum
depression)
p
) that mayy last for several months
after childbirth
Cultural Context for Childbirth & Work

Avg. job-protected leave & paid leave is 14 mo. for
countries in the Organization for Economic
Cooperation & Development (OECD)

US p
provides 12 weeks of unpaid
p
leave for
childbirth under the Family Medical Leave Act
Covers ~ 58% of the nation’s workforce
 Early return to work after childbirth (4-8 wk) associated with
lowest level of resources (Han et al, 2008; McGovern et al,
2000).
2000)

Han, Ruhm, Waldfogel & Washbrook, 2008, June. The timing of mothers’ employment after
childbirth. Monthly Labor Review: 15-27.
Research Objective & Questions
To
o investigate
vest gate the assoc
association
at o o
of tota
total wo
workload,
oad, pe
personal
so a
and work-related factors with women’s health during
the first year after childbirth—focus on modifiable
f t
factors






Total workload
Breastfeeding
Social support at home and at work
Perceived control (ability to predict & plan)
JJob satisfaction and job
j stress
Infant irritability & sleep problems
Hybrid Model of Health &
Workforce Participation

Theoretical model adapted from Gary Becker & Michael
Grossman


Assumes health is determined by genetic endowment &
demographics,
demographics prepre-existing factors (occupation) & personal
choices
Integrated above with stress model of Frankenhaeuser



Stress--- imbalance between perceived demands and perceived
Stress--resources
Situations that balance external demands & personal ability
may evoke satisfaction despite heavy demands.
Personal control (ability to predict and plan) & social support
all strengthen an individual’s ability to cope with heavy
demands
Study Design




Prospective cohort identified at birth & followed for 12 months
postpartum
Study population: all women delivering at 3 Twin Cities hospitals
(Minnesota); est. population: 2,367,204
Sample Selection Criteria
 18 yrs/older, spoke English, employed for at least 20 hrs/wk
in the 3 months before childbirth,
d
,p
plans for return to work,,
singleton infant
Interviews in the hospital; phone interviews at home




5 weeks (4(4-8 wks)
11 weeks (10(10-14 wks)
6 months (5(5-7 mo.)
12 months
th (11(11-13 mo.))
Outcome Measures
Dependent variables:
 Mental & Physical Component Summary (MCS &
PCS)) scores,, SFSF-12 v.2


Items address physical function, role limitations from
physical and emotional health, bodily pain, general health,
social
i l ffunction,
i
mentall h
health,
l h and
d vitality
i li
Postpartum symptom score
 28 items
i
childbirth
childbirthhildbi h-related
l d symptoms (f
(fatigue,
i
headache, neck/backache, respiratory symptoms)
Research Model
5 Weeks
B
Breastfeeding
tf di
Total Workload
Perceived control
Job Stress
Job Satisfaction
Social support
(home, work)
Baby’s Irritability
Baby’s
y Sleep
p
Time
Maternal
Health
11 Weeks
B
Breastfeeding
tf di
Total Workload
Perceived control
Job Stress
Job Satisfaction
Social support
(home, work)
Baby’s Irritability
Baby’s
y Sleep
p
Time
6 months
Breastfeeding
Total Workload
Perceived control
Job Stress
J bS
Job
Satisfaction
ti f ti
Social support
(home, work)
Baby’s Irritability
Baby’s
Baby
s Sleep
Time
12 months
Breastfeeding
Total Workload
Perceived control
Job Stress
J bS
Job
Satisfaction
ti f ti
Social support
(home, work)
Baby’s Irritability
Baby’s
y Sleep
p
Time
Maternal
Health
Maternal
Health
Maternal
Health
Control Variables
Demographics, Education, Family Income, Occupational Classification, Preconception Health, Labor & Delivery
Complications, Delivery Type & Baby Gender
Analytic Plans
Fixed Effects Regression with Panel Data

Statisticallyy controls for stable individual characteristics
 Measured factors: race & age
 Unmeasured factors: intelligence and genetic endowment for
health
e

Allows the analysis to focus on “modifiable” factors

Restricts analysis to within person variation; each woman serves as
her own control

Make comparisons within women from various time periods &
averages differences across all women

Provides a conservative estimate of effects
Maternal Characteristics & Health

Demographics
g p
 Mean age: 30 years (SD: 5.3 yr.)
 73% married, 86% Caucasian, 46% were college graduates,
46% were primiparous

Mental health score (MCS)
 Study participants
 5 Weeks: 49.6 (SD: 7.9 ); 12 Months: 55.4 (SD: 5.8)
 Norm: 47.2 (SD: 12.1)

Physical health score (PCS)
 Study participants
 5 Weeks: 51.4 (SD: 7.2); 12 Months: 55.4(SD: 5.7)
 Norm: 52.7 (SD: 9.1)

Childbirth-related symptoms:
Childbirth 5 Weeks: 6.1 (SD: 3.4); 12 Months 3.6 (SD: 3.3)
Total Workload and Maternal Postpartum Health

Total Workload (TWL) included paid and unpaid work


Employment, Travel to/from Work, Housework, Errands,
Yard work, & Family Caregiving
Measured as 24 hrs – rest, leisure & personal cares
Maternal Workload
Daily Activities
6 WKS
12 WKS 6 MO.
MO 12 MO.
MO
Sample (N)
716
638
603
554
Employment
(All)
0.6
[Only those working] [6.8]
3.9
[7.7]
7.4
[7.9]
7.6
[7.8]
p
Sleep
Personal Care
Caregiving
6.6
1.5
10 5
10.5
6.9
1.5
72
7.2
6.8
1.4
47
4.7
6.9
1.3
41
4.1
Leisure
1.5
1.2
0.8
0.7
Total Workload
14.4
14.4
15.1
15.1
Factors associated with Better Mental Health
((Fixed
d effects regression
g
estimates))
Independent variables
β
Standard
Error (β)
P-value
Total Workload
-0.3038
0.066
0.000
Perceived Control
0.8867
0.206
0.000
Available Social Support
0.3973
0.08
0.000
Infant Sleep Problems
-0.8966
0.387
0.021
Fussy Infant
-0.8042
0 8042
0 3776
0.3776
0 034
0.034
Time: 5 weeks (ref)
11 weeks
6 months
12 months
0.4514
0.6377
1.1223
0.2800
0.3477
0.4336
0.107
0.067
0.010
Factors associated with Fewer ChildbirthChildbirth-Related
Symptoms ((Fixed effects regression estimates)
Independent variables
β
Standard
Error (β)
P-value
Total Workload
0.0701
0.0273
0.010
Perceived Control
-0.2619
0.0777
0.001
Available Social Support
pp
-0.0853
0.0250
0.001
Infant Sleep Problems
0.3358
0.1574
0.033
Time: 5 weeks (ref)
11 weeks
6 months
12 months
-0.9427
-0.2731
-1.2337
0.1117
0.1367
0.1825
0.000
0.046
0.000
Factors associated with Physical Health (Fixed
(
effects regression estimates)
Time:
5 weeks (ref)
11 weeks
6 months
12 months
β
4.4363
4 4363
3.9129
4 2404
4.2404
Standard
Error (β)
0.2808
0 2808
0.3253
0.4173
0 4173
P-value
0.000
0.000
0.000
Time Allocation in Hours/Day
Family care
Minnesota
National
Mothers 12 mo.
Mothers,
mo Norms,
Norms Mothers
postpartum
with Children <
6 yrs.
y
4.1
2.4
Paid Work
7.6
4.9
Leisure
0.7
3.1
Sleep
6.9
8.4
BLS. Time spent in primary activities… 2008 annual averages, Table 8. Economic News Release.
www.bls.gov/newsrelease/atus.t08.htm, Accessed: 6/ 29/09.
Discussion

Increased total workload was associated with better
health, consistent with Swedish studies


IIncreased
d control
t l & iincreased
d social
i l supportt was
associated with better health


Mothers may need assistance balancing total workload with
postpartum recovery & potential workplace accomodations
New mothers may need health to identify sources of support &
how to ask for it; & strategies to increase control
Infant sleep
pp
problems & irritable behavior adverselyy
affected maternal health

New mothers may need help developing infant soothing
techniques
Study Limitations

Generalizability of study findings

Comparability to other states or nations with varying labor
force participation rates & family leave policies?



M
Measurement
off totall workload
kl d


US, 2000, 16 and older: 57.5%
Minnesota, 2000, 16 and older: 66%
Results of sensitivity analysis with diary estimates of TWL
from a substudyy (diary,
(
y, worksheet,, CATI);
); no difference
Use of fixed effects regression vs. multilevel growth
curves to assess within & between person variation for
future investigations
Conclusions

New mothers had heavy workload with limited sleep and
personal time

Mothers, health care providers & employers need to
explore options that enhance social support & promote a
balance between work & rest

Studies are needed to assess the impact of strategies such
as flexible work arrangements
arrangements, paid leave benefits
benefits, &
access to women’s heath care experts and parenting
support groups

Policy makers could provide employers incentives for
options that support work
work--family balance & health such as
paid leave (sick
p
(
or family
y leave),
), flexible work
arrangements, or parenting support groups
The National Institute for Occupational Safety
and Health
The Impact of Total Workload on Maternal
Postpartum Health & Quality of Life
Grant #5 R18 OH003605OH003605-05
Questions
Comparison of Study Population to
National Data




Slightly less likely to be married (77% married) vs.
new mothers nationnation-wide (83% married)
Proportion
p
of Caucasian & Native American
mothers comparable to national data (78% and 1%)
Proportion
p
of African American mothers less than
national estimates (9% vs. 15%)
Proportion of Asian mothers slightly higher than
national data (11% vs. 5%)
Maternal Characteristics

D
Demographics
hi


Mean age: 30 years (SD: 5.3 yr.)
73% married, 86% Caucasian, 46% were college graduates , 54% were multiparous

Breastfeeding: 5 weeks
weeks, 67% to 12 months
months, 13
13.5%
5%

Perceived Control


Available Social Support, Family & Friends



Mean: 5 weeks, 4.2 (2.01) to 12 months, 4.09(2.11); (range: 2-8)
Baby’s Irritability (re: fussy, irritable behavior for at least 2 days or colic )


Supervisor: 5 weeks: 3.61 (0.76) to 12 months, 3.61 (0.69); (satisfied to very satisfied)
Coworker: 5 weeks, 3.86 (0.43) to 12 months, 3.72 (0.58); (satisfied to very satisfied)
Perceived Job Stress (re: experience stress & have too much to do)


Mean : 5 weeks, 20.68 (3.68) to 12 months, 21.25 (3.82) (available most of the time)
Supervisor & Coworker Support (re: taking care of family needs)


Mean : 5 weeks, 3.26 (0.99) to 12 months, 3.79 (0.83) ( a lot of control )
5 weeks, 15.2% to 12 months, 37.5%
Baby’s Sleep (Re: Average night , baby is awake 2 or more hours per night)

5 weeks, 16.8% to 12 months, 21.1%
Response
p
Rates
N=1157
((42%
% of births))
Eligible
(71% of
Eligible)
5 Weeks
N = 731/817
(88%)
11 Weeks
N=661/817
(81%)
2,736 Births
N=340
(29% of eligible)
Refused
N=1,579
(58% of births)
Not Eligible
N=817
Enrolled
6 Months
N = 625/817
(76%)
12 Months
N= 575/817
(70%)