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Programs and pregnancy: A survey of policies
ORIGINALCONTRIBUTION
rograms and Pregnancy: Survey of Policies •
Richard T. Cook, Jr., MD, FACEP; Nancy Flint, RN, BSN; Debra L. Whitten, RN, BSN, CCRN
If a woman becomes pregnant while on flight status, a potential conflict exists between the needs and desires of the program and those of the flight crew member. Association of Air Medical Services (AAMS) member programs were surveyed to determine the extent of pregnancy policy standards within the air medical profession. A survey was mailed to 150 AAMS program directors in the fall of 1988. The survey was followed with a second mailing and a telephone follow-up for clarification. Replies were received from 110 program directors. Fifty-five percent of those responding noted they had a policy on flight crew member (FCM) pregnancy. Thirty percent noted a date prior to term that the pregnant FCM (PFCM) would be removed from flight status. Seventy percent of the programs noted that they had not previously had a PFCM. Over half of the programs allowed PFCMs to fly until the third trimester, with just under a quarter allowing flights until 38 weeks or greater. There are few articles specifically referring to air medical FCM pregnancy, and policies regarding FCM pregnancy differ widely among the AAMS member programs. Key Words: pregnancy, flight crew, air medical service, pregnancy policy.
Introduction GIVEN THATMANYFLIGHT CREWMEMbers in the air medical service prog r a m s are young women, some of them may become pregnant during the c o u r s e of t h e i r e m p l o y m e n t . Owing to the sensitivity of this issue and its potential for medical, social, and employment problems, conflicts may arise when a flight crew member becomes pregnant. Other than an e x c e l l e n t review of a flight crew member pregnancy, there are few articles in the medical l i t e r a t u r e specifically referring to flying and flight crew m e m b e r p r e g n a n c y . 1 Richard T. Cook, Jr., is an assistant professor of emergency medicine at the Milton S. H e r s h e y M e d i c a l Center (Hershey, Pa.); Nancy Flint was a (pregnant) flight nurse at Life Flight, (Pittsburgh, Pa.); Debra L. Whitten was a (pregnant) flight nurse at LIFE LION (Hershey, Pa.) and is now a flight nurse at Life Flight (Atlanta, Ga.).
Therefore, decisions made in these situations about employee capabilities and medical risks may be judged arbitrary. When a decision is made regarding a particular issue of the pregnancy and e m p l o y m e n t , both the p r o g r a m and the p r e g n a n t crew member may be satisfied, or dissatisfied, with the decision. To better u n d e r s t a n d the range of policies among AAMS member programs, we conducted this survey to determine what policies currently exist within the air medical service community.
Methods Two survey forms, one to be completed by the program director and one to be completed by p r e g n a n t flight crew members for a separate study, 2 were developed and sent to the AAMS Survey Review Process Committee for approval and AAMS endorsement for a survey to AAMS member programs. After receiving
The Journal of Air Medical Transport ° May 1992
this endorsement, a copy of the program director survey form (Table 1), the pregnant flight crew member survey form, and a copy of the endorsement letter were sent to 150 AAMS programs in the fall of 1988. A second mailing was sent to elicit more responses, and telephone follow-up was u s e d to clarify r e s p o n s e s as needed.
Results Replies were received from 110 program directors. Sixty of the 110 responding programs (55%) noted that they had a policy on flight crew member FCM pregnancy. Thirty perc e n t of the 110 who r e s p o n d e d reported a date at which the FCM would be removed from flight status prior to term. This group that noted a cutoff date represents half of the 60 respondents who indicated that they have a policy. Any flight crew member could leave flight status as early in pregnancy as she wanted--no program had a minimum gestational; age requirement. When comparing the pregnancy policy for flight crew m e m b e r s to that of other employees within the institution, 26 respondents noted that the policy is the same and 56 indicated that it is different. Table 2 lists major policy differences in job maintenance performance requirements between FCMs who become pregnant and o t h e r e m p l o y e e s who become pregnant. Table 3 lists the differences in employment and budget issues between policies for flight 7
flight status, performing duties such as quality assurance, continuing education, and o t h e r a d m i n i s t r a t i v e duties. Forty-seven percent of the programs noted that a PFCM experienced motion sickness. No attempt was made to differentiate between an increase in motion sickness over the FCM's norm; rather, the question only asked if motion sickness was experienced. The most common solutions included eating frequent small meals, c a r r y i n g c r a c k e r s onboard during flight, eating a meal prior to flight and changes in seating a r r a n g e m e n t s . The most popular a r r a n g e m e n t involved having the PFCM sit in the aft portion of the aircraft in a forward-facing seat.
Policies regarding flight crew member pregnancy differ widely among AAMS member programs.
crew members and other institutional employees once they have become pregnant. Seventy of 108 programs responding to question No. 6 indicated that they had a pregnant FCM now or previously. Of the 60 p r o g r a m s reporting policies, 30% indicated there was a change in policy after having a pregnant flight crew member within the program. Table 4 summ a r i z e s the n u m b e r of w e e k s of pregnancy up to which the PFCMs were actually flying, as reported by the various air medical p r o g r a m directors. A review of Table 4 shows no consensus on a cutoff time in actual practice within the air medical profession. Of note is that over half are allowing P F C M s to fly into t h e i r t h i r d trimester, with 23 programs allowing flying until 38 w e e k s or g r e a t e r . Though not specifically asked in the questionnaire, 21% of the programs noted that they required approval of the PFCM's obstetrician at some point during the pregnancy in order to continue flight status. Since these were unsolicited comments, the number of programs requiring this could even be higher. 8
Concerning accommodations made by the program for the pregnancy, 44 programs indicated that specific accommodations were made by the program for the pregnancy, and 25 indicated no accommodations were made. Special accommodations noted by respondents included one for lifting a s s i s t a n c e , m a n y for changes in the schedule, and one response of particular interest--"taking care toward maintaining the selfrespect of the pregnant FCM." The most commonly cited adjustments concerned changes in uniforms. One p r o g r a m r e p o r t e d the FCM was allowed to fly until she could no longer fit into her uniform. A p p r o x i m a t e l y 25% of the programs noted that no alternate duty option was provided for the flight nurse once she was no longer on flight status. Of those providing alternate duty, the overwhelming majority indicated that opportunities existed for working within the emergency department. Other programs offered the emergency department as one option among several clinical options. Over 15% of the programs indicated that t h e r e was an option to work within the flight program in a non-
Discussion Studies of environmental conditions related to aviation have shown some impact on fetal development or physiology.3-7 These studies did not address air medical services personnel and t h e r e f o r e c a n n o t be cons t r u e d as e v i d e n c e to s u p p o r t restrictions of flight status. The study conditions are notably dissimilar, though they certainly do stimulate thought for further research. Those studies reviewing travel, a facet of air medical transport, show no association between undesirable gestational outcome and the process of traveling, particularly in normal pregnancies in which delivery does not occur during the travel. 8-13 Several studies of gynO ~ cologic and o b s t e t r i c c o n d i t i o n s affecting airline flight attendants have not shown an association with obstetrical problems. 1.18 One study suggested flight status termination for airline flight attendants at 20 weeks, but based this only on hypothetical concerns. 18 A study reviewing employment histories and abortus chromosomal characters s h o w e d no a s s o c i a t i o n between healthcare workers and fetal chromosomal abnormalities, but did not address flight crews or other attendants. 19 In a review of 7700 pregnancies, women who worked during the third trimester, particularly those who
The Journal of Air Medical Transport ° May 1992
stood, had an associated decrease in increased risk for premature birth. 43 existence of this increased risk. 49 A birthweight and increase in placental Increased risk of prematurity and low s t u d y c o m p a r i n g p r e g n a n c y outinfarction compared with w o m e n birth weight is noted to exist in cer- comes among female resident physiwho didn't work. 2° Several reviews of tain g r o u p s of w o m e n w o r k e r s , cians and t h o s e of non-physician pregnancy, trauma, and miscarriage including a subgroup which included wives of residents showed no signifishow no increased risk from normal medical personnel. 44 cant difference between groups with activities or m i n o r t r a u m a , 2124 In other studies, physicians, par- respect to miscarriages, ectopic pregalthough several studies and reviews ticularly resident physicians, have nancy, still births, preterm births, have n o t e d t h a t both major and been noted to be at an increased risk and births of infants who were small minor motor vehicle collisions, even for complications of pregnancy, 45-48 for gestational age in these socioecowith little apparent maternal injury, though not all studies support the nomically matched groups. 5° Women can cause fetal death. 25-33 A review of military flight nurses Table 1 noted menstrual changes but did not address pregnancy, since pregnant Program Director Questionnaire women are not permitted on military flight status. 34A female United States 1. Do you have any established policies regarding pregnancy of flight team Air Force pilot assigned to fly a highmembers? If yes, please mention the highlights, especially regarding altitude TR-1 spy plane has agreed to maternity leave, financial compensation, etc. not become pregnant for at least a year and m u s t submit p r e g n a n c y 2. Do you have a cutoff time by which a pregnant flight team member must tests on a biweekly basis. 35 stop flying? A child born to a small aircraft 3. Do you have an initial stage of the pregnancy at which she may request a pilot involved in a severe crash at 22 change from full flight status? w e e k s was n o t e d to have hydrocephaly. 36 The authors know of no 4, Do you offer alternate duty after the flight team member stops flying? other published study or case review of p r e g n a n t flight crew m e m b e r s 5. Compared with other similar employees (i.e., nurses, paramedics) in involved in aircraft crashes, forced your institution/organization, is the policy on pregnancy: landings, or other traumatic inciA. the same? dents. In two r e c e n t s t u d i e s , B. similar, but modified for flying? increased risks of pregnancy compliC. different? cations were demonstrated among D. question not applicable? flight attendants. 37,38 However, the 6. Have you had, or do you now have, any pregnant flight team members? reader m u s t recognize, as do the authors of both papers, the potential 7. How far into their pregnancies did these flight team members actually fly? for bias related to the socioeconomic factors of the study and control popu8. Did any pregnant flight team members experience motion sickness in their lations. Several studies have shown pregnancies? If yes, what methods (i.e., medications, schedules, seating that it may be difficult to obtain accuposition, etc.), if any, were used for controlling the condition? rate, unbiased data on which to base conclusions. 38-4° T h e s e and other 9. Please discuss any special flight requirements to accommodate the studies on the effects of factors on pregnancy, such as alterations in flight suits, schedule changes, and so on. pregnancy outcome have not been done in groups which adequately match the population and working Table 3 Table 2 conditions of the air medical services, particularly helicopter scene Differences in Characteristics of Differences in flights. Employment/Benefits Issues: Job Performance Requirements Pregnancy among healthcare Pregnant FCM vs. Other Between Pregnancy Policies workers has been looked at in a numPregnant Employees of the of a Flight Program and its ber of articles. 41 Stand/up work, carInstitution Related Institution r y i n g h e a v y loads, and h e a v y • Leave of absence • Altitude limits cleaning tasks were associated with a • Change in pay • Hemoglobin level higher rate of preterm delivery in 600 • Immediate notification • Able to lift given weight French hospital workers. 42 Medi• Maternity leave • Able to move in aircraft cosocial staff personnel were noted • "Light" duty • Weight gain limits to be one of several g r o u p s at The Journal of Air Medical Transport • May 1992
9
residents, however, did experience more preterm labor and preeclampsia. Policies for women physician pregnancy are also non-uniform and usually lacking in hospital residency programs.5L52 The above results indicate that no c o n s e n s u s exists a m o n g AAMS member programs on many of the important issues on the topic of pregnancy and flight programs, such as flight status cutoff, alternate duty, or even the presence of policy. The lack of consensus in the profession shows that for many of the issues regarding pregnancy, there is no nationwide policy.
It is possible that some of the programs not choosing to respond, as well as some of those responding with a negative answer, may indeed have no problems owing to the fact that pregnancy is not an issue within the program (i.e., only males are employed). It is interesting to note that over half the programs do not indicate a cutoff date for removal from flight status. It appears that some do not feel that flight status imposes any additional risks on pregnancy, while others do. While some programs may feel that there are risks and have chosen to require termination of flight status,
there is no consensus as to when this termination of flight status should occur. It is possible that programs selected the time based on different concerns regarding flight crew member safety, pregnancy safety, prog r a m operations, or m i s s i o n performance. Clearly, a consensus exists on the issue of the earliest time a pregnant crew member may choose to terminate flight status. It appears to be universal a m o n g p r o g r a m s t h a t a woman may choOse to remove herself from flight status as early as she wants. For some programs, the pregnancy policy of the program differs from that of the parent hospital or organization. Pregnancy has indeed occurred among flight crew members, with the majority of the responding programs indicating that this situation has o c c u r r e d within t h e i r p r o g r a m s . Some programs noted the need to change their policy once they actually had a pregnant flight crew member. In addition to the differences among policies stating when the last flight may occur, tremendous vari-
Table 4
Gestational
S t a g e at Last Flight
First trimester (0-13 weeks) Second trimester (13-26 weeks) Third trimester (26-40 weeks) Uncertain
.......................... 17 .......................... 54 + .......................... 88 ............................ 9
+ Indicates a response by a program such as "several" or some other non-numeric description of multiple pregnancies. Counted as one in compiling data.
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The Journal of Air Medical Transport ° May 1992
ability existed among the gestational stages at which the last flight actually occurred, again reflecting the many attitudes and reasons toward terminating flight status. Included among them of course could be the possibility of normal delivery prior to the expected date. The accommodations by the program for the p r e g n a n c y did not appear to be burdensome, especially given that most of the r e s p o n s e s regarding a c c o m m o d a t i o n s were with respect to uniform adjustments. Though information on motion sickness was solicited, we did not attempt to differentiate b e t w e e n motion sickness induced by pregnancy and motion sickness that may or may not have been the crew member's baseline. Solutions tend to involve meals and positioning within the aircraft.
crew members. We hope to prospectively enroll all future flight crew members who become pregnant to gain a database for scientific examination of the risks, benefits, and problems of pregnancy and flight crew status. We will also attempt to retrospectively update this database. To that end we will be requesting those flight crew members who have been pregnant to get in touch with the registry and provide the same
information as those who become pregnant in the future. The objectives of the registry are outlined in Table 5. It is obvious that cooperation of p r o g r a m d i r e c t o r s and p r e g n a n t flight crew members will be needed. It is emphasized that the confidence of this information will be strictly maintained by the registry. Responses of flight crew members will not be shared with their pro-
The FIRST
PRACTICAL GUIDE TO
Conclusions
Policies r e g a r d i n g flight c r e w m e m b e r p r e g n a n c y differ widely among the AAMS m e m b e r programs. Some programs do not have such policies. Significant variation exists with respect to the gestational stage at which flight crew members are actually making flights. Some programs make special requirements or accommodations for pregnancy. There is a lack of consistency among policies, and, in addition, there is limited amount of scientific information on which to base such policies and decisions. Registry Of Crew Members
We have proposed and received endorsement from AAMS for a registry of pregnant air medical flight I
Table 5
The Objective of the Registry is the Collection of Data to Review: • • • • • •
The safety of the mother The safety of the fetus Job performance of the PFCM Impact on program Program policy Solutions to problems
The Journal of Air Medical Transport ° May 1992
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grams or with any other persons not privileged to registry information. Our efforts have been recognized by the AAMS endorsement, as well as through a grant from the Foundation for Aeromedical Research. To begin to establish the database, we ask that women who have been pregnant while serving as a member of a flight crew contact the registry and provide your name, phone number, and address for future contact. The address of the registry is Registry of Flight Crew Pregnancy, Richard T. Cook, Jr., MD, Registry Director, c / o LIFE LION, The Milton S. Hershey Medical Center, P.O. Box 850, Hershey, PA 17033; 717/531-7365. •
Acknowledgements Our thanks to Donna Rentzel and John Botti, MD, for their assistance in preparing this article.
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10(7):11-21. 2. Whitten D, Cook RT, Field JM: Flight crew member pregnancy. J Air Med Transport (abst) 1989; 8(9):64. 3. Banfle JA: Effects of mechanical vibrations on the growth and development of mouse embryos. Aerospace Med 1971; 10:1087-1091. 4. Ando Y, Hattori H: Effects of intense noise during fetal life upon postnatal adaptability (statistical study of the reactions of babies to aircraft noise). BritJ Obstert Gyneco11977; 84:115-118. 5. Ando Y, Hattori H: Effects of noise on human placental lactogen (HPL) levels in maternal plasma. BritJ Obstet Gyneco11977; 84:115-118. 6. Parer JT: Effects of hypoxia on the mother and fetus with emphasis on maternal air transport. Am J Obstet Gynecol 1982; 142(8):957-961. 7. Grahn D, Kratchman J: Variation in neonatal death rate and birth weight in the United States and possible relations to environmental radiation, geology and altitude. Am J Human Genetics 1963; 15:329. 8. Barry M, Bia F: Pregnancy and travel. JAMA 1989; 261(5):728-731. 9. Huch R, Baumann H, Fallenstein F, et al: Physiologic changes in pregnant women and their fetuses during jet air travel. Am J Obstet Gynecol 1986; 154(5):996-1000. 10. Whittingham HE: Air transport of pregnant women. Practitioner 1951; 166:156-158. 11. Mills JF, Harding RM: Fitness to travel by air II: Specific medical considerations. Brit Med J 1983; 286:1340-1341. 12. Diddle AW: The effect of travel on the incidence of abortion. Am J Obstet Gynecol 1944; 48:354-360.
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13. Guilbeau JA, Turner JL: The effect of travel upon the interruption of pregnancy. Am J Obstet Gyneco11953; 66(6):1224-1230. 14. Cameron RG: Effect of flying on the menstrual function of air hostesses. Aerospace Med 1969; 40(9) :1020-1023. 15. Cameron RG: Psycho-physiological effects of flying on air hostesses. Aerospace Med 1969; 40(9):1018-1020. 16. Cameron RG: Should air hostesses continue flight duty during the first trimester of pregnancy? Aerospace Med 1973; 44 (5):552-556. 17. Preston FS, Bateman SC, et al: Effects of flying and of time changes on menstrual cycle length and on performance in airline stewardesses. Aerospace Med 1973; 44(4):438-443. 18. Scholten P: Pregnant stewardess--should she fly? Aviation Space Environ Med 1976; 47 (1) :77-81. 19. Silverman J, Kline J, Hutzler M, et al: Maternal employment and the chromosomal characteristics of spontaneously aborted conceptions. J Oceupa Med 1985; 27 (6) :427-438. 20. Naeye RL, Peters EC: Working during pregnancy: Effects on the fetus. Pediatrics 1982; 69 (6) :724-727. 21. Crosby WM: Trauma during pregnancy: Maternal and fetal injury. Obstet Gynecol Survey 1974; 29 (10) :683-699. 22. Javert CT: Role of the patient's activities in the occurrence of spontaneous abortion. Fertility Sterility 1960; 11 (6):550-558. 23. Hertig AT, Sheldon WH: Minimal criteria required to prove prima facie case of traumatic abortion or miscarriage. Ann Surg 1943; 117(4) :596-606. 24. Fort AT, Harlin RS: Pregnancy outcome after non-catastrophic maternal trauma during pregnancy. Obstet Gyneco11970; 35 (6):912-915. 25. Agran PF, Dunkle DE, et al: Fetal death in motor vehicle accidents. Ann Emerg Med 1987; 16(12):1355-1358. 26. Lane PL: Traumatic fetal deaths. JEM 1989; 17:433-435. 27. Pearlman MD, Tintinalli JE, Lorenz RP: Blunt trauma during pregnancy. New Eng J Med 1990; 323 (23) :1609-1613. 28. Rothenberger D, Quattlebanm FW, Perry JF, et al: Blunt maternal trauma: A review of 100 cases.J Trauma 1978; 18(3):173-179. 29. Crosby WM, Costiloe JP: Safety of lap-belt restraint for pregnant victims of automobile collisions. New EngJ Med 1971; 284(12):632-636. 30. Cumming DC, Wren FD: Fetal skull fracture from an apparently trivial motor vehicle accident. Am J Obstet Gynecol 1978; 132 (3):342-343. 31. Pepperell RJ, Rubinstein E, Maclsaac IA: Motor car accidents during pregnancy. Med J Australia 1977; 1:203-205. 32. Stuart GCE, Harding PGR, Davies EM: Blunt abdominal trauma in pregnancy. CMA J 1980; 122:901-905. 33. Ravangard F, Porter CV: Traumatic laceration of the placenta. WV Med J 1980; 76(6):125129. 34. Farrell BL, Allen MF: Physiologic/psychologic changes reported by USAF female flight
nurses during flying duties. Nur Res 1973; 22(1):31-36. 35. Kamowitz B: The right to fight. Newsweek 1991; 5 (8) :23. 36. Fowler M, Brown C, Cabrera KF: Hydrencephaiy in a baby after an aircraft accident to the mother: Case report and autopsy. Pathology 1971; 3:21-30. 37. Daniel1 WE, Vaughan TL, Millies BA: Pregnancy outcomes among female flight attendants. Aria Space Environ Med 1990; 61:840-844. 38. Vaughan TL, Daling JR, Starzyk PM: Fetal death and maternal occupation. J Occupa Med 1984; 26(9) :676-678. 39. Carucci PM, Prasad S: A comparison of mothers' occupations reported on live birth certificates and on a survey questionnaire. Pub Health Reports 1979; 94 (5) :432-437. 40. Wilcox AJ, Homey LF: Accuracy of spontaneous abortion recall. Amer J Epidem 1984; 120(5):727-733. 41. Hemminki K, Kyyronen P, Lindbohn ML: Spontaneous abortions and malformations in the offspring of nurses exposed to anaesthetic gases, cytostatic drugs, and other potential hazards in hospitals, based on registered information of outcome. J Epidemiology Community Health 1985; 39:141-147. 42. Saurel-Cubizolles MJ, Kaminski M, LladoArkhipoff J, et al: Pregnancy and its outcome among hospital personnel according to occupation and working conditions. J Epidemiology Community Health 1985; 39:129-134. 43. Mamelle N, Laumon B, Lazar P: Prematurity and occupational activity during pregnancy. AmerJEpidemiology 1984; 119(3):309322. 44. McDonald AD, McDonald JC, Armstrong B, et al: Prematurity and work in pregnancy. BritJ Indust Med 1988; 45:56-62. 45. Miller NH, Katz VL, Cefalo RD: Pregnancies among physicians: A historical cohort study. J Reproductive Med 1989; 34(10) :790-796. 46. Grunebaum A, Minkoff H, Blake D: Pregnancy among obstetricians: A comparison of births before, during, and after residency. Am J ~, Obstet Gyneco11987; 157 (1):79-83. 47. Schwartz RW: Pregnancy in physicians: Characteristics and complications. Obstet Gynecol 1985; 66 (5) :672-676. 48. Katz VL, Miller NH, Bowes WA: Pregnancy complications of physicians. West J Med 1988; 149(6):704-707. 49. Phelan ST: Pregnancy during residency: II. Obstetric complications. Obstet Gynecol 1988; 72(3):431-436. 50. Klebanoff MA, Shiono PH, Rhoads GG: Outcome of pregnancy in a national sample of resident physicians. NEJM 1990; 323 (15):1040-1043. 51. Sayres M, Wyshak G, Denterlein G, et al: Pregnancy during residency. NEJM 1986; 314(7):418-423. 52. Sinal S, Weavil P, Camp MG: Survey of women physicians on issues relating to pregnancy during a medical career. J Med Education 1988; 63:531-538.
The Journal of Air Medical Transport ° May 1992
rograms and Pregnancy: Survey of Policies •
Richard T. Cook, Jr., MD, FACEP; Nancy Flint, RN, BSN; Debra L. Whitten, RN, BSN, CCRN
If a woman becomes pregnant while on flight status, a potential conflict exists between the needs and desires of the program and those of the flight crew member. Association of Air Medical Services (AAMS) member programs were surveyed to determine the extent of pregnancy policy standards within the air medical profession. A survey was mailed to 150 AAMS program directors in the fall of 1988. The survey was followed with a second mailing and a telephone follow-up for clarification. Replies were received from 110 program directors. Fifty-five percent of those responding noted they had a policy on flight crew member (FCM) pregnancy. Thirty percent noted a date prior to term that the pregnant FCM (PFCM) would be removed from flight status. Seventy percent of the programs noted that they had not previously had a PFCM. Over half of the programs allowed PFCMs to fly until the third trimester, with just under a quarter allowing flights until 38 weeks or greater. There are few articles specifically referring to air medical FCM pregnancy, and policies regarding FCM pregnancy differ widely among the AAMS member programs. Key Words: pregnancy, flight crew, air medical service, pregnancy policy.
Introduction GIVEN THATMANYFLIGHT CREWMEMbers in the air medical service prog r a m s are young women, some of them may become pregnant during the c o u r s e of t h e i r e m p l o y m e n t . Owing to the sensitivity of this issue and its potential for medical, social, and employment problems, conflicts may arise when a flight crew member becomes pregnant. Other than an e x c e l l e n t review of a flight crew member pregnancy, there are few articles in the medical l i t e r a t u r e specifically referring to flying and flight crew m e m b e r p r e g n a n c y . 1 Richard T. Cook, Jr., is an assistant professor of emergency medicine at the Milton S. H e r s h e y M e d i c a l Center (Hershey, Pa.); Nancy Flint was a (pregnant) flight nurse at Life Flight, (Pittsburgh, Pa.); Debra L. Whitten was a (pregnant) flight nurse at LIFE LION (Hershey, Pa.) and is now a flight nurse at Life Flight (Atlanta, Ga.).
Therefore, decisions made in these situations about employee capabilities and medical risks may be judged arbitrary. When a decision is made regarding a particular issue of the pregnancy and e m p l o y m e n t , both the p r o g r a m and the p r e g n a n t crew member may be satisfied, or dissatisfied, with the decision. To better u n d e r s t a n d the range of policies among AAMS member programs, we conducted this survey to determine what policies currently exist within the air medical service community.
Methods Two survey forms, one to be completed by the program director and one to be completed by p r e g n a n t flight crew members for a separate study, 2 were developed and sent to the AAMS Survey Review Process Committee for approval and AAMS endorsement for a survey to AAMS member programs. After receiving
The Journal of Air Medical Transport ° May 1992
this endorsement, a copy of the program director survey form (Table 1), the pregnant flight crew member survey form, and a copy of the endorsement letter were sent to 150 AAMS programs in the fall of 1988. A second mailing was sent to elicit more responses, and telephone follow-up was u s e d to clarify r e s p o n s e s as needed.
Results Replies were received from 110 program directors. Sixty of the 110 responding programs (55%) noted that they had a policy on flight crew member FCM pregnancy. Thirty perc e n t of the 110 who r e s p o n d e d reported a date at which the FCM would be removed from flight status prior to term. This group that noted a cutoff date represents half of the 60 respondents who indicated that they have a policy. Any flight crew member could leave flight status as early in pregnancy as she wanted--no program had a minimum gestational; age requirement. When comparing the pregnancy policy for flight crew m e m b e r s to that of other employees within the institution, 26 respondents noted that the policy is the same and 56 indicated that it is different. Table 2 lists major policy differences in job maintenance performance requirements between FCMs who become pregnant and o t h e r e m p l o y e e s who become pregnant. Table 3 lists the differences in employment and budget issues between policies for flight 7
flight status, performing duties such as quality assurance, continuing education, and o t h e r a d m i n i s t r a t i v e duties. Forty-seven percent of the programs noted that a PFCM experienced motion sickness. No attempt was made to differentiate between an increase in motion sickness over the FCM's norm; rather, the question only asked if motion sickness was experienced. The most common solutions included eating frequent small meals, c a r r y i n g c r a c k e r s onboard during flight, eating a meal prior to flight and changes in seating a r r a n g e m e n t s . The most popular a r r a n g e m e n t involved having the PFCM sit in the aft portion of the aircraft in a forward-facing seat.
Policies regarding flight crew member pregnancy differ widely among AAMS member programs.
crew members and other institutional employees once they have become pregnant. Seventy of 108 programs responding to question No. 6 indicated that they had a pregnant FCM now or previously. Of the 60 p r o g r a m s reporting policies, 30% indicated there was a change in policy after having a pregnant flight crew member within the program. Table 4 summ a r i z e s the n u m b e r of w e e k s of pregnancy up to which the PFCMs were actually flying, as reported by the various air medical p r o g r a m directors. A review of Table 4 shows no consensus on a cutoff time in actual practice within the air medical profession. Of note is that over half are allowing P F C M s to fly into t h e i r t h i r d trimester, with 23 programs allowing flying until 38 w e e k s or g r e a t e r . Though not specifically asked in the questionnaire, 21% of the programs noted that they required approval of the PFCM's obstetrician at some point during the pregnancy in order to continue flight status. Since these were unsolicited comments, the number of programs requiring this could even be higher. 8
Concerning accommodations made by the program for the pregnancy, 44 programs indicated that specific accommodations were made by the program for the pregnancy, and 25 indicated no accommodations were made. Special accommodations noted by respondents included one for lifting a s s i s t a n c e , m a n y for changes in the schedule, and one response of particular interest--"taking care toward maintaining the selfrespect of the pregnant FCM." The most commonly cited adjustments concerned changes in uniforms. One p r o g r a m r e p o r t e d the FCM was allowed to fly until she could no longer fit into her uniform. A p p r o x i m a t e l y 25% of the programs noted that no alternate duty option was provided for the flight nurse once she was no longer on flight status. Of those providing alternate duty, the overwhelming majority indicated that opportunities existed for working within the emergency department. Other programs offered the emergency department as one option among several clinical options. Over 15% of the programs indicated that t h e r e was an option to work within the flight program in a non-
Discussion Studies of environmental conditions related to aviation have shown some impact on fetal development or physiology.3-7 These studies did not address air medical services personnel and t h e r e f o r e c a n n o t be cons t r u e d as e v i d e n c e to s u p p o r t restrictions of flight status. The study conditions are notably dissimilar, though they certainly do stimulate thought for further research. Those studies reviewing travel, a facet of air medical transport, show no association between undesirable gestational outcome and the process of traveling, particularly in normal pregnancies in which delivery does not occur during the travel. 8-13 Several studies of gynO ~ cologic and o b s t e t r i c c o n d i t i o n s affecting airline flight attendants have not shown an association with obstetrical problems. 1.18 One study suggested flight status termination for airline flight attendants at 20 weeks, but based this only on hypothetical concerns. 18 A study reviewing employment histories and abortus chromosomal characters s h o w e d no a s s o c i a t i o n between healthcare workers and fetal chromosomal abnormalities, but did not address flight crews or other attendants. 19 In a review of 7700 pregnancies, women who worked during the third trimester, particularly those who
The Journal of Air Medical Transport ° May 1992
stood, had an associated decrease in increased risk for premature birth. 43 existence of this increased risk. 49 A birthweight and increase in placental Increased risk of prematurity and low s t u d y c o m p a r i n g p r e g n a n c y outinfarction compared with w o m e n birth weight is noted to exist in cer- comes among female resident physiwho didn't work. 2° Several reviews of tain g r o u p s of w o m e n w o r k e r s , cians and t h o s e of non-physician pregnancy, trauma, and miscarriage including a subgroup which included wives of residents showed no signifishow no increased risk from normal medical personnel. 44 cant difference between groups with activities or m i n o r t r a u m a , 2124 In other studies, physicians, par- respect to miscarriages, ectopic pregalthough several studies and reviews ticularly resident physicians, have nancy, still births, preterm births, have n o t e d t h a t both major and been noted to be at an increased risk and births of infants who were small minor motor vehicle collisions, even for complications of pregnancy, 45-48 for gestational age in these socioecowith little apparent maternal injury, though not all studies support the nomically matched groups. 5° Women can cause fetal death. 25-33 A review of military flight nurses Table 1 noted menstrual changes but did not address pregnancy, since pregnant Program Director Questionnaire women are not permitted on military flight status. 34A female United States 1. Do you have any established policies regarding pregnancy of flight team Air Force pilot assigned to fly a highmembers? If yes, please mention the highlights, especially regarding altitude TR-1 spy plane has agreed to maternity leave, financial compensation, etc. not become pregnant for at least a year and m u s t submit p r e g n a n c y 2. Do you have a cutoff time by which a pregnant flight team member must tests on a biweekly basis. 35 stop flying? A child born to a small aircraft 3. Do you have an initial stage of the pregnancy at which she may request a pilot involved in a severe crash at 22 change from full flight status? w e e k s was n o t e d to have hydrocephaly. 36 The authors know of no 4, Do you offer alternate duty after the flight team member stops flying? other published study or case review of p r e g n a n t flight crew m e m b e r s 5. Compared with other similar employees (i.e., nurses, paramedics) in involved in aircraft crashes, forced your institution/organization, is the policy on pregnancy: landings, or other traumatic inciA. the same? dents. In two r e c e n t s t u d i e s , B. similar, but modified for flying? increased risks of pregnancy compliC. different? cations were demonstrated among D. question not applicable? flight attendants. 37,38 However, the 6. Have you had, or do you now have, any pregnant flight team members? reader m u s t recognize, as do the authors of both papers, the potential 7. How far into their pregnancies did these flight team members actually fly? for bias related to the socioeconomic factors of the study and control popu8. Did any pregnant flight team members experience motion sickness in their lations. Several studies have shown pregnancies? If yes, what methods (i.e., medications, schedules, seating that it may be difficult to obtain accuposition, etc.), if any, were used for controlling the condition? rate, unbiased data on which to base conclusions. 38-4° T h e s e and other 9. Please discuss any special flight requirements to accommodate the studies on the effects of factors on pregnancy, such as alterations in flight suits, schedule changes, and so on. pregnancy outcome have not been done in groups which adequately match the population and working Table 3 Table 2 conditions of the air medical services, particularly helicopter scene Differences in Characteristics of Differences in flights. Employment/Benefits Issues: Job Performance Requirements Pregnancy among healthcare Pregnant FCM vs. Other Between Pregnancy Policies workers has been looked at in a numPregnant Employees of the of a Flight Program and its ber of articles. 41 Stand/up work, carInstitution Related Institution r y i n g h e a v y loads, and h e a v y • Leave of absence • Altitude limits cleaning tasks were associated with a • Change in pay • Hemoglobin level higher rate of preterm delivery in 600 • Immediate notification • Able to lift given weight French hospital workers. 42 Medi• Maternity leave • Able to move in aircraft cosocial staff personnel were noted • "Light" duty • Weight gain limits to be one of several g r o u p s at The Journal of Air Medical Transport • May 1992
9
residents, however, did experience more preterm labor and preeclampsia. Policies for women physician pregnancy are also non-uniform and usually lacking in hospital residency programs.5L52 The above results indicate that no c o n s e n s u s exists a m o n g AAMS member programs on many of the important issues on the topic of pregnancy and flight programs, such as flight status cutoff, alternate duty, or even the presence of policy. The lack of consensus in the profession shows that for many of the issues regarding pregnancy, there is no nationwide policy.
It is possible that some of the programs not choosing to respond, as well as some of those responding with a negative answer, may indeed have no problems owing to the fact that pregnancy is not an issue within the program (i.e., only males are employed). It is interesting to note that over half the programs do not indicate a cutoff date for removal from flight status. It appears that some do not feel that flight status imposes any additional risks on pregnancy, while others do. While some programs may feel that there are risks and have chosen to require termination of flight status,
there is no consensus as to when this termination of flight status should occur. It is possible that programs selected the time based on different concerns regarding flight crew member safety, pregnancy safety, prog r a m operations, or m i s s i o n performance. Clearly, a consensus exists on the issue of the earliest time a pregnant crew member may choose to terminate flight status. It appears to be universal a m o n g p r o g r a m s t h a t a woman may choOse to remove herself from flight status as early as she wants. For some programs, the pregnancy policy of the program differs from that of the parent hospital or organization. Pregnancy has indeed occurred among flight crew members, with the majority of the responding programs indicating that this situation has o c c u r r e d within t h e i r p r o g r a m s . Some programs noted the need to change their policy once they actually had a pregnant flight crew member. In addition to the differences among policies stating when the last flight may occur, tremendous vari-
Table 4
Gestational
S t a g e at Last Flight
First trimester (0-13 weeks) Second trimester (13-26 weeks) Third trimester (26-40 weeks) Uncertain
.......................... 17 .......................... 54 + .......................... 88 ............................ 9
+ Indicates a response by a program such as "several" or some other non-numeric description of multiple pregnancies. Counted as one in compiling data.
iiii
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The Journal of Air Medical Transport ° May 1992
ability existed among the gestational stages at which the last flight actually occurred, again reflecting the many attitudes and reasons toward terminating flight status. Included among them of course could be the possibility of normal delivery prior to the expected date. The accommodations by the program for the p r e g n a n c y did not appear to be burdensome, especially given that most of the r e s p o n s e s regarding a c c o m m o d a t i o n s were with respect to uniform adjustments. Though information on motion sickness was solicited, we did not attempt to differentiate b e t w e e n motion sickness induced by pregnancy and motion sickness that may or may not have been the crew member's baseline. Solutions tend to involve meals and positioning within the aircraft.
crew members. We hope to prospectively enroll all future flight crew members who become pregnant to gain a database for scientific examination of the risks, benefits, and problems of pregnancy and flight crew status. We will also attempt to retrospectively update this database. To that end we will be requesting those flight crew members who have been pregnant to get in touch with the registry and provide the same
information as those who become pregnant in the future. The objectives of the registry are outlined in Table 5. It is obvious that cooperation of p r o g r a m d i r e c t o r s and p r e g n a n t flight crew members will be needed. It is emphasized that the confidence of this information will be strictly maintained by the registry. Responses of flight crew members will not be shared with their pro-
The FIRST
PRACTICAL GUIDE TO
Conclusions
Policies r e g a r d i n g flight c r e w m e m b e r p r e g n a n c y differ widely among the AAMS m e m b e r programs. Some programs do not have such policies. Significant variation exists with respect to the gestational stage at which flight crew members are actually making flights. Some programs make special requirements or accommodations for pregnancy. There is a lack of consistency among policies, and, in addition, there is limited amount of scientific information on which to base such policies and decisions. Registry Of Crew Members
We have proposed and received endorsement from AAMS for a registry of pregnant air medical flight I
Table 5
The Objective of the Registry is the Collection of Data to Review: • • • • • •
The safety of the mother The safety of the fetus Job performance of the PFCM Impact on program Program policy Solutions to problems
The Journal of Air Medical Transport ° May 1992
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standards, clinical indicators and thresholds; data monitoring and analysis and utilization review and medical necessi~ This new book, written by professionals actively involved in AAMS QA COMMITTEE, is a MUST for administrators, chief flight nurses, medical directors or any staff involved in supporting the need for and effectiveness of current or new programs. The future of your program could depend on this book.
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grams or with any other persons not privileged to registry information. Our efforts have been recognized by the AAMS endorsement, as well as through a grant from the Foundation for Aeromedical Research. To begin to establish the database, we ask that women who have been pregnant while serving as a member of a flight crew contact the registry and provide your name, phone number, and address for future contact. The address of the registry is Registry of Flight Crew Pregnancy, Richard T. Cook, Jr., MD, Registry Director, c / o LIFE LION, The Milton S. Hershey Medical Center, P.O. Box 850, Hershey, PA 17033; 717/531-7365. •
Acknowledgements Our thanks to Donna Rentzel and John Botti, MD, for their assistance in preparing this article.
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13. Guilbeau JA, Turner JL: The effect of travel upon the interruption of pregnancy. Am J Obstet Gyneco11953; 66(6):1224-1230. 14. Cameron RG: Effect of flying on the menstrual function of air hostesses. Aerospace Med 1969; 40(9) :1020-1023. 15. Cameron RG: Psycho-physiological effects of flying on air hostesses. Aerospace Med 1969; 40(9):1018-1020. 16. Cameron RG: Should air hostesses continue flight duty during the first trimester of pregnancy? Aerospace Med 1973; 44 (5):552-556. 17. Preston FS, Bateman SC, et al: Effects of flying and of time changes on menstrual cycle length and on performance in airline stewardesses. Aerospace Med 1973; 44(4):438-443. 18. Scholten P: Pregnant stewardess--should she fly? Aviation Space Environ Med 1976; 47 (1) :77-81. 19. Silverman J, Kline J, Hutzler M, et al: Maternal employment and the chromosomal characteristics of spontaneously aborted conceptions. J Oceupa Med 1985; 27 (6) :427-438. 20. Naeye RL, Peters EC: Working during pregnancy: Effects on the fetus. Pediatrics 1982; 69 (6) :724-727. 21. Crosby WM: Trauma during pregnancy: Maternal and fetal injury. Obstet Gynecol Survey 1974; 29 (10) :683-699. 22. Javert CT: Role of the patient's activities in the occurrence of spontaneous abortion. Fertility Sterility 1960; 11 (6):550-558. 23. Hertig AT, Sheldon WH: Minimal criteria required to prove prima facie case of traumatic abortion or miscarriage. Ann Surg 1943; 117(4) :596-606. 24. Fort AT, Harlin RS: Pregnancy outcome after non-catastrophic maternal trauma during pregnancy. Obstet Gyneco11970; 35 (6):912-915. 25. Agran PF, Dunkle DE, et al: Fetal death in motor vehicle accidents. Ann Emerg Med 1987; 16(12):1355-1358. 26. Lane PL: Traumatic fetal deaths. JEM 1989; 17:433-435. 27. Pearlman MD, Tintinalli JE, Lorenz RP: Blunt trauma during pregnancy. New Eng J Med 1990; 323 (23) :1609-1613. 28. Rothenberger D, Quattlebanm FW, Perry JF, et al: Blunt maternal trauma: A review of 100 cases.J Trauma 1978; 18(3):173-179. 29. Crosby WM, Costiloe JP: Safety of lap-belt restraint for pregnant victims of automobile collisions. New EngJ Med 1971; 284(12):632-636. 30. Cumming DC, Wren FD: Fetal skull fracture from an apparently trivial motor vehicle accident. Am J Obstet Gynecol 1978; 132 (3):342-343. 31. Pepperell RJ, Rubinstein E, Maclsaac IA: Motor car accidents during pregnancy. Med J Australia 1977; 1:203-205. 32. Stuart GCE, Harding PGR, Davies EM: Blunt abdominal trauma in pregnancy. CMA J 1980; 122:901-905. 33. Ravangard F, Porter CV: Traumatic laceration of the placenta. WV Med J 1980; 76(6):125129. 34. Farrell BL, Allen MF: Physiologic/psychologic changes reported by USAF female flight
nurses during flying duties. Nur Res 1973; 22(1):31-36. 35. Kamowitz B: The right to fight. Newsweek 1991; 5 (8) :23. 36. Fowler M, Brown C, Cabrera KF: Hydrencephaiy in a baby after an aircraft accident to the mother: Case report and autopsy. Pathology 1971; 3:21-30. 37. Daniel1 WE, Vaughan TL, Millies BA: Pregnancy outcomes among female flight attendants. Aria Space Environ Med 1990; 61:840-844. 38. Vaughan TL, Daling JR, Starzyk PM: Fetal death and maternal occupation. J Occupa Med 1984; 26(9) :676-678. 39. Carucci PM, Prasad S: A comparison of mothers' occupations reported on live birth certificates and on a survey questionnaire. Pub Health Reports 1979; 94 (5) :432-437. 40. Wilcox AJ, Homey LF: Accuracy of spontaneous abortion recall. Amer J Epidem 1984; 120(5):727-733. 41. Hemminki K, Kyyronen P, Lindbohn ML: Spontaneous abortions and malformations in the offspring of nurses exposed to anaesthetic gases, cytostatic drugs, and other potential hazards in hospitals, based on registered information of outcome. J Epidemiology Community Health 1985; 39:141-147. 42. Saurel-Cubizolles MJ, Kaminski M, LladoArkhipoff J, et al: Pregnancy and its outcome among hospital personnel according to occupation and working conditions. J Epidemiology Community Health 1985; 39:129-134. 43. Mamelle N, Laumon B, Lazar P: Prematurity and occupational activity during pregnancy. AmerJEpidemiology 1984; 119(3):309322. 44. McDonald AD, McDonald JC, Armstrong B, et al: Prematurity and work in pregnancy. BritJ Indust Med 1988; 45:56-62. 45. Miller NH, Katz VL, Cefalo RD: Pregnancies among physicians: A historical cohort study. J Reproductive Med 1989; 34(10) :790-796. 46. Grunebaum A, Minkoff H, Blake D: Pregnancy among obstetricians: A comparison of births before, during, and after residency. Am J ~, Obstet Gyneco11987; 157 (1):79-83. 47. Schwartz RW: Pregnancy in physicians: Characteristics and complications. Obstet Gynecol 1985; 66 (5) :672-676. 48. Katz VL, Miller NH, Bowes WA: Pregnancy complications of physicians. West J Med 1988; 149(6):704-707. 49. Phelan ST: Pregnancy during residency: II. Obstetric complications. Obstet Gynecol 1988; 72(3):431-436. 50. Klebanoff MA, Shiono PH, Rhoads GG: Outcome of pregnancy in a national sample of resident physicians. NEJM 1990; 323 (15):1040-1043. 51. Sayres M, Wyshak G, Denterlein G, et al: Pregnancy during residency. NEJM 1986; 314(7):418-423. 52. Sinal S, Weavil P, Camp MG: Survey of women physicians on issues relating to pregnancy during a medical career. J Med Education 1988; 63:531-538.
The Journal of Air Medical Transport ° May 1992