abstract: Workplace environment can have a considerable impact on the physical, psychological and maternal health of pregnant healthcare workers. This article aimed to summarise the impact of work-related ergonomic stressors on pregnancy outcomes for healthcare workers, along with potential interventions to resolve these stressors. A narrative review analysis using the Pearl Growing Strategy was conducted between February 2019 and June 2020 to identify English-language articles published between 2000 and 2020. A total of 89 studies were identified from the SCOPUS (Elsevier, Amsterdam, Netherlands), MEDLINE® (National Library of Medicine, Bethesda, Maryland, USA) databases and Google Scholar (Google LLC, Menlo Park, California, USA). The results indicated that poor work-related ergonomics had detrimental effects on pregnancy outcomes, resulting in spontaneous abortions, preterm delivery, low birth weight babies and infertility. Policymakers and employers should conduct ergonomic assessments and implement appropriate practices to ensure the safety of pregnant healthcare workers. Keywords: Healthcare Workers; Physical Ergonomics; Pregnancy Outcomes; Occupational Health; Occupational Exposure. Ergonomic Stressors Among Pregnant Healthcare Workers Impact on pregnancy outcomes and recommended safety practices *Frincy Francis,1 Sheeba E. Johnsunderraj,1 Divya K. Y.,2 Divya Raghavan,1 Atiya Al-Furgani,1 Lily P. Bera,3 Aniamma Abraham4 Sultan Qaboos University Med J, May 2021, Vol. 21, Iss. 2, pp. e172–181, Epub. 21 Jun 21 Submitted 9 Mar 20 Revisions Req. 18 May & 19 Jul 20; Revisions Recd. 1 Jul & 15 Aug 20 Accepted 13 Sep 20 Departments of 1Maternal & Child Health and 2Community & Mental Health, College of Nursing, Sultan Qaboos University, Muscat, Oman; 3Department of Maternal & Child Health, College of Nursing, All India Institute of Medical Sciences, Bhopal, India; 4Directorate of Nursing, Sultan Qaboos University Hospital, Muscat, Oman *Corresponding Author’s e-mail: frincyshalom@gmail.com The world health organisation estimatesthat there are approximately 34.4 million health- care workers worldwide including doctors, nurses, pharmacists and other types of community healthcare providers, of which an increasing proportion are female.1,2 Despite recent improvements in workplace technology and practices, occupational hazards remain an important cause of morbidity and mortality world- wide.3 In particular, healthcare professionals have a high prevalence of musculoskeletal disorders, ranging from 50–90% among nurses to 86.7% among rectovaginal surgeons, 67% among orthopaedic surgeons and 91% among sonographers.4 Ergonomics refers to the study of factors likely to affect interactions between an individual and their working environment.5,6 Approximately 59 million healthcare workers around the globe are exposed to ergonomic hazards daily.2,7 According to the International Ergonomics Association, ergonomics is defined as a “scientific discipline that applies theory, principles, data, and methods to optimise human well-being. It evaluates tasks, jobs, environments, and systems to make it compatible with the needs, abilities, and limitations of people”.8 The application of ergonomic principles in a workplace had been found to prevent musculoskeletal disorders and increase both productivity and job satisfaction among employees.9,10 Certain ergonomic hazards are either created or exacerbated by pregnancy.11,12 Adverse pregnancy outcomes have been linked to poor working conditions including prolonged standing, lifting heavy objects, long working hours and psychological stress.12 Moreover, poor ergonomic practices often exaggerate existing discomfort, resulting in increased rates of work absenteeism, sick leave and a lack of motivation among pregnant healthcare workers.13 Appropriate accommodations are therefore necessary to enhance the comfort of pregnant employees and help them to handle work-related stress as well as the innate physical challenges associated with pregnancy.12,14 This article aimed to review the available literature concerning the impact of work-related ergonomic stressors on pregnancy outcomes for healthcare workers, along with feasible solutions to prevent and mitigate such risks. Methods This narrative review was conducted from February 2019 to June 2020. The primary objective was to highlight the impact of work-related ergonomic stressors on pregnancy outcomes among healthcare workers, as well as to recommend ergonomic interventions to prevent these stressors. The SCOPUS review This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License. https://doi.org/10.18295/squmj.2021.21.02.004 https://creativecommons.org/licenses/by-nd/4.0/ Review | e173 (Elsevier, Amsterdam, Netherlands), MEDLINE® (National Library of Medicine, Bethesda, Maryland, USA) databases and Google Scholar (Google LLC, Mountain View, California, USA) were searched electronically to identify relevant articles for inclusion. To ensure a holistic approach, the following search terms were used: “healthcare workers”, “physical ergonomics”, “pregnancy outcomes”, “occupational safety”, “hospital ergonomics” and “recommendations”. The inclusion criteria comprised all English- language articles published between 2000 and 2020 reporting the impact of work-related ergonomic stressors on pregnancy outcomes in healthcare workers and pregnancy-specific ergonomic interventions for hospital units. Articles related to pregnant women working in other professions were excluded, as were those published prior to 2000 or written in other languages. All types of articles were deemed eligible for inclusion including experimental studies such as randomised controlled trials and quasi-controlled trials, as well as cohort studies, observational studies and surveys. Case reports, action research studies and qualitative studies detailing conceptual information were also included to emphasise the importance of optimal ergonomic practices for pregnant women. As the sources of the retrieved articles were highly variable, the literature search was conducted using the Pearl Growing Strategy.15 This approach was deemed most suitable as the review focused on a specific population (i.e. pregnant healthcare workers). An article extraction checklist listing the inclusion and exclusion criteria was utilised during retrieval in order to confirm the relevancy and appropriateness of each article. A total of eight primary articles were retrieved following the initial screening of titles and abstracts. Subsequently, 46 secondary articles were identified from the reference lists of the primary articles. A further 35 articles were identified via bibliographic mining of the secondary articles. Overall, a total of 89 articles met the inclusion criteria and were included in the narrative analysis [Figure 1]. Although the findings of the literature search were initially compiled according to preconceived themes, these were revised based on data extracted from the articles. Four main themes were therefore applied as follows: (1) ergonomic-related physiological changes in pregnancy; (2) ergonomic stressors and pregnancy outcomes; (3) the psychological impact of ergonomic stressors; and (4) recommended safety practices for pregnant healthcare workers including ergonomic assessment methods. Results and Discussion The following section narratively discusses findings from articles related to work-related ergonomic stressors and their impact on pregnant healthcare workers including stressors and activities related to the working environment. In addition, strategies to overcome or mitigate the impact of these stressors are also recommended based on the findings of the literature review. ergonomic-related physiological changes in pregnancy A pregnant employee requires additional attention and care due to certain physiological and pathological changes that arise during pregnancy. In particular, gait, balance, spinal curvature and pain alter considerably as the pregnancy progresses.16 Moreover, various anatomical, physical, psychological and biochemical changes occur in order to ensure haemostasis, meet the increasing demands of the developing fetus and prepare for labour.17,18 Such changes also affect the quality of life of the expectant mother.19–22 Backache and waddling gait occur due to increased levels of relaxin and oestrogen hormones, joint laxity, hypermobility and spinal curvature; in turn, this Figure 1: Diagram showing the selection process used to identify articles included in the narrative analysis. Frincy Francis, Sheeba E. Johnsunderraj, Divya K. Y, Divya Raghavan, Atiya Al-Furgani, Lily P. Bera and Aniamma Abraham increases the rate of falls among pregnant women.23–26 In the second trimester, several symptoms cease while other physiological adaptations continue.23,24,27 Abnormal conditions can cause anaemia, fluid retention and physiological oedema, thereby compressing the nerves and resulting in numbness and pain in the extremities.18,19,25 Many pregnant women also experience increased levels of tiredness, varicose veins, back pain, muscular cramps, Braxton Hicks contractions and poor sleep quality.26–28 Pregnancy ailments are often exacerbated by the presence of ergonomic stressors at work.14 e r g o n o m i c s t r e s s o r s a n d p r e g n a n c y o u t c o m e s A pregnant employee is more vulnerable to certain occupational hazards, such as radiation exposure (at >100 millirems), infectious bioagents, heavy lifting and prolonged working hours (>12 hours per shift), due to their impact on fetal development.29,30 Expectant mothers should therefore be protected from harmful working conditions, especially after the first trimester.31 This includes ergonomic stressors related to various negative pregnancy outcomes such as spontaneous abortions, prematurity, low birth weight babies and stillbirths. Biological and Chemical Agents A study of 7,500 pregnant nurses working in chemo- therapy administration showed a significant increase in the rate of spontaneous miscarriage after handling cytotoxic drugs.32 In addition, exposure to biological agents such as cytomegalovirus, hepatitis B, human parvovirus B19 and rubella can cause birth defects, low birth weight babies, miscarriages and developmental disorders.33 In particular, seroprevalence rates of cytomegalovirus have been found to be very high among nurses working with immunocompromised and paediatric patients, as well as other healthcare workers in close contact with infected patients or those who provide personal hygiene care like bathing and toileting.34 Ionising Radiation Sources of ionising radiation such as X-rays and gamma rays can cause infertility, miscarriage, birth defects, low birth weight babies and developmental disorders.30 In a study from Israel evaluating 934 pregnant physiotherapists, the researchers reported a significant association between shortwave exposure and low birth weight babies.35 A prospective cohort study of 1,025 female laboratory technicians found that exposure to radio immunoassay work and radio- labelling at approximately 16 gestational weeks increased the rate of preterm delivery.36 In addition, the risk of major fetal malformations was elevated among workers exposed to organic solvents.36 Overexertion and Heavy Lifting Several studies have shown that factors such as physical overexertion, irregular working hours and heavy lifting are associated with an increased risk of spontaneous abortion among pregnant women.29,31,37 As such, employees should be careful when lifting and manoeuvring objects away from the body as the pregnancy progresses.16 Lifting heavy weights (>10 kg) during pregnancy shifts the centre of gravity forward, affecting balance and potentially increasing the risk of falling.38,39 Moreover, lifting heavy loads also increases the risk of preterm birth.38 An elevated risk of stillbirth and spontaneous abortion related to physical effort, lifting heavy objects and working for long hours without rest has been observed among nursing assistants, aides and other female employees.40–42 High levels of physical activity during pregnancy increase the demand for oxygen, reducing fetal nutrition supply and putting stress on the endocrine system. Exhaustion, lifting heavy objects, long work hours without rest and high noise levels (>85 decibels) during pregnancy has been linked to low birth weight babies.31,43−46 Prolonging Working Hours and Standing Prolonged or irregular working hours have been found to increase the risk of small-for-gestational-age babies, with this risk aggravated by other working conditions including night shifts, prolonged standing, increased noise exposure and high psychological needs with low support.47–49 The prevalence of preterm labour among orthopaedic surgeons during their first pregnancies was 11.1%, gradually increasing to 12.5% in second pregnancies and 20% in third pregnancies.50 Urologists have also shown an increased risk of premature labour compared to the general population, likely due to prolonged working hours and continuous standing (>3 hours per day).51 There is also a significant relationship between number of hours worked per week and premature rupture of the membranes.52 Overall, 8.8% of women working 40 hours per week report premature labour, which indicates that occupational fatigue caused by prolonged working hours can lead to preterm delivery.52,53 Occupational fatigue during pregnancy is also believed to lower capacity to endure pain during vaginal delivery, as well as energy levels, potentially affecting the decision to perform a Caesarean section.54 Falls A retrospective cohort study from the USA found the incidence of falls among employed pregnant women to be 26.6%, of which 13.1% occurred at the workplace and the majority during the second and third trimesters.55 Overall, pregnant healthcare workers reported the Ergonomic Stressors Among Pregnant Healthcare Workers Impact on pregnancy outcomes and recommended safety practices e174 | SQU Medical Journal, May 2021, Volume 21, Issue 2 Review | e175 fourth highest prevalence of workplace falls, with rates of 7.9% among dentists, physician assistants, pharmacists and doctors, 5.2% among nurses and 1.3% among dental hygienists, technicians and health aides. Certain fall-related risk factors—such as slippery floors, rushing/hurrying and carrying equipment/ objects—were found to contribute to 66.3% of workplace falls.55 Various obstetric complications such as placental separation, uterine rupture and fetal death can occur due to fall-related trauma; other possible injuries include fractures, strains, sprains and head injuries.56 Musculoskeletal Injuries Musculoskeletal disorders are commonly reported by nurses and this risk is exacerbated in pregnancy, particularly during late gestation.57,58 The occupational tasks of healthcare workers can contribute to these injuries, such as the need to manually handle patients, pull and push beds and trolleys and move or hold awkward body positions while performing patient care procedures.59 The prevalence of musculoskeletal disorders over a 12-month period was 39% among 200 nurses working at a hospital in Ajman, Saudi Arabia.60 Over half of the participants also reported routinely engaging in awkward body positions, working without positional changes and repetitive tasks.60 In addition, working in a confined space has been positively correlated with back pain severity at 34 gestational weeks.12 Wrist pain has been reported by 90% of sonographers due to the routine use of transducers for scanning, with grip technique and pressure being contributing factors.61,62 Muscle strain is aggravated more by pinch grip compared to power grip, as the former technique applies five times more force than the latter.63 An association has also been established between grip strength and muscle function, with lower grip strength increasing the risk of injury and disability.64 A longitudinal study assessing the hand grip strength of pregnant women reported a significant reduction in grip strength from the first to the third trimester, a finding attributed to the metabolic, musculoskeletal and hormonal changes which occur in pregnancy.65 psychological impact of ergonomic stressors All domains of ergonomics are interconnected; for instance, a poorly designed workstation can create stress, thereby altering behaviour which in turn can induce changes in cognitive function and overall performance.66 Although workplace ergonomics primarily focus on physical factors, employers should also consider workers’ mental workload, creativity and productivity. The relationship between environmental risks at work and fetal outcomes remains inconclusive. In general, standard working conditions present little hazard to infant health; however, pregnancy may significantly impact maternal psychosocial wellbeing in the workplace.46 Supporting employees through skill development and coping mechanisms is therefore an important component of workplace ergonomics. Making suitable adjustments to physical, cognitive and organisational ergonomic domains can help employees to remain efficient during pregnancy. In particular, stress during pregnancy has negative outcomes; as such, psychological assessments and counselling should be performed.67 Moreover, previous research indicates an association between poor job control, lack of workplace support and increased levels of workplace stress and the development of depressive symptoms during pregnancy.68 Excessive or insufficient workloads, unclear tasks or instructions, poor support and rotating shifts adversely impacts both work quality and pregnancy outcomes.69 r e c o m m e n d e d s a f e t y p r a c t i c e s Ergonomic Assessment Methods Employers can utilise various ergonomic assessment methods to ensure an optimised working environment for their employees. They should begin by identifying risks for work-related disorders that stem from poor ergonomic practices, for instance by utilising the computer-based SONEX system which predicts the development of work-related musculoskeletal disorders and offers preventive measures to improve a worksite’s ergonomics.70 Subsequently, various available programs are available to provide ergonomic consultations and financial support to obtain ergonomic devices, an effective step in reducing musculoskeletal disorders.71 One particularly useful approach is heuristic evaluation, a general ergonomics inspection method based on accepted theoretical principles and past design experience which allows employers to either create their own structured evaluation checklist or use existing checklists.72 With regards to physical ergonomics, posture- based analysis can be employed to help identify areas of concern, with higher scores indicative of poor posture due to deviation from a neutral standing position. Specifically, the Rapid Upper Limb Assessment (RULA) provides a swift evaluation of the potential for upper limb disorders, while the Rapid Entire Body Assessment (REBA) considers the intensity of work performed by the whole body to evaluate the risk of musculoskeletal disorders.73 Both RULA and REBA assess specific postures during repetitive tasks.73 Another potential method is the Revised National Frincy Francis, Sheeba E. Johnsunderraj, Divya K. Y, Divya Raghavan, Atiya Al-Furgani, Lily P. Bera and Aniamma Abraham Institute for Occupational Safety and Health Lifting Equation (RNLE), an example of a biomechanics- based assessment which determines maximum weight limitations to prevent overexertion injuries related to manual tasks involving pulling, moving, lifting and transferring.74,75 Based on the RNLE, a lifting index of >1.0 indicates a high risk of injury.74 Conducting regular ergonomics evaluations is necessary to ensure a suitable and safe work envi- ronment. Ideally, a task force should be formed to conduct routine ergonomic assessments for the purposes of early risk detection.76 While there is currently no published evaluation method specific to pregnant women, the development of such a method would greatly improve the quality of life of pregnant employees. In particular, longer working hours and shift work have major implications for the short- and long-term health of both mothers and their infants.47−53 These findings may help inform decision-making on occupational directives or workplace design for the prevention of adverse pregnancy outcomes. Healthcare administrators should plan and conduct awareness programmes regarding the potential impact of ergonomic stressors and poor work posture on employees.77 In addition, the ergonomic safety and comfort of pregnant healthcare workers should be prioritised, especially as working conditions are linked to increased rates of sick leave and absenteeism in this population group.78 Fall Risk Assessments Among Pregnant Workers Although fall risk assessments are routinely performed for hospitalised patients, most health institutions do not conduct such assessments for workers. Nevertheless, it is highly recommended that fall risk assessments be provided for pregnant healthcare workers due to the high risk of falling for this population group.55 A few examples of fall risk assessment tools for pregnant women include the Obstetric Fall Risk Assessment System, the Maternity Fall Risk Assessment Scale and the Fall Risk Assessment for Perinatal Patients instrument.79–81 Such tools can be modified and used to assess fall risk among pregnant healthcare workers. Potential Preventative Strategies Several preventative strategies can be used to address ergonomic stressors in pregnant women, such as maintaining ideal posture, taking frequent breaks and avoiding heavy lifting, loud noises and electromagnetic fields.46,82 Potential accommodations to address common ergonomic stressors related to adverse pregnancy risks are shown in Table 1.31–39,43– 46,48,52–56,61,64,65,71,78–100 Viable solutions to avoid heavy lifting by pregnant healthcare workers include apparatuses to lift and transfer patients, biomechanical training, larger rooms and additional team members for support during patient transfers.83 In particular, hydraulic or power-operated mechanical lifts should be provided to help lift patients from a bed to a stretcher or a chair, with appropriate training for caregivers to minimise risk of injury.84 Implementation of a minimal lifting or no lifting policy in healthcare institutions is not only cost-effective, but also results in greater satisfaction and fewer injuries among nursing staff.85,86 According to the American Medical Association, pregnant workers at ≤24 gestational weeks may safely lift up to 23 kg repetitively; subsequently, the weight limit should be reduced to 11 kg.87 With regards to intermittent lifting, it is safe to lift up to 23 kg, even after 30 gestational weeks.87 As the pregnancy progresses, the abdominal muscles stretch to accommodate the growing fetus, especially in the third trimester. Therefore, in order to maintain appropriate body mechanics, workstations should be designed so that the pregnant worker can maintain a reach distance of 38–50 cm. Considering this need for additional space is essential when planning clinical workstations in hospitals.88,89 A previous study found that use of a concave desk board while using a computer for 20 minutes helped pregnant women increase muscle activity in their upper right trapezius and decrease muscle activity in the lower back, thus minimising back discomfort in late pregnancy.90 Sit- stand ergonomic units and standing desks are also potential solutions for alternating work posture while performing repetitive tasks.91,92 Prolonged standing among pregnant healthcare professionals should be limited to <3 hours.82 Anti-slip flooring can help to prevent falls among pregnant workers; similarly, warning signs should be placed near wet or slippery floors by housekeeping staff. Ensuring safety in restrooms is also essential to minimise fall risk. In terms of work attire, pregnant workers should be encouraged to select comfortable work shoes for prolonged standing, with a good base and no laces to reduce the risk of slipping or tripping.93 Finally, the first line of defence in preventing infection, especially when exposed to biological agents such as cytomegalovirus, is adherence to universal precautions like hand hygiene and use of personal protective equipment. It is also essential to minimise the risk of work-to-home contamination by requiring workers to change clothes at their workplace and providing laundry services.94 implications for practice in oman Globally, the number of female healthcare professionals has increased, especially in medicine.1,2 A similar trend has been reported in Oman, with women accounting Ergonomic Stressors Among Pregnant Healthcare Workers Impact on pregnancy outcomes and recommended safety practices e176 | SQU Medical Journal, May 2021, Volume 21, Issue 2 Review | e177 for 64% of medical students at the Sultan Qaboos University in 2015, 61.5% of resident doctors employed by the Ministry of Health and 42% of all doctors.101 Various ergonomic deficiencies were also identified in a survey of typical offices in Oman including issues related to workstation design, furniture and working hours; in addition, the survey participants reported major health problems including eyestrain (58%), shoulder pain (45%), back pain (43%), arm pain (35%) and neck pain (30%).102 Table 1: Impact of ergonomic stressors during pregnancy and recommended practices31–39,43–46,48,52–56,61,64,65,71,78–100 Ergonomic stressor Risk in pregnancy Recommended practice for safety Work shifts (evening/ night shifts) • Preterm delivery • SGA babies • Gestational HTN • Avoid night shifts • Permit convenient shift changes Prolonged working hours (≥40 hours/week) • IUGR • Preterm delivery • Dehydration • Threatened miscarriage • Instrumental delivery due to maternal exhaustion • Reassign shifts • Reduce working hours to 6 hours per day Prolonged standing (≥3 hours) • Decreased fetal growth rate • Provide sit-stand ergonomic units or ergonomic chairs with footrests • Limit continuous standing to <3 hours Prolonged bending • Increased back pain • Provide a chair with minimal rocking facilities to alter the centre of gravity Overexertion (physically demanding work) • Preterm delivery • LBW babies • Decreased fetal growth rate • Reduce physical demands in the workplace • Ensure minimal physical strain Lifting, moving and transferring • Musculoskeletal injuries • Maternal exhaustion • LBW babies • Provide additional staff support • Install hydraulic or power-operated mechanical lifts • Implement a no lifting policy Body posture issues (repetitive jobs and awkward positions) • Lower back pain • Pelvic girdle pain • Wrist pain • Muscle spasms • Sprains • Altered grip strength • Consider a reach distance of 38–50 cm in workstation layouts, particularly in the third trimester • Alternate posture/position every 2 hours • Install concave desk boards for computers Occupational fatigue • PROM • Preterm delivery • Caesarean section delivery due to maternal exhaustion • Take a 10-minute break every hour • Provide comfortable rest rooms • Avoid night shifts Work-related falls • Placental separation • Uterine rupture • Fetal death • Fractures • Injuries • Conduct mandatory fall risk assessments • Install anti-slip flooring • Place caution boards near wet floors • Wear comfortable shoes High noise exposure (>85 decibels) • LBW babies • Avoid loud or noisy environments Exposure to biological and chemical agents • Infertility • Birth defects • Decreased fetal growth rate • Impaired fetal brain development • Preterm delivery • LBW babies • Miscarriage • Developmental disorders • Implement mandatory universal precautions (i.e. handwashing, wearing PPE, etc.) • Minimise the possibility of work-to-home contamination Exposure to ionising radiation • Miscarriage • LBW babies • Preterm delivery • Birth defects • Wear appropriate PPE Stress • Decreased psychological wellbeing • Depression • Gestational HTN • Conduct routine psychological assessments and counselling sessions • Ensure a supportive work environment SGA = small for gestational age; HTN = hypertension; IUGR = intrauterine growth restriction; LBW = low birth weight; PROM = premature rupture of the membranes; PPE = personal protective equipment. Frincy Francis, Sheeba E. Johnsunderraj, Divya K. Y, Divya Raghavan, Atiya Al-Furgani, Lily P. Bera and Aniamma Abraham Accordingly, a health and safety management system should be implemented to help identify, prevent, treat and mitigate ergonomic-related hazards posing a threat to pregnant healthcare workers in Oman. Ideally, this system should proactively assess and correct identified hazards before workers are injured or become ill.103 This can be achieved through a comprehensive programme to promote the safe lifting, handling and transfer of patients. Such a programme would require focused management leadership, participation from employees, early hazard appraisal, anticipation and control, education and training and routine evaluation and improvement activities.105 Ergonomic measures without sufficient management support have shown to have limited success in reducing work related health problems in healthcare workers.106 Currently, there is a dearth of research concerning ergonomic stressors and its impact on pregnant workers in the GCC region, particularly for those in healthcare occupations. Statistical data are necessary to determine the impact of ergonomic stressors on work-related injuries, absenteeism and job turnover in order to assess and mitigate these issues. As such, a well-planned evidence-based ergonomic analysis of pregnant healthcare employees in Oman is recommended to determine how ergonomic principles impact the occupational safety and productivity of this population group. Conclusion This review sought to assess the impact of various ergonomic stressors on pregnancy outcomes among healthcare workers. Reducing work-related risks for pregnant workers can increase employee productivity and safety in healthcare units, whereas poor work- related ergonomics can have serious maternal and fetal consequences including spontaneous abortions, preterm delivery, low birth weight babies and infertility. In order for policymakers to address these concerns, a national research-based ergonomic analysis must be performed to assess the effects of ergonomic stressors on the health and safety of pregnant workers in Oman, specifically those employed in healthcare settings. References 1. World Health Organization. World Health Report: Health workers - Chapter one: A global profile. From: https://www.who.int/ whr/2006/06_chap1_en.pdf Accessed: Aug 2020. 2. Joseph B, Joseph M. The health of the healthcare workers. Indian J Occup Environ Med 2016; 20:71–2. https://doi.org/10.4103/0 019-5278.197518. 3. Rushton L. The global burden of occupational disease. Curr Environ Health Rep 2017; 4:340–8. https://doi.org/10.1007/ s40572-017-0151-2. 4. Dong H, Zhang Q, Liu G, Shao T, Xu Y. Prevalence and associated factors of musculoskeletal disorders among Chinese healthcare professionals working in tertiary hospitals: A cross- sectional study. BMC Musculoskelet Disord 2019; 20:175. https://doi.org/10.1186/s12891-019-2557-5. 5. Salvendy G, Ed. Handbook of Human Factors and Ergonomics, 4th ed. Hoboken, New Jersey, USA: Wiley, 2012. https://doi. org/10.1002/9781118131350. 6. Pheasant S, Haslegrave CM. Bodyspace: Anthropometry, ergo- nomics and the design of work, 3rd ed. Boca Raton, Florida, USA: CRC Press, 2005. 7. Hamid A, Ahmad AS, Dar S, Sohail S, Akram F, Qureshi MI. Ergonomics hazards and musculoskeletal disorders among workers of health care facilities. Curr World Environ 2018; 13:251–8. https://doi.org/10.12944/CWE.13.2.10. 8. Karwowski W. Ergonomics and human factors: The paradigms for science, engineering, design, technology and management of human-compatible systems. Ergonomics 2005; 48:436–63. https://doi.org/10.1080/00140130400029167. 9. Buckle P. Ergonomics and musculoskeletal disorders: Overview. Occup Med (London) 2005; 55:164–7. https://doi.org/10.1093/ occmed/kqi081. 10. Zakerian SA, Monazzam MR, Dehghan SF, Mohraz MH, Safari H, Asghari M. Relationship between knowledge of ergonomics and workplace condition with musculoskeletal disorders among nurses. World Appl Sci J 2013; 24:227–33. https://doi. org/10.5829/idosi.wasj.2013.24.02.651. 11. Adinma JI, Adinma ED, Umeononihu OS, Oguaka V, Adinma- Obiajulu ND, Oyedum SO. Prevalence, perception and risk factors for musculoskeletal discomfort among pregnant women in Southeast Nigeria. J Musculoskelet Disord Treat 2018; 4:63. https://doi.org/10.23937/2572-3243.1510063. 12. Tapp LM. The Pregnant Worker and Ergonomics. In ASSE Professional Development Conference and Exposition 2001 Jan 1. American Society of Safety Engineers. Downloaded from http://onepetro.org/ASSPPDCE/proceedings-pdf/ASSE01/ A l l - A S SE 0 1 / A S SE - 0 1 - 6 2 5 / 1 8 9 5 9 3 3 / a s s e - 0 1 - 6 2 5 . p d f / 1 Accessed: Aug 2020 13. Rogers B, Buckheit K, Ostendorf J. Ergonomics and nursing in hospital environments. Workplace Health Saf 2013; 61:429–39. https://doi.org/10.1177/216507991306101003. 14. Cheng PL, Pantel M, Smith JT, Dumas GA, Leger AB, Plamondon A, et al. Back pain of working pregnant women: Identification of associated occupational factors. Appl Ergon 2009; 40:419–23. https://doi.org/10.1016/j.apergo.2008.11.002. 15. Hadfield R. Pearl growing as a strategy in systematic literature searches. From: https://www.mediwrite.com.au/medical-writi ng/pearl-growing/ Accessed: Aug 2020. 16. Yoo H, Shin D, Song C. Changes in the spinal curvature, degree of pain, balance ability, and gait ability according to pregnancy period in pregnant and non-pregnant women. J Phys Ther Sci 2015; 27:279–84. https://doi.org/10.1589/jpts.27.279. 17. Soma-Pillay P, Nelson-Piercy C, Tolppanen H, Mebazaa A. Physiological changes in pregnancy. Cardiovasc J Afr 2016; 27:89–94. https://doi.org/10.5830/CVJA-2016-021. 18. Muallem MM, Rubeiz NG. Physiological and biological skin changes in pregnancy. Clin Dermatol 2006; 24:80–3. https:// doi.org/10.1016/j.clindermatol.2005.10.002. 19. Yikar SK, Nazik E. The effect of complaints during pregnancy on quality of life. Int J Caring Sci 2018; 11:623–6. 20. Huizink AC, de Medina PG, Mulder EJ, Visser GH, Buitelaar JK. Coping in normal pregnancy. Ann Behav Med 2002; 24:132–40. https://doi.org/10.1207/S15324796ABM2402_10. Ergonomic Stressors Among Pregnant Healthcare Workers Impact on pregnancy outcomes and recommended safety practices e178 | SQU Medical Journal, May 2021, Volume 21, Issue 2 https://doi.org/10.4103/0019-5278.197518 https://doi.org/10.4103/0019-5278.197518 https://doi.org/10.1007/s40572-017-0151-2 https://doi.org/10.1007/s40572-017-0151-2 https://doi.org/10.1186/s12891-019-2557-5 https://doi.org/10.1002/9781118131350 https://doi.org/10.1002/9781118131350 https://doi.org/10.12944/CWE.13.2.10 https://doi.org/10.1080/00140130400029167 https://doi.org/10.1093/occmed/kqi081 https://doi.org/10.1093/occmed/kqi081 https://doi.org/10.5829/idosi.wasj.2013.24.02.651 https://doi.org/10.5829/idosi.wasj.2013.24.02.651 https://doi.org/10.23937/2572-3243.1510063 https://doi.org/10.1177/216507991306101003 https://doi.org/10.1016/j.apergo.2008.11.002 https://doi.org/10.1589/jpts.27.279 https://doi.org/10.5830/CVJA-2016-021 https://doi.org/10.1016/j.clindermatol.2005.10.002 https://doi.org/10.1016/j.clindermatol.2005.10.002 https://doi.org/10.1207/S15324796ABM2402_10 Review | e179 21. Alzboon G, Vural G. Factors influencing the quality of life of healthy pregnant women in North Jordan. Medicina (Kaunas) 2019; 55:278. https://doi.org/10.3390/medicina55060278. 22. Buen M, Amaral E, Souza RT, Passini R Jr, Lajos GJ, Tedesco RP, et al. Maternal work and spontaneous preterm birth: A multi- center observational study in Brazil. Sci Rep 2020; 10:9684. https://doi.org/10.1038/s41598-020-66231-2. 23. Błaszczyk JW, Opala-Berdzik A, Plewa M. Adaptive changes in spatiotemporal gait characteristics in women during pregnancy. Gait Posture 2016; 43:160–4. https://doi.org/10.1016/j.gaitpo st.2015.09.016. 24. Okanishi N, Kito N, Akiyama M, Yamamoto M. Spinal curv- ature and characteristics of postural change in pregnant women. Acta Obstet Gynecol Scand 2012; 91:856–61. https://doi.org/10.1 111/j.1600-0412.2012.01400.x. 25. Dehghan F, Haerian BS, Muniandy S, Yusof A, Dragoo JL, Salleh N. The effect of relaxin on the musculoskeletal system. Scand J Med Sci Sports 2014; 24:e220–9. https://doi.org/10.1111/ sms.12149. 26. Inklebarger J, Galanis N, Michael J, Gyer G. Pregnancy-related hormonal influences on the musculoskeletal system, lumbo- pelvic structures and peripheral joints: Some practical consider- ations for manual therapists. Int J Med Sci Clin Inventions 2017; 4:2816–22. https://doi.org/10.18535/ijmsci/v4i4.01. 27. Motosko CC, Bieber AK, Pomeranz MK, Stein JA, Martires KJ. Physiologic changes of pregnancy: A review of the literature. Int J Womens Dermatol 2017; 3:219–24. https://doi.org/10.1016/j. ijwd.2017.09.003. 28. Taşkıran N. Pregnancy and sleep quality. J Turk Soc Obstet Gynecol 2011; 8:181–7. https://doi.org/10.5505/tjod.2011.14880. 29. Lawson CC, Whelan EA, Hibert EN, Grajewski B, Spiegelman D, Rich-Edwards JW. Occupational factors and risk of preterm birth in nurses. Am J Obst Gynecol 2009; 200:51.e1–8. https:// doi.org/10.1016/j.ajog.2008.08.006. 30. Shaw P, Duncan A, Vouyouka A, Ozsvath K. Radiation exposure and pregnancy. J Vasc Surg 2011; 53:28S–34S. https://doi. org/10.1016/j.jvs.2010.05.140. 31. Banerjee B. Physical hazards in employment and pregnancy outcome. Indian J Community Med 2009; 34:89–93. https:// doi.org/10.4103/0970-0218.51224. 32. Lawson CC, Rocheleau CM, Whelan EA, Hibert EN, Grajewski B, Spiegelman D, et al. Occupational exposures among nurses and risk of spontaneous abortion. Am J Obst Gynecol 2012; 206:e1–8. https://doi.org/10.1016/j.ajog.2011.12.030. 33. Gilani S, Giridharan S. Is it safe for pregnant health-care professionals to handle cytotoxic drugs? A review of the literature and recommendations. Ecancermedicalscience 2014; 8:418. https://doi.org/10.3332/ecancer.2014.418. 34. Sobaszek A, Fantoni-Quinton S, Frimat P, Leroyer A, Laynat A, Edme JL. Prevalence of cytomegalovirus infection among health care workers in pediatric and immunosuppressed adult units. J Occup Environ Med 2000; 42:1109–14. https://doi. org/10.1097/00043764-200011000-00015. 35. Lerman Y, Jacubovich R, Green MS. Pregnancy outcome following exposure to shortwaves among female physiotherapists in Israel. Am J Ind Med 2001; 39:499–504. https://doi.org/10.1002/ ajim.1043. 36. Zhu JL, Knudsen LE, Andersen AM, Hjollund NH, Olsen J. Laboratory work and pregnancy outcomes: A study within the National Birth Cohort in Denmark. Occup Environ Med 2006; 63:53–8. https://doi.org/10.1136/oem.2005.021204. 37. Caruso CC. Reducing risks to women linked to shift work, long work hours, and related workplace sleep and fatigue issues. J Womens Health (Larchmt) 2015; 24:789–94. https://doi. org/10.1089/jwh.2015.5481. 38. Escribá-Agüir V, Perez-Hoyos S, Saurel-Cubizolles MJ. Physical load and psychological demand at work during pregnancy and preterm birth. Int Arch Occup Environ Health 2001; 74:583–8. https://doi.org/10.1007/s004200100259. 39. Hathout HM, El-Dalatony MM, Anwar MM, Al-Batanony MA, Shehata NA. Work related risk factors and pregnancy outcome between working women. Egypt J Occup Med 2015; 39:119–33. https://doi.org/10.21608/ejom.2015.815. 40. Juhl M, Strandberg-Larsen K, Larsen PS, Andersen PK, Svendsen SW, Bonde JP, et al. Occupational lifting during pregnancy and risk of fetal death in a large national cohort study. Scand J Work Environ Health 2013; 39:335–42. https://doi.org/10.5271/ sjweh.3335. 41. Bonde JP, Jørgensen KT, Bonzini M, Palmer KT. Risk of mis- carriage and occupational activity: A systematic review and meta-analysis regarding shift work, working hours, lifting, standing and physical workload. Scand J Work Environ Health 2013; 39:325–34. https://doi.org/10.5271/sjweh.3337. 42. Lee W, Jung SW, Lim YM, Lee KJ, Lee JH. Spontaneous and repeat spontaneous abortion risk in relation to occupational characteristics among working Korean women: A cross- sectional analysis of nationally representative data from Korea. BMC Public Health 2019; 19:1339. https://doi.org/10.1186/ s12889-019-7728-7. 43. Burdorf A, Brand T, Jaddoe VW, Hofman A, Mackenbach JP, Steegers EA. The effects of work-related maternal risk factors on time to pregnancy, preterm birth and birth weight: The Generation R Study. Occup Environ Med 2011; 68:197–204. https://doi.org/10.1136/oem.2009.046516. 44. Hunicke R, Roberts E, Roberts L. How do we know if a worksite is safe for a pregnant worker? In: Teratology Primer, 3rd ed. Reston, Virginia, USA: Society for Birth Defects Research & Prevention, 2007. 45. Hohmann C, Grabenhenrich L, de Kluizenaar Y, Tischer C, Heinrich J, Chen CM, et al. Health effects of chronic noise exposure in pregnancy and childhood: A systematic review initiated by ENRIECO. Int J Hyg Environ Health 2013; 216:217–29. https://doi.org/10.1016/j.ijheh.2012.06.001. 46. Salihu HM, Myers J, August EM. Pregnancy in the workplace. Occup Med (Lond) 2012; 62:88–97. https://doi.org/10.1093/ occmed/kqr198. 47. Mozurkewich EL, Luke B, Avni M, Wolf FM. Working conditions and adverse pregnancy outcome: A meta-analysis. Obstet Gynecol 2000; 95:623–35. https://doi.org/10.1016/s00 29-7844(99)00598-0. 48. Snijder CA, Brand T, Jaddoe V, Hofman A, Mackenbach JP, Steegers EA, et al. Physically demanding work, fetal growth and the risk of adverse birth outcomes: The Generation R Study. Occup Environ Med 2012; 69:543–50. https://doi.org/10.1136/ oemed-2011-100615. 49. Croteau A, Marcoux S, Brisson C. Work activity in pregnancy, preventive measures, and the risk of delivering a small-for- gestational-age infant. Am J Public Health 2006; 96:846–55. https://doi.org/10.2105/AJPH.2004.058552. 50. Hamilton AR, Tyson MD, Braga JA, Lerner LB. Childbearing and pregnancy characteristics of female orthopaedic surgeons. J Bone Joint Surg Am 2012; 94:e77. https://doi.org/10.2106/ JBJS.K.00707. 51. Lerner LB, Stolzmann KL, Gulla VD. Birth trends and pregnancy complications among women urologists. J Am Coll Surg 2009; 208:293–7. https://doi.org/10.1016/j.jamcollsurg.2008.10.012. 52. 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; 70:213–22. https://doi.org/10.1136/oemed-2012-101032. Frincy Francis, Sheeba E. Johnsunderraj, Divya K. Y, Divya Raghavan, Atiya Al-Furgani, Lily P. Bera and Aniamma Abraham https://doi.org/10.3390/medicina55060278 https://doi.org/10.1038/s41598-020-66231-2 https://doi.org/10.1016/j.gaitpost.2015.09.016 https://doi.org/10.1016/j.gaitpost.2015.09.016 https://doi.org/10.1111/j.1600-0412.2012.01400.x https://doi.org/10.1111/j.1600-0412.2012.01400.x https://doi.org/10.1111/sms.12149 https://doi.org/10.1111/sms.12149 https://doi.org/10.18535/ijmsci/v4i4.01 https://doi.org/10.1016/j.ijwd.2017.09.003 https://doi.org/10.1016/j.ijwd.2017.09.003 https://doi.org/10.5505/tjod.2011.14880 https://doi.org/10.1016/j.ajog.2008.08.006 https://doi.org/10.1016/j.ajog.2008.08.006 https://doi.org/10.1016/j.jvs.2010.05.140 https://doi.org/10.1016/j.jvs.2010.05.140 https://doi.org/10.4103/0970-0218.51224 https://doi.org/10.4103/0970-0218.51224 https://doi.org/10.1016/j.ajog.2011.12.030 https://doi.org/10.3332/ecancer.2014.418 https://doi.org/10.1097/00043764-200011000-00015 https://doi.org/10.1097/00043764-200011000-00015 https://doi.org/10.1002/ajim.1043 https://doi.org/10.1002/ajim.1043 https://doi.org/10.1136/oem.2005.021204 https://doi.org/10.1089/jwh.2015.5481 https://doi.org/10.1089/jwh.2015.5481 https://doi.org/10.1007/s004200100259 https://doi.org/10.21608/ejom.2015.815 https://doi.org/10.5271/sjweh.3335 https://doi.org/10.5271/sjweh.3335 https://doi.org/10.5271/sjweh.3337 https://doi.org/10.1186/s12889-019-7728-7 https://doi.org/10.1186/s12889-019-7728-7 https://doi.org/10.1136/oem.2009.046516 https://doi.org/10.1016/j.ijheh.2012.06.001 https://doi.org/10.1093/occmed/kqr198 https://doi.org/10.1093/occmed/kqr198 https://doi.org/10.1016/s0029-7844%2899%2900598-0 https://doi.org/10.1016/s0029-7844%2899%2900598-0 https://doi.org/10.1136/oemed-2011-100615 https://doi.org/10.1136/oemed-2011-100615 https://doi.org/10.2105/AJPH.2004.058552 https://doi.org/10.2106/JBJS.K.00707 https://doi.org/10.2106/JBJS.K.00707 https://doi.org/10.1016/j.jamcollsurg.2008.10.012 https://doi.org/10.1136/oemed-2012-101032 53. Newman RB, Goldenberg R,L Moawad AH, Iams JD, Meis PJ, Das A, et al. Occupational fatigue and preterm premature rupture of membranes: National Institute of Child Health and Human Development Maternal-Fetal Medicine, Units Network. Am J Obstet Gynecol 2001; 184:438–46. https://doi. org/10.1067/mob.2001.110312. 54. Hung S, Morrison DR, Whittington LA, Fein SB. Prepartum work, job characteristics, and risk of Cesarean delivery. Birth 2002; 29:10–17. https://doi.org/10.1046/j.1523-536x.2002.00150.x. 55. Dunning K, LeMasters G, Levin L, Bhattacharya A, Alterman T, Lordo K. Falls in workers during pregnancy: Risk factors, job hazards, and high risk occupations. Am J Ind Med 2003; 44:664–72. https://doi.org/10.1002/ajim.10318. 56. Curet MJ, Schermer CR, Demarest GB, Bieneik EJ 3rd, Curet LB. Predictors of outcome in trauma during pregnancy: Identif- ication of patients who can be monitored for less than 6 hours. J Trauma 2000; 49:18–25. https://doi.org/10.1097/00005373- 200007000-00003. 57. Taghinejad H, Azadi A, Suhrabi Z, Sayedinia M. Musculoskeletal disorders and their related risk factors among Iranian nurses. Biotechnol Health Sci 2016; 3:e34473. https://doi.org/10.17795/ bhs-34473. 58. Alex MR. Occupational hazards for pregnant nurses. Am J Nurs 2011; 111:28–37. https://doi.org/10.1097/01.naj.000039 3056.01687.40. 59. Waters T, Collins J, Galinsky T, Caruso C. NIOSH research efforts to prevent musculoskeletal disorders in the healthcare industry. Orthop Nurs 2006; 25:380–9. https://doi.org/10.10 97/00006416-200611000-00007. 60. Gopal K, Thomas M, Sreedharan J. Work-related musculoskeletal disorders (WMSD) in hospital nurses: Prevalence and coping strategies. In: 4th Annual Scientific Meeting of Gulf Medical University Oral Proceedings 2012. Gulf Med J 2012; 1:S159–63. 61. Evans K, Roll S, Baker J. Work-related musculoskeletal dis- orders (WRMSD) among registered diagnostic medical sono- graphers and vascular technologists: A representative sample. J Diagn Med Sonogr 2009; 25:287–99. https://doi.org/10.1177/87 56479309351748. 62. Harrison G, Harris A. Work-related musculoskeletal disorders in ultrasound: Can you reduce risk? Ultrasound 2015; 23:224–30. https://doi.org/10.1177/1742271x15593575. 63. Hill JJ 3rd, Slade MD, Russi MB. Anthropometric measurements, job strain, and prevalence of musculoskeletal symptoms in female medical sonographers. Work 2009; 33:181–9. https:// doi.org/10.3233/wor-2009-0865. 64. Roberts HC, Denison HJ, Martin HJ, Patel HP, Syddall H, Cooper C, et al. A review of the measurement of grip strength in clinical and epidemiological studies: Towards a standardized approach. Age Ageing 2011; 40:423–9. https://doi.org/10.1093/ ageing/afr051. 65. Żelaźniewicz A, Pawłowski B. Maternal hand grip strength in pregnancy, newborn sex and birth weight. Early Hum Dev 2018; 119:51–5. https://doi.org/10.1016/j.earlhumdev.2018.03.004. 66. Tanja-Dijkstra K, Pieterse ME. The psychological effects of the physical healthcare environment on healthcare personnel. Cochrane Database Syst Rev 2011; 1:CD006210. https://doi. org/10.1002/14651858.CD006210.pub3. 67. Glover V. Maternal depression, anxiety and stress during preg- nancy and child outcome: What needs to be done. Best Pract Res Clin Obstet Gynaecol 2014; 28:25–35. https://doi.org/10.10 16/j.bpobgyn.2013.08.017. 68. Yeh SS, Lee CN, Wu YH, Tu NC, Guo YL, Chen PC, et al. Occupational hazard exposures and depressive symptoms of pregnant workers. J Occup Environ Med 2018; 60:e134–8. https://doi.org/10.1097/JOM.0000000000001255. 69. Yang HJ, Kao FY, Chou YJ, Huang N, Chang KY, Chien LY. Do nurses have worse pregnancy outcomes than non-nurses? Birth 2014; 41:262–7. https://doi.org/10.1111/birt.12118. 70. Pavlovic-Veselinovic S, Hedge A, Veselinovic M. An ergonomic expert system for risk assessment of work-related musculo- skeletal disorders. Int J Ind Ergon 2016; 53:130–9. https://doi. org/10.1016/j.ergon.2015.11.008. 71. Fujishiro K, Weaver JL, Heaney CA, Hamrick CA, Marras WS. The effect of ergonomic interventions in healthcare facilities on musculoskeletal disorders. Am J Ind Med 2005; 48:338–47. https://doi.org/10.1002/ajim.20225. 72. Butlewski M. Heuristic methods aiding ergonomic design. In: Stephanidis C, Antona M (Eds). Universal Access in Human- Computer Interaction: Design methods, tools, and interaction techniques for e-inclusion. Berlin, Heidelberg: Springer, 2013. Pp. 13–20. https://doi.org/10.1007/978-3-642-39188-0_2. 73. Ansari NA, Sheikh MJ. Evaluation of work posture by RULA and REBA: A case study. IOSR J Mech Civ Eng 2014; 11:18–23. https://doi.org/10.9790/1684-11431823. 74. Waters T, Occhipinti E, Colombini D, Alvarez-Casado E, Fox R. Variable Lifting Index (VLI): A new method for evaluating variable lifting tasks. Hum Factors 2016; 58:695–711. https:// doi.org/10.1177/0018720815612256. 75. Waters TR, MacDonald LA, Hudock SD, Goddard DE. Prov- isional recommended weight limits for manual lifting during pregnancy. Hum Factors 2014; 56:203–14. https://doi.org/10.11 77/0018720813502223. 76. Abedini R, Choobineh AR, Hasanzadeh J. Patient manual handling risk assessment among hospital nurses. Work 2015; 50:669–75. https://doi.org/10.3233/wor-141826. 77. Janowitz IL, Gillen M, Ryan G, Rempel D, Trupin L, Swig L, et al. Measuring the physical demands of work in hospital settings: Design and implementation of an ergonomics assessment. Appl Ergon 2006; 37:641–58. https://doi.org/10.1016/j.apergo.2005.08.004. 78. Villar R, Serra L, Serra C, Benavides FG. Working conditions and absence from work during pregnancy in a cohort of healthcare workers. Occup Environ Med 2019; 76:236–42. https://doi.org/10.1136/oemed-2018-105369. 79. Heafner L, Suda D, Casalenuovo N, Leach LS, Erickson V, Gawlinski A. Development of a tool to assess risk for falls in women in hospital obstetric units. Nurs Womens Health 2013; 17:98–107. https://doi.org/10.1111/1751-486x.12018. 80. Xu M, Tan W, Li Q, Cheng S. Design, application and eval- uation of maternal fall risk assessment scale. Biomed Res 2017; 28:1315–20. 81. Hutcheson J, Waggoner B. Development of falls risk tool specific to obstetric patients. In: Abstracts Presented at the National Neonatal, Advanced Practice, and National Mother Baby Nurses Conference Las Vegas, NV, September 13-16, 2017. Neonatal Netw 2017; 36:e33. https://doi.org/10.1891/0730-0832.36.6.e18. 82. Karol S, Robertson MM. Implications of sit-stand and active workstations to counteract the adverse effects of sedentary work: A comprehensive review. Work 2015; 52:255–67. https:// doi.org/10.3233/wor-152168. 83. Vieira ER, Kumar S, Coury HJ, Narayan Y. Low back problems and possible improvements in nursing jobs. J Adv Nurs 2006; 55:79–89. https://doi.org/10.1111/j.1365-2648.2006.03877.x. 84. Li J, Wolf L, Evanoff B. Use of mechanical patient lifts decreased musculoskeletal symptoms and injuries among health care workers. Inj Prev 2004; 10:212–16. https://doi.org/10.1136/ ip.2003.004978. 85. Carlson EA. Safe patient handling and movement: A guide for nurses and other health care providers. Orthop Nurs 2008; 27:153. https://doi.org/10.1097/01.nor.0000315634.76417.c4. Ergonomic Stressors Among Pregnant Healthcare Workers Impact on pregnancy outcomes and recommended safety practices e180 | SQU Medical Journal, May 2021, Volume 21, Issue 2 https://doi.org/10.1067/mob.2001.110312 https://doi.org/10.1067/mob.2001.110312 https://doi.org/10.1046/j.1523-536x.2002.00150.x https://doi.org/10.1002/ajim.10318 https://doi.org/10.1097/00005373-200007000-00003 https://doi.org/10.1097/00005373-200007000-00003 https://doi.org/10.17795/bhs-34473 https://doi.org/10.17795/bhs-34473 https://doi.org/10.1097/01.naj.0000393056.01687.40 https://doi.org/10.1097/01.naj.0000393056.01687.40 https://doi.org/10.1097/00006416-200611000-00007 https://doi.org/10.1097/00006416-200611000-00007 https://doi.org/10.1177/8756479309351748 https://doi.org/10.1177/8756479309351748 https://doi.org/10.1177/1742271x15593575 https://doi.org/10.3233/wor-2009-0865 https://doi.org/10.3233/wor-2009-0865 https://doi.org/10.1093/ageing/afr051 https://doi.org/10.1093/ageing/afr051 https://doi.org/10.1016/j.earlhumdev.2018.03.004 https://doi.org/10.1002/14651858.CD006210.pub3 https://doi.org/10.1002/14651858.CD006210.pub3 https://doi.org/10.1016/j.bpobgyn.2013.08.017 https://doi.org/10.1016/j.bpobgyn.2013.08.017 https://doi.org/10.1097/JOM.0000000000001255 https://doi.org/10.1111/birt.12118 https://doi.org/10.1016/j.ergon.2015.11.008 https://doi.org/10.1016/j.ergon.2015.11.008 https://doi.org/10.1002/ajim.20225 https://doi.org/10.1007/978-3-642-39188-0_2 https://doi.org/10.9790/1684-11431823 https://doi.org/10.1177/0018720815612256 https://doi.org/10.1177/0018720815612256 https://doi.org/10.1177/0018720813502223 https://doi.org/10.1177/0018720813502223 https://doi.org/10.3233/wor-141826 https://doi.org/10.1016/j.apergo.2005.08.004 https://doi.org/10.1136/oemed-2018-105369 https://doi.org/10.1111/1751-486x.12018 https://doi.org/10.1891/0730-0832.36.6.e18 https://doi.org/10.3233/wor-152168 https://doi.org/10.3233/wor-152168 https://doi.org/10.1111/j.1365-2648.2006.03877.x https://doi.org/10.1136/ip.2003.004978 https://doi.org/10.1136/ip.2003.004978 https://doi.org/10.1097/01.nor.0000315634.76417.c4 Review | e181 86. Engkvist IL. Evaluation of an intervention comprising a no lifting policy in Australian hospitals. Appl Ergon 2006; 37:141–8. https://doi.org/10.1016/j.apergo.2005.05.008. 87. MacDonald LA, Waters TR, Napolitano PG, Goddard DE, Ryan MA, Nielsen P, et al. Clinical guidelines for occupational lifting in pregnancy: Evidence summary and provisional recomm- endations. Am J Obstet Gynecol 2013; 209:80–8. https://doi. org/10.1016/j.ajog.2013.02.047. 88. Nelson A, Matz M, Chen F, Siddharthan K, Lloyd J, Fragala G. Development and evaluation of a multifaceted ergonomics program to prevent injuries associated with patient handling tasks. Int J Nurs Stud 2006; 43:717–33. https://doi.org/10.1016/j. ijnurstu.2005.09.004. 89. Szeto GP, Wong TK, Law RK, Lee EW, Lau T, So BC, et al. The impact of a multifaceted ergonomic intervention program on promoting occupational health in community nurses. Appl Ergon 2013; 44:414–22. https://doi.org/10.1016/j.apergo.2012.10.004. 90. Dumas GA, Upjohn TR, Delisle A, Charpentier K, Leger A, Plamondon A, et al. Posture and muscle activity of pregnant women during computer work and effect of an ergonomic desk board attachment. Int J Ind Ergon 2009; 39:313–25. https://doi. org/10.1016/j.ergon.2008.03.003. 91. Danquah IH, Kloster S, Holtermann A, Aadahl M, Bauman A, Ersbøll AK, et al. Take a stand! A multi-component intervention aimed at reducing sitting time among office workers: A cluster randomized trial. Int J Epidemiol 2016; 46:128–40. https://doi. org/10.1093/ije/dyw009. 92. Finch LE, Tomiyama AJ, Ward A. Taking a stand: The effects of standing desks on task performance and engagement. Int J Environ Res Public Health 2017; 14:939. https://doi.org/10.33 90/ijerph14080939. 93. Szeto GP, Law KY, Lee E, Lau T, Chan SY, Law SW. Multifaceted ergonomic intervention programme for community nurses: Pilot study. J Adv Nurs 2010; 66:1022–34. https://doi.org/10.11 11/j.1365-2648.2009.05255.x. 94. Cannon MJ, Davis KF. Washing our hands of the congenital cytomegalovirus disease epidemic. BMC Public Health 2005; 5:70. https://doi.org/10.1186/1471-2458-5-70. 95. Pompeii LA, Savitz DA, Evenson KR, Rogers B, McMahon M. Physical exertion at work and the risk of preterm delivery and small- for-gestational-age birth. Obstet Gynecol 2005; 106:1279–88. https://doi.org/10.1097/01.aog.0000189080.76998.f8. 96. Van Beukering MD, van Melick MJ, Mol BW, Frings-Dresen MH, Hulshof CT. Physically demanding work and preterm delivery: A systematic review and meta-analysis. Int Arch Occup Environ Health 2014; 87:809–34. https://doi.org/10.1007/s00420-013- 0924-3. 97. Anand N, Gandhi A, Varma V, Kaur S. Ergonomically designed workstation for pregnant workers in apparel industry. IOSR J Humanit Soc Sci 2014; 19:14–23. https://doi.org/10.9790/0837- 19561423. 98. Cai C, Vandermeer B, Khurana R, Nerenberg K, Featherstone R, Sebastianski M, et al. The impact of occupational shift work and working hours during pregnancy on health outcomes: A systematic review and meta-analysis. Am J Obstet Gynecol 2019; 221:563–76. https://doi.org/10.1016/j.ajog.2019.06.051. 99. Suzumori N, Ebara T, Matsuki T, Yamada Y, Kato S, Omori T, et al. Effects of long working hours and shift work during pregnancy on obstetric and perinatal outcomes: A large prospective cohort study - Japan Environment and Children’s Study. Birth 2020; 47:67–79. https://doi.org/10.1111/birt.12463. 100. Specht IO, Hammer PE, Flachs EM, Begtrup LM, Larsen AD, Hougaard KS, et al. Night work during pregnancy and preterm birth: A large register-based cohort study. PLoS One 2019; 14:e0215748. https://doi.org/10.1371/journal.pone.0215748. 101. Mohamed NA, Abdulhadi NN, Al-Maniri AN, Al-Lawati NR, Al-Qasmi AM. The trend of feminization of doctors’ workforce in Oman: Is it a phenomenon that could rouse the health system? Hum Resour Health 2018; 16:19. https://doi.org/10.1186/s12 960-018-0283-y. 101. Shikdar AA, Al-Kindi MA. Office ergonomics: Deficiencies in computer workstation design. Int J Occup Saf Ergon 2007; 13:215–23. https://doi.org/10.1080/10803548.2007.11076722. 103. Springer T. Ergonomics for healthcare environments. From: https ://skgtexas .com/wp-content/uploads/2020/04/healt hcare_ergonomics.pdf Accessed: Aug 2020. 104. Van der Beek AJ, Dennerlein JT, Huysmans MA, Mathiassen SE, Burdorf A, van Mechelen W, et al. A research framework for the development and implementation of interventions preventing work-related musculoskeletal disorders. Scand J Work Environ Health 2017; 43:526–39. https://doi.org/10.5271/sjweh.3671. 105. Coskun Beyan A, Dilek B, Demiral Y. The effects of multifaceted ergonomic interventions on musculoskeletal complaints in intensive care units. Int J Environ Res Public Health 2020; 17:3719. https://doi.org/10.3390/ijerph17103719. Frincy Francis, Sheeba E. Johnsunderraj, Divya K. Y, Divya Raghavan, Atiya Al-Furgani, Lily P. Bera and Aniamma Abraham https://doi.org/10.1016/j.apergo.2005.05.008 https://doi.org/10.1016/j.ajog.2013.02.047 https://doi.org/10.1016/j.ajog.2013.02.047 https://doi.org/10.1016/j.ijnurstu.2005.09.004 https://doi.org/10.1016/j.ijnurstu.2005.09.004 https://doi.org/10.1016/j.apergo.2012.10.004 https://doi.org/10.1016/j.ergon.2008.03.003 https://doi.org/10.1016/j.ergon.2008.03.003 https://doi.org/10.1093/ije/dyw009 https://doi.org/10.1093/ije/dyw009 https://doi.org/10.3390/ijerph14080939 https://doi.org/10.3390/ijerph14080939 https://doi.org/10.1111/j.1365-2648.2009.05255.x https://doi.org/10.1111/j.1365-2648.2009.05255.x https://doi.org/10.1186/1471-2458-5-70 https://doi.org/10.1097/01.aog.0000189080.76998.f8 https://doi.org/10.1007/s00420-013-0924-3 https://doi.org/10.1007/s00420-013-0924-3 https://doi.org/10.9790/0837-19561423 https://doi.org/10.9790/0837-19561423 https://doi.org/10.1016/j.ajog.2019.06.051 https://doi.org/10.1111/birt.12463 https://doi.org/10.1371/journal.pone.0215748 https://doi.org/10.1186/s12960-018-0283-y https://doi.org/10.1186/s12960-018-0283-y https://doi.org/10.1080/10803548.2007.11076722 https://doi.org/10.5271/sjweh.3671 https://doi.org/10.3390/ijerph17103719