INTRODUCTION

Women's participation in the American labor force has steadily increased from 38% in 1960 to 60% in 2002 (1). Women of childbearing age have the highest rate of labor force participation of all women and no longer leave the workforce when pregnant (2). Among employed pregnant women, nearly 80% work during the third trimester of pregnancy and the majority hold full-time jobs (2).

Economic necessity, increased education, changing expectations, and a strong work commitment account for much of this shift (3). Women are contributing to the family's economic well-being by working in less traditional jobs, many of which require excessive time demands and physical endurance (4). Managing work and family often requires exceptional motivation and stamina. Yet, while the gender composition of the workforce has diversified, employer policies and federal employment laws often fail to recognize the shared financial responsibilities or reproductive realities of women, still reflecting the concept of a full-time, male workforce (3, 4).

Making it easier for women to combine work and parenting roles enables families to function more effectively while also helping businesses attract and retain the best workers (5). Delaying childbearing due to career concerns often means decreased fertility as couples age (6). Facilitating women's multiple roles requires family-friendly policies (3). The Family and Medical Leave Act (FMLA), enacted by Congress in 1993, allows parents to take up to 12 weeks of unpaid job protected leave around the birth of a child or to provide family care (7). The law applies to full-time employees working for at least 1 year in companies with 50 or more employees. FMLA covers less than half of the workers in the private sector; part-time employees and those working in informal labor markets do not benefit. Studies show increases in family leave up-take beginning in 1993, particularly for full-time employees in medium- and large-sized establishments and in the public sector. Yet because leave is unpaid, many FMLA-eligible employees cannot afford to take leave (8).

California is one of five states providing paid pregnancy leave, generally for up to 4 weeks before birth, and up to 6 weeks after a vaginal delivery or 8 weeks after a caesarean section. Cash benefits, averaging $293/week in 2003, derive from temporary state-sponsored non-occupational disability insurance funded through employee payroll deductions (9). Women working for public or private employers with five or more employees are covered. Although employers vary widely in the maternity benefits that they offer, women are legally allowed to work as long as they desire and they are generally encouraged to plan ahead for maternity leave and communicate their intentions to their employers. While a few studies have tracked maternity leave coverage, little is known about the actual patterns of antenatal leave taking and the occupational, demographic and health characteristics associated with leave (2, 3). Women may take leave if they are stressed and fatigued during pregnancy or may avoid taking leave if they must forgo promotion and income. Information about antenatal leave utilization patterns and correlates is needed to shape evidence-based health care guidelines and inform health policy and legislation. Antenatal leave utilization patterns can also address labor concerns about worker retention associated with pregnancy.

In this article, we examine the maternity leave arrangements that women use prior to delivery and focus specifically on antenatal leave, i.e. the extent to which women go on maternity leave while they are pregnant with the expectation of returning to their job sometime after delivery. We address the following questions: To what extent do women take antenatal leave, quit work or not take any leave during pregnancy? What occupational, demographic, and well-being factors influence these decisions? Among leave takers, what is the duration, source of compensation and main reason for leave? We discuss the implications of our findings for evaluating maternity leave policies in California and other states. In subsequent papers, we will examine the impact of antenatal leave on pregnancy outcomes. Although this relationship has not been explored in US women, studies conducted abroad show a protective effect of antenatal leave on low birthweight (LBW) (10), small for gestational age (11), and mean birthweight (12).

METHODS

Subjects derive from a case–control study, Juggling Work and Life During Pregnancy, designed to examine the relationship between stress and pregnancy outcomes. All women participated in the California Department of Health Services Prenatal Screening Program (XAFP) in three Southern California counties (Orange, Imperial, and San Diego). Women delivering live births between July 2002 and November 2003 were eligible for contact if they were at least 18 years old, delivered within 6.5 months of the interview date, had a singleton birth without congenital anomalies, and had a US mailing address. Live birth records were matched against XAFP records corresponding to the regional laboratory serving these three counties, yielding 38,383 women with linked data in our sampling frame.

All women delivering preterm (PTD) or LBW infants (n = 3865) and a random sample of controls (n = 3367) frequency matched on race and month-of-birth were mailed an introductory letter 1–6 months after delivery using the mailing address recorded in birth records as well as menstrual period and birthweight. Potential participants were subsequently contacted by telephone. At least 15 attempts were made to contact each subject. Contacted women were prescreened to ascertain their employment history during pregnancy. Women who had worked 20 h or more per week during the first two trimesters of pregnancy or through the date of XAFP testing were considered eligible for study and invited to participate in a 45 min telephone interview.

Out of 3655 successful contacts, 740 women (20%) refused participation and 1591 (44%) were not eligible because they were not working at least 20 h/week during the designated period. Women who were contacted (on average 20 weeks post delivery) were more likely than those not contacted to be age 30 or older (51% vs. 40%), White (33% vs. 24%), have post-high school education (53% vs. 42%), and have a term infant (61% vs. 54%), but were as likely to have delivered a LBW infant (26% for both groups). Refusers were more likely than study participants to be Asian, primiparous and college educated. They did not differ with respect to age or birth outcome. Eligibility and refusal rates were identical among women delivering preterm or LBW infants and women delivering term/normal weight infants. Of the remaining 1323 eligible women, 109 were unable to complete the interview, yielding 1214 completed interviews. There were 592 cases (21% LBW, 47% PTD, and 21% both PTD and LBW). Participants were queried about their maternity leave arrangements, work environment, occupational and reproductive characteristics, and demographic background. The overall imputed response rate among eligible women was 73%.

Measures and Data Collection Instruments

Women were categorized into one of five outcome groups: those who (i) used antenatal leave with the expectation of returning to their job or employer sometime after giving birth; (ii) quit their jobs; (iii) took no leave prior to giving birth; (iv) cut back on their work hours; or (v) were fired. Among women who took antenatal leave or quit work (the two main time-off arrangements) we examined additional features: whether the time off was paid and by whom (state disability insurance, the employer or a private insurance carrier), gestational age at which time off was taken, the length of time taken prior to delivery, and the reason for taking leave or quitting.

Among independent variables, occupational variables included type of occupation, work shift, years employed, company size, flexibility in setting one's own work schedule, job fulfillment, whether the employer offered maternity leave benefits and health insurance coverage, and job strain (13). Job strain was categorized as low strain (low demands and high control over demands); passive (low demands and low control); active (high demands and high control), and high strain (high demands and low control). Demographic variables included annual household income, highest educational attainment at the time of delivery, maternal age, marital status, race/ethnicity, and the number of children under age 5. We measured well-being through a combination of reported stress or tiredness during the second trimester of pregnancy, as follows: low (neither stressed nor tired), medium (either stressed or tired), and high (both stressed and tired). This measure correlated strongly with health problems during pregnancy, a field we were unable to use because we could not establish the temporality of events.

Bilingual Spanish-English interviewers were trained by the study investigators and supervised by Survey Research Group (Sacramento, California). Interviewers used Computer Assisted Telephone Interviewing (CATI) software to enter the responses into a database and verified 5% of the interviews through repeat calls. A $10 gift card was offered to participants in return for a completed interview. The study protocol was approved by the Committees for the Protection of Human Subjects at the University of California, Berkeley (No. 2003-5-115) and by the California Health and Human Services Agency (No. 02-10-18).

Data Analysis

We estimated the take-up rates (%) of antenatal leave, quitting, no leave, and other time off. Chi-square tests were used to compare occupational, demographic and well-being characteristics among the main study groups: leave takers, quitters, and no leave takers. We used logistic regression to estimate adjusted odds ratios and their 95% confidence intervals of (a) taking antenatal leave versus no leave, (b) antenatal leave versus quitting, and (c) quitting versus no leave, controlling for occupational, demographic characteristics, and well-being.

Because cases and controls were sampled from the universe of live births, the sampling probability for each individual is known. Analytic weights constructed from the inverse of the known sampling probabilities were used to adjust the sample back to the birth population by accounting for the over sampling of PTD and/or LBW infants and frequency matching of controls to cases. All weighted analyses were conducted using survey procedures in SAS version 9.1.2 (14) to calculate appropriate standard errors.

RESULTS

Maternity Leave Arrangements

As shown in Fig. 1, the majority of working women (52%) worked up to the time of delivery, while 32% took antenatal leave, 9% quit their jobs, 5% cut back on their hours, and 2% were fired during pregnancy. Only 1% of non-leave takers worked from home.

Fig. 1.
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Antenatal leave arrangements among working women in three southern California counties, 2002–2003.

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Overall, 63% of women and 69% of antenatal leave takers were offered leave by their employer. Quitters were less likely than antenatal leave takers to have paid maternity leave (39% vs. 75%) (Fig. 2). The sources of pay for women with paid leave were similar for leave takers and quitters, with the state covering 74 and 78%, and employers covering 21 and 23%, respectively. On average, antenatal leave takers stopped work 1 month later in pregnancy than quitters (33 weeks [95% CI = 32.6–34.2] vs. 29 weeks gestation [95% CI = 27.1–31.3]); 55% of leave takers exceeded the 4 weeks of antenatal leave allowed by the state (Fig. 3). Medical problems (52%) rather than access to maternity benefits (25%) were the most commonly stated reasons for stopping work and taking antenatal leave at that time (Fig. 4). Similarly, 48% of quitters reported that they stopped work due to medical problems. Lifetable analysis reveals that 50% of leave takers, 51% of non-leave takers, and 15% of quitters returned to work by 3 months postpartum.

Fig. 2.
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Source of pay among working women with paid time off in three southern California counties, 2002–2003.

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Fig. 3.
figure 3

Distribution (% and 95% confidence intervals) of length of time off among antenatal leave takers and quitters in three southern California counties, 2002–2003.

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Fig. 4.
figure 4

Distribution (% and 95% confidence intervals) of reasons for stopping work among antenatal leave takers and quitters in three southern California counties, 2002–2003.

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Determinants of Antenatal Leave Takers Versus Non-Leave Takers

Several occupational factors are shown to contribute to antenatal leave taking compared to non-leave taking (Table I). After controlling for the covariates listed in the table, working the night shift was associated with an almost threefold-increased odds of taking antenatal leave and lack of fulfillment in the job with nearly a twofold increase, while lack of work flexibility and work tenure of less than 1 year were associated with lower odds of leave taking. Job strain was not a significant predictor of leave. As for demographic and well-being characteristics, women completing high school were more likely to take leave, and having more than one child under the age of 5 doubled the odds of leave. Furthermore, being either stressed or tired doubled the odds of leave taking, and being both stressed and tired quadrupled the odds.

Table I. Characteristics Predicting Antenatal Leave Taking Versus Non-Leave Taking: Working Women in Three Southern California Counties, 2002–2003 (n = 1214)
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Antenatal Leave Takers Versus Quitters

Adjusting for covariates, being stressed or tired, and having a high strain job were related to higher odds of leave taking relative to quitting (Table II). Women were more likely to quit than take leave if they were not offered maternity leave benefits by their employer or had less than a full high school education.

Table II. Characteristics Predicting Leave Taking Versus Quitting: Working Women in Three Southern California Counties, 2002–2003 (n = 1214)
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Quitters Versus Non-Leave Takers

After controlling for covariates, not having maternity leave benefits offered by the employer was associated with a threefold-increased odds of quitting compared to no leave taking (Table III). Additionally, women whose employer did not offer health insurance, and those with a high stress/tired index had elevated odds of quitting. The odds of quitting decreased as maternal age increased.

Table III. Characteristics and Determinants of Quitters Versus Non-Leave Takers: Working Women in Three Southern California Counties, 2002–2003 (n = 1214)
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DISCUSSION

As our findings show, the majority of women (52%) work through their pregnancy; 32% take antenatal leave with the expectation of returning to their job after delivery, and an additional 9% quit employment. A recent Census Bureau report showed that between 1991 and 1995, 35% of US pregnant working women took antenatal leave and 23% quit their jobs (2). Our findings suggest that paid state disability benefits offered in California are not contributing to excess antenatal leave taking or quitting among working women.

Among antenatal leave takers, the majority state that they stop work due to health reasons or physical discomfort that prevents them from carrying out their work activities. Women are far less likely to use time off to take advantage of the antenatal leave cash benefits, to prepare for the birth, or to give themselves rest and relaxation. Moreover, as our multivariate models indicate, the strongest predictors of leave taking compared to working through pregnancy are feeling stressed and tired during the second trimester and having children under the age of 5. These findings suggest that rather than being used predominantly as a health-promoting behavior, antenatal leave constitutes a coping response to stress and tiredness and the need to mother young children, in itself a potentially stressful and tiring activity. Our findings also indicate that antenatal leave is being used as a protective measure against occupational stressors such as night work and low control over job demands. Night shift workers were almost three times more likely than day shift workers to take antenatal leave. And, women in either passive or high-strain jobs with low control were more likely to take leave than quit their jobs, after controlling for other factors.

Women who are stressed and tired in the second trimester also tend to have more medical problems. Studies done abroad suggest that antenatal leave may protect against obstetric interventions and poor pregnancy outcomes (11,13,15). Physicians often advise women to take leave for hypertension, diabetes, preterm labor, or a history of reproductive adverse outcomes. According to one population-based study in Georgia, despite receiving advice from their physicians or nurses to stop working during pregnancy, only half of the high-risk patients followed this recommendation (16).

Three out of four antenatal leave takers received paid leave. Yet after controlling for other factors, household income did not seem to play an important role in predicting women's leave arrangements. Most class-related effects seem to be reflected by educational and occupational characteristics. The multivariate models, adjusted for demographic characteristics, identified lack of work flexibility, short work tenure, and no high school diploma, as deterrents of antenatal leave-taking. These findings point to potential barriers to leave-taking.

Most non-leave takers are offered leave by their employers and are eligible for state-funded benefits. Non-leave takers are more likely to be affluent and to have a post-graduate education compared to women who take antenatal leave or quit work. Non-leave takers are also more likely than leave takers to feel fulfilled with their work. These findings corroborate the recent Census Bureau report on national maternity leave and employment patterns (2). The results further suggest that a strong work attachment and fear of sacrificing career advancement opportunities deter such women from taking leave, rather than immediate financial need. Non-leave takers also feel less stressed and/or tired during the second trimester of pregnancy, allowing them to work through pregnancy and bank leave for after childbirth. Future studies must determine how this affects birth outcomes and postpartum adjustment.

Lack of maternity leave benefits appears to create a work disincentive as does lack of health insurance since women are more likely to terminate their employment if their employer does not offer such benefits. In contrast, maternity leave offers by the employer may increase the likelihood that women will plan to return to their jobs sometime after childbirth. Employers who offer antenatal leave benefits may perhaps promote worker retention thereby minimizing turnover costs (17).

The findings from this study require cautious interpretation. Self-appraised measures such as job fulfillment or levels of stress and fatigue are vulnerable to recall bias (18). Yet, women interviewed up to 16 weeks postpartum were as likely to report high stress as women interviewed later, suggesting that recall of stress was not strongly biased by time of interview. Similar lack of recall bias of stressful events has been found in retrospective studies using PRAMS (19). We were unable to confirm the reported employment and leave patterns, benefits, or demographics of our study population, yet these measures are objective and presumably less subject to recall bias (16). Furthermore, we employed seasoned telephone interviewers and provided training and continuous feedback. Non-leave takers could have been subject to misclassification as we were unable to identify women who used sick and vacation days off in lieu of formal leave. Non-leave takers may have had less opportunity to take leave due to preterm delivery. However, we estimate that only 0.3% of non-leave takers would have taken leave had they not delivered early. Furthermore, because younger women were underrepresented in our study, the proportion of quitters may be underestimated. In addition, compared to census data, our sample included a higher proportion of professional and managerial women and a lower proportion of workers in clerical, high skilled technical and manufacturing jobs (20).

We conclude that availability of benefits does not alone determine antenatal leave-taking behaviors; occupational factors, education, stress and fatigue influence women's decision making on this issue. Working pregnant women in California appear to be cautious in their leave-taking behaviors utilizing antenatal leave less for health promotion than to cope with health problems and fatigue. Health care providers can facilitate access to antenatal leave for working women for whom leave is necessary by fostering an environment that promotes antenatal leave as a viable option. More information about patterns and correlates of antenatal leave utilization can help form evidenced-based health care guidelines, educate women on the importance of adhering to these guidelines, and inform public policy and legislation. Job-protected, paid antenatal leave can strengthen work stability and economic security, while potentially promoting women's health.