Sick leaves among healthy pregnant Croatian healthcare workers during the COVID-19 pandemic due to loopholes in the occupational safety system

The findings of this study should be viewed in light of the limitations pertinent to data collection through social media and self-reporting. The questionnaire’s strength, however, lies in its anonymity, thanks to which pregnant HCWs felt free to report having taken sick leave even if the pregnancy was normal, as they saw no other option to protect pregnancy.

Table 2 lists healthcare institutions where the study participants worked. The participants were diagnosed with pregnancy in the sixth (IQR 6.0–8.0) week and informed their employers in the eighth (IQR 7.0–11.0) week of pregnancy. More than a third (37.6 %) did not inform their employers about pregnancy immediately after being diagnosed. The reasons for the delay were as follows: the opinion that pregnancy did not affect their work ability (52.3 %), the opinion that their workplace did not have a harmful effect on their own and foetus’s health (33.8 %), the fear of getting fired or being mobbed at work (20.0 %). Such a delay entails postponing risk mitigation beyond the first trimester, the most vulnerable period of the foetus’s development (19,20,21), as the working status of pregnant HCWs remains unclear: do they continue to work until further notice, are they on a sick leave and on what basis, do they have to take paid leave?

Delaying to notify the employer about pregnancy over fear of losing the job or getting bullied points to psycho-social risks at their workplace. This is in line with recent studies reporting that younger women HCWs were exposed to mobbing (22,23,24,25,26,27,28) and puts additional burden on the psycho-physical health of pregnant workers, besides the one posed by the pandemic (11, 12, 29,30,31).

After having notified the employer about pregnancy, 139 or 80.4 % of the participants did not receive individual risk assessment, and 34 or 19.6 % received it, mostly on their own initiative (26 of 34 participants) rather than on the initiative of the employers (eight participants). This suggests that most employers – healthcare institutions no less – did not recognise pregnant HCWs as workers in need of special attention. Only 19 of the 34 participants who did receive individual risk assessment received it within two weeks of notifying the employers, while 14 had to wait for more than two weeks. Risk assessment was made by OHPs (for 21 participants) – who not once visited participants’ workplaces – participants themselves (19 participants), occupational safety experts (for 16 participants), and colleagues working at the same workplace (for six participants).

Furthermore, while the COVID-19 pandemic brought some positive revisions to individual risk assessment in Slovenia (32), mainly involving both the employer and an OHP, no such revision took place in Croatia (internal communication by occupational medicine specialists and safety experts). No professional guidelines for risk assessment were provided and neither were the guidelines for health protection of pregnant HCWs during the pandemic. Only recently did the Department of Occupational Health (within the national public health institute) publish a flowchart detailing protective actions to be taken after notifying employer of pregnancy (33).

With the aim of defining exposure risks at workplace, experts from Denmark, the Netherlands, and the United Kingdom developed a COVID-19 job exposure matrix (JEM), which establishes four determinants of transmission risk (number of people, nature of contacts, contaminated workspaces, and indoor/outdoor location), two mitigation measures (social distancing and face covering), and two factors for precarious work (income insecurity and proportion of migrants) (34). Similar JEMs have also been developed by other experts (35, 36), as such tools can greatly help to identify occupational risks and to create risk reduction policies for future epidemic outbreaks, especially when it comes to vulnerable workers. According to the national ordinance on risk assessment (37), once informed about worker’s pregnancy, the employer should already have complete workplace risk assessment information ready to decide whether the pregnant worker can continue to work at the current workplace and what adjustments are necessary, if any. At this point, OHPs, whose participation in the assessment is currently not mandatory, should be involved to speed up the process following pregnancy notification actions in terms of worker’s protection and safety.

Table 3 summarises participants’ answers as to what actions followed when they notified the employer about pregnancy. 37.0 % claimed temporary work incapacity (TWI) due to pregnancy complications, even though their pregnancy was normal, while 16.8 % were granted a paid leave by the employer. We believe that these quite desperate actions are owed to a sore lack of systematic approach to individual risk assessment and mitigation for HCWs in Croatia. Coincidentally, the pandemic years 2020–2022 saw an increase in the share of diagnosed “high-risk pregnancies” (36.5–37.7 % of all pregnancies) over complications that require close monitoring compared to the five-year period before the pandemic (27.5–33.3 %, from 2015 to 2019) (38). Such diagnosis and recommendation of monitoring, issued by a primary healthcare gynaecologist, entails sick leave. It is possible that our participants also contributed to this increase. All this suggests that a more transparent system of pregnancy sick leave entitlement is required in Croatia as is a better control of its use.

One limitation of our study is that we could not ascertain the facts about risk assessment, risk factors at the workplace other than SARS-CoV-2, or work ability during pregnancy or other self-reported items in the questionnaire, which is why our findings should be interpreted with some reserve.

Since only 5.8 % of our participant reported to have continued to work throughout pregnancy at workplaces they considered high-risk, more research is needed to evaluate HCWs’ knowledge of occupational risks. If this knowledge is found to be insufficient, HCWs would benefit from retraining that would help to build a safer working environment.

Table 4 summarises differences in between physicians and nurses as to what actions followed when they notified the employer about pregnancy. The reasons for these differences should be sought in different job tasks. Nurses more often come into close contact with patients and are the first to respond to patients’ inquiries and emergencies (4). If the risks cannot be minimised or the nurses transferred to a safer position, the employer is required to provide paid leave (15). The nurses in our study reported this to have happened significantly less often than did physicians, so more than a half (20 of 34 nurses) resorted to TWI due to pregnancy complications.

Occupational safety procedures for pregnant HCWs in Croatia lack a systematic and more transparent approach to protecting their health and pregnancy, which came under the spotlight during the COVID-19 pandemic. Employers did not fully recognise pregnant HCWs as a vulnerable group who need individual risk assessment and mitigation at the workplace. The systemic weaknesses included late notification of pregnancy, which delayed any protection of the most vulnerable first trimester of pregnancy, and unclear procedures as to risk assessment and mitigation for this specific group of HCWs. In the absence of clear employers’ prevention strategies, pregnant HCWs resorted to sick leave due to pregnancy complications, even though there were none.

A solution to this issue would be to include OHPs in risk assessment for pregnant HCWs from the start, so that the prevention and protection measures during pregnancy are known in advance to both the worker and the employer, and that the loopholes in the healthcare system are not misused. This means that OHPs and specialists in gynaecology and obstetrics should cooperate more in protecting the health of the pregnant worker and preserving their ability to work, not only in terms of exposure to biological hazards but other workplace risks as well. Employers should encourage healthy interpersonal relations at the workplace and implement measures to prevent psycho-social risks, so that HCWs feel safe to report pregnancy in time.