Reproductive Health Concerns Among Female Firefighters

Abstract

There has been little research conducted on the reproductive health of female firefighters. The purpose of this study was to determine whether female reproductive health is a concern among firefighters and to identify key associated issues. Eighty-seven United States (US) firefighters participated in focus groups or interviews. Themes were created using grounded theory with NVivo analysis software and a three-phase coding process. The major finding emerging from the study is that female firefighter reproductive health is a significant concern among firefighters.

Introduction (L1)

Females make up 50.9% of the United States (US) workforce (Hulett, Bendick, Thomas, & Moccio, 2008), and this number continues to rise (Bureau of Labor Statistics, 2003). Traditional male-dominated occupations such as the military and law enforcement have female-employment rates of approximately 14% (Women in Military Service for America Memorial Foundation, Inc., 2010) and 13% (US Department of Labor, 2009), respectively. Despite a target of 16–22% representation by females in the fire service (International Association of Women in Fire and Emergency Services [iWomen], 1995), only 3.7% of career firefighters (n = 12,850) are estimated to be female (Haynes & Stein, 2017). This representation is remarkably low, especially when compared to other tactical careers or occupations that have similar requirements in strength, endurance, and hazardous work conditions like logging and roofing (Hulett et al., 2008).

A number of reasons are offered for why female representation is so low in the fire service. The firefighter workplace culture has been traditionally unaccepting of females (Bielby & Reskin, 2005). The psychological and physical strains of fire fighting are cited as possible explanations for the low proportion of female firefighters (Hulett et al., 2008). Gender-based harassment has also been suggested as an explanation and is suspected to account for issues in female firefighter recruitment and retention (Hulett et al., 2008; Rosell, Miller, & Barber, 1995).

While these explanations surely account for some of the representation disparity between men and women in the US fire service, the proposition offered in this article is that the impact of fire fighting on reproductive health may be partially responsible for the underrepresentation of females in the fire service. To test this proposition, a qualitative study of a national sample of 87 firefighters was undertaken to identify reproductive-health concerns among female firefighters.

The study is organized into six sections. Section one provides an overview of the literature on the reproductive health concerns of fire fighting, with a focus on female firefighters. The second section discusses the methods used in the study. Section three presents the results of the analysis of responses provided by focus groups and interviews with the 87 study participants. A discussion of the findings emerging from the qualitative analyses is provided in section four. Section five outlines limitations of the study. Finally, in section six, conclusions and recommendations are offered.

Reproductive Health Concerns Among Firefighters: A Review of Findings (L1)

Female firefighter’s reproductive health concerns were first documented over 20 years ago (Federal Emergency Management Agency [FEMA], 1996). Improper fit of personal protective ensembles/equipment (PPE), including the possible effect of improper fitting equipment on reproductive health, was female firefighters’ second largest concern about their occupation, with the stress of fitting into a nontraditional occupation being their first concern (FEMA, 1996).

A survey conducted by the International Association of Women in Fire & Emergency Services (iWomen), the largest organization of female firefighters in the US, echoed these early concerns. Survey findings found that 58% of female firefighters reported ill-fitting PPE (iWomen, 1995). Fourteen percent of the females specifically cited ill-fitting self-contained breathing apparatus (SCBA) and face pieces that protect firefighters against potential toxic particles in the air. Many female firefighters reported that they were unable to get an adequate seal with their SCBA face pieces (iWomen, 1995), which could dramatically increase exposure risk to potentially harmful chemicals and toxins (Jahnke et al., 2012).

Research findings do, in fact, suggest certain exposures may negatively impact the reproductive health of firefighters. For example, studies report that certain toxic exposures may increase birth defects among the offspring of male firefighters (Olshan, Teschke, & Baird, 1990), and exposure to carbon monoxide and high temperatures may increase the risk of birth defects among female firefighters (McDiarmid, Lees, Agnew, Midzenski, & Duffy, 1991). In addition, exposure to loud noises during pregnancy may result in lower fetal weight and increase chances of fetal mortality (Olshan et al., 1990).

In short, various workplace exposures and hazards can affect the reproductive health of females. Certain exposures and hazards can have consequences not only on the ability to become pregnant, but also fetal health and development (National Institute of Occupational Safety and Health [NIOSH], 2015). Workplace health and safety laws do not always protect a woman’s reproductive health. Hazards encountered in the workplace can lead to reproductive health problems such as infertility/reduced fertility, menstrual/ovulatory cycle disorders, sex-hormone imbalances, miscarriages, stillbirths, birth defects, child developmental disorders, premature births, or lower birth-weight babies (NIOSH, 2015).

Although the National Institute of Occupational Safety and Health (NIOSH) states that while most pregnant employees can still safely perform their jobs, it admits that pregnancy can sometimes negatively affect worker safety (NIOSH, 2015). It has also been posited that shift work, which is very common among firefighters, has a connection to miscarriage and preterm delivery (Amani & Gill, 2013; Mozurkewich, Luke, Avni, & Wolf, 2000; Nurminen, 1995; Puttonen, Härmä, & Hublin, 2010). It is well documented that shift work negatively impacts physiological function through disruption of circadian rhythms (Knutsson, 2003). An in-depth review of health disorders among shift workers summarized the findings of the effects of shift work while pregnant and reported a strong association between shift work and miscarriage, low birth weight, and preterm birth (Knutsson, 2003).

Recent research conducted by Jahnke, Poston, Jitnarin, & Haddock (2018) attempted to quantify birth outcomes among female firefighters. They noted that miscarriage rates among female firefighters were at least 2.3 times higher among firefighters compared to the US National average of 10% (American College of Obstetricians and Gynecologists [ACOG], 2015). They also found that history of preterm birth was higher among female firefighters than the general population (Jahnke et al., 2018).

Pregnancy-policy existence and language varies among fire departments. Unfortunately, some departments do not even have a policy in place for pregnant firefighters (Sprenger & Bates, 2003). Fire departments should educate all firefighters on the potential of risks on reproductive health associated with job duties. An example using National Fire Protection Association® (NFPA®) 1582 ([National Fire Protection Association® NFPA®], 2018) will illustrate this point. The NFPA® is the governing body for fire departments or organizations that provide rescue, fire suppression, emergency medical services, hazardous-materials mitigation, special operations, and other emergency services and specifies the minimum requirements for occupational safety. NFPA® 1582 is the policy standard on fire-department comprehensive occupational medical programs (NFPA®, 2018). The Essential Job Tasks outlined by NFPA® 1582 (2018) contains 14 essential job duties that have the potential to result in negative birth outcomes for the pregnant firefighter. (See Appendix A for NFPA®’s Essential Job Tasks). For example, the first-listed essential job task states the following:

While wearing personal protective ensembles and self-contained breathing apparatus (SCBA), performing fire-fighting tasks (e.g., hoseline operations, extensive crawling, lifting and carrying heavy objects, ventilating roofs or walls using power or hand tools, or forcible entry), rescue operations, and other emergency-response actions under stressful conditions, including working in extremely hot or cold environments for prolonged time periods. (pp. 12–13)

In this first essential job task, there are several potential risks to the pregnant firefighter. PPE may not adequately fit the firefighter over the course of a pregnancy, and poor-fitting turnout jackets and pants may increase exposure to toxic air particles and harmful chemicals (iWomen, 1995). Certain chemicals and metals may be absorbed faster by pregnant females compared to nonpregnant females, and certain chemical exposures are riskier for a fetus because of its rapid development and size than for the pregnant woman (NIOSH, 2015). Second, high ambient temperatures are associated with shorter gestation periods and greater occurrence of stillbirth (Strand, Barnett, & Tong, 2011). In addition, maternal hyperthermia is associated with neural-tube defects during early pregnancy (Moretti, Bar-Oz, Fried, & Koren, 2005). Both El-Metwalli, Badawy, El-Baghdadi, & El-Wehady (2001) and Wong et al. (2010) report that extensive bending/crouching is associated with elevated risk of miscarriage.

In summary, despite research findings that suggest toxic exposures, occupational hazards, job duties, and shift work can negatively impact the reproductive health of female firefighters, there is still much to learn (Jahnke et al., 2012; McDiarmid et al., 1991; Olshan et al., 1990). The purpose of the current study is to add to the growing literature in this area of inquiry by identifying perceptions and concerns about the occupational impact of fire fighting on reproductive health for females. In order to better understand these perceptions and concerns, focus groups and interviews were held with 87 US firefighters. The next section outlines the methods used to guide the study.

Methods (L1)

This methods section is divided into three parts. First, the study design and participants from which the data were gathered are outlined. Second, the questions asked study participants are reviewed. Third, grounded theory and the data-analysis methods are discussed.

Study Design and Participants (L2)

This qualitative study included a national sample of 46 female firefighters, 27 female fire-service leaders, and 14 male fire-service leaders — a total of 87 individuals. Participants were recruited via national conferences, fire departments where the research team had access to large numbers of female firefighters, and recommendations from fire-service advisors. The female firefighters participated in one of eight focus groups. Based on recommendations from fire-service advisors, individual interviews were conducted with the fire-service leaders. Participants ranged in age from 25 to 66 and had been in the fire service from 3 to 30 years.

Questions Asked Participants (L2)

Once the purpose and operating procedures of the study were explained, all participants were given the opportunity to ask questions. An informed consent document was then signed, and participants completed a demographic questionnaire.

The guided discussion on reproductive health generally began with the question, “What concerns exist related to reproductive health among women in the fire service?” In addition to the responses collected from the reproductive-health domain, other questions were asked about reproductive-health education, recruitment and retention, and leave and pregnancy policies. One such question was, “What policies are you aware of that are most common concerning pregnancy?” All focus groups and interviews were transcribed verbatim, and responses from the resulting discussions that were relevant to reproductive health were analyzed.

Data Analysis (L2)

Focus-group transcriptions were uploaded into QSR International’s NVivo10 (a qualitative data analysis software product). Two trained qualitative researchers analyzed the data through the process of grounded theory. Through developing, checking, and integrating theoretical categories, emerging key words and ideas were drawn from the data. Gradually, codes and themes were created so that inferences could be made from the data and conceptualizations developed (Miles & Huberman, 1994).

One research team member read and reread each transcript to develop initial codes and subsequent themes. Then, the second researcher read and reread each transcript to create, refine, and add further codes and themes. The researchers then discussed discrepancies until a consensus was achieved. After this process, a third trained researcher read the coded data for final confirmation of the overall themes — thus completing the three-phase coding process.

Grounded theory is a qualitative research-method procedure that flows from one inductive inference to another through selective data collection (Glaser, Strauss, & Strutzel, 1968). Using grounded theory involves a systematic collection and data-analyzing process that leads to creation of theories on patterns of human behavior in social contexts. This research method can increase our understanding of social phenomena (Clamp, Gough, & Land, 2005), but it also enables a solid generation of theories that are informed by the data, as opposed to using the data to text an existing theory (Harris, 2015). This study adhered to the RATS guidelines for reporting qualitative research developed by J. P. Clark (2003).¹

Results (L1)

Study results were centered around five key themes that emerged from the analysis of the focus group and interview data. Four of the five key themes focused directly on concerns about reproductive health among female firefighters. These four concerns included the following: (1) a wide variation among fire departments in pregnancy policies; (2) decision-making choices among firefighters for disclosure of a pregnancy; (3) the lack of education, research, and information for firefighters on reproductive-health issues; (4) and how reproductive health concerns impact female recruitment and retention. The fifth study-participant theme emerging from the data analysis was not related to a reproductive-health concern. Rather, the theme focused on successful and positive policies implemented by departments with regards to female firefighter reproductive health and innovations within the fire service with regard to female reproductive-health policy. A discussion of each theme is given in the following sections.

Wide Variation Among Fire Departments in Pregnancy Policies (L2)

Among American fire departments, there is no single policy to follow for a firefighter who becomes pregnant. Study participants, however, unanimously agreed that departments should have a policy in place to guide firefighters who become pregnant. Most participants reported that their respective departments either had no policy or that its policy was unfavorable toward females in some way. Departments with no set pregnancy policies usually had few female firefighters; which resulted in a scramble to find a policy and caused confusion within the department when a pregnancy was announced. Three examples of statements about this concern from participants included the following:

• Female Fire-Service Leader: “ … it was a scramble to find a policy that — that could — that they could use to protect both the firefighter and the department and the baby. It was interesting, you know, it was almost like wait until you’re walking through the door, and now I got to come up with something? Never a good move.”

• Female Firefighter: “A lot of places don’t have policies … And we still don’t have a policy.”

• Female Fire-Service Leader: “No policies for like, when we’re pregnant or anything like that. Um, we had two females in the past that neither one of them had kids while they were working, so it was never an issue.”

Pregnancy policies that were viewed as unfavorable occurred when firefighters had to use sick time, vacation time, or a combination of both when they were no longer able to work during a pregnancy. This situation happened in small departments that did not have light-duty assignments or that had budgetary constraints. One study participant noted the following:

• Female Firefighter: “Mine is you use up your sick time, vacation time, and you go on unpaid leave.”

For the participants that knew of their department’s pregnancy policy, it was typical that the firefighter was given a light-duty assignment for the remainder of her pregnancy. A light-duty assignment is typically clerical day work and means that they do not respond to emergency calls. One large difference noted in light-duty assignments was that some firefighters had a policy that let them and/or their health-care practitioners decide when to go on light duty, and some departments had a policy that immediately removed pregnant firefighters from active duty. The following three statements highlight these issues:

• Female Firefighter: “Our folks all have a light duty or a temporary modified work-assignment option. So, if they choose, if they choose, as soon as they find out, um, that they’re pregnant, they go on temporary modified.”

• Male Fire Service Leader: “The moment that a female firefighter notifies the fire department that she is pregnant, um, we bring her off line. Um, we put her on day work … . She remains on day work, um, in a nonoperational capacity until she delivers.”

• Female Fire-Service Leader: “We have a policy that once you become pregnant, you have to tell our administration, and they take you off-line. So our administration is pretty proactive in that. And we’ve actually taken some heat from that.”

Decision-Making by Firefighters for Disclosure of a Pregnancy (L2)

Disclosure of pregnancy by firefighters greatly varied, along with reasons for choosing when to do so. Some females chose to disclose their pregnancies to their departments right away, while some chose to wait as long as possible before letting their departments know in order to stay working on active duty. The most cited reason for early disclosure of pregnancy included concern for fetal and/or maternal health when responding to calls. Two study participants noted the following situations:

• Female Firefighter: I would never want to have to make a choice between somebody in the — a firefighter in a house, or my child. I don’t want to make that choice. And so I — I made the choice to go to days and to go to limited duty, off shift. And I — I feel it was a good choice.”

• Female Firefighter: “When I got pregnant, um, I — I was very careful not to let anyone know for a — a good period of time. Because one, I was afraid I was going to be forced to go off shift or there would be other decisions to make.”

Few participants reported disclosing a pregnancy and then staying on active duty. In these cases, judgment and criticism from coworkers were received, along with unnecessary protective treatment. Firefighters who disclosed a pregnancy but chose to continue to ride the engine reported being accused by coworkers of being irresponsible and negligent of their unborn children. For example, two female firefighters said the following:

• Female Firefighter: “But he’s like, ‘… doesn’t she risk … the fetus? And then won’t the coworkers feel responsible to have to, you know, watch her a little bit closer?’ ”

• Female Firefighter: “There’s a perception that a woman, once she becomes pregnant, has a handicap.”

Many participants reported they decided to stay on active duty as long as possible until their pregnancies prevented them from continuing. Some firefighters reported coming off the line once their turnout gear no longer fit or when they felt they could not perform their duties adequately. One study participant commented as follows:

• Female Firefighter: “I didn’t tell anybody — as soon as — I felt like that I was going to be, um, harmful to the crew or I wasn’t pulling — able to pull my own weight, well then it was time for me to try to find some light duty. Somewhere you know, you know, not to be a hindrance. Um, so I just didn’t tell anybody — for me, at six months it was, you know, it was time to go.”

One of the most cited reasons for choosing to stay on active duty while pregnant was to avoid being placed in a light-duty assignment. This type of work was reported to involve a position that was mainly clerical day work and was generally viewed as a boring or meaningless job. Coworkers also sometimes viewed it as an excuse for the pregnant firefighter to choose light duty as a way to slack off but still be paid. Three examples of participant statements that reflect this viewpoint are as follows:

• Female Firefighter: “… light duty is a punishment. It’s the worst.”

• Female Firefighter: “I don’t want to sit there and do desk stuff and menial job; I want to work my shift 24 hours. You know, Monday through Friday sucks for people that aren’t used to that kind of shift.”

• Female Firefighter: “They think that ‘Oh, you want light duty for pregnancy, oh you just want to get paid to do nothing.’ ”

In some cases, the decision to stay on active duty was a financial issue, since other assignments were not available for the firefighter. Other reasons reported for staying on active duty included believing that their pregnancy had no impact on being a firefighter as long as they could perform their job or to prove a point to the men that pregnancy was not a handicap. One female noted the following:

• Female Fire Service Leader: “Boy, it is a heated, heated issue — you got the people that don’t think you should be working and endangering your child.”

Some participants said that their decision to disclose a pregnancy or not had to do with promotional or seniority factors. One participant recounted disclosing a pregnancy early and going off active duty only to lose a promotion because of it. The same participant chose to keep her pregnancy a secret with her second pregnancy so she would not lose her seniority again. Other firefighters reported not disclosing a pregnancy and staying on active duty because they did not want to use up their sick time and vacation time.

Lack of Education, Research, and Information for Firefighters on Reproductive Health (L2)

It was unanimously agreed that the fire-fighting industry lacked education, research, and general knowledge about female firefighters’ reproductive health. Participants reported that there were limited informational resources to guide or counsel them if they became pregnant. Two firefighters believed the following:

• Female Firefighter: “We really need to have some … kind of guidelines for women that — that they can look at and whether there’s an impact on — on their, uh their children long term, uh, or not. Or you know, something that is solid to be able to look to for information.”

• Female Firefighter: “It would be nice if somebody had, you know, some rhyme or reason to when is a good time to go and when’s not, you know? But it seems like we’re all on our own.”

Extreme heat, hazardous-material incidents, exposure risk (hydrogen cyanide, smoke, sick people, carcinogens, byproducts of combustion, chemicals, and blood-borne pathogens), poor fit of personal-protective ensembles, and carrying/transporting heavy victims were cited as possible and questionable threats to firefighter and fetal safety. Three study participants said the following:

• Male Fire-Service Leader: “We’ve had some people who have gotten pregnant recently, and I don’t think they realized what the risk is, because some of them have stayed on duty six, seven months into their pregnancy.”

• Female Fire-Service Leader: “There should be more, um, information out there for women who are planning to be pregnant while they’re in the fire service as to know when it is safe for them to be in combat and then not, you know, and then have to go on light duty.”

• Female Firefighter: “When the baby’s making, you know, the critical time in the first trimester … you’re going in a heated environment and things like that. Isn’t that bad?”

Lack of knowledge, specifically from health-care practitioners and fire-service leaders, was also reported by participants. Several firefighters reported that when they asked for information or counsel regarding the risks involved with fire fighting while pregnant, they were not given satisfactory answers. Two examples of such statements included the following:

• Female Firefighter: “Even my doctor, my OB had no idea. She’s like, ‘So what do you want to do?’ I’m like, ‘Well, I thought you could answer that for me.’

• Female Firefighter: “My chief at the time comes up to me and goes, ‘Now what do I do with you?’ Like I said, nobody has a clue.”

Although research and education for pregnancy while working active duty were the primary concerns from participants, other areas that needed more research and information for firefighters included breast-milk contamination, reproductive cancers, fertility, long-term health of a child conceived by a working firefighter, and the overall long-term impacts on female-firefighters’ reproductive health.

Reproductive Health Concerns Impact Female Recruitment and Retention (L2)

Many firefighters reported delaying becoming pregnant during their careers. Reasons for delaying pregnancy were trying to save up or bank sick time so that they could accrue time off in the pregnancy or postpartum period, to get past their probationary period, or because they were trying to get promoted. These planned delays in pregnancy were reported to cause fertility issues in some cases, especially for those firefighters who waited until their 30s to try and conceive. This situation was said to have caused additional stress, uncovered fertility-treatment bills, and questioning by females of whether a career in the fire service was worth it. Two female firefighters noted the following:

• Female Firefighter: “I understand some of the issues, but when — I’m like, when you look at the big picture of, I’m here for this entire career.”

• Female Firefighter: “… we’ve lost women who’ve become pregnant and because of the policy.”

It was also reported that when firefighters declared pregnancy and could no longer work active duty, they were unfairly treated. Some departments, due to budget restrictions and department size, forced pregnant firefighters to use sick time, vacation time, or take unpaid leave during the rest of their pregnancies. Three statements about these issues included the following:

• Female Firefighter: “You’re kind of penalized for being female.”

• Female Firefighter: “And so I think if pregnancy leave and return isn’t really well done, that could be a big black hole as to why women fall out of the fire service after getting, uh, after becoming mothers.”

• Female Fire-Service Leader: “Out of the four ladies that I can tell you left the fire service, three of them left because they became mothers.”

It was reported by participants that pregnancy and managing a family were sometimes treated like inconveniences for the department. It was mentioned multiple times that firefighters felt as though they had to choose between starting a family and their careers because doing both did not benefit the department. Two firefighters said the following:

• Female Firefighter: “You chose to have this family. You know what the rules are.”

• Female Firefighter: “You chose this. You want to be one of us.”

Many female firefighters also pointed out that their departments or unions often chose to ignore their reproductive-health concerns and pregnancy-leave options because there were so few females overall. Also, their gender was a discriminatory factor in making departmental decisions. The following two statements reflect these concerns:

• Female Firefighter: “The unions are like, ‘Well, that only, you know, we’re here to protect the greater — the majority.’… I’m stuck being a woman.”

• Female Firefighter: “They’re just like, ‘Well we can only bring so many things to the table, and you’re one person. So, you know, are we going to sacrifice one of our important things for just helping one person?’”

It was generally agreed that many female firefighters had to battle to find their place within the male-dominated profession of fire fighting. In certain cases, female firefighters reported not wanting to recruit or convince other females to join the fire service because they did not want other females to experience what they went through with regards to having fertility issues, taking leave due to starting a family, or receiving judgment from other firefighters for taking leave due to pregnancy. One female firefighter noted the following, for example:

• Female Firefighter: “… yesterday their big thing was the recruitment drive, and we have to get more women involved. And I struggle with that because I have a hard time going and recommending this to any woman. I’m like ‘Why would you put yourself through what I did?’”

Family building and pregnancy were also framed by one firefighter as being relatively short amounts of time in the context of a 30-year career. She reported it was unfair for females to have so few options when pregnant or to feel as though females were penalized by less pay, leave options, or opportunity for promotion because they wanted to start a family. Others felt as though being a firefighter and female forced them to choose between having a family or continuing to be a firefighter, because having both was not an option. One study participant believed the following:

• Female Firefighter: “It was such an inconvenience to everybody that I had a child, and it was such a big deal.”

A lot of females agreed unanimously that they felt uncomfortable being the person who spoke up to say that things were unfair for female firefighters. They did not want to be a person who was viewed as a troublemaker or a whistle-blower because this view would reflect negatively upon them. Participants also felt that while fire departments had gotten better in recent years with respect to how they treated females and their specific issues in the fire-service workplace, there was still a long way to go with females and reproduction within the fire service.

Innovations within the Fire Service with Respect to Female Reproductive- Health Policies (L2)

A minority of participants reported successful and positive policies implemented by departments with regard to female-firefighter reproductive health. These innovations are presented in Table 1.

Table 1:

Innovations Within Fire Departments

Department Strategy	Example
Create an opportunity to take paid leave during pregnancy	“They instituted … . a short-term disability you could opt into. And so that was what the … females … would utilize once they couldn’t work anymore. They would … take the short-term disability and then … maternity leave after that.” — Male Fire-Service Leader
Give female firefighters options to decide	“Our folks all have a light duty or temporary modified-work assignment option. So if they choose … as soon as they find out that they’re pregnant, they go on temporary modified.” — Female Fire Service Leader
Give female firefighters job security	“when you got pregnant, there was a spot for you to go to continue working … they either put them at the chief’s office answering phones, at fire prevention, … they have worked in applicant processing, recruiting.” — Female Firefighter
Create modified work assignments that do not feel like punishment	“take people’s talents and find some place to … have them productive and giving back … I never realized how exciting it could be and how I can make a bigger influence being in a staff assignment as opposed to just being an operations battalion chief.”— Female Fire Service Leader
Offer female firefighters longer than 12 weeks of leave from FMLA (Family and Medical Leave Act)	“I get 70% of my pay … for one year.” — Female Firefighter “We have a year maternity leave from the time that the baby’s born. And then from there … if we require additional time, um, it’s something that we have to coordinate with the fire chief.”— Female Firefighter

Attention now turns to a discussion of the female reproductive-health concerns mentioned in this section.

Discussion (L1)

Study participants’ comments presented in the previous Results section clearly show that female reproductive health is a significant, although frequently underrecognized, area of concern in the fire service. Data analyses of responses gathered from the national sample of 87 firefighters identified four themes that represented major areas of reproductive health concerns expressed by study participants. The following sections offer a discussion of these concerns.

Concern 1: Wide Variation among Fire Departments in Pregnancy Policies (L2)

Within NFPA® 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments, there is a recommended policy for the treatment and care of pregnant firefighters in Section 9.18 (see Appendix B) (NFPA®, 2013). Although the standard offers policy recommendations for fire departments, it is important to note that the recommendations are just that, recommendations; they are not mandatory, enforced, nor monitored within fire departments (NFPA®, 2018). However, it is also important to note that the recommended policy language addresses many of the concerns highlighted by participants in the present study. The recommendations include (1) an immediate report to the department physician once a pregnancy is known; (2) full disclosure to the firefighter of fire-related hazards that can affect the pregnancy and fetus; (3) provision of an alternative-duty assignment that is safe; and (4) on-going medical evaluation to determine any restrictions from activities that the female firefighter is not able to perform in a safe manner (NFPA®, 2013).

The standard also states that educational materials should be provided, highlighting reproductive health risks for both male and female firefighters (NFPA®, 2013). The standard notes that certain essential job tasks will eventually become unsafe for the pregnant firefighter due to her diminished aerobic capacity, speed, balance, and agility, and that the firefighter will need to be restricted from those job tasks upon medical evaluation from the fire-department physician. Additionally, the pregnant firefighter may also request an alternative-duty assignment at any stage of pregnancy (NFPA®, 2013).

In short, fire departments need to have a pregnancy policy in place. It is not acceptable or fair to the female firefighter to have to figure out what to do in the event of a pregnancy. As noted in the Results section, the majority of fire departments from which participants came either lacked a policy altogether or had a limited pregnancy policy in place that did not satisfy the needs of the firefighters interviewed.

Concern 2: Decision-making Choices among Firefighters for Disclosure of a Pregnancy and Concern 3: Lack of Education, Research, and Information for Firefighters on Reproductive Health Issues (L2)

Some study participants reported that they suffered judgment and criticism from coworkers after disclosing a pregnancy and choosing to remain on active duty. They were accused of being irresponsible and negligent of their unborn child. Occupations that exhibit harassment and discrimination towards women prevent women from fully engaging in their work environments (Hulett et al., 2008).

While the NFPA® pregnancy policy (2013) is a strong starting point, especially for departments that have nothing in place, it is important to point out that some of the largest concerns highlighted from research reported here appear to be the overall lack of knowledge and education of health-care providers and fire-service leadership. Subsequently, this situation has led to a lack of educational materials for firefighters. In support of our findings, FEMA (Federal Emergency Management Agency) (1996) has also stated that physicians need to be better updated on the demands of first-responder duties.

There is a body of occupational-health research (although the majority of the research is not firefighter specific), associating certain firefighter job duties with adverse reproductive-health outcomes (American Pregnancy Association, 2018; Bhatt, 2000; El-Metwalli et al., 2001; Fabian et al., 2010; iWomen 1995; McDiarmid & Agnew, 1995; McDiarmid et al., 1991; McDonald et al., 1988; Moretti et al, 2005; NIOSH, 2015; NIOSH, 1999; Strand et al., 2011; Taskinen, Kyyrönen, & Hemminki, 1990; Treitman, Burgess, & Gold, 1980; Wong et al., 2010). This research is a good starting point for learning about reproductive health in the fire service and should be shared with as many fire departments as possible.

Providing information and education to health-care providers about the essential job tasks of fire fighting could help close this knowledge gap (FEMA, 1996). Although our research has focused on the female firefighter, much of this evidence is not limited to females. For example, as noted previously in the study, toxic exposures may also increase the risk of birth defects among children of male firefighters (Olshan et al., 1990).

In response to study participants’ concerns over the lack of information and education on reproductive health, it is proposed that a pregnant firefighter bring a copy of Table 2 to discuss with her primary-care physician to help her decide whether she should continue working active duty. Under Title VII of the Civil Rights Act, a department cannot forbid a female firefighter from performing certain job tasks; otherwise they will face liability for violation of the sex-discrimination prohibition (Miller, 1966). Table 2 outlines NFPA® 1582 Essential Job Tasks (2018) and specifically highlights the potential reproductive-health risks for a pregnant firefighter so that an informed decision on working active duty can be made. Fire departments should also provide reproductive-health education for all firefighters in order to decrease stigma or negative judgment that may follow a pregnant firefighter going off active duty.

Table 2:

Reproductive Health Concerns within Essential Firefighter Job Tasks

NFPA® 1582 Essential Job Tasks (2018)	Reproductive Health Concerns
(1)“While wearing personal protective ensembles (PPE) and self-contained breathing apparatus (SCBA), performing fire-fighting tasks (e.g., hoseline operations, extensive crawling, lifting and carrying heavy objects, ventilating roofs or walls using power or hand tools, forcible entry), rescue operations, and other emergency-response actions under stressful conditions, including working in extremely hot or cold environments for prolonged time periods”	Maternal hyperthermia is associated with neural-tube defects during early pregnancy (Moretti, Bar-Oz, Fried, & Koren, 2005). PPE may not adequately fit the female firefighter over the course of a pregnancy, and poorly fitted turnout jackets and pants may increase workplace exposure to toxic air particles and harmful chemicals (FEMA, 1996). High ambient temperatures are associated with shorter gestation periods and greater occurrence of still birth (Strand, Barnett, & Tong, 2011). Bending/crouching have been associated with elevated risk of miscarriage (El-Metwalli, Badawy, El-Baghdadi, & El-Wehady, 2001; Wong et al., 2010).
(2) “Wearing an SCBA, which includes a demand valve-type positive-pressure facepiece or HEPA filter masks, which requires the ability to tolerate increased respiratory workloads”
(3) “Exposure to toxic fumes, irritants, particulates, biological (infectious) and nonbiological hazards, and heated gases, despite the use of personal protective ensembles and SCBA”	Certain chemicals and metals are absorbed faster by pregnant females compared to nonpregnant females, and certain chemical exposures are riskier for a fetus than the pregnant woman because of its rapid development and size (National Institute of Occupational Safety and Health [NIOSH], 2015). Lead exposure: Found in smoke particles, (Fabian et al., 2010) can lead to miscarriage, low birth weight, infertility, or developmental disorders (NIOSH, 1999). Lead can cross the placental barrier at 12 weeks of gestation, which could lead to brain-development issues (Bhatt, 2000; NIOSH, 1999). Carbon disulfide exposure (found in personal air-sampling devices among firefighters) (Treitman, Burgess, & Gold, 1980) can lead to menstrual-cycle changes, which can lead to fertility issues (NIOSH, 1999). Carbon-monoxide (a gas created when fuels burn incompletely) exposure (NFPA®, 2008) likely increases risk of birth defects in pregnant female firefighters (McDiarmid & Agnew, 1995). Other products of combustion: aldehydes (e.g., acetaldehyde, formaldehyde, acrolein), benzene, carbon dioxide, chloroform, dichlorodifluoromethane, hydrogen chloride, hydrogen cyanide, methylene chloride, nitrogen dioxide, nitrogen oxide, perchloroethylene, sulfur dioxide, toluene, trichloroethylene, and trichlorophenol) have been found to be of concern for reproductive health in either animals or humans (McDiarmid, Lees, Agnew, Midzenski, & Duffy, 1991).
(4) “Depending on the local jurisdiction, climbing six or more flights of stairs while wearing a fire- protective ensemble, including SCBA, weighing at least 50 lb. (22.6 kg) or more, and carrying equipment/tools weighing an additional 20 to 40 lb (9 to 18 kg)”	Heavy occupational lifting has an observed effect of miscarriage late in pregnancy or premature delivery (McDonald et al., 1988; NIOSH, 1999; Taskinen, Kyyrönen, & Hemminki, 1990).* Excessive occupational physical activity (reported high intensity, high fatigue, and unfavorable working hours) (El-Metwalli et al., 2001) and bending or crouching have been associated with elevated risk of miscarriage (El-Metwalli et al., 2001; Wong et al., 2010)*
(5) “Wearing a fire-protective ensemble, including SCBA, that is encapsulating and insulated, which will result in significant fluid loss that frequently progresses to clinical dehydration and can elevate core temperature to levels exceeding 102.2°F (39°C)”	Maternal hyperthermia is associated with neural-tube defects during early pregnancy (Moretti et al., 2005) Maternal dehydration can lead to pregnancy complications like neural-tube defects, low amniotic fluid, inadequate milk production, premature labor, and birth defects (American Pregnancy Association, 2018).
(6) “While wearing personal protective ensembles and SCBA, searching, finding, and rescue-dragging or carrying victims ranging from newborns to adults weighing over 200 lb (90kg) to safety despite hazardous conditions and low visibility”	Heavy occupational lifting has an observed effect of miscarriage late in pregnancy or premature delivery (McDonald et al., 1988; NIOSH, 1999; Taskinen et al., 1990).*
(7) “While wearing personal protective ensembles and SCBA, advancing water-filled hoselines up to 2 1/2 in. (65 mm) in diameter from fire apparatus to occupancy [approximately 150 ft. (50 m)], which can involve negotiating multiple flights of stairs, ladders, and other obstacles”	Excessive occupational physical activity (reported high intensity, high fatigue, and unfavorable working hours) has been associated with elevated risk of miscarriage (El-Metwalli et al., 2001).
(8) “While wearing personal protective ensembles and SCBA, climbing ladders, operating from heights, walking or crawling in the dark along narrow and uneven surfaces that might be wet or icy, and operating in proximity to electrical power lines or other hazards”	Bending/crouching have been associated with elevated risk of miscarriage (El-Metwalli et al., 2001; Wong et al., 2010).
(9) “Unpredictable emergency requirements for prolonged periods of extreme physical exertion without benefit of warmup, scheduled rest periods, meals, access to medication(s), or hydration”	Excessive occupational physical activity (reported high intensity, high fatigue, and unfavorable working hours) has been associated with elevated risk of miscarriage (El-Metwalli et al., 2001).
(10) “Operating fire apparatus or other vehicles in an emergency mode with emergency lights and sirens
(11) “Critical, time-sensitive, complex problem solving during physical exertion in stressful, hazardous environments, including hot, dark, tightly enclosed spaces, that is further aggravated by fatigue, flashing lights, sirens, and other distractions”	High job stress is associated with increased risk of miscarriage and low birth weight in females (Brandt & Nielsen, 1992). Bending/crouching have been associated with elevated risk of miscarriage (El-Metwalli et al., 2001; Wong et al., 2010).
(12) “Ability to communicate (give and comprehend verbal order) while wearing personal protective ensembles and SCBA under conditions of high background noise, poor visibility, and drenching from hoselines and/or fixed protection systems (sprinklers)”	Textile workers exposed to more than 85 decibels from a wide range of noise exposures were found to have significantly increased rates of miscarriage (Zhan et al., 1991)**
(13) “Functioning as an integral component of a team, where sudden incapacitation of a member can result in mission failure or in risk of injury or death to civilians or other team members”
(14) “Working in shifts, including during nighttime, that can extend beyond 12 hours”	Evidence strongly suggests that shift-work is associated with higher rates of miscarriage, preterm birth (Amani & Gill, 2013; Knuttson, 2003; Mozurkewich, Luke, Avni, & Wolf, 2000; Nurminen, 1995; Puttonen, Härmä & Hublin, 2010) and low birth weight. Working long hours has a strong association with miscarriage (Schenker, Eaton, Green, & Samuels, 1997).

^*Epidemiologic evidence for physical activity has not been consistent (Wong et al., 2010).

Occupational heavy lifting has been previously associated with both risk reductions and elevations (McDonald et al., 1988; Taskinen et al., 1990). Occupational physical exertion research has been mixed with some null studies (Axelsson, Rylander & Molin 1989; Fenster, Hubbard, Windham, Waller, & Swan, 1997; John, Savitz, & Shy 1994).

^**Epidemiologic evidence for noise exposure has not been consistent (no elevations in miscarriage risk were identified for females holding jobs considered to have moderate or loud noise levels) (Wong et al., 2010).

Concern 4: Reproductive Health Concerns Impacts Female Recruitment and Retention (L2)

Evidence suggests that showing employees that their health and safety and the health of their families are valued improves employee morale and retention (NIOSH, 2015). Pregnancy among female firefighters tends to be treated as a sickness and not a condition, and many female firefighters are forced to save sick time and vacation time to use once they become pregnant due to a lack of or poor policy provisions. This situation has obvious negative retention and recruitment implications, since the ability to utilize sick time for its actual purpose is impacted. Similarly, taking vacation time to have a child loses the designation and purpose of this time off from work.

Study participants’ statements clearly suggest that making female firefighters use their sick times and/or vacation times as “pregnancy policies” negatively impacts firefighter recruitment and retention; it makes more traditional jobs with clear maternity- and pregnancy-leave policies more appealing than working for the fire service. Female-firefighter retention may be improved if better policies regarding pregnancy and maternity leave are implemented. In addition to potentially increased retention, departments may also benefit financially. Research suggests that implementing successful health systems (such as a pregnancy policy) could reduce injury and illness costs and have a high return on investment (NIOSH, 2015).

Limitations of Study (L1)

As with any qualitative study, the limitations of the research presented includes the possibility that results may be specific to our participants. However, findings reported align with previous research and bolster the suggestion that reproductive health is a warranted concern among firefighters, both male and female (FEMA, 1996). Although study participants were drawn from a national sample of mostly female firefighters (with several key male leaders), it is possible that some attitudes and experiences may have been missed in this study. As such, more research is clearly required.

Conclusions and Recommendations (L1)

The concern and call for more research on firefighters’ reproductive health highlighted by this study are the same issues identified more than 20 years ago by FEMA (1996). Yet, too little focus has been placed on female firefighters’ reproductive health needs. This situation highlights a huge gap in the literature and possibly exposes some of the problems with recruitment and retention of females in the fire service.

The research presented indicates that reproductive health is both a significant and major concern of US female firefighters. Findings reinforce the need for further research and lay a foundation for the identification of key issues. It would be interesting to know if similar concerns exist outside the US. In addition, it would be useful to know if reproductive health is as great of a concern to male firefighters as it is to female firefighters. For instance, exposure risks are harmful to not only pregnant females but males also. One study, for example, found that birth defects such as heart anomalies, hypospadias, and ventricular and atrial septal defects, were significantly higher among firefighters overall and that paternal exposure prior to conception was to blame (Chia & Shi, 2002).

Whether females compose a small percentage of a fire department or even in departments where females have yet to be employed, it is imperative that every fire department has a clear pregnancy policy in place. Employers are required to provide a safe workplace for employees (NIOSH, 2015). This provision includes educating employees about safe work practices and providing them with appropriate equipment for job safety (NIOSH, 2015). The pregnancy policy set by departments should involve the department’s physician and should clearly communicate the risks involved (iWomen, 1995) as outlined in this study (see Table 2).

Implementation of a sound policy should also include guidelines for the firefighter to report her condition. Once a firefighter has disclosed her condition, ideally, her department’s physician will administer a medical release form that complies with NFPA® 1582 (2018), so that her ability to perform essential job tasks can be assessed and a guideline can be given to the firefighter as to when those duties should be modified.

One of the larger concerns is the possibility of exposure during the early stages of pregnancy. The first 12 weeks of a pregnancy is a particularly vulnerable time for the fetus, because it is a critical developmental stage (NIOSH, 1999). Even small exposures can elicit lasting adverse fetal health outcomes (Grandjean et al., 2008). Education for the firefighter, the department, and any health-care practitioners working with firefighters should acknowledge the potential negative implications of fire fighting and pregnancy. Education specifically for male firefighters could potentially decrease the reports of discrimination and harassment from female firefighters, which could, in turn, lead to increased work engagement (Hulett et al., 2008). Sharing successful program information between and among fire departments is also a simple strategy that may lead to a more uniform approach to reproductive health-care policies and could also avoid false starts in which a department tries an unsuccessful attempt to implement something new (FEMA, 1996).

Table 1 showed examples of fire departments that have championed reproductive health in various ways. Sharing successful policy creation, reproductive health education, recruitment and retention tactics, and connecting fellow departments with informed departmental physicians are some of the areas where departments could support one another. A successful program-sharing option could be developed using firefighter publications or through national firefighter conferences.

The military, which boasts a much higher representation of females than does the fire service generally, has invested in research for adjustments that make its equipment more accessible to men and women (FEMA, 1996). A centralized focus on proper fitting PPE for a female firefighter could be an important next step for decreasing reproductive-health concerns due to poor-fitting clothing and breathing apparatus.

A combination of an appropriate pregnancy policy, dissemination of what is known regarding occupational health, and further research on the maternal and fetal risks from fire fighting prior to conception and while pregnant is the recommended starting point. A strongly implemented pregnancy policy could lead to safer pregnancy outcomes, healthier firefighters, and better retention and recruitment for current and future female firefighters. Further research and subsequent dissemination to departments and health-care practitioners that work with this population are desperately needed.

Pregnant firefighters deserve to make an informed decision when it comes to working active duty. In order to make an informed decision, the repercussions of fire fighting while pregnant need further research. Staying on active duty because of poor or lacking pregnancy policies, fear of harassment, avoidance of light duty, or loss of promotion/seniority should not be deciding factors for the female firefighter. The implications of this research benefit not just the current female firefighter, but could pave the way for better reproductive health protection for future firefighters and their children.

About the Authors

Dr. Ainslie Kehler works as a consultant in occupational health and strength and conditioning. Her areas of expertise are women’s prenatal and postpartum fitness, first-responder health and fitness, and corporate wellness. She has worked on a number of grants funded by the National Institutes of Health (NIH) and has done work for companies such as the US Army, local fire and police departments, lululemon Apparel, and Apple. Dr. Kehler serves as the corresponding author and can be contacted at ainsliekehler@ksu.edu

Dr. Sara A. Jahnke is a Principal Investigator in The Institute for Biobehavioral Health Research and Director of the Center for Fire, Rescue & EMS Research at NDRI. Dr. Jahnke served as the Principal Investigator of two large-scale studies of the health and readiness of the US Fire Service and has published research on health behaviors of military personnel. She has served as the principal investigator or coinvestigator for a number of studies funded by FEMA, NIH, and AHA.

Dr. C. Keith Haddock is Senior Principal Investigator and Deputy Director of the Institute for Biobehavioral Health Research at NDRI. Dr. Haddock is currently Principal Investigator on two NIH-sponsored studies of tobacco control among veterans and active-duty military personnel. In addition, he serves as the biostatistician for several epidemiological studies and randomized clinical trials.

Dr. Walker S. Carlos Poston is the Senior Principal Investigator and Director of the Institute for Biobehavioral Health Research. His research focuses primarily in the areas of obesity, tobacco control, and cardiovascular-disease prevention with an emphasis on minority populations and military and first-responder health. He has been a Principal/Coinvestigator on grants from the American Heart Association, the National Heart, Lung, and Blood Institute, the Department of Defense US Army Medical Research and Material Command, and the Department of Homeland Security/FEMA.

Dr. Nattinee Jitnarin is a Principal Investigator at the Institute for Biobehavioral Health Research at the National Development and Research Institutes. Dr. Jitnarin is involved in the conduct and analysis of a number of large cohort studies and randomized controlled trials focusing on firefighters and military personnel. Her research area currently focuses on both health and addictive-behaviors research, particularly smoking and smokeless tobacco use.

Dr. Katie M. Heinrich is the Director of the Functional Intensity Training Laboratory and an Associate Professor of Exercise Behavioral Science at Kansas State University. Her research expertise includes high-intensity functional training with a focus on tactical athlete populations, obesity prevention, physical-activity policy, and environmental correlates of physical activity and obesity. She has served as Principal or Coinvestigator on grants funded by the National Institute of Digestive Disorders and Kidney Diseases, the National Cancer Institute, the Centers for Disease Control and Prevention, the Robert Wood Johnson Foundation, the Sunflower Foundation of Kansas, and the State of Hawai’i.

Appendix A

NFPA® 1582 (2018)

Standard on Comprehensive Occupational Medical Program for Fire Departments

Chapter 5: Essential Job Tasks

(1) While wearing personal protective ensembles and self-contained breathing apparatus (SCBA), performing fire-fighting tasks (e.g., hoseline operations, extensive crawling, lifting and carrying heavy objects, ventilating roofs or walls using power or hand tools, or forcible entry), rescue operations, and other emergency-response actions under stressful conditions, including working in extremely hot or cold environments for prolonged time periods

(2) Wearing an SCBA, which includes a demand valve–type positive-pressure facepiece or high-efficiency particulate air (HEPA) filter mask, which requires the ability to tolerate increased respiratory workloads

(3) Exposure to toxic fumes, irritants, particulates, biological (infectious) and nonbiological hazards, and heated gases, despite the use of personal protective ensembles and SCBA

(4) Depending on the local jurisdiction, climbing six or more flights of stairs while wearing a fire-protective ensemble, including SCBA, weighing at least 50 lb (22.6 kg) or more and carrying equipment/tools weighing an additional 20 to 40 lb (9 to 18 kg)

(5) Wearing a fire-protective ensemble, including SCBA, that is encapsulating and insulated, which will result in significant fluid loss that frequently progresses to clinical dehydration and can elevate core temperature to levels exceeding 102.2°F (39°C)

(6) While wearing personal protective ensembles and SCBA, searching, finding, and rescue-dragging or carrying victims ranging from newborns to adults weighing over 200 lb (90 kg) to safety despite hazardous conditions and low visibility

(7) While wearing personal protective ensembles and SCBA, advancing water-filled hoselines up to 2½ in. (65 mm) in diameter from fire apparatus to occupancy [approximately 150 ft. (50 m)], which can involve negotiating multiple flights of stairs, ladders, and other obstacles

(8) While wearing personal protective ensembles and SCBA, climbing ladders, operating from heights, walking or crawling in the dark along narrow and uneven surfaces that might be wet or icy, and operating in proximity to electrical power lines or other hazards

(9) Unpredictable emergency requirements for prolonged periods of extreme physical exertion without benefit of warm-up, scheduled rest periods, meals, access to medication(s), or hydration

(10) Operating fire apparatus or other vehicles in an emergency mode with emergency lights and sirens

(11) Critical, time-sensitive, complex problem solving during physical exertion in stressful, hazardous environments, including hot, dark, tightly enclosed spaces, that is further aggravated by fatigue, flashing lights, sirens, and other distractions

(12) Ability to communicate (give and comprehend verbal order) while wearing personal protective ensembles and SCBA under conditions of high background noise, poor visibility, and drenching from hoselines and/or fixed protection systems (sprinklers)

(13) Functioning as an integral component of a team, where sudden incapacitation of a member can result in mission failure or in risk of injury or death to civilians or other team members

(14) Working in shifts, including during nighttime, that can extend beyond 12 hours

Appendix B

NFPA® 1582 (2013)

Standard on Comprehensive Occupational Medical Program for Fire Departments

Chapter 4: Roles and Responsibilities

9.18 Pregnancy and Reproductive Health.

9.18.1 Fire Departments shall make available to all male and female firefighters educational materials outlining the risks from fire fighting on reproductive health.

9.18.2 It is recommended that members who become pregnant report the pregnancy immediately to the fire-department physician. Once informed of the pregnancy, the fire-department physician shall inform the pregnant member of the numerous hazards to the pregnancy and the fetus encountered during routine fire-fighting tasks.

9.18.2.1 If the member requests an alternative duty assignment in an environment deemed safe for the pregnancy and the fetus, the physician shall provide appropriate restrictions for essential job tasks 1, 3, 5, 6, 7, and 8 that are unsafe for her or her fetus.

9.18.3 During later stages of pregnancy, the member will eventually be unable to safely perform essential job tasks 1, 2, 3, 4, 5, 6, 7, 8, and 9 due to issues with diminished aerobic capacity, balance, speed, and agility. As with any other member, when performance due to medical issues is of concern, the AHJ (authority having jurisdiction) shall inform the fire-department physician, and a medical evaluation will be performed to determine the need for restricting the member from those activities that they are not able to safely perform. The NFPA® has no power, nor does it undertake, to police or enforce compliance with the contents of NFPA® Documents. Nor does the NFPA® list, certify, test, or inspect products, designs, or installations for compliance with this document. Any certification or other statement of compliance with the requirements of this document shall not be attributable to the NFPA® and is solely the responsibility of the certifier or maker of the statement.