Pregnancy vs. Paycheck: A qualitative study of patient’s experience with employment during pregnancy at high risk for preterm birth

Pregnancy vs. Paycheck: A qualitative study of patient’s experience with employment during pregnancy at high risk for preterm birth | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Pregnancy vs. Paycheck: A qualitative study of patient’s experience with employment during pregnancy at high risk for preterm birth Sarahn M. Wheeler, Kelley E. C. Massengale, Konyin Adewumi, Thelma A. Fitzgerald, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-36777/v3 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Sep, 2020 Read the published version in BMC Pregnancy and Childbirth → Version 3 posted 4 You are reading this latest preprint version Show more versions Abstract Background: Pregnant women with a history of preterm birth are at risk for recurrence, often requiring frequent prenatal visits for close monitoring and/or preventive therapies. Employment demands can limit uptake and adherence to recommended monitoring and preterm birth prevention therapies. Method: We conducted a qualitative descriptive study using in-depth interviews (IDIs) of pregnant women with a history of preterm birth. IDIs were conducted by trained qualitative interviewers following a semi-structured interview guide focused on uncovering barriers and facilitators to initiation of prenatal care, including relevant employment experiences, and soliciting potential interventions to improve prompt prenatal care initiation. The IDIs were analyzed via applied thematic analysis. Results: We described the interview findings that address women’s employment experiences. The current analysis includes 27 women who are majority self-described as non-Hispanic Black (74%) and publically insured (70%). Participants were employed in a range of professions; food services, childcare and retail were the most common occupations. Participants described multiple ways that being pregnant impacted their earning potential, ranging from voluntary work-hour reduction, involuntary duty hour reductions by employers, truncated promotions, and termination of employment. Participants also shared varying experiences with workplace accommodations to their work environment and job duties based on their pregnancy. Some of these accommodations were initiated by a collaborative employee/employer discussion, others were initiated by the employer’s perception of safe working conditions in pregnancy, and some accommodations were based on medical recommendations. Participants described supportive and unsupportive employer reactions to requests for accommodations. Conclusions: Our findings provide novel insights into women’s experiences balancing a pregnancy at increased risk for preterm birth with employment obligations. While many women reported positive experiences, the most striking insights came from women who described negative situations that ranged from challenging to potentially unlawful. Many of the findings suggest profound misunderstandings likely exist at the patient, employer and clinical provider level about the laws surrounding employment in pregnancy, safe employment responsibilities during pregnancy, and the range of creative accommodations that often allow for continued workplace productivity even during high risk pregnancy. Sexual & Reproductive Medicine employment work preterm birth high risk pregnancy Background In the US, preterm birth (PTB) and its complications are among the leading cause of neonatal death 1 . Women with a history of prior PTB are at increased risk for recurrence in future pregnancy. To reduce the risk of recurrent PTB, detailed care plans that require more frequent prenatal visits and monitoring are often recommended. For maximum benefit, preventive care must be initiated early and followed diligently throughout pregnancy. Recent data shows that one in seven US women receive inadequate prenatal care 2 . Despite these alarming rates and the urgent need for initiation and adherence to PTB prevention strategies, there are limited data on barriers to early prenatal care initiation in women with a history of PTB from the patient perspective. With the goal of uncovering patient perceived barriers to early initiation of prenatal care and developing interventions to mitigate barriers, we conducted a qualitative study of pregnant women at high risk for PTB. In the US, over 50% of pregnant women work outside the home 3 , and more than 20% of pregnant women are employed in low-wage jobs, earning less than $11.50 per hour 4 . Low-wage jobs often have limited flexibility in assigned work schedule and paid-time-off, making adherence to more frequent prenatal visits or monitoring even more challenging. In the US, there is also a well-documented race disparity in PTB such that non-Hispanic black women are 49% more likely than other racial/ethnic groups to experience PTB 5 . It is imperative to understand women’s employment experiences during high risk pregnancy, particularly experiences of non-Hispanic black women working in lower income wage jobs. These insights are critical to identify potential interventions that may alter the workplace experience to increase early initiation of care and adherence to PTB prevention. Here we describe findings from a larger qualitative study focused on barriers and facilitators to prenatal care in women with a history of prior PTB. As part of those interviews, women provided varied and important insights on the impact of employment on their high risk pregnancy care. The aim of this sub-study was to describe women’s experiences with employment during a pregnancy at high risk for PTB. Methods Parent Study The current manuscript is a sub-study of a larger parent study. The parent study was a qualitative descriptive study using in-depth interviews (IDIs). The IDIs were conducted between September 2018 and June 2019 in Durham, NC. The study was approved by the Duke Health Institutional Review Board (Pro00100090) on May 29, 2017. All participants provided written consent prior to participation. The parent study was focused on uncovering barriers and facilitators to initiation of prenatal care. The interview guide investigated numerous aspects of participants’ lives, ranging from how and when participants discovered they were pregnant, to how and when they disclosed their pregnancy to their partner and logistical barriers of scheduling appointments. The interview guide included questions that focused on the participant’s experience navigating pregnancy and employment (Supplemental File). The current analysis is focused on the data gathered from those interview questions. Eligibility Criteria and Recruitment Procedures Participants were recruited from the high risk obstetrical clinic of a large academic medical center. Participants were also recruited via a registry of women who delivered at the same institution after prior high risk pregnancy. This high risk obstetrical clinic is located in the southeastern US and serves approximately 2,000 women per year, of which approximately 50% are non-Hispanic White and 40% are non-Hispanic Black. Women were recruited during their routine prenatal visit or via phone solicitation. Women were offered compensation for their time. Women were eligible for study enrollment if they were currently or recently pregnant (within 2 months postpartum) and at high risk for PTB, defined as history of a prior spontaneous singleton PTB. We excluded women who did not speak English fluently. The current analysis also excludes women who were unemployed during their index pregnancy because the interview guide questions focused on employment were not applicable in that situation. Additionally, participation in the parent study was limited to women whose self-reported race and ethnicity is non-Hispanic Black or non-Hispanic White. We focused on these groups because the intent of the parent study was to descriptively compare experiences between the most prevalent racial/ethnic groups from the clinic population from which women were recruited. Data Collection Demographic information including age, race, insurance status and employment were obtained via electronic health record review and patient report. IDIs were conducted by trained qualitative interviewers in a private room near the clinic space or via phone at a time convenient to the participant. The interviewer followed a semi-structured interview guide focused on identifying barriers and facilitators to initiation of prenatal care and soliciting patient-perceived potential interventions to improve prompt prenatal care initiation. We asked participants to describe their current employment setting and experiences communicating with their supervisor about their pregnancy, scheduling shifts, and any pregnancy-related workplace accommodations. Interviews were audio-recorded with participant permission and transcribed verbatim. Analysis Demographic data were analyzed and presented using descriptive statistics. The IDIs were analyzed via applied thematic analysis 6 , by two analysts trained in qualitative data analysis. The codebook was developed incorporating structural and emergent codes. Structural codes were applied to the transcripts to organize participant responses based on the interview guide question to which the participant was responding and/or a related topic(s) spontaneously mentioned during the interview. The codebook was then expanded to include additional emergent codes associated within each structural code after reviewing the transcript passages associated with each structural code. We then applied the emergent codes to the transcripts. Inter-rater reliability procedures were conducted on 27% (n=33) of interview transcripts with coding differences resolved by discussing individual instances until consensus was reached. Focusing on employment experiences, we then examined the narratives within the emergent codes to discover common themes among participant responses. Patterns across responses were identified within individual codes, then patterns across codes were identified to reveal salient themes. We first identified experiences that participants perceived asimpacting their abilities to maintain employment during a high risk pregnancy. We then organized those experiences into two categories based on whether the experiences influenced participants’ income or were related to the implementation of pregnancy-related workplace accommodations. Results The current analysis includes 27 of the 33 women interviewed for the parent study. We excluded six women from the current analysis because they were not employed during their index pregnancy, and therefore they were not asked the employment questions during the interview. Participants (N=27) were on average 29 years old, majority non-Hispanic Black (NHB) (74%), and most often publically insured (70%) (Table1). Participants were involved in diverse fields of employment. Food services, childcare and retail were the most common occupations (Table 2). Our analysis identified two broad over-arching themes: negative implications of pregnancy on income and challenges related to workplace accommodations. Income Implications Participants described multiple ways that they felt their income decreased due to their pregnancy. Some of the pay decreases were the result of reduced duty hours, while other participants described limitations due to unpaid leave (Table 3). Women working in non-hourly employment also said that pregnancy negatively impacted their income. Reduced Duty Hours: Participant Initiated Many of the study participants (n=13) described income reduction due to decreased hours worked that they attributed to their pregnancies. Over half (n=7) of the work hour reductions that were described resulted from participant-initiated requests for a reduced workload. Some (n=4) participants requested to work shorter shifts and some (n=3) chose to leave their jobs. Most often the participant-initiated duty hour reductions or employment terminations were linked to pregnancy discomfort. One of these participants, a food service worker, described reducing her hours at a job that did not allow for much sitting: “ I used to work full time, but now I work part time because it’s more of, I work in hospitality so I be on my feet a lot… now that I’m further along I experienced more lower back pain, under my stomach.” Another participant, also working in food service said, “I stopped working [at fast food restaurant] … when like, my back started hurting or I was being like, I was moving slower like, I wasn’t with production time and stuff like that.” The participant also explained that the smells from certain foods cooking at the restaurant made her vomit during her shifts. Reduced Duty Hours: Supervisor Initiated Multiple participants (n=6) described supervisors who reduced the number of hours participants worked despite their desire to continue working. For example, a participant working in retail described that her employer responded to her pregnancy by: “ Cutting my hours, that’s how she really responded to the whole [pregnancy] thing. She just cut my hours.” Another participant, a food service worker, described a similar experience: “They didn’t know I was pregnant right away… they was like, ‘you know, you’re showing a little.’ So that’s when that came out. So that’s definitely, [fast food restaurant] changed my schedules, [from 7am to 4pm to] like 8 to 4, whatever you know, 10 to 4. They tried to sneak an 11 to 4.” There were also participants who expressed positive work experiences prior to their pregnancy, yet during their pregnancy they terminated their employment due to decreased earnings and truncated advancement. A participant working in food service commented, “[Supervisor] was really like communicative and nice, but at the same time she was cutting my hours... so she was really nice about it, but at the same time, she knew that I needed the hours and she was still cutting them. So, that’s why I had to leave because I was not making any money.” Another participant also a food service worker, who was excited for an upcoming promotion, described leaving her job due to unsupportive attitudes towards her pregnancy: “I worked so hard you know, I fought for that spot… ‘cause I love working there, eating there, but [fast food restaurant] weren’t really supportive of pregnant women working there at all you know.” Unpaid Leave Less than one-third of the participants in our study were eligible for paid or partially-paid leave from their jobs. One participant, working in real estate, described a finite amount of time she could take off from work to attend prenatal visits before delivery and during postpartum recovery. She had to weigh when to use paid time-off: “I try not to use my PTO [paid time off] because you know you have to use PTO when you go on FMLA [Family and Medical Leave Act], before your short-term disability starts, so sometimes I just have to take the hit and not hit my forty hours, which means a lower check. ” Some participants (n=3) described situations in which unpaid leave was couched as a benefit to employees who were told they could return to work after delivery without having to reapply for their jobs. A food service worker explained she was told: “ Just a leave, basically like you’re just quitting and then you just get rehired .” Another food service worker said she knew to expect being removed from the work schedule towards the end of her pregnancy: “…so as far as my due date, I told him that I’m due in September and he knows like, when it gets close to August, he’ll actually be preparing to take me off the schedule until I’m ready to return to work .” Reduced Income in Non-Hourly Employees Participants whose time at work was not scheduled in hourly shifts also experienced negative impacts to their take-home pay due to pregnancy. One participant, who worked for a small retail business, reported that her supervisor allowed her to make-up the missed work due to prenatal visits at another time so that her take-home pay was not impacted, but only during the business’ “ busy season .” Otherwise, she had to take unpaid leave from work to attend prenatal visits. Another participant who works in real estate, had a flexible work schedule. However, since she was paid on commission, time away from work could still impact her take-home pay as she explained, “ If I’m not there then I’m just not there [to earn money]. ” Many of the participants who worked in childcare reported positive experiences because they were able to balance work with prenatal and postpartum care. For one participant, the timing of her pregnancy meant that she could avoid reduced work hours. As the childcare worker explained, she did not have to take unpaid leave to attend prenatal visits since she disclosed her pregnancy during the summer, prior to the finalization of teaching assignments for the current school year . “I wanted to tell [supervisor] when my schedule was being like, figured out because I wanted to try and build in certain pockets of time when work was easier for me to get away for appointments.” The participant further explained that she was then able to attend healthcare visits during her planning period and make-up the missed work time on her own to avoid any impacts to her take-home pay, since she requested the schedule changes before the school year started. Workplace Accommodations Participants discussed accommodations that their employers and coworkers made in their workplace environment or within job duties during their pregnancies. These accommodations were sometimes a collaborative effort between the participant and her employer; in other situations they were employer-initiated based on the employer’s perception of safe working conditions during pregnancy, and in other instances accommodations were medically recommended by an obstetrical care provider (Table 3). Collaborative Employer/Employee Accommodations Some of the most positive employment experiences recounted were collaborative efforts between the participant and her employer to adjust the workplace environment and job duties allowing the participant to continue performing her job duties while feeling safe and supported. A healthcare worker described: “ They were very supportive. They told me that, you know, I wanted to do night shift and I wanted to do like an easier hall, like maybe rehab or something like that, and they were completely open to it; they were fine .” Another healthcare worker, whose job required several hours of sitting and typing, described how her employer helped to make her workstation more comfortable: “ … if I need to be off or whatever, if I needed any accommodations to my workspace like, I had to buy, I didn’t have to buy it, they reimbursed me for it, but just different, like back supports and footstools and stuff that I started needing later ‘cause I was sitting a lot you know, they reimburse for, but anything I mean anything I needed they were onboard for. ” Employer-Initiated Accommodations In other situations, workplace restrictions stemmed from the employer’s perception of safe working conditions during pregnancy. For example, a real estate worker explained that her manager “ barely lets me carry the water ” even though her medical provider had not recommended any lifting restrictions. Another participant working in food service without any provider-documented restrictions, described how her employer frequently considered her pregnancy: “ They were strict with me of doing a lot of things. I couldn’t lift nothing, I couldn’t do too much bending like, kind of you know, they took my health into consideration, most definitely. ” Medically Recommended Accommodations Participants also described situations where their medical provider recommended modifications to their job duties. These medically recommended restrictions were met with varied reactions at the workplace. A participant working in retail described a very supportive response from her employer. She said, “They’re supportive of me and they’ve been working with my accommodations… right now I’m on a twenty-five-pound weight restriction, so anything that would feel too heavy for me to lift, or to move, they actually do it for me.” Other participants described more negative reactions from their employers upon requesting medically-recommended accommodations during the workday. Two participants recounted experiences in which they perceived that their employment was terminated due to a request for accommodations recommended by a medical provider. One participant shared her experience of being laid off from her job at a grocery store when she shared that her physician had recommended an accommodation to her job duties: “ I was just laid off yesterday… due to my limits and restrictions from the doctors…. I was put on a ten-pound lifting limit, which is very, very small and unfortunately with all the job descriptions at my employer I wasn’t eligible for employment anymore. … I busted my butt at that place and gave it everything that I had, even very sick and ill and not well and they, I feel like they tossed me in the trash.” When another participant started a new job as a nurse, she found her new employer was unwilling to accommodate job duty recommendations from her healthcare provider: “I told her like maybe on day seven that I had a nurse’s note and when she told me that she was not going to accommodate it, I just basically let her know like, ‘well I can’t continue to work here. Like I need to,’ you know in the note it says like okay well, ‘I need to be able to take frequent breaks like to sit down, I can’t stand for longer than two hours, I should be able to take water breaks, bathroom breaks and stuff like that.’… She had a whole attitude about it and told me that she was not going to accommodate my nurse’s note so I was like ‘okay, you’re not going to accommodate my nurse’s note like so you want me to put myself and my baby in danger; no thank you, you can keep this job .’” Ultimately, the participant quit the new job because the employer would not accommodate the requests in her healthcare provider’s note. Discussion We present novel qualitative data that provides insights into US women’s experiences balancing a pregnancy at increased risk for preterm birth (PTB) with employment obligations. The participants were majority non-Hispanic Black (NHB), as NHBs bear a disproportionate burden of PTB within in our clinic and across the nation. Additionally, the majority of women in the study were publically insured and employed in occupations that are most often low income. While many women reported positive experiences, the most striking insights came from women who described negative situations that ranged from challenging to potentially unlawful. Employment status changes including voluntary and involuntary reduction of hours and termination were some of the most notable findings of the study. Multiple participants described voluntarily reducing their work hours or terminating their employment due to physical discomfort or perceived risks their employment posed to pregnancy. These findings may represent women taking bold measures to advocate for their health during pregnancy. However, in most cases, even during high risk pregnancy, it is considered safe and healthy for women to continue working during pregnancy. A meta-analysis evaluating the impact of work activities on pregnancy outcomes including prematurity, low birth weight and hypertensive complications found increasing evidence to suggest that employment-related risks to pregnancy are minimal 7 . Based on these and other data, the American College of Obstetricians and Gynecologists (ACOG) recommends that it is “generally safe” for women to work during pregnancy 3 . Notably, most of these data do not directly address women with a history of PTB. Although the data is limited in this setting, most experts agree that a history of PTB alone does not necessitate activity restriction such that women are unable to work. Simple modifications such as a sitting stool or more frequent breaks often allow a woman to safely and more comfortably complete her work duties during a high risk pregnancy 8 . Accommodations to limit standing and lifting may be indicated in physically demanding professions, as there are data to suggest lifting cumulative weight over 100 kg per day and standing for over three hours per day increases the risk of PTB 9,10 . Many of the participants in our study reported positive experiences with employers who proactively made simple accommodations to facilitate continued safe and comfortable employment during pregnancy. Other participants described employers who were unable and/or unwilling to modify job duties, leading to loss of employment. The Americans with Disabilities Act requires employers to provide “reasonable” accommodations for pregnancy-related impairments, as long as it does not cause “undue hardship” to the employer 3 . This legislation requires employers to provide accommodations for pregnant women that would be rendered to other employees with a time-limited medical impairment. For example, if an employee was accommodated with a sitting stool after a back injury, a pregnant women with a similar job description should also have access to a sitting stool. However, the Americans with Disabilities Act only applies to employers with 15 or more employees and is similarly challenging to enforce 3 . Perhaps the most concerning disclosures were women who reported involuntary reduction in their employment hours and coercion to prompt resignation. Although it is important to note that the data presented represents events solely from the patient perspective, without insights from the employer or provider, an involuntary reduction in employment hours simply due to pregnancy is unlawful in many circumstances. The US Pregnancy Discrimination Act prohibits forcing a pregnant woman to take leave, who is otherwise capable of performing her work functions 3 . However, the protections offered by this legislation are limited. This legislation only applies to specific employers (i.e. employers with over 15 employees) and can be difficult to enforce, as one must file a claim with the Equal Employment Opportunity Commission when there is an infringement 3 . Our study presents important insights from the patient perspective about their experiences balancing employment with high risk pregnancy. Despite the impact of our findings, important limitations must be considered. The original intent of the IDIs was not focused solely on employment. Given that the parent study was broader in scope, the IDI guide omitted key follow-up probes to employment-related questions that could have yielded even greater insights on this topic. For example, many participants described situations where it is unclear if the physical limitations in the workplace were based on recommendations from a medical provider or based on the participant’s own comfort level. Additionally, due to logistical limitations, our study excluded non-English speaking women. Non-English speaking women in the US may be the most vulnerable to challenging work conditions with limited ability to modify their job duties in the setting of high risk pregnancy. Women who identify as Hispanic ethnicity were outside of the scope of the original research aims of the parent study; therefore, the undoubtedly valuable insights from this patient population are not represented in the current study. Further studies incorporating Hispanic and non-English speaking women are urgently needed. The data in the current study also include participants recruited from a single academic institution and therefore may have limited generalizability. The majority of participants in our study are non-Hispanic Black and publically insured. Although it is unknown whether their experiences reflect the broader experiences of pregnant women across the US, NHB women in our clinic and across the US bear a disproportionate burden of PTB 5 and more commonly work in lower-income, less flexible occupations; 4 therefore their insights into employment barriers within the setting of high risk pregnancy care are essential. The literature has documented that adherence to PTB prevention strategies is often uniquely challenging for NHB women 11,12 . For example, despite recommendations from the American College of Obstetricians and Gynecologists (ACOG) supporting weekly injections of 17-hydroxyprogesterone caproate (17-P) to reduce the risk of recurrent PTB, multiple studies document reduced adherence to 17-P in NHB women 11,12 . Although the efficacy of 17-P is being re-evaluated, it was once the cornerstone of PTB prevention; therefore, much of the published work on adherence to PTB prevention focuses on 17-P. In a study of women who previously delivered preterm, patients identified limited time-off from work and inflexible work schedules as barriers impeding adherence to the weekly 17-P injection schedule 13 . The findings within the 17-P literature surrounding adherence highlight the urgent need for uncovering and addressing barriers to adherence that are culturally sensitive and inclusive of women from racial and ethnic backgrounds most impacted by PTB. The impact of PTB is also disproportionate among women with lower socio-economic status 5 and most of the women in our study work in occupations that are traditionally lower-paying. While the interview guide did not inquire directly about income or educational attainment, given the high number of women in the study on public insurance, we suspect that many likely had lower incomes and less formal education. Participants were also employed in two of the most common occupations held by women in general (healthcare/nurse and customer service), four of the most common occupations held by pregnant women (food service, retail, healthcare/nurse and customer service), and the three of the most commonly held occupations by pregnant Black women (retail, healthcare/nurse and customer service) 4,14 . Although the experiences recounted may not be representative of all pregnant women at high risk for PTB, the findings suggest the workplace environment could be improved, thus mitigating barriers for pregnant women working across an array of commonly held occupations. Our findings highlight important opportunities to mitigate barriers to high risk prenatal care and potentially improve adherence to PTB prevention strategies through education. Many of the findings suggest that profound misunderstandings likely exist at the patient, employer and provider level about the laws surrounding employment in pregnancy, the medical risks of continued employment, and the range of creative accommodations that often allow for continued workplace productivity even during high risk pregnancy. To address this need, we have established a collaboration with the Duke Health Justice Clinic to develop trainings and educational materials. Future studies using educational interventions aimed at patients, employers and medical providers to improve understanding about appropriate limitations and accommodations may be uniquely impactful to improve timely initiation of and adherence to high risk prenatal care and PTB preventive care plans. Conclusions Women balancing pregnancy at high risk for preterm delivery with employment obligations report a variety of experiences. While some women reported positive experiences, many women described situations that ranged from challenging to potentially unlawful. Our findings suggest that profound misunderstandings likely exist at the individual, employer and provider level about the laws surrounding employment in pregnancy, safe employment responsibilities during pregnancy, and the range of creative accommodations that often allow for continued workplace productivity even during high risk pregnancy. Future interventions aimed at individuals, employers and medical providers to improve understanding about appropriate modifications and accommodations may be uniquely impactful to improve timely initiation of and adherence to high risk prenatal care and preterm birth preventive care plans. Abbreviations IDIs: in-depth interviews NHB: non-Hispanic Black PTB: preterm birth Declarations Ethics approval and consent to participate: The study was approved by the Duke Health Institutional Review Board (Pro00100090) on May 29, 2017. All participants provided written consent prior to participation. Consent for publication: N/A Availability of data and materials: Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Competing interests: The authors declare that they have no competing interests. Funding: Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR001117. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr. Wheeler is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number 1KL2TR002554. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Authors’ contributions: All authors have read and approved the manuscript. SW: major contributor to the concept and manuscript writing, KM: analyzed data, contributed to manuscript preparation, KA: data collection, TF: data collection, CD: data collection and analysis, TS: data collection, GS: contributions to overall concept and manuscript revisions, AC: guidance on data collection methodology and manuscript review Acknowledgements: We wish to acknowledge the women who participated in this study. They bravely and honestly shared their experiences. We thank them for sharing their stories. References Murphy SL, Xu J, Kochanek KD, Arias E. Mortality in the United States, 2017. NCHS Data Brief. 2018(328):1-8. Osterman MJK, Martin JA. Timing and Adequacy of Prenatal Care in the United States, 2016. Natl Vital Stat Rep. 2018;67(3):1-14. ACOG Committee Opinion No. 733: Employment Considerations During Pregnancy and the Postpartum Period. Obstet Gynecol. 2018;131(4):e115-e123. Harwood MaH, Sarah David By the Numbers: Where Do Pregnant Women Work? 2019. 2019 March of Dimes Report Card. 2019; https://www.marchofdimes.org/mission/reportcard.aspx#:~:text=2019%20MARCH%20OF%20DIMES%20REPORT,to%2010.02%20percent%20in%202018.&text=Choose%20your%20state%20to%20see,on%20this%20year's%20Report%20Card . Guest G, MacQueen KM, Namey EE. Applied thematic analysis. Los Angeles: Sage Publications; 2012. Palmer KT, Bonzini M, Harris EC, Linaker C, Bonde JP. Work activities and risk of prematurity, low birth weight and pre-eclampsia: an updated review with meta-analysis. Occup Environ Med. 2013;70(4):213-222. Satterfield N, Newton ER, May LE. Activity in Pregnancy for Patients with a History of Preterm Birth. Clin Med Insights Womens Health. 2016;9(Suppl 1):17-21. Magann EF, Evans SF, Chauhan SP, et al. The effects of standing, lifting and noise exposure on preterm birth, growth restriction, and perinatal death in healthy low-risk working military women. J Matern Fetal Neonatal Med. 2005;18(3):155-162. Cai C, Vandermeer B, Khurana R, et al. The impact of occupational activities during pregnancy on pregnancy outcomes: a systematic review and metaanalysis. Am J Obstet Gynecol. 2020;222(3):224-238. Yee LM, Liu LY, Sakowicz A, Bolden JR, Miller ES. Racial and ethnic disparities in use of 17-alpha hydroxyprogesterone caproate for prevention of preterm birth. Am J Obstet Gynecol. 2016;214(3):374 e371-376. Timofeev J, Singh J, Istwan N, Rhea D, Driggers RW. Spontaneous preterm birth in African-American and Caucasian women receiving 17alpha-hydroxyprogesterone caproate. Am J Perinatol. 2014;31(1):55-60. Wheeler SM, Massengale KEC, Blanchard KP, et al. Improving Uptake and Adherence to 17-Hydroxyprogesterone Caproate in Non-Hispanic Black Women: A Mixed Methods Study of Potential Interventions from the Patient Perspective. Biores Open Access. 2019;8(1):155-161. U.S. Department of Labor WsB. Most Common Occupations for Women in the Labor Force 2017; https://www.dol.gov/agencies/wb/data/employment-earnings-occupations . Tables Table 1. Participant Characteristics (n=27) Age (mean, SD) 29.1 (5.1) Self-Described Race (n,%) Non-Hispanic Black (20, 74%) Non-Hispanic White (6, 22%) Mixed race (1, 4%) Insurance status (n,%) Private (7, 26%) Public (19, 70%) Uninsured (1, 4%) Table 2. Study Participant Occupations Employment Study Population Most Common Occupations among US Women by Rank 14 All Pregnant Women Pregnant Black Women All Women Food Service 8 (29%) 7 Childcare (Daycare / Preschool) 5 (19%) Retail 5 (19%) 3 1 Healthcare/Nurse 3 (11%) 5 2 1 Customer Service 2 (7%) 6 3 5 Real estate/property management 2 (7%) Biology Lab 1 (4%) Hotel Housekeeping 1 (4%) Other top ranked occupations not represented in the study cohort 1 Elementary teacher 2 Registered nurse 4 Administrative assistant 4 Personal care aides 5 Registered nurse 2 Administrative assistant 3 Elementary / Middle teacher 4 Managers, all other Table 3. Participant employment experiences Income Implications Reduced duty hours “They understood I worked another job besides them, so they didn’t want me to overwork myself so they would like have me come like, all the way to [street name] like, two days a week, whatever, which really wasn’t worth my time you know, just to go to the bank or whatever for the what, twenty dollars, ten, twenty dollars. That’s all I really made a week you know, for those two days [food service worker, age 31].” “That’s why my hours are cut now because I kept having to get off early, like take off on these days just to go to get my [prenatal care]. So that’s really the conflict [retail worker, age 25].” Unpaid leave “[Taking time off is] pretty much what was interfering and like I told them, I am pregnant, I do gotta receive prenatal care, so if you don’t feel I’m reliable because of that then, go ahead, do what you gotta do…. ‘cause my child’s life is more important than this freaking job. The same way I got this job, I can always find me another one… she tells me, I’m pregnant and I’m not reliable. Okay, that ain’t a good reason to let somebody go. That’s just discrimination on your part… [food service worker, age 31].” “Oh, it just you know, makes the paycheck a little smaller, but other than that, that’s it [retail worker, age 37].” Consequences for non-hourly employees “I usually take off, when I have to go in the morning I’ll do like from 9:00 to 11:00, so I try to do like two, three, about two hours. …the only thing it really messed with is like my adherence at work. My adherence and my, basically my adherence and attendance. It kind of messes with those… Adherence is just your time on the phone, time away from the phone, and being on the phone when you’re actually supposed to be on the phone [customer service, age 29].” “I would say, just because I am being monitored more closely [by my doctor], I do have a fair number of more doctor’s appointments than I did last time. I will say it has been a little tricky with the balance of you know, work and then having my workday kind of interrupted with an appointment. I never would skip my appointment just because I feel like I have to be at work, but there are some times where I feel you know, a little guilty, oh I’m missing that meeting or something like that. But like I mentioned before, my boss has never once said like, no you really need to be here, you can’t go to your doctor’s appointment you know, kind of thing. It’s more of a, I just personally feel a little guilty, yeah [scientist, age 32].” Workplace Accommodations Collaborative employer/employee accommodations ”So, it’s usually, it’s a fairly loose working environment. I mean the schedules are pretty flexible and our boss is extremely understanding of just you know, family and personal needs and so we’ve kind of you know, as long as we’re there for you know, our eight hours a day and we’re actually making progress on our work, we kind of the ability to be pretty flexible with what we do [scientist, age 32].” Employer initiated accommodations “… we talked about when I get further along, closer to my due date, instead of me serving, we’ll move to a different position, it’s hosting, so it would still require me to be on my feet, but I wouldn’t be walking as much and it’s not a lot of lifting like, of trays and food and drinks and things like that. I would just be picking up things and wiping off tables and that stuff [food service worker, age 29].” Medically recommended accommodations “And I didn’t really work there too much longer after that ‘cause I was like you know, they don’t want to be supportive then, you know, they can just kick rocks and I can be happy with my healthy baby [food service worker, age 20].” Supplementary Files SupplementaryFile1.pdf SupplementaryFileInterviewGuide8.28.2020.docx Cite Share Download PDF Status: Published Journal Publication published 25 Sep, 2020 Read the published version in BMC Pregnancy and Childbirth → Version 3 posted Editorial decision: Accept 11 Sep, 2020 Editor assigned by journal 07 Sep, 2020 Submission checks completed at journal 06 Sep, 2020 Editor invited by journal 06 Sep, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-36777","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":2144571,"identity":"bc26348e-6e98-4754-b5b3-4d5a65df54df","order_by":0,"name":"Sarahn M. Wheeler","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYJACZhBhwMDAeICBwYaxgQfEZSNOCwNQSxrpWg4T1iLffvbh58IdDInb2ZsPHPi457zshjOHDzB8KDuMU4vBmXRj6ZlnGBJ39hxLODjj2W3jDWfbEhhnnMOjhSGNQZq3jSF3w40cg8M8B24nbjjPY8DM24Zbi3z/M+bfYC333384/OfAOaAW/g/Mf/FoYbiRxga1hYfhMMOBA4kbzvYwMDPi0WJw4xmbNW+bRP2GM2kGB3sOJBvPPHMMyDiXjsdhacy3edtsjA2OH3744McBO9m+M8lARpk1bodBgAQq9wAh9aNgFIyCUTAK8AMAAbJhiumGRZ8AAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0001-8384-3721","institution":"Duke University School of Medicine","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Sarahn","middleName":"M.","lastName":"Wheeler","suffix":""},{"id":2144572,"identity":"1c612240-0258-49f5-a710-4d631f79ff28","order_by":1,"name":"Kelley E. C. Massengale","email":"","orcid":"","institution":"Diaper Bank of North Carolina","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kelley","middleName":"E. C.","lastName":"Massengale","suffix":""},{"id":2144573,"identity":"fee4ba66-0b67-4f72-95d6-e45e8637816c","order_by":2,"name":"Konyin Adewumi","email":"","orcid":"","institution":"Duke University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Konyin","middleName":"","lastName":"Adewumi","suffix":""},{"id":2144574,"identity":"e1058454-51eb-4850-8360-a7322093b8d4","order_by":3,"name":"Thelma A. Fitzgerald","email":"","orcid":"","institution":"Duke University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Thelma","middleName":"A.","lastName":"Fitzgerald","suffix":""},{"id":2144575,"identity":"555d3996-849d-4389-93b6-82bcf41affeb","order_by":4,"name":"Carrie B. Dombeck","email":"","orcid":"","institution":"Duke University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Carrie","middleName":"B.","lastName":"Dombeck","suffix":""},{"id":2144576,"identity":"de53dfea-6ae6-4439-8290-b3c893f9bfa3","order_by":5,"name":"Teresa Swezey","email":"","orcid":"","institution":"Duke University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Teresa","middleName":"","lastName":"Swezey","suffix":""},{"id":2144577,"identity":"bed71bc5-fed1-4702-9932-cded47562069","order_by":6,"name":"Geeta K. Swamy","email":"","orcid":"","institution":"Duke University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Geeta","middleName":"K.","lastName":"Swamy","suffix":""},{"id":2144578,"identity":"c28d0569-24a4-4734-abac-ea1e520e7014","order_by":7,"name":"Amy Corneli","email":"","orcid":"","institution":"Duke University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Amy","middleName":"","lastName":"Corneli","suffix":""}],"badges":[],"createdAt":"2020-06-19 22:14:23","currentVersionCode":3,"declarations":"","doi":"10.21203/rs.3.rs-36777/v3","doiUrl":"https://doi.org/10.21203/rs.3.rs-36777/v3","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-020-03246-7","type":"published","date":"2020-09-25T12:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":13590482,"identity":"04a233b2-44d1-484c-97bd-5528e17f3247","added_by":"auto","created_at":"2021-09-17 05:04:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":329115,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-36777/v3/1d443fd2-6603-4738-947b-79a7c13841d2.pdf"},{"id":2361587,"identity":"4bba36e1-2b37-4ace-b12b-9de400b92d0e","added_by":"auto","created_at":"2020-09-11 14:26:18","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":232205,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-36777/v3/SupplementaryFile1.pdf"},{"id":2361588,"identity":"16989964-5ec3-4c0a-88c0-793037b13ecb","added_by":"auto","created_at":"2020-09-11 14:26:18","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":21118,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFileInterviewGuide8.28.2020.docx","url":"https://assets-eu.researchsquare.com/files/rs-36777/v3/SupplementaryFileInterviewGuide8.28.2020.docx"}],"financialInterests":"","formattedTitle":"Pregnancy vs. Paycheck: A qualitative study of patient’s experience with employment during pregnancy at high risk for preterm birth","fulltext":[{"header":"Background","content":"\u003cp\u003eIn the US, preterm birth (PTB) and its complications are among the leading cause of neonatal death\u003csup\u003e1\u003c/sup\u003e.\u0026nbsp; Women with a history of prior PTB are at increased risk for recurrence in future pregnancy.\u0026nbsp; To reduce the risk of recurrent PTB, detailed care plans that require more frequent prenatal visits and monitoring are often recommended.\u0026nbsp; For maximum benefit, preventive care must be initiated early and followed diligently throughout pregnancy. Recent data shows that one in seven US women receive inadequate prenatal care\u003csup\u003e2\u003c/sup\u003e.\u0026nbsp; Despite these alarming rates and the urgent need for initiation and adherence to PTB prevention strategies, there are limited data on barriers to early prenatal care initiation in women with a history of PTB from the patient perspective. With the goal of uncovering patient perceived barriers to early initiation of prenatal care and developing interventions to mitigate barriers, we conducted a qualitative study of pregnant women at high risk for PTB.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the US, over 50% of pregnant women work outside the home\u003csup\u003e3\u003c/sup\u003e, and more than 20% of pregnant women are employed in low-wage jobs, earning less than $11.50 per hour\u003csup\u003e4\u003c/sup\u003e.\u0026nbsp; Low-wage jobs often have limited flexibility in assigned work schedule and paid-time-off, making adherence to more frequent prenatal visits or monitoring even more challenging.\u0026nbsp; In the US, there is also a well-documented race disparity in PTB such that non-Hispanic black women are 49% more likely than other racial/ethnic groups to experience PTB\u003csup\u003e5\u003c/sup\u003e. It is imperative to understand women\u0026rsquo;s employment experiences during high risk pregnancy, particularly experiences of non-Hispanic black women working in lower income wage jobs.\u0026nbsp; These insights are critical to identify potential interventions that may alter the workplace experience to increase early initiation of care and adherence to PTB prevention. Here we describe findings from a larger qualitative study focused on barriers and facilitators to prenatal care in women with a history of prior PTB. As part of those interviews, women provided varied and important insights on the impact of employment on their high risk pregnancy care.\u0026nbsp; The aim of this sub-study was to describe women\u0026rsquo;s experiences with employment during a pregnancy at high risk for PTB.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eParent Study \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe current manuscript is a sub-study of a larger parent study. The parent study was a qualitative descriptive study using in-depth interviews (IDIs). The IDIs were conducted between September 2018 and June 2019 in Durham, NC. The study was approved by the Duke Health Institutional Review Board (Pro00100090) on May 29, 2017. All participants provided written consent prior to participation. The parent study was focused on uncovering barriers and facilitators to initiation of prenatal care. The interview guide investigated numerous aspects of participants\u0026rsquo; lives, ranging from how and when participants discovered they were pregnant, to how and when they disclosed their pregnancy to their partner and logistical barriers of scheduling appointments. The interview guide included questions that focused on the participant\u0026rsquo;s experience navigating pregnancy and employment (Supplemental File). The current analysis is focused on the data gathered from those interview questions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility Criteria and Recruitment Procedures \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were recruited from the high risk obstetrical clinic of a large academic medical center. Participants were also recruited via a registry of women who delivered at the same institution after prior high risk pregnancy. This high risk obstetrical clinic is located in the southeastern US and serves approximately 2,000 women per year, of which approximately 50% are non-Hispanic White and 40% are non-Hispanic Black. Women were recruited during their routine prenatal visit or via phone solicitation. Women were offered compensation for their time.\u003c/p\u003e\n\u003cp\u003eWomen were eligible for study enrollment if they were currently or recently pregnant (within 2 months postpartum) and at high risk for PTB, defined as history of a prior spontaneous singleton PTB. We excluded women who did not speak English fluently. The current analysis also excludes women who were unemployed during their index pregnancy because the interview guide questions focused on employment were not applicable in that situation. Additionally, participation in the parent study was limited to women whose self-reported race and ethnicity is non-Hispanic Black or non-Hispanic White. We focused on these groups because the intent of the parent study was to descriptively compare experiences between the most prevalent racial/ethnic groups from the clinic population from which women were recruited.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDemographic information including age, race, insurance status and employment were obtained via electronic health record review and patient report. IDIs were conducted by trained qualitative interviewers in a private room near the clinic space or via phone at a time convenient to the participant. The interviewer followed a semi-structured interview guide focused on identifying barriers and facilitators to initiation of prenatal care and soliciting patient-perceived potential interventions to improve prompt prenatal care initiation. We asked participants to describe their current employment setting and experiences communicating with their supervisor about their pregnancy, scheduling shifts, and any pregnancy-related workplace accommodations. Interviews were audio-recorded with participant permission and transcribed verbatim.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDemographic data were analyzed and presented using descriptive statistics. The IDIs were analyzed via applied thematic analysis\u003csup\u003e6\u003c/sup\u003e, by two analysts trained in qualitative data analysis. The codebook was developed incorporating structural and emergent codes. Structural codes were applied to the transcripts to organize participant responses based on the interview guide question to which the participant was responding and/or a related topic(s) spontaneously mentioned during the interview. The codebook was then expanded to include additional emergent codes associated within each structural code after reviewing the transcript passages associated with each structural code. We then applied the emergent codes to the transcripts. Inter-rater reliability procedures were conducted on 27% (n=33) of interview transcripts with coding differences resolved by discussing individual instances until consensus was reached. Focusing on employment experiences, we then examined the narratives within the emergent codes to discover common themes among participant responses. Patterns across responses were identified within individual codes, then patterns across codes were identified to reveal salient themes. We first identified experiences that participants perceived asimpacting their abilities to maintain employment during a high risk pregnancy. We then organized those experiences into two categories based on whether the experiences influenced participants\u0026rsquo; income or were related to the implementation of pregnancy-related workplace accommodations.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe current analysis includes 27 of the 33 women interviewed for the parent study. We excluded six women from the current analysis because they were not employed during their index pregnancy, and therefore they were not asked the employment questions during the interview. Participants (N=27) were on average 29 years old, majority non-Hispanic Black (NHB) (74%), and most often publically insured (70%) (Table1). Participants were involved in diverse fields of employment. Food services, childcare and retail were the most common occupations (Table 2). Our analysis identified two broad over-arching themes: negative implications of pregnancy on income and challenges related to workplace accommodations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIncome Implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described multiple ways that they felt their income decreased due to their pregnancy. Some of the pay decreases were the result of reduced duty hours, while other participants described limitations due to unpaid leave (Table 3). Women working in non-hourly employment also said that pregnancy negatively impacted their income.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eReduced Duty Hours: Participant Initiated\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMany of the study participants (n=13) described income reduction due to decreased hours worked that they attributed to their pregnancies. Over half (n=7) of the work hour reductions that were described resulted from participant-initiated requests for a reduced workload. Some (n=4) participants requested to work shorter shifts and some (n=3) chose to leave their jobs. Most often the participant-initiated duty hour reductions or employment terminations were linked to pregnancy discomfort. One of these participants, a food service worker, described reducing her hours at a job that did not allow for much sitting: \u0026ldquo;\u003cem\u003eI used to work full time, but now I work part time because it\u0026rsquo;s more of, I work in hospitality so I be on my feet a lot\u0026hellip; now that I\u0026rsquo;m further along I experienced more lower back pain, under my stomach.\u0026rdquo;\u003c/em\u003e Another participant, also working in food service said, \u003cem\u003e\u0026ldquo;I stopped working [at fast food restaurant] \u0026hellip; when like, my back started hurting or I was being like, I was moving slower like, I wasn\u0026rsquo;t with production time and stuff like that.\u0026rdquo;\u003c/em\u003e The participant also explained that the smells from certain foods cooking at the restaurant made her vomit during her shifts.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eReduced Duty Hours: Supervisor Initiated\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMultiple participants (n=6) described supervisors who reduced the number of hours participants worked despite their desire to continue working. For example, a participant working in retail described that her employer responded to her pregnancy by: \u0026ldquo;\u003cem\u003eCutting my hours, that\u0026rsquo;s how she really responded to the whole [pregnancy] thing. She just cut my hours.\u0026rdquo;\u003c/em\u003e Another participant, a food service worker, described a similar experience:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They didn\u0026rsquo;t know I was pregnant right away\u0026hellip; they was like, \u0026lsquo;you know, you\u0026rsquo;re showing a little.\u0026rsquo; So that\u0026rsquo;s when that came out. So that\u0026rsquo;s definitely, [fast food restaurant] changed my schedules, [from 7am to 4pm to] like 8 to 4, whatever you know, 10 to 4. They tried to sneak an 11 to 4.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThere were also participants who expressed positive work experiences prior to their pregnancy, yet during their pregnancy they terminated their employment due to decreased earnings and truncated advancement. A participant working in food service commented, \u003cem\u003e\u0026ldquo;[Supervisor] was really like communicative and nice, but at the same time she was cutting my hours... so she was really nice about it, but at the same time, she knew that I needed the hours and she was still cutting them. So, that\u0026rsquo;s why I had to leave because I was not making any money.\u0026rdquo; \u003c/em\u003eAnother participant also a food service worker, who was excited for an upcoming promotion, described leaving her job due to unsupportive attitudes towards her pregnancy: \u003cem\u003e\u0026ldquo;I worked so hard you know, I fought for that spot\u0026hellip; \u003c/em\u003e\u003cem\u003e\u0026lsquo;cause I love working there, eating there, but [fast food restaurant] weren\u0026rsquo;t really supportive of pregnant women working there at all you know.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eUnpaid Leave \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eLess than one-third of the participants in our study were eligible for paid or partially-paid leave from their jobs. One participant, working in real estate, described a finite amount of time she could take off from work to attend prenatal visits before delivery and during postpartum recovery. She had to weigh when to use paid time-off:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I try not to use my PTO [paid time off] because you know you have to use PTO when you go on FMLA [Family and Medical Leave Act], before your short-term disability starts, so sometimes I just have to take the hit and not hit my forty hours, which means a lower check.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eSome participants (n=3) described situations in which unpaid leave was couched as a benefit to employees who were told they could return to work after delivery without having to reapply for their jobs. A food service worker explained she was told: \u0026ldquo;\u003cem\u003eJust a leave, basically like you\u0026rsquo;re just quitting and then you just get rehired\u003c/em\u003e.\u0026rdquo; Another food service worker said she knew to expect being removed from the work schedule towards the end of her pregnancy: \u003cem\u003e\u0026ldquo;\u0026hellip;so as far as my due date, I told him that I\u0026rsquo;m due in September and he knows like, when it gets close to August, he\u0026rsquo;ll actually be preparing to take me off the schedule until I\u0026rsquo;m ready to return to work\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eReduced Income in Non-Hourly Employees\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants whose time at work was not scheduled in hourly shifts also experienced negative impacts to their take-home pay due to pregnancy. One participant, who worked for a small retail business, reported that her supervisor allowed her to make-up the missed work due to prenatal visits at another time so that her take-home pay was not impacted, but only during the business\u0026rsquo; \u0026ldquo;\u003cem\u003ebusy season\u003c/em\u003e.\u0026rdquo; Otherwise, she had to take unpaid leave from work to attend prenatal visits. Another participant who works in real estate, had a flexible work schedule. However, since she was paid on commission, time away from work could still impact her take-home pay as she explained, \u0026ldquo;\u003cem\u003eIf I\u0026rsquo;m not there then I\u0026rsquo;m just not there [to earn money].\u003c/em\u003e\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMany of the participants who worked in childcare reported positive experiences because they were able to balance work with prenatal and postpartum care. For one participant, the timing of her pregnancy meant that she could avoid reduced work hours. As the childcare worker explained, she did not have to take unpaid leave to attend prenatal visits since she disclosed her pregnancy during the summer, prior to the finalization of teaching assignments for the current school year\u003cem\u003e. \u0026ldquo;I wanted to tell [supervisor] when my schedule was being like, figured out because I wanted to try and build in certain pockets of time when work was easier for me to get away for appointments.\u0026rdquo;\u003c/em\u003e The participant further explained that she was then able to attend healthcare visits during her planning period and make-up the missed work time on her own to avoid any impacts to her take-home pay, since she requested the schedule changes before the school year started.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWorkplace Accommodations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants discussed accommodations that their employers and coworkers made in their workplace environment or within job duties during their pregnancies. These accommodations were sometimes a collaborative effort between the participant and her employer; in other situations they were employer-initiated based on the employer\u0026rsquo;s perception of safe working conditions during pregnancy, and in other instances accommodations were medically recommended by an obstetrical care provider (Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCollaborative Employer/Employee Accommodations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome of the most positive employment experiences recounted were collaborative efforts between the participant and her employer to adjust the workplace environment and job duties allowing the participant to continue performing her job duties while feeling safe and supported. A healthcare worker described: \u0026ldquo;\u003cem\u003eThey were very supportive. They told me that, you know, I wanted to do night shift and I wanted to do like an easier hall, like maybe rehab or something like that, and they were completely open to it; they were fine\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eAnother healthcare worker, whose job required several hours of sitting and typing, described how her employer helped to make her workstation more comfortable:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003e\u0026hellip; if I need to be off or whatever, if I needed any accommodations to my workspace like, I had to buy, I didn\u0026rsquo;t have to buy it, they reimbursed me for it, but just different, like back supports and footstools and stuff that I started needing later \u0026lsquo;cause I was sitting a lot you know, they reimburse for, but anything I mean anything I needed they were onboard for.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEmployer-Initiated Accommodations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn other situations, workplace restrictions stemmed from the employer\u0026rsquo;s perception of safe working conditions during pregnancy. For example, a real estate worker explained that her manager \u0026ldquo;\u003cem\u003ebarely lets me carry the water\u003c/em\u003e\u0026rdquo; even though her medical provider had not recommended any lifting restrictions. Another participant working in food service without any provider-documented restrictions, described how her employer frequently considered her pregnancy: \u0026ldquo;\u003cem\u003eThey were strict with me of doing a lot of things. I couldn\u0026rsquo;t lift nothing, I couldn\u0026rsquo;t do too much bending like, kind of you know, they took my health into consideration, most definitely.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMedically Recommended Accommodations \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants also described situations where their medical provider recommended modifications to their job duties. These medically recommended restrictions were met with varied reactions at the workplace. A participant working in retail described a very supportive response from her employer. She said, \u003cem\u003e\u0026ldquo;They\u0026rsquo;re supportive of me and they\u0026rsquo;ve been working with my accommodations\u0026hellip; right now I\u0026rsquo;m on a twenty-five-pound weight restriction, so anything that would feel too heavy for me to lift, or to move, they actually do it for me.\u0026rdquo; \u003c/em\u003eOther participants described more negative reactions from their employers upon requesting medically-recommended accommodations during the workday. Two participants recounted experiences in which they perceived that their employment was terminated due to a request for accommodations recommended by a medical provider. One participant shared her experience of being laid off from her job at a grocery store when she shared that her physician had recommended an accommodation to her job duties:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI was just laid off yesterday\u0026hellip; due to my limits and restrictions from the doctors\u0026hellip;. I was put on a ten-pound lifting limit, which is very, very small and unfortunately with all the job descriptions at my employer I wasn\u0026rsquo;t eligible for employment anymore. \u0026hellip; I busted my butt at that place and gave it everything that I had, even very sick and ill and not well and they, I feel like they tossed me in the trash.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhen another participant started a new job as a nurse, she found her new employer was unwilling to accommodate job duty recommendations from her healthcare provider:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I told her like maybe on day seven that I had a nurse\u0026rsquo;s note and when she told me that she was not going to accommodate it, I just basically let her know like, \u0026lsquo;well I can\u0026rsquo;t continue to work here. Like I need to,\u0026rsquo; you know in the note it says like okay well, \u0026lsquo;I need to be able to take frequent breaks like to sit down, I can\u0026rsquo;t stand for longer than two hours, I should be able to take water breaks, bathroom breaks and stuff like that.\u0026rsquo;\u0026hellip; She had a whole attitude about it and told me that she was not going to accommodate my nurse\u0026rsquo;s note so I was like \u0026lsquo;okay, you\u0026rsquo;re not going to accommodate my nurse\u0026rsquo;s note like so you want me to put myself and my baby in danger; no thank you, you can keep this job\u003c/em\u003e.\u0026rsquo;\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eUltimately, the participant quit the new job because the employer would not accommodate the requests in her healthcare provider\u0026rsquo;s note.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe present novel qualitative data that provides insights into US women\u0026rsquo;s experiences balancing a pregnancy at increased risk for preterm birth (PTB) with employment obligations. The participants were majority non-Hispanic Black (NHB), as NHBs bear a disproportionate burden of PTB within in our clinic and across the nation. Additionally, the majority of women in the study were publically insured and employed in occupations that are most often low income. While many women reported positive experiences, the most striking insights came from women who described negative situations that ranged from challenging to potentially unlawful.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEmployment status changes including voluntary and involuntary reduction of hours and termination were some of the most notable findings of the study. Multiple participants described voluntarily reducing their work hours or terminating their employment due to physical discomfort or perceived risks their employment posed to pregnancy. These findings may represent women taking bold measures to advocate for their health during pregnancy. However, in most cases, even during high risk pregnancy, it is considered safe and healthy for women to continue working during pregnancy. A meta-analysis evaluating the impact of work activities on pregnancy outcomes including prematurity, low birth weight and hypertensive complications found increasing evidence to suggest that employment-related risks to pregnancy are minimal\u003csup\u003e7\u003c/sup\u003e. Based on these and other data, the American College of Obstetricians and Gynecologists (ACOG) recommends that it is \u0026ldquo;generally safe\u0026rdquo; for women to work during pregnancy\u003csup\u003e3\u003c/sup\u003e. Notably, most of these data do not directly address women with a history of PTB. Although the data is limited in this setting, most experts agree that a history of PTB alone does not necessitate activity restriction such that women are unable to work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSimple modifications such as a sitting stool or more frequent breaks often allow a woman to safely and more comfortably complete her work duties during a high risk pregnancy\u003csup\u003e8\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAccommodations to limit standing and lifting may be indicated in physically demanding professions, as there are data to suggest lifting cumulative weight over 100 kg per day and standing for over three hours per day increases the risk of PTB\u003csup\u003e9,10\u003c/sup\u003e. Many of the participants in our study reported positive experiences with employers who proactively made simple accommodations to facilitate continued safe and comfortable employment during pregnancy. Other participants described employers who were unable and/or unwilling to modify job duties, leading to loss of employment. The Americans with Disabilities Act requires employers to provide \u0026ldquo;reasonable\u0026rdquo; accommodations for pregnancy-related impairments, as long as it does not cause \u0026ldquo;undue hardship\u0026rdquo; to the employer\u003csup\u003e3\u003c/sup\u003e. This legislation requires employers to provide accommodations for pregnant women that would be rendered to other employees with a time-limited medical impairment. For example, if an employee was accommodated with a sitting stool after a back injury, a pregnant women with a similar job description should also have access to a sitting stool. However, the Americans with Disabilities Act only applies to employers with 15 or more employees and is similarly challenging to enforce\u003csup\u003e3\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePerhaps the most concerning disclosures were women who reported involuntary reduction in their employment hours and coercion to prompt resignation. Although it is important to note that the data presented represents events solely from the patient perspective, without insights from the employer or provider, an involuntary reduction in employment hours simply due to pregnancy is unlawful in many circumstances. The US Pregnancy Discrimination Act prohibits forcing a pregnant woman to take leave, who is otherwise capable of performing her work functions\u003csup\u003e3\u003c/sup\u003e. However, the protections offered by this legislation are limited. This legislation only applies to specific employers (i.e. employers with over 15 employees) and can be difficult to enforce, as one must file a claim with the Equal Employment Opportunity Commission when there is an infringement\u003csup\u003e3\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eOur study presents important insights from the patient perspective about their experiences balancing employment with high risk pregnancy. Despite the impact of our findings, important limitations must be considered. The original intent of the IDIs was not focused solely on employment. Given that the parent study was broader in scope, the IDI guide omitted key follow-up probes to employment-related questions that could have yielded even greater insights on this topic. For example, many participants described situations where it is unclear if the physical limitations in the workplace were based on recommendations from a medical provider or based on the participant\u0026rsquo;s own comfort level. Additionally, due to logistical limitations, our study excluded non-English speaking women. Non-English speaking women in the US may be the most vulnerable to challenging work conditions with limited ability to modify their job duties in the setting of high risk pregnancy. Women who identify as Hispanic ethnicity were outside of the scope of the original research aims of the parent study; therefore, the undoubtedly valuable insights from this patient population are not represented in the current study. Further studies incorporating Hispanic and non-English speaking women are urgently needed. The data in the current study also include participants recruited from a single academic institution and therefore may have limited generalizability.\u003c/p\u003e\n\u003cp\u003eThe majority of participants in our study are non-Hispanic Black and publically insured. Although it is unknown whether their experiences reflect the broader experiences of pregnant women across the US, NHB women in our clinic and across the US bear a disproportionate burden of PTB\u003csup\u003e5\u003c/sup\u003e and more commonly work in lower-income, less flexible occupations;\u003csup\u003e4\u003c/sup\u003e therefore their insights into employment barriers within the setting of high risk pregnancy care are essential. The literature has documented that adherence to PTB prevention strategies is often uniquely challenging for NHB women\u003csup\u003e11,12\u003c/sup\u003e. For example, despite recommendations from the American College of Obstetricians and Gynecologists (ACOG) supporting weekly injections of 17-hydroxyprogesterone caproate (17-P) to reduce the risk of recurrent PTB, multiple studies document reduced adherence to 17-P in NHB women\u003csup\u003e11,12\u003c/sup\u003e. Although the efficacy of 17-P is being re-evaluated, it was once the cornerstone of PTB prevention; therefore, much of the published work on adherence to PTB prevention focuses on 17-P. In a study of women who previously delivered preterm, patients identified limited time-off from work and inflexible work schedules as barriers impeding adherence to the weekly 17-P injection schedule\u003csup\u003e13\u003c/sup\u003e. The findings within the 17-P literature surrounding adherence highlight the urgent need for uncovering and addressing barriers to adherence that are culturally sensitive and inclusive of women from racial and ethnic backgrounds most impacted by PTB.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe impact of PTB is also disproportionate among women with lower socio-economic status\u003csup\u003e5\u003c/sup\u003e and most of the women in our study work in occupations that are traditionally lower-paying. While the interview guide did not inquire directly about income or educational attainment, given the high number of women in the study on public insurance, we suspect that many likely had lower incomes and less formal education. Participants were also employed in two of the most common occupations held by women in general (healthcare/nurse and customer service), four of the most common occupations held by pregnant women (food service, retail, healthcare/nurse and customer service), and the three of the most commonly held occupations by pregnant Black women (retail, healthcare/nurse and customer service)\u003csup\u003e4,14\u003c/sup\u003e. Although the experiences recounted may not be representative of all pregnant women at high risk for PTB, the findings suggest the workplace environment could be improved, thus mitigating barriers for pregnant women working across an array of commonly held occupations.\u003c/p\u003e\n\u003cp\u003eOur findings highlight important opportunities to mitigate barriers to high risk prenatal care and potentially improve adherence to PTB prevention strategies through education. Many of the findings suggest that profound misunderstandings likely exist at the patient, employer and provider level about the laws surrounding employment in pregnancy, the medical risks of continued employment, and the range of creative accommodations that often allow for continued workplace productivity even during high risk pregnancy. To address this need, we have established a collaboration with the Duke Health Justice Clinic to develop trainings and educational materials. Future studies using educational interventions aimed at patients, employers and medical providers to improve understanding about appropriate limitations and accommodations may be uniquely impactful to improve timely initiation of and adherence to high risk prenatal care and PTB preventive care plans.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWomen balancing pregnancy at high risk for preterm delivery with employment obligations report a variety of experiences.\u0026nbsp; While some women reported positive experiences, many women described situations that ranged from challenging to potentially unlawful.\u0026nbsp; Our findings suggest that profound misunderstandings likely exist at the individual, employer and provider level about the laws surrounding employment in pregnancy, safe employment responsibilities during pregnancy, and the range of creative accommodations that often allow for continued workplace productivity even during high risk pregnancy.\u0026nbsp; Future interventions aimed at individuals, employers and medical providers to improve understanding about appropriate modifications and accommodations may be uniquely impactful to improve timely initiation of and adherence to high risk prenatal care and preterm birth preventive care plans.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eIDIs: in-depth interviews\u003c/p\u003e\n\u003cp\u003eNHB: non-Hispanic Black\u003c/p\u003e\n\u003cp\u003ePTB: preterm birth\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: The study was approved by the Duke Health Institutional Review Board (Pro00100090) on May 29, 2017. All participants provided written consent prior to participation.\u003c/p\u003e\n\u003cp\u003eConsent for publication: N/A\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding: Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR001117. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.\u003c/p\u003e\n\u003cp\u003eDr. Wheeler is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number 1KL2TR002554. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions: All authors have read and approved the manuscript. SW: major contributor to the concept and manuscript writing, KM: analyzed data, contributed to manuscript preparation, KA: data collection, TF: data collection, CD: data collection and analysis, TS: data collection, GS: contributions to overall concept and manuscript revisions, AC: guidance on data collection methodology and manuscript review\u003c/p\u003e\n\u003cp\u003eAcknowledgements: We wish to acknowledge the women who participated in this study. They bravely and honestly shared their experiences. We thank them for sharing their stories.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMurphy SL, Xu J, Kochanek KD, Arias E. Mortality in the United States, 2017. \u003cem\u003eNCHS Data Brief. \u003c/em\u003e2018(328):1-8.\u003c/li\u003e\n\u003cli\u003eOsterman MJK, Martin JA. Timing and Adequacy of Prenatal Care in the United States, 2016. \u003cem\u003eNatl Vital Stat Rep. \u003c/em\u003e2018;67(3):1-14.\u003c/li\u003e\n\u003cli\u003eACOG Committee Opinion No. 733: Employment Considerations During Pregnancy and the Postpartum Period. \u003cem\u003eObstet Gynecol. \u003c/em\u003e2018;131(4):e115-e123.\u003c/li\u003e\n\u003cli\u003eHarwood MaH, Sarah David By the Numbers: Where Do Pregnant Women Work? 2019.\u003c/li\u003e\n\u003cli\u003e2019 March of Dimes Report Card. 2019; \u003ca href=\"https://www.marchofdimes.org/mission/reportcard.aspx#:~:text=2019%20MARCH%20OF%20DIMES%20REPORT,to%2010.02%20percent%20in%202018.\u0026amp;text=Choose%20your%20state%20to%20see,on%20this%20year's%20Report%20Card\"\u003ehttps://www.marchofdimes.org/mission/reportcard.aspx#:~:text=2019%20MARCH%20OF%20DIMES%20REPORT,to%2010.02%20percent%20in%202018.\u0026amp;text=Choose%20your%20state%20to%20see,on%20this%20year's%20Report%20Card\u003c/a\u003e.\u003c/li\u003e\n\u003cli\u003eGuest G, MacQueen KM, Namey EE. \u003cem\u003eApplied thematic analysis.\u003c/em\u003e Los Angeles: Sage Publications; 2012.\u003c/li\u003e\n\u003cli\u003ePalmer KT, Bonzini M, Harris EC, Linaker C, Bonde JP. Work activities and risk of prematurity, low birth weight and pre-eclampsia: an updated review with meta-analysis. \u003cem\u003eOccup Environ Med. \u003c/em\u003e2013;70(4):213-222.\u003c/li\u003e\n\u003cli\u003eSatterfield N, Newton ER, May LE. Activity in Pregnancy for Patients with a History of Preterm Birth. \u003cem\u003eClin Med Insights Womens Health. \u003c/em\u003e2016;9(Suppl 1):17-21.\u003c/li\u003e\n\u003cli\u003eMagann EF, Evans SF, Chauhan SP, et al. The effects of standing, lifting and noise exposure on preterm birth, growth restriction, and perinatal death in healthy low-risk working military women. \u003cem\u003eJ Matern Fetal Neonatal Med. \u003c/em\u003e2005;18(3):155-162.\u003c/li\u003e\n\u003cli\u003eCai C, Vandermeer B, Khurana R, et al. The impact of occupational activities during pregnancy on pregnancy outcomes: a systematic review and metaanalysis. \u003cem\u003eAm J Obstet Gynecol. \u003c/em\u003e2020;222(3):224-238.\u003c/li\u003e\n\u003cli\u003eYee LM, Liu LY, Sakowicz A, Bolden JR, Miller ES. Racial and ethnic disparities in use of 17-alpha hydroxyprogesterone caproate for prevention of preterm birth. \u003cem\u003eAm J Obstet Gynecol. \u003c/em\u003e2016;214(3):374 e371-376.\u003c/li\u003e\n\u003cli\u003eTimofeev J, Singh J, Istwan N, Rhea D, Driggers RW. Spontaneous preterm birth in African-American and Caucasian women receiving 17alpha-hydroxyprogesterone caproate. \u003cem\u003eAm J Perinatol. \u003c/em\u003e2014;31(1):55-60.\u003c/li\u003e\n\u003cli\u003eWheeler SM, Massengale KEC, Blanchard KP, et al. Improving Uptake and Adherence to 17-Hydroxyprogesterone Caproate in Non-Hispanic Black Women: A Mixed Methods Study of Potential Interventions from the Patient Perspective. \u003cem\u003eBiores Open Access. \u003c/em\u003e2019;8(1):155-161.\u003c/li\u003e\n\u003cli\u003eU.S. Department of Labor WsB. Most Common Occupations for Women in the Labor Force 2017; \u003ca href=\"https://www.dol.gov/agencies/wb/data/employment-earnings-occupations\"\u003ehttps://www.dol.gov/agencies/wb/data/employment-earnings-occupations\u003c/a\u003e.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif; font-size: 10px; color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" style=\"width: 378.9pt;border-collapse: collapse;\" width=\"505\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 378.9pt;border: 1pt solid rgb(143, 178, 207);background-color: rgb(43, 116, 181);padding: 0.05in 0.1in;height: 28.45pt;vertical-align: top;\" valign=\"top\" width=\"100%\"\u003e\n \u003cp style=\"margin: 0in;line-height: 29.333335876464844px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u003cstrong\u003eTable 1.\u0026nbsp;Participant Characteristics (n=27)\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 184.1pt;border-style: none none solid solid;border-left-width: 1pt;border-left-color: rgb(143, 178, 207);border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);padding: 0.05in 0.1in;height: 28.45pt;vertical-align: top;\" valign=\"top\" width=\"48.51485148514851%\"\u003e\n \u003cp style=\"margin: 0in;line-height: 29.333335876464844px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eAge (mean, SD)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 194.8pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0.05in 0.1in;height: 28.45pt;vertical-align: top;\" valign=\"top\" width=\"51.48514851485149%\"\u003e\n \u003cp style=\"margin: 0in;line-height: 29.333335876464844px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e29.1 (5.1)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 184.1pt;border-style: none none solid solid;border-left-width: 1pt;border-left-color: rgb(143, 178, 207);border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);padding: 0.05in 0.1in;height: 28.45pt;vertical-align: top;\" valign=\"top\" width=\"48.51485148514851%\"\u003e\n \u003cp style=\"margin: 0in;line-height: 29.333335876464844px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eSelf-Described \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in;line-height: 29.333335876464844px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eRace (n,%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 194.8pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0.05in 0.1in;height: 28.45pt;vertical-align: top;\" valign=\"top\" width=\"51.48514851485149%\"\u003e\n \u003cp style=\"margin: 0in;line-height: 29.333335876464844px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eNon-Hispanic Black (20, 74%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in;line-height: 29.333335876464844px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eNon-Hispanic White (6, 22%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in;line-height: 29.333335876464844px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eMixed race (1, 4%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 184.1pt;border-style: none none solid solid;border-left-width: 1pt;border-left-color: rgb(143, 178, 207);border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);padding: 0.05in 0.1in;height: 28.45pt;vertical-align: top;\" valign=\"top\" width=\"48.51485148514851%\"\u003e\n \u003cp style=\"margin: 0in;line-height: 29.333335876464844px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eInsurance status (n,%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 194.8pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0.05in 0.1in;height: 28.45pt;vertical-align: top;\" valign=\"top\" width=\"51.48514851485149%\"\u003e\n \u003cp style=\"margin: 0in;line-height: 29.333335876464844px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003ePrivate (7, 26%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in;line-height: 29.333335876464844px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003ePublic (19, 70%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in;line-height: 29.333335876464844px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eUninsured (1, 4%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"margin: 0in;line-height: 29.333335876464844px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" style=\"width: 467.2pt;border-collapse: collapse;\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 467.2pt;border: 1pt solid rgb(143, 178, 207);background-color: rgb(43, 116, 181);padding: 0.75pt 5.4pt 0in;height: 37.6pt;vertical-align: top;\" valign=\"top\" width=\"100%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u003cstrong\u003eTable 2. Study Participant Occupations\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 150.15pt;border-style: none none solid solid;border-left-width: 1pt;border-left-color: rgb(143, 178, 207);border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 27.3pt;vertical-align: top;\" valign=\"top\" width=\"32.102728731942214%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u003cstrong\u003eEmployment\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 67.65pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 27.3pt;vertical-align: top;\" valign=\"top\" width=\"14.446227929373997%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u003cstrong\u003eStudy Population\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 249.4pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 27.3pt;vertical-align: top;\" valign=\"top\" width=\"53.45104333868379%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u003cstrong\u003eMost Common Occupations among US Women by Rank\u003csup\u003e14\u003c/sup\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85.7pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 11.4pt;vertical-align: top;\" valign=\"top\" width=\"34.33734939759036%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u003cstrong\u003eAll Pregnant Women\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83.85pt;border-top-width: 1pt;border-right-width: 1pt;border-bottom-width: 1pt;border-style: solid solid solid none;border-top-color: rgb(143, 178, 207);border-right-color: rgb(143, 178, 207);border-bottom-color: rgb(143, 178, 207);padding: 0in;height: 11.4pt;vertical-align: top;\" valign=\"top\" width=\"33.734939759036145%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u003cstrong\u003ePregnant Black Women\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79.85pt;border-top-width: 1pt;border-right-width: 1pt;border-bottom-width: 1pt;border-style: solid solid solid none;border-top-color: rgb(143, 178, 207);border-right-color: rgb(143, 178, 207);border-bottom-color: rgb(143, 178, 207);padding: 0in;height: 11.4pt;vertical-align: top;\" valign=\"top\" width=\"31.927710843373493%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u003cstrong\u003eAll Women\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.15pt;border-style: none none solid solid;border-left-width: 1pt;border-left-color: rgb(143, 178, 207);border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 10.2pt;vertical-align: top;\" valign=\"top\" width=\"32.154340836012864%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eFood Service\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.65pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 10.2pt;vertical-align: top;\" valign=\"top\" width=\"14.469453376205788%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e8 (29%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.7pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 10.2pt;vertical-align: top;\" valign=\"top\" width=\"18.327974276527332%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e7\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83.85pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 10.2pt;vertical-align: top;\" valign=\"top\" width=\"18.006430868167204%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79.85pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 10.2pt;vertical-align: top;\" valign=\"top\" width=\"17.041800643086816%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.15pt;border-style: none none solid solid;border-left-width: 1pt;border-left-color: rgb(143, 178, 207);border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 8.4pt;vertical-align: top;\" valign=\"top\" width=\"32.154340836012864%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eChildcare (Daycare / Preschool)\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.65pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 8.4pt;vertical-align: top;\" valign=\"top\" width=\"14.469453376205788%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e5 (19%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.7pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 8.4pt;vertical-align: top;\" valign=\"top\" width=\"18.327974276527332%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u003cs\u003e\u0026nbsp;\u003c/s\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83.85pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 8.4pt;vertical-align: top;\" valign=\"top\" width=\"18.006430868167204%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u003cs\u003e\u0026nbsp;\u003c/s\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79.85pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 8.4pt;vertical-align: top;\" valign=\"top\" width=\"17.041800643086816%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u003cs\u003e\u0026nbsp;\u003c/s\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.15pt;border-style: none none solid solid;border-left-width: 1pt;border-left-color: rgb(143, 178, 207);border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 12.45pt;vertical-align: top;\" valign=\"top\" width=\"32.154340836012864%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eRetail\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.65pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 12.45pt;vertical-align: top;\" valign=\"top\" width=\"14.469453376205788%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e5 (19%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.7pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 12.45pt;vertical-align: top;\" valign=\"top\" width=\"18.327974276527332%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e3\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83.85pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 12.45pt;vertical-align: top;\" valign=\"top\" width=\"18.006430868167204%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e1\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79.85pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 12.45pt;vertical-align: top;\" valign=\"top\" width=\"17.041800643086816%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.15pt;border-style: none none solid solid;border-left-width: 1pt;border-left-color: rgb(143, 178, 207);border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"32.154340836012864%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eHealthcare/Nurse\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.65pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"14.469453376205788%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e3 (11%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.7pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"18.327974276527332%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e5\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83.85pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"18.006430868167204%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e2\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79.85pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"17.041800643086816%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e1\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.15pt;border-style: none none solid solid;border-left-width: 1pt;border-left-color: rgb(143, 178, 207);border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"32.154340836012864%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eCustomer Service\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.65pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"14.469453376205788%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e2 (7%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.7pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"18.327974276527332%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e6\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83.85pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"18.006430868167204%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e3\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79.85pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"17.041800643086816%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e5\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.15pt;border-style: none none solid solid;border-left-width: 1pt;border-left-color: rgb(143, 178, 207);border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 25.05pt;vertical-align: top;\" valign=\"top\" width=\"32.154340836012864%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eReal estate/property management\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.65pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 25.05pt;vertical-align: top;\" valign=\"top\" width=\"14.469453376205788%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e2 (7%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.7pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 25.05pt;vertical-align: top;\" valign=\"top\" width=\"18.327974276527332%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83.85pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 25.05pt;vertical-align: top;\" valign=\"top\" width=\"18.006430868167204%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79.85pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 25.05pt;vertical-align: top;\" valign=\"top\" width=\"17.041800643086816%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.15pt;border-style: none none solid solid;border-left-width: 1pt;border-left-color: rgb(143, 178, 207);border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 9.75pt;vertical-align: top;\" valign=\"top\" width=\"32.154340836012864%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eBiology Lab\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.65pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 9.75pt;vertical-align: top;\" valign=\"top\" width=\"14.469453376205788%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e1 (4%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.7pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 9.75pt;vertical-align: top;\" valign=\"top\" width=\"18.327974276527332%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83.85pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 9.75pt;vertical-align: top;\" valign=\"top\" width=\"18.006430868167204%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79.85pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 9.75pt;vertical-align: top;\" valign=\"top\" width=\"17.041800643086816%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150.15pt;border-style: none none solid solid;border-left-width: 1pt;border-left-color: rgb(143, 178, 207);border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"32.154340836012864%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eHotel Housekeeping\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67.65pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"14.469453376205788%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e1 (4%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.7pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"18.327974276527332%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83.85pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"18.006430868167204%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79.85pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"17.041800643086816%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 217.8pt;border-right-width: 1pt;border-bottom-width: 1pt;border-left-width: 1pt;border-style: none solid solid;border-right-color: rgb(143, 178, 207);border-bottom-color: rgb(143, 178, 207);border-left-color: rgb(143, 178, 207);padding: 0.75pt 5.4pt 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"46.62379421221865%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eOther top ranked occupations not represented in the study cohort\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.7pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"18.327974276527332%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e1 Elementary teacher\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e2 Registered nurse\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e4 Administrative assistant\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83.85pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"18.006430868167204%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e4 Personal care aides\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e5 Registered nurse\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79.85pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: rgb(143, 178, 207);border-right-width: 1pt;border-right-color: rgb(143, 178, 207);padding: 0in;height: 2pt;vertical-align: top;\" valign=\"top\" width=\"17.041800643086816%\"\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e2 Administrative assistant\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e3 Elementary / Middle teacher\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e4 Managers, all other\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"margin: 0in;line-height: 29.333335876464844px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin: 0in;line-height: 29.333335876464844px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u003cstrong\u003eTable 3. Participant employment experiences\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" style=\"border-collapse: collapse;border: none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 467.5pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"100%\"\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u003cstrong\u003eIncome Implications\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 106.8pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: windowtext;border-right-width: 1pt;border-right-color: windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"22.792937399678973%\"\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eReduced duty hours\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 360.7pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"77.20706260032102%\"\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026ldquo;They understood I worked another job besides them, so they didn\u0026rsquo;t want me to overwork myself so they would like have me come like, all the way to [street name] like, two days a week, whatever, which really wasn\u0026rsquo;t worth my time you know, just to go to the bank or whatever for the what, twenty dollars, ten, twenty dollars. That\u0026rsquo;s all I really made a week you know, for those two days [food service worker, age 31].\u0026rdquo;\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026ldquo;That\u0026rsquo;s why my hours are cut now because I kept having to get off early, like take off on these days just to go to get my [prenatal care]. So that\u0026rsquo;s really the conflict\u0026nbsp;[retail worker, age 25].\u0026rdquo;\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 106.8pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: windowtext;border-right-width: 1pt;border-right-color: windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"22.792937399678973%\"\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eUnpaid leave\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 360.7pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"77.20706260032102%\"\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026ldquo;[Taking time off is] pretty much what was interfering and like I told them, I am pregnant, I do gotta receive prenatal care, so if you don\u0026rsquo;t feel I\u0026rsquo;m reliable because of that then, go ahead, do what you gotta do\u0026hellip;. \u0026lsquo;cause my child\u0026rsquo;s life is more important than this freaking job. The same way I got this job, I can always find me another one\u0026hellip; she tells me, I\u0026rsquo;m pregnant and I\u0026rsquo;m not reliable. Okay, that ain\u0026rsquo;t a good reason to let somebody go. That\u0026rsquo;s just discrimination on your part\u0026hellip; [food service worker, age 31].\u0026rdquo;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026ldquo;Oh, it just you know, makes the paycheck a little smaller, but other than that, that\u0026rsquo;s it [retail worker, age 37].\u0026rdquo;\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 106.8pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: windowtext;border-right-width: 1pt;border-right-color: windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"22.792937399678973%\"\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eConsequences for non-hourly employees\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 360.7pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"77.20706260032102%\"\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026ldquo;I usually take off, when I have to go in the morning I\u0026rsquo;ll do like from 9:00 to 11:00, so I try to do like two, three, about two hours. \u0026hellip;the only thing it really messed with is like my adherence at work. My adherence and my, basically my adherence and attendance. It kind of messes with those\u0026hellip; Adherence is just your time on the phone, time away from the phone, and being on the phone when you\u0026rsquo;re actually supposed to be on the phone [customer service, age 29].\u0026rdquo;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026ldquo;I would say, just because I am being monitored more closely [by my doctor], I do have a fair number of more doctor\u0026rsquo;s appointments than I did last time. I will say it has been a little tricky with the balance of you know, work and then having my workday kind of interrupted with an appointment. I never would skip my appointment just because I feel like I have to be at work, but there are some times where I feel you know, a little guilty, oh I\u0026rsquo;m missing that meeting or something like that. But like I mentioned before, my boss has never once said like, no you really need to be here, you can\u0026rsquo;t go to your doctor\u0026rsquo;s appointment you know, kind of thing. It\u0026rsquo;s more of a, I just personally feel a little guilty, yeah [scientist, age 32].\u0026rdquo;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 467.5pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"100%\"\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;text-align: center;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u003cstrong\u003eWorkplace Accommodations\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 106.8pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: windowtext;border-right-width: 1pt;border-right-color: windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"22.792937399678973%\"\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eCollaborative employer/employee accommodations\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 360.7pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"77.20706260032102%\"\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026rdquo;So, it\u0026rsquo;s usually, it\u0026rsquo;s a fairly loose working environment. I mean the schedules are pretty flexible and our boss is extremely understanding of just you know, family and personal needs and so we\u0026rsquo;ve kind of you know, as long as we\u0026rsquo;re there for you know, our eight hours a day and we\u0026rsquo;re actually making progress on our work, we kind of the ability to be pretty flexible with what we do [scientist, age 32].\u0026rdquo;\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 106.8pt;border-style: none solid solid none;border-bottom-width: 1pt;border-bottom-color: windowtext;border-right-width: 1pt;border-right-color: windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"22.792937399678973%\"\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eEmployer initiated accommodations\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 360.7pt;border-style: none none solid;border-bottom-width: 1pt;border-bottom-color: windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"77.20706260032102%\"\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026ldquo;\u0026hellip; we talked about when I get further along, closer to my due date, instead of me serving, we\u0026rsquo;ll move to a different position, it\u0026rsquo;s hosting, so it would still require me to be on my feet, but I wouldn\u0026rsquo;t be walking as much and it\u0026rsquo;s not a lot of lifting like, of trays and food and drinks and things like that. I would just be picking up things and wiping off tables and that stuff [food service worker, age 29].\u0026rdquo;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 106.8pt;border-style: none solid none none;border-right-width: 1pt;border-right-color: windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"22.792937399678973%\"\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003eMedically recommended accommodations\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 360.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"77.20706260032102%\"\u003e\n \u003cp style=\"margin: 0in;line-height: normal;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 10px;\"\u003e\u0026ldquo;And I didn\u0026rsquo;t really work there too much longer after that \u0026lsquo;cause I was like you know, they don\u0026rsquo;t want to be supportive then, you know, they can just kick rocks and I can be happy with my healthy baby [food service worker, age 20].\u0026rdquo;\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"margin: 0in 0in 8pt;line-height: 15.693333625793457px;font-size:15px;font-family: Calibri, sans-serif;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif; font-size: 10px; color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"employment, work, preterm birth, high risk pregnancy","lastPublishedDoi":"10.21203/rs.3.rs-36777/v3","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-36777/v3","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Background: Pregnant women with a history of preterm birth are at risk for recurrence, often requiring frequent prenatal visits for close monitoring and/or preventive therapies. Employment demands can limit uptake and adherence to recommended monitoring and preterm birth prevention therapies. \n \nMethod: We conducted a qualitative descriptive study using in-depth interviews (IDIs) of pregnant women with a history of preterm birth. IDIs were conducted by trained qualitative interviewers following a semi-structured interview guide focused on uncovering barriers and facilitators to initiation of prenatal care, including relevant employment experiences, and soliciting potential interventions to improve prompt prenatal care initiation. The IDIs were analyzed via applied thematic analysis. \n \nResults: We described the interview findings that address women’s employment experiences. The current analysis includes 27 women who are majority self-described as non-Hispanic Black (74%) and publically insured (70%). Participants were employed in a range of professions; food services, childcare and retail were the most common occupations. Participants described multiple ways that being pregnant impacted their earning potential, ranging from voluntary work-hour reduction, involuntary duty hour reductions by employers, truncated promotions, and termination of employment. Participants also shared varying experiences with workplace accommodations to their work environment and job duties based on their pregnancy. Some of these accommodations were initiated by a collaborative employee/employer discussion, others were initiated by the employer’s perception of safe working conditions in pregnancy, and some accommodations were based on medical recommendations. Participants described supportive and unsupportive employer reactions to requests for accommodations.\n \nConclusions: Our findings provide novel insights into women’s experiences balancing a pregnancy at increased risk for preterm birth with employment obligations. While many women reported positive experiences, the most striking insights came from women who described negative situations that ranged from challenging to potentially unlawful. Many of the findings suggest profound misunderstandings likely exist at the patient, employer and clinical provider level about the laws surrounding employment in pregnancy, safe employment responsibilities during pregnancy, and the range of creative accommodations that often allow for continued workplace productivity even during high risk pregnancy.","manuscriptTitle":"Pregnancy vs. Paycheck: A qualitative study of patient’s experience with employment during pregnancy at high risk for preterm birth","msid":"","msnumber":"","nonDraftVersions":[{"code":3,"date":"2020-09-11 14:26:13","doi":"10.21203/rs.3.rs-36777/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept","date":"2020-09-11T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-09-07T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-09-06T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-09-06T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":2,"date":"2020-09-03 13:25:35","doi":"10.21203/rs.3.rs-36777/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2020-09-02T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-08-30T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-08-29T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-08-29T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-07-02 10:27:02","doi":"10.21203/rs.3.rs-36777/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-08-09T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-08-08T12:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after discretionary revisions\nForm responses:\n---\n\nComments to Author:\n---\nCould you provide further information about sampling and selection criteria and what is the impact of the employed process on the external validity of the findings and its interpretation?* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **none**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorInvitedReview","content":"","date":"2020-07-29T12:00:00+00:00","index":1,"fulltext":"Recommendation: Reject\nForm responses:\n---\n\nComments to Author:\n---\nThis is an important topic - a qualitative study of women's experiences of attempting to adhere to PTB care and guidelines which are often incompatible with their own needs to generate income.\n\nMethod:\nMore description about the 'larger study' from which these data were 'leveraged' is vital. What was the aim and purpose of this overall study? How were the overall sample identified, invited and recruited? How were participants chosen then for this smaller / nested set of interviews? This section needs to be much more transparent with more detail about both studies, and citations for prior publications provided if relevant.\nMore detail also about the content of the interview guide would be valuable here in the body of the paper itself (I see it as appendices, but this seems important to appear in main paper)\n\nResults\nLine 140-2 only two themes noted here but there are more than these reported in headings and sub-headings below? Please be consistent in reporting - also check major and minor sub-headings (font etc) - it is not clear if this is an error or reporting some hierarchy in findings - please be clear about themes / sub-themes etc.\n\nline 145-150 re reduced hours, income and pregnancy. These sentences are hard to disentangle, please explain clearly the attribution women made - was it their request for reduced hours that was the issue? Or the financial hardship, or both? Please order this section so it is clear how women experienced and reported this - I think it it is in contrast to the next section where women described where they had their hours reduced not by choice (i.e. by supervisors?)\n\n\nThe themes are all interesting and intuitive, but it is not quite clear how they are distinct overall from those expressed by all pregnant women - that is, not only those who are at high risk of PTB. This begs the question about the extent to which the interview questions probed these issues (or not) - and the 'monitoring' issue discussed in the Introduction is absent from these data. This could well be a true refletion of the data and women's reports, but I am not sure as there is not enough detail in the paper to make this judegment. Is it that these women experience their concerns akin to all pregnant women? Or is it that they had more concerns than most?\n\nLine 327 - suggest avoid 'patient' here and replace with women throughout too.\n\nThe authors themselves acknowledge limits in the IDIs schedule, such that it was unclear \" the physical limitations in the workplace were based on recommendations from a medical provider or based on the participant's own comfort level\" - However, the Introduction suggests these are key foci of the study, so it is disappointing that the findings do not shed further light on this particular sub-population of pregnant, at-risk of PTB women.\n\nTables 1 and 2 are not particularly informative - can these be combined, or reported in text? As an international reader it is unclear why the sample characteristics are stratified by race, it is not required and not central to the research question, so suggest either explain the purpose of this reporting or amend.\n\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **I declare I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **No**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **No**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-07-13T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-07-08T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-07-08T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-06-29T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-06-28T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-06-28T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"10e31d72-478e-4650-be1e-1b0b28e4bfba","owner":[],"postedDate":"September 11th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":426765,"name":"Sexual \u0026 Reproductive Medicine"}],"tags":[],"updatedAt":"2020-09-27T15:02:41+00:00","versionOfRecord":{"articleIdentity":"rs-36777","link":"https://doi.org/10.1186/s12884-020-03246-7","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2020-09-25 12:00:00","publishedOnDateReadable":"September 25th, 2020"},"versionCreatedAt":"2020-09-11 14:26:13","video":"","vorDoi":"10.1186/s12884-020-03246-7","vorDoiUrl":"https://doi.org/10.1186/s12884-020-03246-7","workflowStages":[]},"version":"v3","identity":"rs-36777","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-36777","identity":"rs-36777","version":["v3"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}