Experiences of Dutch nurses and doctors with pregnancy and menopause in the workplace

Abstract

Background

The scope of research on pregnancy and menopause is growing, but the actual workplace changes that can support women during these transitional stages are falling behind.

Objective

To understand various interactional processes on the work floor that hamper changes in the context of an academic hospital we (i) explore how female nurses and doctors experience pregnancy and menopause in the workplace, and (ii) what management knows about these experiences.

Methods

This is an empirical qualitative exploratory study based on semi-structured interviews (n = 21), focus groups (n = 2) and discussion groups (n = 2) with female nurses and doctors, male and female managers, occupational specialists and external experts (in total N = 33). The focus groups and dialogue sessions were used to enrich and to validate the results. The data was analysed with the use of MAXQDA and followed the grounded theory approach.

Results

Three processes were identified: (1) internalisation of work ethos that transforms maternal bodies into work instruments; (2) self-silencing and physical invisibility of maternal bodies as survival strategies; and (3) normalisation of silence about pregnancy and/or menopause at all levels of the organisation.

Conclusion

Maternal bodies of the female employees become instruments of providing care and disappear in the workplace. These processes are facilitated by the current structure of an academic hospital and are a part of the organisational culture within the healthcare system in the Netherlands. Making these processes open to discussion will contribute to development of the tailor-made education and interventions involving all stakeholders.

Keywords

pregnancy menopause maternal body female employees occupational health workplace silencing

Introduction

Female labour force participation worldwide is estimated at 50% today, hence only a half of working age women participate in the labour market.¹ Involvement in paid work positively influences women's economic independence, health and wellbeing,² therefore new policies and interventions are needed to involve more women in labour force and to ensure their sustainable employment until retirement. One of the positive patterns of change relevant to our study is a growing and more prolonged labour force participation among women in high income countries.³ According to the figures of the Dutch Central Statistical Office 47% of the Dutch labour force today is represented by women. About 68,9% of Dutch women work today, which is a significant shift compared to the status quo in 1960s, when merely 25% of Dutch women had paid jobs.⁴ Another noticeable change in the Dutch labour market during the last 10 years is the increase of 19,7% in participation among Dutch women who are 55 years and older.⁵ Given the contemporary shortages in the labour market, especially in the sectors healthcare or education where most of the employees are women,⁶ these trends are likely to increase. Yet, a preliminary scan of the organisation of work related to women's vitality and wellbeing shows a lack of structural policies and workplace interventions that support the continuity of women's careers until retirement age.^7,8 One of the reasons is little awareness of the fact that a woman's life course is characterised by a number of female-specific transitional stages, which when left unattended can shorten the working life of female employees and have negative consequences for their health, wellbeing and economic independence.⁹

Attention towards pregnancy and menopause is important because the (post-)reproductive stages of women's lives nowadays are incorporated in women's working lives. Grandey and colleagues¹⁰ summarise it vividly in the metaphor of the three Ms, i.e., menstruation, maternity (fulfilled or potential) and menopause, which are natural phenomena and therefore cannot be severed from women's working lives. Additionally, a recent Dutch study calculated that the timely recognition and treatment of menopausal symptoms and endometriosis, would boost the Dutch economy with 7,6 billion euros annually due to less healthcare expenditures, less sick leave, and higher productivity.¹¹ The number of studies about pregnancy and menopause which focus on the health aspects of these transitions is steadily growing.¹² However, occupational health, organisation of work, discrimination and stigmatising (self-)attitudes towards women in these transitional stages remain insufficiently reflected in policies and interventions.¹³ For example, the studies that looked specifically into the workplace interventions regarding sick leave during pregnancy establish a lack of evidence where efficiency of such interventions is concerned.¹⁴ A recent systematic review of the workplace interventions for menopausal women has identified only five articles regarding effectiveness of such interventions and suggested to implement the evidence-supported interventions on a much broader scale than it has been done so far.¹⁵

The question arises why despite the wealth of available medical research and some recent research on experiences with pregnancy and menopause at work effective work-floor changes lag behind?

The need for successful change must be made explicit at various levels of the organisation and has to be supported by all interested parties.¹⁶ To accomplish this, we need a thorough analysis of the interactional processes on the work floor that could be resistant to the adjustments in organisational policy and culture.¹⁷ In this study we describe the interactional processes of female employees with their maternal bodies, and between female and male employees, employees and their managers and occupational health specialists, as experienced by the stakeholders themselves, which may hamper the work-floor changes in support of female employees during pregnancy and menopause.

Focus on female health care professionals

For this study we focus on female health care professionals and their male and female managers who work in a Dutch academic hospital. The authors approached the HRM department of the hospital in 2019 with the request to conduct an explorative study about how female nurses and doctors experience pregnancy and menopause at work. This group of female employees is of a particular interest because (a) more than 80% of all Dutch employees in the healthcare sector are female,¹⁸ (b) more than 88% of all registered nurses in the Netherlands are women,¹⁹ among which the largest group are women of 55 years and older, and (c) because there are structural and increasing staff shortages among the healthcare personnel in the Netherlands.²⁰ The study²¹ conducted among 6397 health professionals identified the three most frequent reasons for healthcare professionals to leave the healthcare sector: (1) dissatisfaction with the management/policies within the organisation (36%), (2) the content of their work (33%) and (3) increasing job demands (31%). Under changing demographic conditions, it is essential for the healthcare sector to attract young professionals, and even more important to keep the most experienced professionals active to share their knowledge with the younger generation. Yet, the Dutch labour market today demonstrates that young as well as more experienced health care workers leave the labour market prematurely, often because of job demands and/ or for health reasons.²² All these developments encouraged us to design and conduct an explorative research study based on the following questions: how do female nurses and doctors experience the transitional stages and what do their managers know about these experiences in the context of work at an academic hospital?

Concept of maternal body

In our analysis we use the concept ‘maternal body’ as a lens through which we zoom in on the situations in the workplace as experienced by female nurses and doctors. The concept was introduced by Walker, who described how women lose their ‘voice’ by their association with maternity and how ‘the maternal body operates as the site of women's radical silence’.²³ In many countries including the Netherlands, due to a low labour participation among women in the first half of the twentieth century the maternal body was almost absent in the workplace. And although the labour market is open to female employees today, maternal bodies remain largely invisible.²⁴ This invisibility is reciprocated by the imagery of the maternal body as a reproductive body, a body which produces blood, babies, breastmilk, fluids and sweat. Such a body is often labelled as unstable, capable of disturbing the existing organisational system.²⁵ This ‘physical instability’ of the maternal body is sometimes extrapolated to other capabilities and strengthened by existing gender stereotypes, about women as less intellectually capable then men.²⁶

In our study we use the notion of the maternal body as a point of intersection between its reproductive function, most visible during pregnancy and menopause, and women's participation in the workplace. This intersection colours women's life course and plays an important role in women's occupational health and wellbeing.²⁷ In women's lives, expectations that women must fulfil their reproductive function as well as participate in the labour market form an entanglement of physical cycles and life stages. Because of these intersections the life courses of women can be seen as a set of intersecting temporalities.²⁸ This complexity manifests itself in persistent mismatches at work. For instance, the most productive years in terms of biological fertility often coincide with the period when women have the best career opportunities. Sick leave related to pregnancy or maternity leave can result in stagnation in a woman's career.²⁹ And while professional women often have advanced careers during their peri- and postmenopausal years, hot flashes, being among the most frequent menopausal symptoms, occur unannounced and can undermine women's sense of authority and professional appearance.³⁰ The intersection of a biographical timeline, a career timeline and a physiological timeline of female bodies can generate different forms of tension. Any manifestation of such tensions may be experienced as a surprise in the workplace,³¹ where stable and predictable bodies are more valued, and therefore, accommodated more easily.

The study

Aims

In this study we aim to understand the interactional processes on the work floor that can hamper careers of female nurses and doctors during female-specific transitional stages like pregnancy and menopause by exploring (i) how female nurses and doctors experience pregnancy and menopause in the workplace, and (ii) what management of the academic medical hospital know about these experiences.

Study design

This empirical qualitative exploratory interview study brings together various perspectives of stakeholders on pregnancy and menopause in the workplace as understood by women and people working in management at a Dutch academic hospital. The study was conducted in a large academic hospital in the Netherlands in 2019–2020 and consisted of four stages: the consultation stage (semi-structured interviews), the validation stage (focus groups), the analysis stage (grounded theory approach) and the integration stage (discussion groups). The study was conducted by a team of four researchers. Two of the researchers were involved in the stages of data collection and data analysis only.

Participants

In total 33 individuals participated in this study,³² which is in accordance with the latest academic insights about reaching data saturation in qualitative research.³³ Participants received information through personal networks and via snowballing. We used purposive sampling to obtain maximum variation: younger and older women, participants at various functional and hierarchical levels and across cultural background and age ranged from 28 to 63 years. We aimed for transferability by describing the participants and their context in detail (thick description) and by discussing how the findings resonate with existing literature.³⁴ Of the individually interviewed nurses and doctors, five had had experience with pregnancy only, five with menopause only, and five with both transitional stages. The interviewed nurses worked in two different clinical departments, whereas the medical specialists represented three different medical disciplines. Four nurses and one expert who participated in one of the discussion groups had a migrant background.

In order to enrich and validate our findings based on the interviews with female nurses and doctors we have chosen for a stakeholder approach. Using purposive recruitment we held interviews with six male and female hospital managers and occupational specialists about their experiences with the employees’ questions or issues related to pregnancy and menopause on the work floor.

Data collection

Two interview guides were developed: one for female nurses and doctors and another one for managers and occupational specialists. With nurses and doctors, we addressed physical experiences during the transitional stages at work, social contacts with colleagues and managers during the transitional life stages, coping strategies and the organisational changes that could support them. Topic lists for managers and occupational specialists focused on their awareness of issues related to pregnancy and menopause in the workplace, how they could initiate a conversation about these life stages, and what they would need at the organisational level to be able to adequately support female employees.

The consultation stage comprised 21 semi-structured interviews with female nurses (n = 8), female medical specialists (n = 7), female and male hospital managers and occupational physicians (n = 6). Individual interviews were held by two members of the project team at the university and took 45–90 min. The audio recordings were transcribed verbatim. Summaries of interviews were sent to the interviewees for member check. The suggestions from the interviewees were added to the original transcripts. Additionally, we used the field notes with researchers’ impressions and non-verbal information during the interviews.

The validation stage consisted of two focus groups (n = 10), where we discussed the initial results with new participants: occupational health professionals, female nurses, medical specialists and hospital managers. The focus groups, 60 min each, were held at the university and supervised by two researchers. The participants consented to the audio recording, which were used by the research team for further analysis. The transcripts of the interviews, the reports of the focus group meetings and the field notes constitute the data of this study.

Ethical approval

All participants signed the letter of Informed Consent. The study was embedded into the research programme ‘Societal Participation and Health’ of the Amsterdam Public Health research institute (SQC2018–047) and reviewed by the Medical Ethics Review Committee of the VU University Medical Centre (2018.346) on July 16, 2018. According to Dutch legislation, no ethical consent is needed for this type of study (https://english.ccmo.nl).

Data analysis

Analysis, based on constructivist grounded theory,³⁵ took place during the third stage of the study. All audio records of the interviews were transcribed verbatim, and at least two researchers coded the transcripts in MAXQDA. Initial coding has been accompanied by extensive theoretical sampling. We applied an iterative approach to data analysis, which allowed us to use the first codes to sharpen the interview guides and continue comparing the codes generated from the new interviews until data saturation has been reached, meaning that both researchers involved in coding did not find new topics. Open coding resulted in more than 100 codes, which we reduced to 29 during the axial coding by categorising and clustering them based on our research question. After open coding and clustering, we actively searched for interactional relations on the work floor. For example, interactions on the work floor were reflected in codes ‘don’t complain’ and ‘patient [comes] first’. By comparing these codes with the overarching theoretical concept of ‘maternal body’ which focuses on reproductive function, we grouped these codes under the axial code ‘work ethos above self-care’. Another example refers to colleagues’ explicit or implicit responses to sick leave due to pregnancy or menopause, reflected in codes like ‘limits of collegiality’ and ‘collegial credits’. These codes were clustered around the axial code of ‘flexibility and shared responsibility on the work floor’. Finally, we connected the codes and clusters to the concept of ‘maternal body’ by identifying three major interactional processes, which we tested during the final round of selective coding. Our theoretical sampling resulted in the concepts ‘work ethos’, ‘invisibility’ and ‘self-silencing’, which we finally translated in three work-floor processes that could at least partly explain the slow introduction of changes. Two brainstorm sessions of the project team, consisting of four researchers, were held to discuss the results of the analysis and to reach consensus about the codes, memos and final formulation of the interactional processes.

Rigour and reflexivity

The results were validated according to qualitative rigour criteria.³⁶ Besides member checks with participants (credibility), we checked during the focus groups whether the theoretical sampling that emerged from the interviews so far covered the range of issues that were important for our participants in relation to transitional stages in life and their careers (transferability). During the analysis stage we went back and forth comparing codes until we reached consensus within the research team (dependability). We repeatedly reflected on our possible biases, since two of the researchers were going through the perimenopausal phase at that time themselves and one was postmenopausal (confirmability). During the integration stage, we discussed main results with already familiar and external (outside the hospital) experts, medical professionals and representatives of public organisations, involved with women's health issues, in two discussion groups (n = 14). We presented our preliminary results to them for further deliberation and as an additional validity check.

Findings

Three interactional processes on the work floor were identified in the data:

internalisation of work ethos that transforms maternal bodies into work instruments;

self-silencing and physical invisibility of maternal bodies as survival strategies; and

normalisation of silence about pregnancy and/or menopause in communication at work.

Internalisation of work ethos that transforms maternal bodies into work instruments

The participants emphasise that patient care in the hospital continues 24/7. Nurses and doctors are expected to come into action at any point in time when a patient needs their care. Emergencies can be anticipated but are never planned, so when an urgent situation occurs, healthcare workers take immediate action to provide proper care. For our participants, this call for urgency often means having to ignore the needs of their own bodies:

Yes, the patient comes first. When I was in the last stages of pregnancy I participated in resuscitation. I wouldn’t recommend that… But you just do this as a nurse. And I also used to postpone pumping milk, because we were so busy here. (Nurse)

Doctors have a high work ethos. Yesterday in the news I heard that teachers often stand in front of the class while being ill. I thought: a doctor is never ill… If you are ill, then you are really very ill, because doctors don’t take sick leave. (Doctor)

According to interviewees, the organisational culture at the hospital benefits from such a work ethos. As long as patients receive care, there seems to be no reason to question the status quo: work hard, save lives. This implicit incentive internalised by staff prevents nurses and doctors from even considering a request for flexible schedules or adjusted tasks because of pregnancy or menopausal symptoms:

I was mega-irritated, because I couldn’t walk quickly and run quickly anymore, because my belly was in the way. (Doctor)

Throughout the pregnancy I felt so sick that I thought: ‘I am going to die’… I worked in the surgical theatre then. Each time they used diathermy, the electric cutting of muscles, there was a kind of barbeque smell. And each time I ran to throw up, because I couldn’t stand it. (Nurse)

Participants’ stories reflect what can be called institutional blindness towards the transitional stages. According to them, invisibility of their bodies becomes a part of their work ethos and can have a seamy side. Some participants shared concerns about their health condition, which may in turn affect future vitality and careers. Moreover, as the following example shows, neglect of personal health could result in dangerous situations for the patients as well:

I must admit, there were situations when I stood here only half fit to do my work [during pregnancy]. And I thought to myself, that could cause some unpredictable situations. (Nurse)

Our results do not show significant differences between experiences of nurses and doctors. The interactions on the work floor that allow for transformation of the body into a work instrument are often implicit to both employers and employees, and therefore difficult to untangle. Only when asked explicitly about their work experience during pregnancy or menopause, the nurses and doctors appear to realise that the only sacrifice they were ready to make when they felt tired or ill, were their own maternal bodies. The paradox of needing their own maternal bodies to do their jobs while simultaneously neglecting them, did not strike our participants as unusual. So deeply rooted is their vocational devotion, sustained by the profession's traditional ‘patients first’ narrative, that disregarding their own bodies seems self-evident, even in those stages of life when these bodies require extra attention and care.

Self-silencing and physical invisibility of maternal bodies as survival strategies

Our participants admit that only when the health consequences of neglect can no longer be ignored, the issues surrounding pregnancy and menopause do attract attention in the workplace. However, our participants feel that they themselves are responsible for their health. There is no mention of shared responsibility with their employer who can be also held accountable for occupational health of the employees:

[Why didn’t you take sick leave?]

I felt ashamed. You try to prove yourself. And I don’t want to be looked upon as if I were sick or miserable. You are simply pregnant, and that is a choice. Personally, I think that work should not suffer because of it. (Nurse)

This is but one example of how presenteeism, i.e., remaining at work when feeling unwell or ill, is legitimised among nurses and doctors. Based on our data, presenteeism seems to feed on the work ethos, and since this is a professional norm, self-silencing is incorporated in professional identity. The nurse's referral to shame implies that she would otherwise transgress social norms about pregnancy and work.

Presenteeism is also closely linked with the value that the women attach to their jobs:

I have always worked with pleasure. This hasn’t changed since I have a little one,

but I worried about it beforehand. You hear all kinds of stories. There are mothers who find it awful to go back to work… I am somebody who found it very nice to be able to work again. (Nurse)

Even when the participants are satisfied with their work they emphasise that over the years their work has intensified and that boundaries between home and work become vague. When it comes to the coping strategies during pregnancy or menopause, they rather keep quiet at work and let their emotions play out at home:

You are so busy at work, and then you come home, and your battery is empty, and then you collapse. At home they find it difficult, but at work they almost never notice it. (Nurse)

Work interferes more often in people's private lives than vice versa.37 In spite of changing moods or exhaustion, our participants keep quiet both at work and at home. The emotional toll at work during pregnancy and menopause is hardly addressed, and, according to our participants, those who cannot or do not want to cope may quit their jobs. As one of the doctors succinctly put it: ‘It sorts itself out’. If this is indeed the case, silencing contributes to a ‘natural’ selection process, as silence about the maternal body becomes a basic requirement for survival in the academic hospital workplace.

Besides keeping quiet, another coping strategy our participants talk about is dissociation from their own bodies. Since the maternal body of the employee is not a topic for conversation in the hospital, a bodily surprise can cause problems:

At some point [menopause] I had such a heavy period that, while I was operating, they said: ‘Hey, you can’t make such a mess here, can you?’ Because there was blood on the floor, and it turned out to be my own blood. I hadn’t noticed it. (Doctor)

[Hot flashes] Suddenly it started in my hand and went right through my entire body. And I start sweating, my back, and my neck, everywhere. And I feel sticky against the chair. In a state like that I am not going to take care of a patient, am I? (Nurse)

In these two examples, the temporalities of the individual menopausal bodies manifest themselves as a surprise in the workplace, at moments and in places where maternal bodies are not taken into consideration. Bleeding and sweating make maternal bodies visible unexpectedly. The participants feel that the ‘problem’ is their own, that they actually disturb their colleagues and hospital routines, and therefore they must find solutions on their own. As a result, the nurses and doctors simply bite the bullet and go on, hoping that pregnancy and menopause are just temporary, short-lived, as one of the participants put it: ‘The best thing of it is that it will pass’.

Normalisation of silence about pregnancy and/or menopause in communication at work

During the interviews, we explicitly asked whether pregnancy and menopause were ever discussed with colleagues and supervisors. The answers point in the direction of silencing as normalised:

Women during menopause, that topic… I have been a manager for 20 years now… Menopause was never mentioned explicitly as a reason for sick leave. This is a neglected topic. (Hospital manager)

There are nuances in how pregnancy and menopause are discussed and reacted to by colleagues and managers. In both life stages, colleagues are concerned with the limitations to the women's flexibility regarding work and their replacement. According to one of the hospital managers the flexibility of the team is framed in terms of ‘personal credit’ and collegiality which can be built up by covering for each other. Our respondents are concerned that work in a hospital today requires a lot of flexibility from employees, and they consider it essential to be able to anticipate on critical situations. At the same time, the hospital shows little flexibility in return, like for instance the scheduling of shifts. ‘Bodily surprises’ are not considered to be essential to anticipate upon within the organisational culture, even though most of the care personnel are women. Hence, when a woman takes sick leave due to pregnancy or to menopausal symptoms, her immediate colleagues are held responsible for continuity of care at the wards. The team then faces even higher work strain, which puts pressure on their feelings of solidarity:

Of course, when somebody announces that she is pregnant, everybody is enthusiastic, ‘congratulations!’. And in the meantime, everybody thinks: ‘shit!’ And that is logical, because that ‘shit’ means that somebody will be absent from work, but their work will go on. (Doctor)

Some women have several pregnancies in a row. And they are hardly present in between the pregnancies. And you see that they lose their credit among their colleagues, …that causes friction. (Hospital manager)

The absence of a colleague becomes a team problem and is not framed as an organisational issue. Therefore, there is a limit to flexibility that colleagues have to offer, given the intensity of their own tasks. The frequency of legitimate absence, especially in cases of successive pregnancies, undermines solidarity between colleagues and results in blaming the absent colleague rather than addressing the organisation which should meet the needs and ensure the rights of its own employees. These matters are rarely spoken about in the workplace, and when they are, misconceptions, lack of knowledge, or even jealousy become apparent:

A male colleague of mine said this: ‘It's not fair, really. Because women have various things like pregnancy, time in between. We [men] get none of that. We can never get time off. (Doctor)

It must be possible to simply say that you have hot flashes. The point is, you don’t want to be seen as an old woman all at once, somebody over the hill, with problems. You want to be taken seriously, but also that this transition is allowed to be visible, that there is time and room for it. (Doctor)

People usually make jokes about menopause. And you notice that you kind of play along with it, because that is the easiest way out. But in fact, you should simply say: ‘I really feel unwell’. (Hospital manager)

One reason for silencing is that neither the women themselves nor their colleagues are aware of the long-term consequences that these transitional stages can have on the women's working lives and health. Another reason is straightforward ageism:

It's true, we live in a society where we must be young and beautiful. So, if we talk about menopause, that means the end of being young and beautiful. (Occupational physician)

Because of living in a society obsessed with idealisation of youth, women are often reluctant to be associated with the post-reproductive stage in life:

No, I'm not thinking about [menopause] yet. I'm not afraid of anything, but this transition is a problem to me. I think, once you're in menopause, everything would eventually go downhill. You're going to get older, because your skin gets uglier…, and your hair gets duller, the shine in your eyes is gone, and you get health complaints. (Nurse)

As a coping strategy women prefer to laugh bodily symptoms away, instead of engaging in a conversation about them. Their colleagues, male and female, follow this lead and the women keep their experiences to themselves:

A lot of these topics are addressed only in the form of a joke. And then you just join in, because this is the easiest way. But in the end, you really have to address it like: ‘Come on! It [symptoms] really bothers me!’ (Hospital manager)

Bringing those issues up with a manager may be a good place to start to break the silence. Yet, as the interviews show, the female employees and their managers do not easily initiate such conversations. When asked about it, many participants took a pause before answering, as the possibility had never occurred to them before. For the nurses and doctors, the difficulties to interact with their supervisors are often due to differences in gender and age between the employee and the supervisor. For the managers, the main obstacle is their general lack of knowledge about the transitional stages, how they can relate them to the work situation and what changes are needed to support the women during these stages:

I think that is something you won’t discuss with your male colleague easily, because… Pooh! ‘Here comes another one again…’ (Hospital manager)

Menopause symptoms must be taken seriously… I have a new manager, so I don’t know how he is going to react to it. But it shouldn’t depend on the manager. There have to be certain regulations, especially in a hospital where three quarters of the employees are women. (Nurse)

[Menopause] is not directly mentioned. I don’t give a second thought about it myself. …I find this a rather intimate topic. Still, some of the employees mention it, and that is okay. I am prepared to discuss it. (Hospital manager)

Additionally, occupational health physicians often lack the guidelines how to support women whose symptoms interfere with their work:

Everybody is aware of the fact that we all have stress, and that is all bad, and we have to do something to reduce absenteeism. But regarding menopause, there is no attention for that at all yet. (Occupational physician)

The circle of silence is completed when female employees decide in advance that the transitional stages in their lives are their own personal problems and responsibility, which they cannot burden their colleagues with:

If I take sick leave, then I have this idea about how annoying it will be for my colleagues, that they have to work harder. That is an obstacle for me. (Nurse)

Why am I standing in the middle of the night operating, the night before my maternal leave? Why am I doing it? That is because you don’t want to be a burden to others, you know? (Doctor)

This is an example of a dilemma that our respondents face. The responsibility towards their colleagues and the neglect of their own health is a recurrent theme in almost all the interviews we have held with nurses and doctors. The question who bears the responsibility for the women-employees’ health during their pregnancies and menopause, does not receive an unequivocal answer in our data. So far, the women have carried this responsibility themselves, in silence, but the employees as well as the managers admit the necessity to change. At the same time, some managers cherish the idea that the women themselves should take the first step in order to break the silence:

Menopause is a neglected phase in life. That is how I see it. But this is also your own fault. As women. Because I think that you don’t bring it up enough. (Hospital manager)

Summarising, based on our analysis, there are various processes on the work floor that ensure that maternal bodies remain invisible and silent in the workplace: internalisation of the work ethos, self-silencing due to collegiality or shame, and normalisation of silence in the vacuum of knowledge and organisational policies and interventions addressing pregnancy and menopause in the workplace.

Discussion

Our aim was to describe interactional processes on the work floor, as experienced by our participants, that may hamper support for female employees during pregnancy and menopause in the context of the academic hospital. Our results demonstrate that the processes that reinforce current invisibility and silencing of maternal bodies play out at intrapersonal, interpersonal and organisational levels. At intrapersonal level the nurses and doctors use their bodies as instruments to provide proper care to patients. In line with this instrumentality, the women seem to render their bodies disposable like any other medical equipment.³⁷ At the interpersonal level, the nurses and doctors are left to deal with the consequences of temporal absences, lower productivity, or moments of social ‘unease’ caused for example by hot flashes. In the meantime, the work is intensified to an extent that often does not allow for planned self-care, such as breaks, let alone for unplanned physical surprises. This discourages the women to even consider asking for flexible working hours.³⁸

At the organisational level, the hospital sustains silencing because it is either unaware about the influence of these transitional stages on women's health and wellbeing, or the management lacks skills to initiate a conversation about the topic and therefore is incapable of introducing necessary policies and interventions that can support female employees. Various international studies confirm our results relating to practices of silencing within their own national settings, which points to universality of these processes.^39,40

We looked explicitly for possible differences in how female nurses and doctors handle their bodily needs on the work floor given differences in education level, autonomy and status in the workplace between the groups. However, our data show striking consistency in nurses’ and doctors’ responses, which, at least for our participants, accounts for relative high universality of their experiences. Both doctors and nurses often describe their experiences in terms of ‘bodily surprise’,³¹ and the women's knowledge of their own bodily surprises seems relatively limited. Menstruation, pregnancy and menopause as manifestation of reproductive function within maternal bodies are often still experienced as something ‘out of the ordinary’. And although pregnancy can be also accompanied by joy, menopause usually solely brings about negative connotation and self-stigmatisation related to ageing.⁴¹

Our data do not contain references to whether female care professionals who experienced both transitional stages had connected them in any way. Our life-course approach appeared to be useful to integrally address the female-specific life stages and health of female employees and to demonstrate the universality of their experiences. The possibility that due to their education, female nurses and doctors would be knowledgeable about underlying physiological and mental processes which they undergo during pregnancy and menopause was not confirmed in the interviews. Other studies also demonstrate that healthcare professionals are often insufficiently informed about and therefore do not recognise menopausal symptoms as such.⁴²

Our findings are supported by the systematic review of Arena and colleagues⁴³ who looked into the maternity bias in the workplace and identified similar mechanisms that occur at various organisational levels, including internalisation of biases, interpersonal devaluation like losing credit among the colleagues in our study, and organisational penalties like lower salaries, as experienced by female employees. Additionally, the researchers demonstrate that the outcomes of the maternity bias include negative consequences for physical and psychological health, interpersonal relationships at work and work-related outcomes, which has been confirmed by our participants as well.

Transferability of the results of our study is confirmed by research among another group of women in a similar setting⁴⁴ and in a different setting, namely the Dutch military.⁴⁵ Research in a large academic hospital with women in low-paid jobs confirmed the processes of self-silencing and internalisation of ageist attitudes by women in the menopausal life stage. The study in the context of the Dutch military expanded our understanding of self-silencing and self-stigmatisation among female military employees, which confirms the relative universality of the organisational bias which aims to render female bodies invisible. In a more masculine-typed organisation such as the Dutch Armed Forces, self-silencing was just as normalized as in a more feminine-typed organization such as a hospital.

Understanding how the processes of silencing and invisibility work at the academic hospital and having evidence that our findings may be applicable in various domains of labour market we see various work-related and societal implication of this work, in the Netherlands and other countries. Our study was one of the pieces of evidence used by the Dutch parlement when it took a motion about addressing the taboo about menopause at work.⁴⁶ Today in the hospital where our study has been conducted the female employees may use a free of charge consultation hour with a specialist to discuss any issues specifically related to women's health. More hospitals and healthcare centres consider opening menopause clinics, and more healthcare specialists are trained as menopause consultants. Having seen that self-silencing and self-stigmatisation work at various levels we conclude that in order to address them properly we need a multilevel (political, organisational, educational) approach. Based on the available literature and our own experience two routes can be most effective: distribution of effective interventions based on cognitive behavioural therapy, mindfulness or online organisational toolkit.^47,48 In our own research we have good experiences with a work-life programme, an intervention that promotes health at the workplace among women in low-paid jobs.⁴⁹

Based on the processes described above we promote a broader education programme in particular but not only for women. To our knowledge adult women are hardly informed about menopause in advance.⁵⁰ Although employers are beginning to pay attention to the issue, the introduction of changes in the work floor is slow. To give a few examples, in 2022 according to HRreview in the UK, two-thirds of the FTSE 100 companies failed to publish menopause-related support.⁵¹ At the moment of writing we are not aware of any broadly accessible adult educational courses which can provide women and their family members with the basic information about transitional stages in life and their possible impact on their work, health and wellbeing.

Limitations

This study has been conducted in a Dutch academic medical hospital, and our conclusions are based on a relatively small group of participants. Also, we zoom in on experiences of pregnancy and work and menopause and work; but within the limited time frame of this study, we have not been able to investigate how experiences in the two life stages are associated.

Generalisability and transferability of our results are subjects to cultural aspects of the Dutch labour market that might play a role in our results. First, there is a strong gender segregation of the labour market, which means that Dutch female employees are strongly concentrated in a few sectors, like healthcare and education. Second, the majority of female employees in the Netherlands work parttime.⁵² Nevertheless, as we have demonstrated already, transferability of our results is supported by a surge in studies also from abroad.⁵³

Conclusion

The study promotes open discussion and development of the interventions at all levels in the healthcare organisations and beyond, which could help female nurses, doctors, their managers and occupational specialists address the issues related to pregnancy and menopause in the workplace. Breaking taboos and providing tailor-made support could ensure longer and more satisfactory working lives among female nurses and doctors.

Footnotes

Acknowledgments

The authors wish to acknowledge the input of all participants and our two colleagues, Ijoya van Gemert and Anke Heijsman, to this project.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was financially supported by the Institute GAK and WOMEN Inc.

GAK Institute, (grant number n.v.t.).

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

UN Women. Facts and figures: Economic empowerment. 2024. Available from: https://www.unwomen.org/en/articles/facts-and-figures/facts-and-figures-economic-empowerment [accessed February 26, 2026].

International Monetary Fund. Pursuing women’s economic empowerment. Washington (DC): IMF. 2018. Available from; https://www.imf.org/en/Publications/Policy-Papers/Issues/2018/05/31/pp053118pursuing-womens-economic-empowerment [accessed February 26, 2026].

World Bank. Female labor force participation: data story. 2022. Available from: https://genderdata.worldbank.org/en/data-stories/flfp-data-story#:∼:text=The%20global%20labor%20force%20participation,business%20expansion%20or%20career%20progression [accessed February 26, 2026].

Tijdens

Een wereld van verschil: arbeidsparticipatie van vrouwen 1945–2005. Rotterdam: Erasmus Universiteit; 2006. Available from: https://repub.eur.nl/pub/7550/Tijdens%20De%20grote%20verandering.pdf [accessed February 26, 2026].

Centraal Bureau voor de Statistiek. Arbeidsparticipatie naar leeftijd en geslacht [Internet]. 2025. Available from: https://www.cbs.nl/nl-nl/visualisaties/dashboard-arbeidsmarkt/werkenden/arbeidsparticipatie-naar-leeftijd-en-geslacht [accessed February 26, 2026].

Fleck

Somers

Stolp

, et al. The effectiveness of interventions to increase employment in education and healthcare: a systematic literature review. Economist (Leiden) 2025; 173: 1–45. 10.1007/s10645-024-09440-8

Geukes

Anema

Vermeer

, et al. Evaluation of a workplace educational intervention on menopause: a quasi-experimental study. Maturitas 2023; 174: 48–56.

Verdonk

Bendien

Appelman

. Menopause and work: a narrative literature review about menopause, work and health. Work 2022; 72: 483–496.

Verdonk

Bendien

Verburgh

, et al. Duurzame inzetbaarheid: beschouwing van het concept vanuit een levensloop-en diversiteitsperspectief. Gedrag Organ 2022; 35: 316–349.

10.

Grandey

Gabriel

King

. Tackling taboo topics: a review of the three ms in working women’s lives. J Manage 2019; 45: 2204–2231.

11.

Bosmans

Schootanus

Volleberg

. De maatschappelijke kosten van gezondheidsproblemen bij vrouwen. WOMEN Inc. 2024. Available from: https://www.womeninc.nl/wp-content/uploads/2024/03/Kosten-Baten-Analyse-WOMEN-Inc.pdf

12.

https://www.arboportaal.nl/site/binaries/site-content/collections/documents/2025/11/18/factsheet-hormoongerelateerde-gezondheidsklachten-bij-vrouwen/factsheet-hormoongerelateerde-gezondheidsklachten-bij-vrouwen-tno.pdf [accessed February 26, 2026]

13.

Safwan

Saadedine

Shufelt

, et al. Menopause in the workplace: challenges, impact, and next steps. Maturitas 2024: 107983. 10.1016/j.maturitas.2024.107983

14.

Pedersen

Labriola

Nielsen

, et al. Systematic review of interventions targeting sickness absence among pregnant women in healthcare settings and workplaces. BMJ Open 2018; 8: e024032.

15.

Rodrigo

Sebire

Bhattacharya

, et al. Effectiveness of workplace-based interventions to promote wellbeing among menopausal women: a systematic review. Post Reprod Health 2023; 29: 99–108.

16.

Laker

Rowson

. Making the invisible visible: why menopause is a workplace issue we cannot ignore. BMJ Leader 2024; 8: 186–188.

17.

Cowell

Gilmour

Atkinson

. Support mechanisms for women during menopause: perspectives from social and professional structures. Women 2024; 4: 53–72.

18.

Centraal Bureau voor de Statistiek. Aandeel vrouwen in gezondheids- en welzijnszorg. 2024. Available from: https://www.cbs.nl/nl-nl/nieuws/2024/35/zorg-en-welzijn-bedrijfstak-met-grootste-aandeel-vrouwen [February 26, 2026].

19.

CIBG. The Dutch Ministry of Health, Welfare and Sport. 2025. Available from: https://www.bigregister.nl/over-het-big-register/cijfers [accessed February 26, 2026].

20.

TNO. Werkgevers ervaren personeelstekorten. 2024. Available from: https://www.tno.nl/nl/newsroom/2024/11/werkgevers-ervaren-personeelstekorten/#:∼:text=Actuele%20en%20verwachte%20tekorten,ook%20niet%20binnen%20twee%20jaar [accessed February 26, 2026].

21.

Lang

Koop

Horwitz

. Zorg & welzijn. 2022. Available from: https://www.pfzw.nl/content/dam/pfzw/web/over-ons/nieuws/pdf/pfzw-juni-2022-waarom-verlaten-werknemers-de-sector-zorg-en-welzijn.pdf [accessed February 26, 2026].

22.

De Wijn

Fokkema

van der Doef

. The prevalence of stress-related outcomes and occupational well-being among emergency nurses in The Netherlands and the role of job factors: a regression tree analysis. J Nurs Manag 2022; 30: 187–197.

23.

Walker

. Philosophy and the maternal body: Reading silence. London: Routledge, 2002.

24.

Hutson

. The silent shift: pregnant women doing aesthetic and emotional labor at work. Gend Work Organ 2025; 32: 281–301.

25.

Gatrell

Ladge

Powell

. Profane pregnant bodies versus sacred organizational systems: exploring pregnancy discrimination at work (R2). J Bus Ethics 2024; 192: 527–542.

26.

Reilly

Neumann

Andrews

. Gender differences in self-estimated intelligence: exploring the male hubris, female humility problem. Front Psychol 2022; 13: 812483.

27.

Moen

Miller

. Inequalities in work and the intersectional life course. In: Magda

Pollock

(eds) The Routledge handbook of contemporary inequalities and the life course. London: Routledge, 2021, pp.349–361. 10.4324/9780429470059

28.

West

Boughton

Byrnes

. Juggling multiple temporalities: the shift work story of mid-life nurses. J Nurs Manag 2009; 17: 110–119.

29.

Maxwell

Connolly

Ní Laoire

. Informality, emotion and gendered career paths: the hidden toll of maternity leave on female academics and researchers. Gend Work Organ 2019; 26: 140–157.

30.

Angco

. Women in menopause and the workplace experience: a meta-synthesis. Int J Public Health Res 2025; 15: 2105–2113. https://spaj.ukm.my/ijphr/index.php/ijphr/article/view/462

31.

Jack

Riach

Bariola

. Temporality and gendered agency: menopausal subjectivities in women’s work. Hum Relat 2019; 72: 122–143.

32.

Guest

Bunce

Johnson

. How many interviews are enough? An experiment with data saturation and variability. Field Methods 2006; 18: 59–82.

33.

Hennink

Kaiser

. Sample sizes for saturation in qualitative research: a systematic review of empirical tests. Soc Sci Med 2022; 292: 114523.

34.

Frambach

van der Vleuten

Durning

. AM Last page: quality criteria in qualitative and quantitative research. Acad Med 2013; 88: 552. https://academic-oup-com-s.web.bisu.edu.cn/academicmedicine/article/88/4/552/8351701?searchresult=1

35.

Charmaz

. Constructing grounded theory. 2nd ed. London: Sage, 2014.

36.

Forero

Nahidi

De Costa

, et al. Application of four-dimension criteria to assess rigour of qualitative research in emergency medicine. BMC Health Serv Res 2018; 18: 91.

37.

Wolf

. Critical perspectives on nursing as bodywork. Adv Nurs Sci 2014; 37: 147–160.

38.

Cho

Sagherian

Scott

, et al. Occupational fatigue, workload and teamwork in hospital nurses. J Adv Nurs 2022; 78: 2313–2326.

39.

Shams

Aurangzaib

Sherazi

SFA

. Breaking The Silence: Understanding Menopause, Stigma, And Support In Under Served Communities. Journal of Medical & Health Sciences Review 2025; 2. 10.62019/q7br6g72

40.

Thomas

McCarthy

Wood

, et al. Menopause is not a dirty word.” Australian women’s opinions about increased public attention to menopause. SSM-Qualitative Research in Health 2025: 100634. 10.1016/j.ssmqr.2025.100634

41.

Vincent

Bodnaruc

Prud’homme

, et al. Associations between menopause and body image: a systematic review. Women's Health 2023; 19: 17455057231209536.

42.

Aljumah

Phillips

Harper

. An online survey of postmenopausal women to determine their attitudes and knowledge of the menopause. Post Reprod Health 2023; 29: 67–84.

43.

Arena

Jr Volpone

Jones

KP.

(Overcoming) maternity bias in the workplace: a systematic review. J Manag. 2023;49:52–84. (Wikipedia)

44.

Verburgh

Verdonk

Muntinga

, et al. But at a certain point, the lights literally went out”: a qualitative study exploring midlife women’s experiences of health, wellbeing, and functioning in relation to paid work. Work 2023; 77: 799–809. https://journals-sagepub-com-s.web.bisu.edu.cn/doi/full/10.3233/WOR-220567

45.

Diacone

Bendien

van Baarle

, et al. Women in the Military: Navigating Through Female Life Stages and Military Career by “Acting Normally”. Armed Forces & Society. 2025; 0095327X251336195. 10.1177/0095327X251336195

46.

https://www.tweedekamer.nl/kamerstukken/moties/detail?id=2021Z18870&did=2021D40539

47.

Spector

, et al. The effectiveness of psychosocial interventions on non-physiological symptoms of menopause: a systematic review and meta-analysis. J Affect Disord 2024; 352: 460–472.

48.

Hardy

Clarry

Hunter

, et al. Assessing the effects of an online organisational toolkit to support menopause in the workplace (MENO-kit). Maturitas 2025; 199: 108304.

49.

Verburgh

Verdonk

Appelman

, et al. I get that spirit in me”—mentally empowering workplace health promotion for female workers in low-paid jobs during menopause and midlife. Int J Environ Res Public Health 2020; 17: 6462.

50.

Harper

Phillips

Biswakarma

, et al. An online survey of perimenopausal women to determine their attitudes and knowledge of the menopause. Womens Health (Lond) 2022; 18: 17455057221106890.

51.

Brand

. Two-thirds of FTSE 100 companies have failed to publish menopause support. HRreview 2022. Available from: https://hrreview.co.uk/hr-news/diversity-news/two-thirds-of-ftse-100-companies-have-failed-to-publish-menopause-support/145656 [accessed September 1, 2025].

52.

Portegijs W. Eens deeltijd, altijd deeltijd. Waarom vrouwen in deeltijd blijven werken als ze ‘uit’ de kleine kinderen zijn. Den Haag: Sociaal en Cultureel Planbureau; 2022. https://www.scp.nl/documenten/2022/09/28/eens-deeltijd-altijd-deeltijd.-waarom-vrouwen-in-deeltijd-blijven-werken-als-ze-uit-de-kleine-kinderen-zijn

53.

Baird

Hill

Colussi

. The reproductive body and the workplace: maternity, menstrual and menopause policies. In: Williamson

Parker

Donnelly

Gavin

Ressia

(eds) Research handbook on gender, work and employment relations. UK: Edward Elgar Publishing, 2025, pp.19–31.