Postpartum RTW calls for sensitivity, creativity

FMLA helps, but only in certain cases

Return to work can be challenging for any recovering or rehabilitating worker, but helping a new mother adjust to being back at work can require an occupational health nurse to be especially creative and understanding. Aside from the physical recovery that follows childbirth, a postpartum woman has to adjust to the emotional repercussions of going back to work and leaving a child at home as well as the demands of keeping up with breast-feeding.

Financial stressors enter the picture, too. While many workers are covered by the federal Family Medical Leave Act (FMLA), many others are not. But FMLA is unpaid leave, and many working mothers — particularly single ones — are unable to afford to take full advantage of it.

Physical recovery takes weeks

Studies of postpartum women indicate that most experience an average of six postpartum symptoms, which can include fatigue, breast pain, constipation, hemorrhoids, surgical site pain (after cesareans), episiotomy pain, and other symptoms.

Patricia M. McGovern, PhD, RN, director of the occupational health nursing program at University of Minnesota in Minneapolis, told attendees at the American Association of Occupational Health Nurses expo in Minneapolis in April that a study she and her colleagues conducted of 700 employed women who planned to return to work after their babies were born shows that at around the time many of them were going back to work — at around six weeks postpartum — they were feeling their worst.

"Not surprisingly, at six weeks, C-section mothers were doing much worse," she explains. "We have a record high number of C-sections in the United States, in part because mothers like them, because [these procedures] give them control over when their babies arrive."

McGovern says an occupational health nurse working with an expectant mother who anticipates having a caesarean section should urge the woman to talk with her obstetrician in depth about the support she will need in the weeks after delivery. "For at least six weeks postpartum, the [occupational health] nurse needs to be cognizant of the signs and symptoms of depression," says McGovern. "Mood swings, anxiety, and feeling a lack of control can lead to worse health."

Postpartum depression, in particular, is potentially a truly serious health problem, and a nurse who sees signs of depression in a new mother should refer the woman to a mental health specialist as quickly as possible, she emphasizes.

Under the FMLA, covered employers (generally, those who employ 50 or more employees for each working day during each of 20 or more calendar workweeks in the current or preceding calendar year) must grant an eligible employee up to a total of 12 workweeks of unpaid leave during any 12-month period for the birth and care of a newborn child; for permanent adoption or foster care of a child; to care for an immediate family member (spouse, child, or parent) with a serious health condition; or to take medical leave when the employee is unable to work because of a serious health condition.

The FMLA was drafted with working mothers in mind, but passage of the bill was a hard-won fight, and the finished law broadened it to cover others who need time away from work.

Using intermittent leave can be tricky

Consequently, one feature of FMLA — intermittent leave — can be tricky to use for childbirth, says McGovern. Intermittent leave, she explains, would allow a new mother to take the 12 weeks of unpaid leave permitted by FMLA in ways other than strictly 12 full weeks off. For example, a new mother might opt to take eight weeks of full-time leave and then spread the remaining four weeks out as eight weeks of part-time leave. But for intermittent leave to apply to a postpartum mother, the employer would have to decide that childbirth is a "serious medical condition."

"FMLA allows intermittent leave, but technically, it’s not a given that you can have it in association with childbirth," she says. "Usually, it is tied to a serious health condition."

The occupational health nurse can tip the scales in the mother’s favor, she says, by engaging the woman’s physician to make the argument that postpartum recovery is a serious health issue. "Doctors don’t always think about doing that, and the nurse may be able to facilitate that," McGovern suggests. "With intermittent leave, return to work is a little easier to accomplish because it allows the woman to gradually build up her stamina, and the only way to do that is over time."

Other problems arise when a woman’s employer is not covered by the FMLA due to the size of the company, if the woman is in the highest-paid 10% in her company, or if she can’t afford to take 12 weeks of unpaid leave. "Single mothers are most at risk of having no paid leave benefits; even if they do, taking unpaid leave can be difficult for them to do," McGovern reports. "Larger companies have vacation, sick leave, and other paid disability; but when that’s not there, it speaks to the need for nurses to be cognizant of how people are adapting when they are returning to work."

Though California has passed a paid family and medical leave act, which provides for up to six weeks of paid leave after vacation, disability leave, and sick leave are exhausted, the United States still stacks up poorly against other industrialized nations when it comes to time off for women who give birth, McGovern says. "The states will have to continue to be the laboratory for change," she predicts. "We won’t be seeing anything at the national level for quite a while."

Finding creative solutions

Women not covered by FMLA but who have employer- or self-funded short-term disability can use it for typically six weeks of paid leave, but those who are not covered still might have options other than simply returning full-time after their sick leave, vacation, or unpaid leave ends. "Maybe having some control over their hours, if that is possible within their job, can be a coping mechanism" for the returning-to-work mother, McGovern says. "If the employer can give some flexibility, that might give her more of a sense of control over her situation."

Companies can take other small steps to help in the transition back to work, she suggests. Maintaining a list of reliable day care or backup emergency (or drop-in) child care options can go a long way toward reducing stress over child care, McGovern points out. "Larger employers can subscribe to programs that help find child care that fits the family’s situation," she says. "There are things that employers can do, that nurses are good at, to identify small things they can do to help."

One of the ways nurses can help is to be a support source for mothers who are breast-feeding their babies — and for those who need to choose not to breast-feed. While La Leche League and other organizations and health care providers stress the benefits of breast-feeding for babies, and offer support for women who need to balance breast-feeding with being away from their babies for hours at a time, McGovern says there needs to be room to consider that breast-feeding might not be the best choice for some mothers.

"There is such a push on breast-feeding moms, but it might be that breast-feeding isn’t the best thing for mom; and if it’s causing more symptoms such as hot flashes and fatigue, that might not be the best thing for her," she says. "That’s where nurses may have an important role to play, to find out what’s best for the woman and support her in what’s best."