Pregnant women’s experiences with sick leave caused by low back pain. A qualitative study

Abstract

BACKGROUND:

In Scandinavia, women of childbearing age represent nearly 50% of the overall workforce. Two-thirds of these women spend a considerable time on sick leave during their pregnancies. Low back pain accounts for a significant portion of all pregnancy-related sick leave. However, pregnant women’s experiences with pain-induced sick leave remains unexplored.

OBJECTIVE:

The study aimed to investigate women’s experiences with sick leave in relation to pregnancy-induced low back pain.

METHODS:

An inductive, qualitative study based on semi-structured, in-depth, face-to-face interviews with 19 purposefully selected Danish women. Interviews were analysed by means of thematic content analysis.

RESULTS:

The analysis revealed 4 categories: (1) Stuck in a diagnosis, (2) Inflexibility of the labour market, (3) Adapting to reduced capacity for work, and (4) Being socially excluded. The women’s experiences revolved around disruption of their physical functioning and expected capacity for work, a loss of professional identity, and a sense of inflexibility and exclusion from important relationships at work.

CONCLUSIONS:

Our findings illuminate the possibilities for workplace adjustments with the intention of reducing time spent on sick leave, maintaining pregnant women’s affiliation with their workplace, and a need to explore the role of healthcare professionals in addressing women’s supportive needs in relation to sick leave.

Keywords

Pregnancy women’s health workplace policies occupational health work-life balance

1 Introduction

In Scandinavia, more than 70% of women of childbearing age are employed and thus represent a considerable part (nearly 50%) of the overall workforce [1]. The prevalence of sick leave during pregnancy among Scandinavian women has been increasing over the last decades [2 –4]. Recent estimates have shown that two-thirds of pregnant women spend an average of 48–73 days on sick leave, more commonly in late than early pregnancy, and with a general tendency towards more long-term sick leaves, specified as continuous periods lasting beyond 2-3 weeks [3 , 5–7]. As such, sick leave during pregnancy constitutes a major health care challenge with considerable socioeconomic implications.

Several risk factors have been associated with sick leave during pregnancy, one of the strongest predictors being low back pain (LBP) [2 , 8]. Overall, LBP affects more than half of all pregnant women, a majority of whom indicate moderate to severe pain [3, 9]. Three out of four women with LBP spend some time on sick leave during their pregnancy [10]. Hence, LBP accounts for approximately one-third of the total number of women on sick leave during pregnancy, a significant portion of the whole [2 , 8–10]. Sick leave during pregnancy has also been associated with younger maternal age, multi-parity, socio-economic status, maternal overweight, and occupational exposures such as long working days, high job demands, poor job control, shift work, stressful work posture, conflicts in the work place, and little practical support from supervisors and colleagues [5 , 11].

Previous studies have investigated women’s experiences of living with LBP during pregnancy [12 –16], and other studies have explored women’s experiences of their capacity for work during pregnancy [17 –19], However, while the frequency and extent of sick leave during pregnancy is well-established and risk factors partially understood, the women’s experiences with sick leave and maintenance of capacity for work specifically due to pregnancy-related LBP remain unexplored.

To gain an in-depth understanding of the personal and work-related mechanisms surrounding LBP-induced sick leave among working pregnant women, this study aimed to investigate women’s experiences with sick leave in relation to pregnancy-induced LBP.

2 Methods

2.1 Research design and setting

The present study was designed as a qualitative study based on semi-structured in-depth face-to-face interviews with women who had experienced full-time sick leave during pregnancy in relation to LBP. The interviews were performed in August and September 2016, among women who had given birth between January and May 2016 at the Zealand University Hospital, Denmark. The hospital serves as a primary birth facility with 2600 deliveries annually and serves both rural and urban areas.

2.2 Sampling

Potential participants were identified from a cohort study conducted at the Zealand University Hospital [7] in which 513 women answered a questionnaire at 32 weeks of gestation concerning LBP intensity, total days of sick leave, lifestyle factors, and socio-demographic details. With the intention of recruiting information-rich cases, participants were selected by means of purposeful sampling [20], using both criterion- and maximum variation sampling. Women who had spent days on sick leave while pregnant were considered eligible. Further inclusion criteria were: (a) employment prior to and during pregnancy and (b) indication of moderate to severe LBP, defined as a score between 4–10 on the 11-point Numeric Rating Scale (NRS-11) [21]. In order to obtain maximum variation in experiences while also investigating core elements and shared outcomes [20], participants were selected to encompass a diverse range of characteristics relevant to the research question, including age, parity, current employment, educational status and total amount of days of sick leave at gestation week 32 (Table 1). An initial sample size of 20 participants was estimated prior to recruitment, and a final sample size ascertained by continual evaluation and reflection of the information power of the included participants throughout the research process [22].

Table 1
Participants’ characteristics (n = 19)

Characteristics Frequency

Maternal age

Median (min-max) 30 (22–42)

Parity

Ip 8 (1x twins)

IIp 7 (1x twins)

IIIp 2

IVp 2

Educational status

Higher grade professionals 4

Lower grade professionals 8

Skilled workers 3

Unskilled workers 4

Occupation at time of sick leave

Caregivers/health care (physician, nurses, social and health assistant, pedagogues, apprentice) 7

Sedentary jobs (office workers, accountant) 5

Retail workers (shop assistant, trainee) 2

Coordinating function or manager 2

Laboratory or factory workers 3

Sector / employment area

Public 10

Private 9

Total days of sick leave

Median (min-max) 70 (14–270)

Ethnicity

Eastern European 1

Middle European 2

Danish origin 16

Characteristics	Frequency
Maternal age
Median (min-max)	30 (22–42)
Parity
Ip	8 (1x twins)
IIp	7 (1x twins)
IIIp	2
IVp	2
Educational status
Higher grade professionals	4
Lower grade professionals	8
Skilled workers	3
Unskilled workers	4
Occupation at time of sick leave
Caregivers/health care (physician, nurses, social and health assistant, pedagogues, apprentice)	7
Sedentary jobs (office workers, accountant)	5
Retail workers (shop assistant, trainee)	2
Coordinating function or manager	2
Laboratory or factory workers	3
Sector / employment area
Public	10
Private	9
Total days of sick leave
Median (min-max)	70 (14–270)
Ethnicity
Eastern European	1
Middle European	2
Danish origin	16

2.3 Procedure

The flow of study participants through the study is shown in Fig. 1. According to the inclusion criteria, 75 eligible participants were initially identified and 23 women were scheduled to an interview at the hospital or at home, depending on their preference. Four women cancelled their interview. The final sample constituted 19 women.

Fig.1

The flow of study participants.

2.4 Data collection

The interviews were performed according to the women’s preferences; nine women were interviewed at the hospital, ten in their own homes. All interviews were conducted by AS and lasted between 20 and 55 minutes.

2.5 Interview guide

A thematic interview guide based on existing literature was developed. Main topics included working conditions, interaction with the workplace and health care professionals; and reflections and experiences regarding coping with LBP and sick leave. Questions were constructed in order to prompt narration, reflection and evaluation rather than rationalization, thus allowing for unexpected topics to arise [23]. All women were presented with the same introductory question and asked to describe how they had experienced their pregnancy. During the interviews, the women were encouraged to speak freely of their experiences. Clarifying or probing questions were used during interviews to prompt participants to elaborate on their narratives. Topics on the interview guide were only introduced if the informants did not spontaneously address them. To ensure consistency between interviews and the applicability of the content of the interview guide as related to the research question, the first two interviews were performed as pilot interviews by both AS and MGB. As no changes to the interview guide were necessary, the two interviews were included in the final analysis.

2.6 Data analysis

The interviews were recorded in full and transcribed verbatim. Interview transcripts were analysed by means of thematic content analysis, as described by Burnard [24, 25]. Using a low-inference approach, this method allows researchers to stay close to the original material, yet permits categories to be generated with minimal interpretation [24]. The analysis process involved a detailed and systematic recording of themes and issues addressed in the interviews, and a subsequent linking of the themes and interviews together in a reasonably exhaustive category system. Analysis was performed according to Burnard’s 14 steps, with the exception of step 11, which involves informant checking [24]. As this could lead to confusion rather than confirmation [23] this step was omitted.

After each interview, notes were made regarding topics and ways of categorising the data. All interview transcripts were read and notes taken on general topics by three authors (AS, MGB and LB). All five authors read through four transcripts, and the process of open coding was conducted independently by four authors (AS, MGB, LB and HKH), thus creating a system of codes to account for all aspects of the interview data. Sets of codes were compared and discussed in plenum (as a group) by all five authors. As codes were almost identical, consensus was reached. The first author coded the remaining interviews and grouped together the list of codes under higher-order sub-categories, and further reduced these sub-categories into broader categories. The new list of codes, sub-categories, and categories was then reviewed and repetitious or similar codes and sub-categories removed to produce a final list. This final category system was subsequently discussed by all five authors and revised, until consensus was reached. Subsequently, all interviews were carefully read through to ensure that the finally agreed-upon list of categories and sub-categories covered all aspects of the interviews and that the contexts of the coded sections were rendered correctly. Adjustments were made as necessary. During the process of writing up the results, the importance of staying close to original meanings and contexts was emphasized.

2.7 Research team

The authors (all female), who represent two professions: midwifery and psychology, possessed broad experience from clinical obstetric practice (AS, LB, MGB; midwives) and quantitative as well as qualitative health research (HKH; experienced midwife and JM; experienced psychologist). Before initiating the study, preconceptions were declared and discussed among the authors.

The interviewer (AS) had sparse experience with interviewing, however due to profession was experienced in communicating with women during pregnancy and after birth. The participants were informed about the interviewer’s professional background and interests in the study. The research team had no further professional or personal relationship with the participants prior to study commencement.

3 Ethical considerations

All participants were informed verbally and in writing of the purpose of the study, and interviewers obtained written informed consent before each interview. Participants were assured that all data would be treated confidentially and anonymously, and that they were free to withdraw at any time without impact on their future health counselling or treatment. According to Danish law, ethical approval is not required for non-invasive studies. The study was approved by the Danish Data Protection Agency (no. REG-59-2016).

4 Results

This study included 19 women between 22–42 years of age. Eight women were primiparous and eleven multiparous. Educational status was evenly distributed, as was employment at time of sick leave in the private or public sector. Days of sick leave amounted to a median of 70 days, with a range of 14 to 270 days, at gestation week 32 (Table 1). All participants but one were on full-time sick leave or planned maternity leave from gestation week 32 until birth.

The analysis of the interview transcripts resulted in 4 categories and 9 sub-categories (Table 2).

Table 2
Overview of analysis and development of categories, examples

Open coding/codes (sample) Sub-categories Categories

From a functional to a dysfunctional body, despair and endurance, counting down to birth Feeling trapped within a sick pregnant body Stuck in a diagnosis

Insufficient diagnostics, left to yourself, evasive professionals, lack of commitment and information Pregnancy as a fall-back explanation

Working or out of order, work-related adjustments to pregnancy, dispensable or appreciated, work satisfaction, convenient solution Feeling caught in the principle of either-or Inflexibility of the labour market

Work and pregnancy as unbalanced parts of your identity, staying loyal to yourself and workplace Striving to preserve a professional self

Colleagues and managers, influence on decision making Affiliation with the workplace

Loss of expectations, dedication to workplace and health, being sick without feeling sick, coming to terms with sick leave An inner conflict Adapting to reduced capacity for work

Dedicated to work and family, work-life balance, allocating resources, restoring balance Prioritizing resources and striving for balance

Feeling unjustifiably unhappy and troublesome, a burden to others, collegial conscientiousness Inadequacy and guilt Being socially excluded

Loss of social contexts, opting out of social activities, excluded from real life A sense of belonging

Open coding/codes (sample)	Sub-categories	Categories
From a functional to a dysfunctional body, despair and endurance, counting down to birth	Feeling trapped within a sick pregnant body	Stuck in a diagnosis
Insufficient diagnostics, left to yourself, evasive professionals, lack of commitment and information	Pregnancy as a fall-back explanation
Working or out of order, work-related adjustments to pregnancy, dispensable or appreciated, work satisfaction, convenient solution	Feeling caught in the principle of either-or	Inflexibility of the labour market
Work and pregnancy as unbalanced parts of your identity, staying loyal to yourself and workplace	Striving to preserve a professional self
Colleagues and managers, influence on decision making	Affiliation with the workplace
Loss of expectations, dedication to workplace and health, being sick without feeling sick, coming to terms with sick leave	An inner conflict	Adapting to reduced capacity for work
Dedicated to work and family, work-life balance, allocating resources, restoring balance	Prioritizing resources and striving for balance
Feeling unjustifiably unhappy and troublesome, a burden to others, collegial conscientiousness	Inadequacy and guilt	Being socially excluded
Loss of social contexts, opting out of social activities, excluded from real life	A sense of belonging

4.1 Stuck in a diagnosis

Subcategories related to women’s experiences of pain as a disruptive factor interfering with their bodily functioning and work capacity: Feeling trapped within a sick pregnant body, and Pregnancy as a fall-back explanation.

4.1.1 Feeling trapped within a sick pregnant body

Women initially anticipated that some degree of discomfort and pain would be a natural part of a healthy pregnancy. However, as pain intensified and persisted they reported being overwhelmed by the extent of their bodily limitations. Could not rely upon their usual physical capacity and pain had a violating impact on maintenance of their capacity for work. As they strived to understand pregnancy under new conditions, they reflected on their ambivalence about being pregnant and using pregnancy as a reason for sick leave.

“I felt terrible (\dots) and then there was the whole thing about being on sick leave and having it linked to being pregnant, that I thought was hard to swallow because everyone tells you that pregnancy is not an illness (\dots) You feel a little stigmatized, like ok, I can’t even cope with being pregnant.” (I:13)

When pregnancy advanced and pain became persistent, the women had difficulties accepting reduced functionality and felt trapped in a dysfunctional body. They described how they literally counted down to birth, and how this became a source of withstanding and enduring daily pain. As such, pregnancy was perceived as a phase of life to be overcome, lived through and emerge from.

4.1.2 Pregnancy as a fall-back explanation

When women recognized the need for sick leave, they consulted their general practitioners (GPs). Most GPs acknowledged the need for sick leave. Once diagnosed with pregnancy-related LBP, however, the women found it hard to navigate within the health care system and often felt left to themselves. Health professionals (midwives and GPs) were generally reported as being too evasive when participants asked for the possible reasons for their LBP, and the women also reported experiences of pregnancy being used as an excuse and fall-back explanation for not further investigating their LBP.

“[N]obody really bothered taking it like seriously (\dots) it was a complete waste of time, because they did not bother examining pregnant women because all pregnant women have back pain (..)You also felt stuck with a diagnosis, because you were pregnant (\dots) people everywhere has been pretty evasive about it I think.” (I:13)

4.2 Inflexibility of the labour market

This category included three sub-categories dealing with the challenges of pregnancy-related pain in relation to work: Feeling caught in the principle of either-or, striving to preserve a professional self, and Affiliation with the workplace.

4.2.1 Feeling caught in the principle of either-or

Workplace adjustments to pregnancy and possibilities of alternative arrangements at work were experienced as extremely rare. The women clearly described how they felt that they had more to offer at work. They wished that there had been room for creative thinking in regard to alternative work tasks, enabling them to remain functional, make use of their professional skills and thus stay longer in their working roles. In the lack of flexibility, the women felt caught in the principle of either-or. The majority eventually had to give in to full time sick leave, often initiated and encouraged by colleagues or managers.

“[T]here wasn’t any great understanding for me being ill and for me wanting to try. Either I should be poorly at home or else I should go to work (\dots) I was asked to stay away all together or to be there.” (I:7)

Some women experienced collegial interference as an expression of caring, while others referred to economic issues and aspects of work planning as explanations for why they felt sick leave was conveniently imposed on them.

“[T]o her [the manager] it was actually easier if I was on full time sick leave because she could then get a replacement in for me, instead of me only doing half the work, ehh, that way it also suited her interests.” (I:10)

4.2.2 Striving to preserve a professional self

Early in pregnancy, pain was experienced as a significant interference and the majority of women were confronted with the fact that pregnancy-induced LBP was incompatible with their usual capacity for work. As pain intensified, they found themselves changing their perceptions of self. Women emphasized how they strived to balance pain and capacity for work by accepting part- or full-time sick leave or by pursuing ways to work in spite of pain. They generally described feelings of inner peace knowing they had done their utmost, even though at the same time they felt rejected and replaceable.

“I knew I did everything I could to accommodate my employer or the work life that I still really would have liked to have been part of but wasn’t really allowed to.” (I:9)

Some women found alternative ways of maintaining work potential, i.e., an opportunity to work from the home, thereby keeping their days of sick leave at a minimum. Either way, the women generally pointed out the importance of staying loyal to their own expectations to perform and their obligations at work in order to preserve their professional identity.

“I was able to do my job, and that made me feel safer (\dots) I was very calm ehh and felt comfortable, even though I was in pain (\dots) I have done it in a good way, ehh, in a loyal way towards my work place and towards myself.” (I:2)

4.2.3 Affiliation with the workplace

When feeling appreciated by managers and colleagues, the women managed to maintain work satisfaction. On the other hand, when met with lack of flexibility and without influence on decision-making power concerning their changed work situation, the women described loosing interest and a reduced sense of responsibility towards their workplace.

“[T]hat feeling of being discarded and useless, that was a bit like, how do I put it, a failure (\dots) during this pregnancy I’ve gotten a little tired of them, so it [work] is not as important as it used to be.” (I:18)

Some women described distress caused by collegial responses, including experiences with collegial bullying and feelings of interference with their personal rights to choose pregnancy. Consequently, they found it hard to return after maternity leave and planned to seek work elsewhere.

“[T]he reaction I’ve gotten to my pregnancy and my illness or to my sick leave, ehh, it’s disappointed me very, very much (\dots) it will be really difficult to return to them” (I:7)

4.3 Adapting to reduced capacity for work

Two sub-categories in relation to the process of coming to terms with the need for sick leave were identified: An inner conflict and Prioritizing resources and striving for balance.

4.3.1 An inner conflict

The women primarily expressed their experiences with occupational limitations as being a source of inner conflict. They reported expectations that LBP would be a passing condition and anticipation of regaining their normal work potential. However, they described how they gradually recognized the seriousness of their physical conditions and somehow came to terms with their reduced capacity for work. Not being able to let go of work was widespread.

“[E]ven though I was at home, it was a little hard to like properly relax, like mentally at least, because then the body was relaxing but the mind it was like working a little anyway.” (I:1)

Acknowledgement of their efforts to keep up their work from managers and colleagues made sick leave more legitimate and acceptable. Some women described how they had refrained from making decisions about their need for sick leave and reflected on the importance of having others take on that responsibility for them.

“[M]aybe there has to be a manager or some health care professionals involved, saying stop (\dots) you maintain a front and you fight and you fight, despite pain (\dots) you push yourself a lot, when you are a conscientious person, it’s probably been unhealthy for me not having someone to say: forget it, stop.” (I:5)

Eventually, acceptance of full-time sick leave was experienced as a process of relief, as the women could let go of worries about stressful conditions at work. Some women described that when their worries about working and sick leave disappeared, pain also lessened.

4.3.2 Prioritizing resources and striving for balance

Women generally regarded pregnancy-related pain as a disruptive factor, disturbing their work-life balance. Many found themselves fighting to stay at work, pushing themselves to the edge at the expense of family, with the result being dissatisfaction with performance both at home and at work.

“[T]his struggle at work and for the house and home and for the child (\dots) maybe it wasn’t fair (\dots) that I just about did my job for a few hours a day and still not able to do it (\dots) you felt you had done something, but maybe you should have done that something at home instead.” (I:5)

Everyday tasks were experienced as troublesome, and some felt forced to compromise their own health. Acceptance of sick leave remained difficult, however eventually led to reflections on work as less important. This gave rise to considerations about future work-life and pregnancies, if any. To some, thoughts of being pregnant again seemed unthinkable due to fear of reliving pain and consequences at work and at home. Women found balance by allocating resources to family and other children.

“[A]nd so I nicely accepted (\dots) if I was to be just a little bit happy and not be in pain all the while, and be able to be something for our son (...) then work would sort of have to do without me (\dots) it is just so hard to accept that you are not able to go to work.” (I:1)

4.4 Being socially excluded

This category comprised two sub-categories in relation to the women’s reflections on social consequences of pain and sick leave at work and in general: A sense of belonging and Inadequacy and guilt.

4.4.1 A sense of belonging

The women described how their professional identity, to a large extent, depended on their social interactions at work. Work meant being part of a meaningful social and professional context and being intellectually and socially stimulated.

“[M]y colleagues have been a part of me and I of them, they have shared joys and sorrows and such, and suddenly I don’t have them anymore (..) I cried every day in, how long was it, a long time full well knowing that now, now once again my working life was ending.” (I:9)

Experiences of a supporting and understanding environment strengthened the women’s sense of belonging, whereas disappointment with collegial responses consequently made women question their return to work after maternity leave.

“ \dots [T]hen, they asked me if I could take full time take sick leave, because this would allow them to find someone to replace me.” (I:13)

4.4.2 Inadequacy and guilt

Due to reduced capacity for work, the women often perceived themselves as a burden, leaving colleagues with extra loads of work. Before sick leave or during part-time sick leave, they did not feel able to perform their usual tasks or take part in teamwork, as they had previously. During the process, they experienced feelings of guilt and inadequacy, as their sense of collegial conscientiousness was tested.

“[I]t was one of the reasons why I actually chose, you know, sick leave, it was also this enormous sense of guilt that, I can’t, I can’t be there for my colleagues the way I want to be.” (I:9)

Feelings of being met with a widespread ignorance and lack of understanding from society in general was a further source of frustration, leaving women with an urge to explain or defend themselves in order to justify their pain and reduced capacity for work.

“[E]very time you have to call work, you feel guilty, every time you have to consider these things, you are affected by feeling guilty, and that is really not fair, when you are actually in a lot of pain.” (I:5)

5 Discussion

Results of our qualitative study of women’s experiences of sick leave in relation to LBP during pregnancy showed that women struggled to restore balance and regain control of their professional and private lives, which may lead to feelings of defeat, self-blame and inadequacy.

Notably, the women generally felt stuck and let down by the healthcare system, managers, colleagues, and prevailing attitudes of society. The circumstances surrounding sick leave disturbed their perception of themselves as individuals and professionals. These perspectives are supported by other studies [14 , 26]. Similar to the findings in our study, Persson et al. [16] found that pregnant informants held strong professional identities. Sick leave was perceived as a deviation that caused feelings of incapacity, vulnerability, frustration and resignation. As in our study, the participants in Persson et al’s study experienced a lost sense of coherence and togetherness that came with being part of a team at work [16]. Social interactions at work was also perceived as the most important factor that supports work performance, satisfaction, and well-being, among non-pregnant individuals, with long term sick leave experiences [27].

The high degree of flexibility and willingness to adapt to conditions at work and the loss of social interactions, expressed by the women in our study has not previously been described. The women's request for creative thinking and alternative use of their professional skills with the intention of postponing, reducing or eliminating the need for sick leave also represents new knowledge. In an interview study focusing on women’s experiences of living with pelvic girdle pain, Elden et al. [13] found that confirmation of women’s importance within the workforce as well as necessary changes at work are essential to women’s ability to maintain their capacity for work in spite of pain. Further research is needed to illuminate the possibilities of workplace adjustments in order to reduce sick leave, prevent social isolation, and maintain women’s affiliation with work place and work satisfaction during prolonged absence from work during pregnancy.

The women in the current study described flexibility of work tasks as very limited or non-existent. In an interview study including pregnant women without physical impairment [28], pregnancy care-work was experienced as incompatible with workplace settings, partly because women were met with a workplace mantra: ‘pregnancy is not an illness’ and thus experienced some level of pressure to pursue work tasks, and also partly because they had a desire to present themselves as normal and able to perform as usual. Gatrell found that some women may tend to deny their own health problems during pregnancy and resist taking sick leave due to fear of being considered weak or incompetent [19]. This is similar to the findings in our study where some women described having fought to stay at work, knowing that they did so at the expense of their own health.

The women in our study generally described information and evaluations about LBP from healthcare professionals as limited and inconsistent and requested follow-up evaluations after the birth. Recent studies have found that a lack of individually tailored, evidence-informed advice may precipitate psychological stress among women with LBP during pregnancy [12, 13]. Further research is needed into how healthcare professionals may better support and advise pregnant women in relation to LBP specifically and working life in general.

Overall, our findings reflect the importance of working life for pregnant women’s identity. The results indicate that women have high expectations to perform well and consequently experience profound feelings of defeat when unable to live up to their own expectations and what they perceived as societal and workplace norms. An advantageous reduction of the overall rate of sick leave during pregnancy might be based on multifaceted efforts to increase flexibility at workplaces to better meet women’s needs and maintain work satisfaction and engagement in spite of pregnancy-related LBP. Overall, our results challenge our current understanding of the complex nature of sick leave during pregnancy.

5.1 Implications for clinical practice and research

Our findings suggest that midwives and general practitioners function as mediators between women and the workplace when capacity for work is reduced due to pregnancy-related complications (29)]. Thus, a better understanding of how sick leave affects pregnant women’s professional and personal lives is required within these professions in order to optimize maternity care during pregnancy and beyond. Healthcare providers and workplace managers should approach the issue of reduced capacity for work during pregnancy in a respectful manner and avoid using ‘pregnancy’ as a catch-all explanation and sick leave as the sole solution to reduced capacity for work. Hence, a wider focus on optimizing the cooperation and dialogue between healthcare professionals, workplace managers, and the individual woman is warranted. Healthcare providers may thus, to a broader extent, function as a useful resource, supporting the individual woman’s attempts to integrate pregnancy and pregnancy-related complications in her work-life balance.

Workplace adjustment policies could aim to improve the individual pregnant woman’s occupational health, maintaining attachment to her work place for a longer period of time and optimizing the use of womens’ potential during pregnancy, in spite of pregnancy-related complications [30]. Such policies would preferably be based on both the views and needs of the woman and her employer. Including healthcare providers in this process would be beneficial.

5.2 Methodological considerations

The trustworthiness of this study was ensured through researcher triangulation in a collaboration between authors who represent different professions and various experiences within clinical practice and research which gave rise to different perspectives on the research field [31]. Preconceptions were identified and shared, and care was taken to bracket these throughout the process of sampling, recruitment, data collection and analysis. Committing to reflexivity, consensus during the analysis phase was reached by contesting and supplementing each other’s statements. The applied coding scheme served to strengthen the overall validity and dependability of our study [23]. Considerations about dependability were further taken into account by asking participants the same introductory question and referring to the topics of the interview guide. Our sampling strategy allowed for a great diversity of participant experiences, enabling us to explore and clarify the research topic from various perspectives, and thus strengthen the credibility of our study [23]. The transferability of our findings should be approached cautiously. Small qualitative studies normally should not be used that way. Comparable working conditions within similar cultural settings, including the position of women within the labour market and the societal views of pregnancy are only a few of the factors that would need to be considered. Replication of this study in relation to sick leave in general, would be recommended. The interviews were conducted at an average of 26 weeks after the women had given birth, giving them a considerable time to adapt to their new life situation and reflect on the circumstances surrounding sick leave. These retrospective reflections may have affected the women, influencing their description by their present state of mind in relation to pain and life circumstances. However, it has been well documented that women remember well the period surrounding their pregnancy and childbirth [32].

6 Conclusions

Sick leave in relation to pregnancy-related LBP leads to experiences of loss of professional identity, exclusion from important social relationships at work, and an overall sense of imbalance in pregnant women’s professional and personal lives. Our findings suggest an unmet need for further research, which illuminates the possibility of workplace adjustments intended to reduce sick leave, prevent social isolation, and maintain pregnant women’s affiliation with their workplace during prolonged absence from work. Further research is needed to explore the role of healthcare professionals when addressing women’s experiences and individual needs in relation to sick leave.

Authors’ contributions

All five authors participated in the planning of the study and the data analyses. AS carried out the data collection. AS wrote the drafts of the manuscript, which HH, JM, LB and MB commented on. All five authors approved the final manuscript.

Conflict of interest

The authors declare no conflicts of interest related to this study.

Footnotes

Acknowledgments

We are most grateful to the women who participated in this study for sharing their experiences with us. The study was supported by midwife Hanne Kjærgaard’s memorial grant.

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