Dr Isabelle Niedhammer
email: isabelle.niedhammer@inserm.fr

D O'mahony

S Daly

J J Morrison

C Kelleher

Occupational predictors of pregnancy outcomes in Irish working women in the Lifeways cohort

Keywords: birth weight, occupational factors, pregnancy outcomes, preterm delivery, small-for-gestational-age

Objective: The objective of this study was to explore the association between occupational factors and pregnancy outcomes in a prospective cohort of Irish pregnant women.

Design: This study has a prospective design. Population: The Lifeways cohort included 1124 pregnant women, 676 of whom delivered a single baby, and were working at their first prenatal care visit when they filled in a self-administered questionnaire.

Methods: Occupational factors were measured using this questionnaire, and included 8 factors describing job and working conditions. Data including pregnancy outcomes were also obtained from clinical hospital records. Logistic regression analysis was used to adjust for well-known risk factors.

Main outcome measures: Birth weight (≤3000g and ≤2500g), preterm delivery (<37 gestation weeks), and small-for-gestational-age.

Results: Significant associations were found between physical work demands and low birth weight (≤2500g), and between working with a temporary contract and preterm delivery. Trends were also observed between working 40 hours or more a week and shift work, and birth weight of 3000g or less. The study of a cumulative index showed that being exposed to at least two of these occupational factors significantly predicted birth weight of ≤3000g (OR=2.44, 95% CI:1.17-5.08) and of ≤2500g (OR=4.65, 95% CI:1.08-20.07), and preterm delivery (OR=5.18, 95% CI:1.00-27.01).

Conclusions: Our findings suggest that occupational factors may predict birth weight through their predictive effects on preterm delivery. This is one of the few prospective studies on pregnancy outcomes that include working conditions. As they may be modifiable, occupational factors deserve more attention in relation to birth outcomes.

INTRODUCTION

Pregnancy outcomes such as low birth weight and preterm delivery are considered to be major risk factors for subsequent morbidity and mortality of newborns. [START_REF] Martin | Annual summary of vital statistics--2003[END_REF] Birth weight may be low either because of premature birth, because of intrauterine growth retardation, or because of a combination of both. Life-course epidemiological evidence suggests that birth weight may be associated with longer-term risk of adult disease and this consequence is not confined to the clinically accepted cut-off point of 2500g for obstetrical outcomes. [START_REF] Whincup | Birth weight and risk of Type 2 Diabetes: A quantitative systematic review of published evidence[END_REF] Although these outcomes may be linked to different mechanisms, a certain number of risk factors of these pregnancy outcomes have been identified such as those related to maternal risk factors (e.g. age, body mass index, behavioural factors, marital status, education) and obstetrical risk factors (e.g. parity, complications, previous events). Nevertheless, it is likely that risk factors remain undiscovered.

As a growing percentage of women work outside home before, during, and after pregnancy in most industrialised countries (in Ireland, the employment rate of women was 59.3% in 2006), work and its related occupational factors deserve to be studied in relation to pregnancy outcomes. Several published literature reviews and metaanalysis have pointed out that physical work demands, long working hours, shift work and/or measures of job stress may be associated with these outcomes. [START_REF] Bonzini | Risk of prematurity, low birthweight and pre-eclampsia in relation to working hours and physical activities: a systematic review[END_REF][START_REF] Mozurkewich | Working conditions and adverse pregnancy outcome: a meta-analysis[END_REF][START_REF] Nurminen | Shift work and reproductive health[END_REF] However, most previous studies were retrospective or case-control studies, and may suffer from recall bias. [START_REF] Ahmed | Maternal occupation and adverse pregnancy outcomes: a Finnish population-based study[END_REF][START_REF] Bell | Maternal Work and Birth Outcome Disparities[END_REF][START_REF] Bodin | The association of shift work and nitrous oxide exposure in pregnancy with birth weight and gestational age[END_REF][START_REF] Brandt | Job stress and adverse outcome of pregnancy: a causal link or recall bias?[END_REF][START_REF] Ceron-Mireles | The risk of prematurity and small-for-gestational-age birth in Mexico City: the effects of working conditions and antenatal leave[END_REF][START_REF] Croteau | Work activity in pregnancy, preventive measures, and the risk of delivering a small-for-gestational-age infant[END_REF][START_REF] Croteau | Work activity in pregnancy, preventive measures, and the risk of preterm delivery[END_REF][START_REF] Escriba-Aguir | Physical load and psychological demand at work during pregnancy and preterm birth[END_REF][START_REF] Fortier | Maternal work during pregnancy and the risks of delivering a small-for-gestational-age or preterm infant[END_REF][START_REF] Homer | Work-related psychosocial stress and risk of preterm, low birthweight delivery[END_REF][START_REF] Luke | The association between occupational factors and preterm birth: a United States nurses' study. Research Committee of the Association of Women's Health, Obstetric, and Neonatal Nurses[END_REF][START_REF] Meyer | Job control, substantive complexity, and risk for low birth weight and preterm delivery: an analysis from a state birth registry[END_REF][START_REF] Meyer | Maternal Occupation and Risk for Low Birth Weight Delivery: Assessment Using State Birth Registry Data[END_REF][START_REF] Peoples-Sheps | Characteristics of maternal employment during pregnancy: effects on low birthweight[END_REF][START_REF] Saurel-Cubizolles | Employment, working conditions, and preterm birth: results from the Europop case-control survey[END_REF][START_REF] Wergeland | Work pace control and pregnancy health in a population-based sample of employed women in Norway[END_REF][START_REF] Xu | Association of rotating shiftwork with preterm births and low birth weight among never smoking women textile workers in China[END_REF] So far, there have been few prospective studies. [START_REF] Hatch | Do standing, lifting, climbing, or long hours of work during pregnancy have an effect on fetal growth[END_REF][START_REF] Henriksen | The relation between psychosocial job strain, and preterm delivery and low birthweight for gestational age[END_REF][START_REF] Oths | A prospective study of psychosocial job strain and birth outcomes[END_REF][START_REF] Pompeii | Physical exertion at work and the risk of preterm delivery and small-for-gestational-age birth[END_REF][START_REF] Tuntiseranee | The effect of heavy maternal workload on fetal growth retardation and preterm delivery. A study among southern Thai women[END_REF][START_REF] Zhu | Shift work, duration of pregnancy, and birth weight: the National Birth Cohort in Denmark[END_REF] Furthermore, a large number of studies focused on the impact of occupation or job title on pregnancy outcomes, 6;18 or on a reduced number (a maximum of 3 or 4) of occupational factors, 7;9;15;22;23;25;26;28 or on occupational factors evaluated through a job-exposure matrix (i.e. derived from job titles), that may present several shortcomings in terms of exposure misclassification or under-estimation of the actual risk. 7;15;17 Finally, most studies did not explore the effects of occupational factors on birth weight, preterm delivery, and small-for-gestational-age simultaneously, but one or two outcomes only, making the interpretation of the results difficult to disentangle the respective contribution of premature birth and intrauterine growth retardation to birth weight.

The aim of the present study was to respond to these limitations and provide the first answer to this issue for Irish working women.

The objective of this study was to examine the predictive effects of various occupational factors on the pregnancy outcomes of birth weight, preterm delivery, and small-for-gestational-age in a prospective cohort of working women. This study included a careful consideration of other well-known risk factors.

METHODS

The Lifeways cohort is a prospective study established in 2001. [START_REF] Murrin | Self-reported pre-pregnancy maternal body mass index and infant birthweight[END_REF][START_REF] O'mahony | The Lifeways Cross-Generation Study: design, recruitment and data management considerations[END_REF][START_REF] Segonds-Pichon | Socio-demographic, lifestyle and cross-generation predictors of self-rated health in mothers during pregnancy[END_REF] It included a sample of 1124 pregnant women, who were recruited at their first maternity hospital booking visit, i.e. between 14 and 16 weeks of pregnancy. Women were selected randomly, and all women were Irish-born (non-Irish women, because of anticipated small numbers in the sample, were excluded). Two regions were chosen, one urban, one rural, and within those regions two major hospitals providing maternity services Baseline data for mothers were collected using a self-completed questionnaire. This questionnaire included several sections relating to health, lifestyle behaviours, and demographic, occupational and social characteristics. Hospital medical records provided information relating to mothers' health during pregnancy and pregnancy outcomes.

Four pregnancy outcomes derived from hospital records were studied: two outcomes of birth weight (≤3000g and ≤2500g) as general measures of adverse pregnancy outcome, preterm delivery (<37 gestation weeks) as a specific measure of prematurity, and small-for-gestational-age. The threshold of ≤3000g was included in addition to the one of ≤2500g to give complementary results regarding birth weight especially in relatively small sample sizes, [START_REF] Hatch | Do standing, lifting, climbing, or long hours of work during pregnancy have an effect on fetal growth[END_REF] and because of its potential long-term association with adult chronic disease outcomes. The associations between occupational factors and pregnancy outcomes were studied using the Chi-Square test or Fisher's exact test, the same tests were used to examine the associations between well-known risk factors and pregnancy outcomes. In a first step, logistic regression analysis was used to study simultaneously occupational factors and well-known risk factors as potential predictive factors of one of the four pregnancy outcomes. Note that parity was not included in the multivariate analysis of SGA, as parity was a criterion in the definition of SGA standards. In a second step, a cumulative index of occupational factors was constructed to study the cumulative impact of occupational exposures on pregnancy outcomes and was examined as a potential predictor of pregnancy outcomes after adjustment for well-known risk factors using logistic regression analysis. The occupational factors included in the first logistic regression models were those associated with at least one pregnancy outcome at a p-value of less than 0.15 in the bivariate associations for beta error considerations and/or have already been observed in the literature as being significant risk factors of pregnancy outcomes. The construction of the cumulative index was also based on the selection of occupational factors that were associated with at least one pregnancy outcome at a p-value of less than 0.15 in the first logistic regression models. The choice was guided by two considerations; reducing the number of occupational factors in the multivariate analysis and not missing pertinent factors that would have not been associated with pregnancy outcomes at the conventional 5% level for power reasons. Such a strategy has already been used in other studies. 34;35 Odds-ratios (OR)

and Wald 95% confidence intervals (CIs) were then calculated to characterise the significance, strength and precision of the associations. Statistical analysis was performed using SAS statistical software.

RESULTS

The Lifeways cohort included initially a sample of 1124 pregnant women, and 676 of them delivered a single baby and were working at their first prenatal care visit.

Miscarriages, stillbirths, neonatal deaths, and twins were excluded from the study.

The description of the sample studied for well-known risk factors and occupational factors is presented in Tables 1 and2. The prevalences were 15.42% (N=101) for birth weight of 3000g or less, 3.21% (N=21) for birth weight of 2500g or less, 4.10% (N=24) for preterm delivery, and 6.53% (N=38) for small-for-gestational-age in the total sample of the 676 working women. The associations between well-known risk factors and pregnancy outcomes are shown in Table 1. Complications during pregnancy such as bleeding or foetal problems increased the risk of all pregnancy outcomes. Smoking was associated with birth weight using both definitions (≤2500g and ≤3000g), and SGA. Nulliparity and alcohol consumption was associated with birth weight of 3000g or less. Some trends were also observed for other variables: BMI, planned pregnancy, and living in the East region.

The associations between occupational factors and pregnancy outcomes are presented in Table 2. Working 40 hours or more a week was found to be associated with the pregnancy outcomes of birth weight of 3000g or less (p<0.01), birth weight of 2500g

or less (p=0.15), and preterm delivery (p=0.10). Tendencies were observed between high physical work demands and birth weight of less or equal 3000g (p=0.07) and 2500g (p=0.08), and small-for-gestational age (p=0.13). Temporary contract tended to predict preterm delivery (p=0.10). The variables of work contract, working hours, and physical demands, as well as shift work and job stress, that have been found to be risk factors in the literature, were retained in the multivariate analysis.

The results of the logistic regression analysis including the five occupational factors selected as well as well-known risk factors are presented in Table 3 2. This index displayed a dose-response association with all pregnancy outcomes, but was not associated with small-for-gestational-age. This result was confirmed in logistic regression analysis (Table 4) that showed that being exposed to at least two of these four occupational factors increased the risk of birth weight of 3000g or less (OR=2.44, 95% CI: 1.17-5.08), birth weight of 2500g or less (OR=4.65, 95% CI: 1.08-20.07), and preterm delivery (OR=5.18, 95% CI: 1.00-27.01).

Regarding well-known risk factors, logistic regression analysis (Tables 3 and4)

showed that complications during pregnancy predicted birth weight, preterm delivery, and small-for-gestational age. Smoking predicted birth weight of 3000 g or less and of 2500g or less. Higher age, nulliparity, and high alcohol consumption (as well as no consumption at all) were predictive of birth weight of 3000g or less.

DISCUSSION

This prospective study showed that occupational factors played a substantial role in predicting pregnancy outcomes. These factors were temporary work contract, long working hours, shift work, and physical demands. The study of a cumulative index showed that exposure to at least two of these factors increased the risk by 4.6 and 5.2

for birth weight of 2500g or less and preterm delivery. Predictive effects were also observed for well-known risk factors that were nulliparity, complications during pregnancy, higher age, smoking, and alcohol consumption.

Our results showed that four occupational factors may be associated with pregnancy outcomes; temporary work contract with preterm delivery, and long working hours, shift work, and physical demands with birth weight. Temporary contract may be considered as a marker of poor working conditions that may not have been evaluated

per se in the present study, and may be associated with new challenges and adaptation to the job and may generate feelings of stress and anxiety to find another future job.

This type of contract and perceived job insecurity have already been observed to be associated with other health outcomes. [START_REF] Virtanen | Temporary employment and health: a review[END_REF] To our knowledge, no previous study has already studied and found an association between temporary employment and pregnancy outcomes. The three last occupational factors that were long working hours, shift work, and physical demands have more commonly been associated with pregnancy outcomes in the literature. Long working hours, especially more than 40 hours per week, have been observed to be associated with pregnancy outcomes; 10;12;16;19;20;23;27 with preterm delivery, 12;16;19;20 and also with small-forgestational-age. 7;12;13;16 The predictive role of physically demanding work has been confirmed by literature review and meta-analysis. 3;4 Several occupational factors were not found to be predictive factors of pregnancy outcomes in our study. This was especially the case for job stress, that was found to be a risk factor in some other studies. 9;12;25 Finally, the cumulative index constructed using the four occupational factors described previously displayed strong predictive effects on low birth weight and preterm delivery with ORs reaching values of 4.6 and 5.2 for exposure to two occupational factors or more.

Furthermore, this index showed dose-response relationships with these pregnancy outcomes. Other authors studied and found significant effects of similar indexes on preterm delivery, confirming the negative impact of the combination of several occupational factors on this outcome. [START_REF] Croteau | Work activity in pregnancy, preventive measures, and the risk of preterm delivery[END_REF] All these studies suggested that occupational factors may be more powerful to predict preterm delivery than growth retardation, reinforcing our own findings.

This study also underlined the importance of health behaviours in pregnancy outcomes, smoking being a strong predictor of birth weight of 2500g or less and of 3000g or less, and alcohol consumption a strong predictor of birth weight of 3000g or less. We also found that no alcohol consumption at all was observed to predict birth weight of 3000g or less, suggesting a J-shaped association. This result might be explained by at least two factors: a healthy drinker effect; women with health problems like chronic diseases, or in the case of pregnancy, with history of adverse pregnancy outcomes, may be more likely to abstain from having alcoholic drinks during their pregnancy, and an under-reporting of alcohol consumption and even a complete denial of consumption for the women who had the highest alcohol intakes.

Several studies pointed out that alcohol consumption, even moderate, may be associated with adverse birth outcomes 37 confirming our own findings. Our results are also in agreement with previous results from other studies showing that smoking is associated with pregnancy outcomes.

38;39

Our study also found that age, complications during pregnancy, and nulliparity were associated with pregnancy outcomes; these findings are in agreement with previous studies 7;12;16;19;21;26 and reinforced the validity of our own results.

This study has several major strengths: the selection process yielded a sample of women at baseline, whose social circumstances may be considered as broadly representative of Irish women. This is a prospective study, consequently the evaluation of risk factors including occupational factors was done at the beginning of pregnancy, and thus before the pregnancy outcomes which we are reporting had actually occurred, consequently there is no possibility of a recall bias. We studied the pregnancy outcomes of birth weight, preterm delivery, and small-for-gestational-age simultaneously, which has seldom been done before in relation to working conditions, 7;8;10-12;24;27;28 and allows us to disentangle the respective contribution of premature birth and intrauterine growth retardation to birth weight. There is also no possibility of a reporting bias, as pregnancy outcomes were measured using hospital records, and thus independently of women' answers. This study included a large number of occupational factors and covered the main occupational factors that have previously been suspected to be risk factors. Evaluation of occupational factors was performed using a self-administrated questionnaire already used in Irish national surveys, [START_REF] Kelleher | Socio-demographic predictors of selfrated health in the Republic of Ireland: findings from the National Survey on Lifestyle, Attitudes and Nutrition[END_REF] and consistent results were found regarding social gradients in these factors in Lifeways working women; women employed in low-skilled occupations were more likely to be exposed to shift work, high physical demands, low job satisfaction, and low job influence, providing elements supporting the validity of the evaluation of working conditions. Furthermore, our study took into account education level (a marker of socioeconomic status) in the multivariate analysis, consequently the associations observed can be considered as independent of socioeconomic status. This study included a large number of well-known risk factors of pregnancy outcomes allowing us to control adequately for potential confounding in our analyses.

This study also had some limitations. The cohort was designed for 5 year follow-up with power calculations to detect significant trends according to socioeconomic status on outcome measures including annual rates of health care utilisation and vaccinations. [START_REF] Murrin | Self-reported pre-pregnancy maternal body mass index and infant birthweight[END_REF] As the present analysis is confined to working mothers, sample size may be considered as relatively small with reduced statistical power to detect subtle differences. This is why we decided to retain variables associated with pregnancy outcomes at a p-value of less than 15%, and not 5%, so as not miss some pertinent occupational factors. This selection process identified occupational factors that have already been found as risk factors in the literature (one exception was work contract), supporting the validity of our strategy. No data were available on whether, when and why women stopped working during their pregnancy, or whether working conditions changed during pregnancy. This may have led to potential exposure misclassification, that is likely to be non-differential and that may have led to underestimation of risks.

Gestational age was not routinely verified by ultrasound measures in the two hospitals at the time of recruitment, which may arguably have led to potential misclassifications. Over-adjustment may be possible, as for example we controlled for complications during pregnancy that may be a mediating variable between occupational factors and pregnancy outcomes. This may have led to underestimates of the predictive effects of occupational factors. However, excluding the variable of pregnancy complications in the multivariate analyses did not modify the results.

Finally, since the analysis was restricted to four pregnancy outcomes and did not consider other outcomes such as stillbirths and neonatal deaths, our findings may arguably have underestimated the effects of occupational factors. Given the very few numbers of stillbirths ( 5) and neonatal deaths (2) in the total Lifeways sample, the analysis of these outcomes was not possible.

CONCLUSION

This study is one of the rare prospective studies focusing on the predictive effects of occupational factors on pregnancy outcomes, and the first one to be set up in Ireland.

It urges further research effort on the subject of occupational predictors of pregnancy health and outcomes. As working conditions may be modifiable, intensifying research on this topic may have a substantial impact on the understanding of determinants of pregnancy outcomes and on prevention policies.

DISCLOSURE OF INTERESTS

DETAILS OF ETHICS APPROVAL

Ethical approval was obtained both from the hospitals and from the Irish College of General Practitioners ethical committees. Consent was obtained from the pregnant women at recruitment when attending their first antenatal care visit at the maternity hospital.

FUNDING

The Lifeways cohort was funded by the Health Research Board, Ireland.

  were selected: University College Hospital Galway (West Ireland) and Coombe Women's Hospital in Dublin (East Ireland). These two hospitals are among the biggest units in Ireland. Comparison between the Lifeways sample and a nationally representative sample of women of the same ages (16-44) from the Irish SLAN national surveys in 2002 32 suggests a satisfactory representativeness of the Lifeways sample, on socio-demographic characteristics including employment situation.

  No conflict of interest CONTRIBUTION TO AUTHORSHIP wrote the first draft of the manuscript. D.O., S.D., J.J.M., and C.C.K. all made substantial contributions to the study design, interpretation of results, and manuscript revisions. S.D., J.J.M., and C.C.K. instigated the original cohort establishment and follow-up. The Lifeways Cross-Generation Cohort Study Steering Group has overseeing responsibility for the project.

  [START_REF] Whincup | Birth weight and risk of Type 2 Diabetes: A quantitative systematic review of published evidence[END_REF] Gestational age at birth was calculated from the mother's expected delivery date recorded at the booking visit (that was derived from last menstrual period, and clinical examination, as well as in some cases from ultrasounds examination) and the baby's actual date of birth. Small-for-

	gestational-age (SGA) was defined by weight below the 10 th percentile for gestational
	age on the basis of gender-and parity-specific standards. As no Irish standards were
	available, Scottish standards were used. 33
	Eight occupational factors were studied and were extracted from the self-completed
	questionnaire and were based on the following items: occupation coded using ISCO-
	08 (International Standard Classification of Occupations -2008), work contract:
	permanent/contract post, number of working hours per week, time schedules: no shift
	work, shift work without night shifts, and shift work with night shifts, physical work
	demands: job very, fairly, not very, or not at all physically active, job satisfaction:
	very dissatisfied, dissatisfied, neither satisfied or dissatisfied, satisfied, or very
	satisfied, job stress: work is a source of stress (frequently, sometimes, only
	occasionally, or never), and 2 items of job influence: level of influence in deciding
	what tasks to do, and in deciding how to carry out the tasks (a great deal, a fair
	amount, a little, or none). This variable was constructed by adding the 2 items. All
	variables (except occupation) were dichotomised.
	Some well-known risk factors were derived from the self-completed questionnaire:
	maternal age, Body Mass Index (BMI) calculated from the formula: pre-pregnant
	weight in kilos/(height in metre)	2 , smoking status: non-smoker, ex-smoker, smoker,
	alcohol consumption calculated from number of days and number of drinks during a
	typical week, marital status, and educational level as a marker of socioeconomic
	status. The other risk factors were extracted from hospital records: planned
	pregnancy, parity, complications during pregnancy: bleeding and/or foetal problems,
	and region: West/East.

  10;27 The literature review by Bonzini et al

	several studies. 8;14;22;26;28 Various indicators of physical demands have already been
	found to predict birth outcomes, 7;12;13;16;17;21 especially preterm delivery.
	4;5 as demonstrated in

[START_REF] Bonzini | Risk of prematurity, low birthweight and pre-eclampsia in relation to working hours and physical activities: a systematic review[END_REF]

confirmed that prolonged working hours may have a detrimental impact on pregnancy outcomes. Shift work, especially night work, has already been studied in several literature reviews and metaanalysis suggesting predictive effects on preterm delivery,

Table 1 .

 1 Well-known risk factors, birth weight, preterm delivery, and small-for-

	gestational age (SGA)
	Women (N=676) Birth weight (≤ 3000 g) N % No cases % 119 17.60 20 17.09 190 28.11 26 13.83 224 33.14 33 15.28 143 21.15 22 16.42 ** 309 46.61 36 11.92 354 53.39 64 18.29 **** 551 81.66 69 12.95 124 18.34 32 26.23 * 68 11.33 16 24.24 364 60.67 48 13.56 168 28.00 25 15.43 **** 297 44.93 32 11.11 121 18.31 34 28.57 243 36.76 32 13.62 *** 264 39.05 45 17.79 225 33.29 23 10.41 129 19.08 16 12.80 58 8.58 17 30.36 70 10.36 14 21.54 215 31.80 35 16.59 Higher than secondary 391 57.84 Age (years) < 25 25-29 30-34 ≥ 35 Parity 1+ 0 Complications during pregnancy No Yes BMI (kg/m 2 ) < 20 20-24 ≥ 25 Smoking Non-smoker Smoker Ex-smoker Alcohol consumption (drinks/week) 0 1-7 8-14 > 14 Educational level Lower than secondary Complete secondary 52 13.72 Marital status In couple 555 82.10 78 14.53 Alone 121 17.90 23 19.49 Planned pregnancy * Yes 480 71.01 64 13.91 No 196 28.99 37 18.97 Region * West 224 33.14 25 11.74 East 452 66.86 76 17.19	Birth weight (≤ 2500 g) No cases % 5 4.27 8 4.26 5 2.31 3 2.24 * 6 1.99 15 4.29 *** 12 2.25 9 7.38 1 1.52 10 2.82 8 4.94 ** 7 2.43 8 6.72 5 2.13 11 4.35 5 2.26 3 2.40 2 3.57 1 1.54 8 3.79 12 3.17 16 2.98 5 4.24 13 2.83 8 4.10 5 2.35 16 3.62	Preterm delivery No cases % 5 5.26 10 5.88 6 3.06 3 2.42 * 7 2.55 17 5.50 *** 14 2.92 10 9.52 2 3.64 12 3.73 7 4.86 7 2.65 5 5.26 10 4.67 * 13 5.63 5 2.51 2 1.87 4 8.33 3 5.26 4 2.19 17 4.93 19 3.89 5 5.21 16 3.78 8 4.94 7 3.41 17 4.47	SGA No cases 8 8 13 9 18 20 25 13 4 21 9 17 11 8 19 7 9 3 6 11 21 31 7 23 15 9 29	% 8.42 4.76 6.67 7.26 6.59 6.51 *** 5.23 12.50 7.27 6.54 6.29 ** 6.46 11.58 3.77 8.30 3.54 8.41 6.25 10.53 6.01 6.14 6.38 7.29 * 5.48 9.26 * 4.43 7.65
	*p<0.15 **p<0.05 ***p<0.01 ****p<0.001

Table 2 .

 2 Occupational factors, birth weight, preterm delivery, and small-for-

	gestational-age (SGA)
	Women (N=676) N % 143 21.70 Technicians, associate professionals (3) 203 30.81 Occupational group (ISCO-08) Managers, professionals (1, 2) Clerical support workers (4) 122 18.51 Service and sales workers (5) 128 19.42 Blue collar workers (6, 7, 8, 9) 63 9.56 Work contract Permanent post 586 88.39 Contract post 77 11.61 Working hours per week < 40 499 75.26 ≥ 40 164 24.74 Shift work No 529 79.91 Yes 133 20.09 Physical demands Fairly, or not very or not at all physically active 550 81.85 Job very physically active 122 18.15 Job satisfaction High 492 73.43 Low 178 26.57 Job stress Low 299 44.43 High 374 55.57 Job influence High 312 46.71 Low 356 53.29 Cumulative index of occupational factors 0 282 43.79 1 264 40.99 2 or more 98 15.22	Birth weight (≤ 3000 g) No cases % 21 14.89 26 13.61 19 15.97 21 16.67 12 19.67 88 15.52 13 17.33 *** 65 13.46 35 22.01 75 14.65 24 18.60 76 * 14.29 25 21.01 70 14.55 31 18.34 45 15.46 56 15.51 48 15.84 52 15.12 *** 28 10.29 49 19.22 21 21.88	Birth weight (≤ 2500 g) No cases % No cases Preterm delivery % No cases SGA 6 4.26 7 5.47 6 4 2.09 6 3.37 15 5 4.20 2 1.87 9 3 2.38 6 5.94 5 2 3.28 2 3.64 3 * 18 3.17 18 3.59 34 3 4.00 6 8.57 3 * * 13 2.69 14 3.24 26 8 5.03 9 6.38 12 16 3.13 17 3.70 28 5 3.88 6 5.36 9 14 * 2.63 20 4.17 28 7 5.88 4 3.96 10 15 3.12 17 3.96 28 6 3.55 7 4.64 10 9 3.09 10 3.85 18 12 3.32 14 4.35 20 10 3.30 14 5.15 16 11 3.20 10 3.27 21 ** * 4 1.47 5 2.02 12 11 4.31 12 5.38 16 6 6.25 5 5.88 8	% 4.72 8.43 8.41 5.00 5.56 6.81 4.29 6.05 8.57 6.13 8.04 * 5.86 10.00 6.56 6.67 7.00 6.21 5.93 6.89 4.90 7.17 9.52

Table 3 .

 3 Predictive factors of birth weight, preterm delivery, and small-for-.47-1.36 0.65 0.23-1.86 1.11 0.36-3.45 0.60 0.26-1.37

	gestational-age (SGA): results from logistic regression analysis
	Age (years) < 25 25-29 30-34 ≥ 35 Parity 1+ 0 Complications during pregnancy No Yes BMI (kg/m 2 ) < 20 20-24 ≥ 25 Smoking Non-smoker Smoker Ex-smoker Alcohol consumption (drinks/week) 0 1-7 8-14 > 14 Educational level Lower than secondary Complete secondary Higher than secondary Marital status In couple Alone Planned pregnancy Yes No Region West East Work contract Permanent post Contract post Working hours per week < 40 ≥ 40 Shift work No Yes Physical demands Fairly, or not very or not at all physically active Job very physically active Job stress Low High	Birth weight (≤ 3000 g) N=538 OR 95% CI OR 95% CI OR 95% CI OR Birth weight (≤ 2500 g) N=538 Preterm delivery N=481 1 1 1 1 1.20 0.48-3.00 1.05 0.23-4.86 0.91 0.14-5.86 0.74 0.17-3.13 SGA N=479 95% CI 1.70 0.67-4.32 0.63 0.11-3.57 0.53 0.07-4.30 1.28 0.32-5.14 2.67 0.96-7.42 0.91 0.14-5.82 0.88 0.10-8.20 1.25 0.28-5.67 1 1 1 -1.71 0.94-3.10 2.39 0.69-8.34 2.36 0.60-9.37 1 1 1 1 2.24 1.24-4.04 5.77 1.89-17.68 6.97 2.20-22.09 2.51 1.07-5.86 1.63 0.76-3.52 0.38 0.04-3.69 1.20 0.22-6.67 1.13 0.29-4.45 1 1 1 1 1.16 0.64-2.09 2.56 0.85-7.69 1.98 0.59-6.65 1.18 0.48-2.90 1 1 1 1 3.86 1.98-7.53 3.90 1.10-13.78 2.10 0.48-9.23 1.83 0.70-4.78 1.32 0.70-2.50 1.33 0.33-5.41 1.73 0.46-6.57 0.57 0.20-1.62 2.20 1.14-4.23 1.42 0.40-5.00 1.97 0.52-7.53 2.46 0.82-7.40 1 1 1 1 1.04 0.47-2.32 0.51 0.09-2.88 0.34 0.04-3.20 3.05 0.91-10.27 2.86 1.16-7.05 0.73 0.10-5.33 1.06 0.17-6.68 2.18 0.44-10.87 0.90 0.36-2.25 0.35 0.03-4.04 1.38 0.21-9.23 1.04 0.28-3.84 0.94 0.53-1.68 0.94 0.30-2.88 0.46 0.11-1.94 0.74 0.30-1.84 1 1 1 1 1 1 1 1 0.72 0.29-1.79 0.67 0.12-3.88 0.59 0.08-4.32 0.52 0.12-2.19 1 1 1 1 1.19 0.60-2.36 0.66 0.15-2.97 0.63 0.13-3.11 1.62 0.62-4.21 0.78 0.44-1.39 0.86 0.27-2.76 0.56 0.15-2.08 0.55 0.22-1.39 1 1 1 1 1 1 1 1 1.22 0.55-2.72 1.98 0.37-10.69 4.58 1.09-19.22 0.52 0.11-2.45 1 1 1 1 1.67 0.93-2.98 1.80 0.56-5.80 2.25 0.69-7.32 1.42 0.58-3.51 1 1 1 1 1.63 0.88-3.02 0.92 0.26-3.26 1.68 0.44-6.34 1.32 0.50-3.46 1 1 1 1 1.25 0.64-2.46 4.32 1.24-15.00 1.20 0.25-5.66 1.44 0.53-3.86 1 1 1 1 0.80 0

Table 4 .

 4 Predictive factors of birth weight, preterm delivery, and small-forgestational-age (SGA): results from logistic regression analysis (use of a cumulative index of occupational factors) Cumulative index based on the sum of the following items: work contract, working hours, shift work, and physical demands.

	Birth weight (≤ 3000 g) N=539 95% CI 1.21 0.48-3.03 0.92 0.20-4.20 0.94 0.16-5.58 Birth weight (≤ 2500 g) Preterm delivery N=482 N=539 OR OR 95% CI OR 95% CI 1 1 1 1.72 0.68-4.34 0.60 0.11-3.44 0.54 0.07-3.96 2.81 1.02-7.74 0.97 0.15-6.22 0.92 0.11-7.96 1 1 1 1.78 1.00-3.20 2.18 0.64-7.41 2.40 0.65-8.91 1 1 1 2.23 1.24-4.00 5.53 1.86-16.47 6.02 1.97-18.38 2.61 1.14-6.00 SGA N=480 OR 95% CI 1 0.73 0.17-3.08 1.32 0.34-5.19 1.35 0.30-6.00 -1 1.59 0.73-3.45 0.41 0.04-3.77 1.06 0.19-5.95 1.00 0.25-3.91 1 1 1 1 1.21 0.67-2.18 2.33 0.79-6.85 1.76 0.54-5.70 1.26 0.52-3.04 1 1 1 1 3.88 1.99-7.58 4.11 1.15-14.66 2.40 0.56-10.27 1.75 0.67-4.58 1.34 0.71-2.52 1.44 0.37-5.62 1.88 0.50-7.01 0.57 0.20-1.59 2.25 1.18-4.30 1.81 0.52-6.24 2.02 0.53-7.68 2.57 0.86-7.66 1 1 1 1 1.00 0.45-2.20 0.53 0.09-3.02 0.33 0.04-3.18 2.76 0.83-9.20 2.76 1.12-6.78 0.75 0.11-5.17 1.32 0.22-7.71 1.91 0.38-9.58 Lower than secondary 0.89 0.36-2.25 0.35 0.03-4.14 1.14 0.16-7.89 Age (years) < 25 25-29 30-34 ≥ 35 Parity 1+ 0 Complications during pregnancy No Yes BMI (kg/m 2 ) < 20 20-24 ≥ 25 Smoking Non-smoker Smoker Ex-smoker Alcohol consumption (drinks/week) 0 1-7 8-14 > 14 Educational level 1.19 0.33-4.26 Complete secondary 0.94 0.53-1.67 1.06 0.35-3.17 0.38 0.09-1.56 0.82 0.34-2.03 Higher than secondary 1 1 1 1 Marital status In couple 1 1 1 1 Alone 0.72 0.29-1.80 0.87 0.15-4.94 0.72 0.10-5.38 0.57 0.14-2.33 Planned pregnancy Yes 1 1 1 1 No 1.17 0.59-2.34 0.62 0.14-2.83 0.52 0.10-2.66 1.64 0.63-4.28 Region West 0.80 0.45-1.42 1.01 0.32-3.21 0.69 0.19-2.44 0.56 0.22-1.41 East 1 1 1 1 Cumulative index of occupational factors 0 1 1 1 1 1 2.08 1.15-3.76 3.59 0.94-13.78 4.11 0.99-17.04 1.55 0.63-3.82 2 or more 2.44 1.17-5.08 4.65 1.08-20.07 5.18 1.00-27.01 1.64 0.54-4.98

Cumulative index based on the sum of the following items: work contract, working hours, shift work, and physical demands *p<0.15 **p<0.05 ***p<0.01 ****p<0.001