Danish National Research Centre for the Working Environment

Norwegian National Institute of Occupational Health

Finnish Institute of Occupational Health

Fertility among female hairdressers

Author(s): Anna Axmon, Lars Rylander, Linnéa Lillienberg, Maria Albin and Lars Hagmar
Source: Scandinavian Journal of Work, Environment & Health, Vol. 32, No. 1 (February 2006), pp
. 51-60
Published by: the Scandinavian Journal of Work, Environment & Health , the Finnish Institute
of Occupational Health , the Danish National Research Centre for the Working Environment ,
and the Norwegian National Institute of Occupational Health
Stable URL: http://www.jstor.org/stable/40967543
Accessed: 19-02-2016 08:49 UTC

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Originalarticle
Scand J WorkEnvironHealth2006;32(1):51-60

amongfemalehairdressers
Fertility
byAnnaAxmon, LarsRylander,
PhD,1 Linnéa
PhD,1 MariaAlbin,
PhD,2
Lillienberg, MD,1LarsHagmar,
MD1

AxmonA,Rylander L,Albin
L, Lillienberg L. Fertility
M,Hagmar amongfemale
hairdressers.
ScandJ Work
Environ
Health
2006;32(1):51-60.
Objectives The studyinvestigated whether workingas a hairdresser has a negativeimpacton fertility,
measured as timetopregnancy andmiscarriage risk.
Methods Self-administered weresentto5289Swedishhairdressers
questionnaires (response rate50%) andto
5299age-matched womenfrom thegeneralSwedishpopulation (response rate54%). Information wascollected
ontimetopregnancy ortryingtimeforwomenwhohadtried, butfailed,toconceiveatthetimeofthestudy. The
outcomeofthepregnancy was determinedandcategorized as eithermiscarriage orlivebirth.
or stillbirth The
hairdressers
werecompared withthereferentswithrespecttothesetwooutcomes. Within thehairdresser
cohort,
theeffects as wellas physical
ofhairtreatments, workload andstresswereinvestigated.
Results Thehairdressers werelesssuccessfulthanthereference cohort inconceiving ratio0.91,
(fecundability
95% confidence 0.83-0.99).The effect
interval was reducedafterfirst-month conceptions wereexcluded, the
indicationbeingthattheeffect maybe theresultof birthcontrolbias.Withinthehairdresser cohort,a self-
perceivedstressfulworksituation seemedto prolongthetimeto pregnancy. No effects werefoundforthe
different
chemicalhairtreatments.Therewas no cohortdifference withrespectto miscarriage risk(oddsratio
1.12,95% confidence 0.88-1.42),butmiscarriage
interval riskswereincreased formostofthehairtreatments
andforself-perceived worksituations.
stressful However, noneoftheseeffects werestatisticallysignificant.
Conclusions The present study indicatesa negativeimpacton timeto pregnancy andmiscarriage riskfor
"
workingas a hairdresser.

Keyterms hairpreparations; abortion.

spontaneous
reproduction;

Hairdressers are exposedon a dailybasis to several spontaneous abortions (18-20), as wellas an increased
chemicalsubstances thatmaybe hazardous toreproduc- riskforlow birthweight (20-22), fetalgrowth retarda-
tion.Some animalstudiessupportreproductive toxic tion(21, 22), andmalformations (20, 21) amonginfants
effectsfordyescontaining agentssuchas 2,5-diamino- bornto exposed women.
tolueneandphenylenediamines (1-4), andfordibutyl- Giventhenumber ofhazardousfactors in thework
phthalate,whichis usedin hairspray(5-7). environment of hairdressersand the resultsalready
In additionto differentchemicalexposures,hair- found,it is of interestto investigatefurther therepro-
dressersmaybe exposedtoseveralotherfactors thatare ductiveeffects amongthesewomen.Timeto pregnan-
possiblyunfavorable forreproduction, includingwork cyis a sensitive measureofa couple'sfertility (23, 24),
ina standingposition(8-10) anda stressfulworksitua- whichhas notyetbeenused in assessingreproductive
tion(11-15). Nevertheless,
so faronlya fewstudieson healthrisksamonghairdressers. The aimof thisstudy
reproductive outcomesamonghairdressers have been was to investigate whether working as a hairdresserin-
carriedout(16). Theresultsfromthesestudiesindicate creasesthetimeto pregnancy forwantedpregnancies
an increasedriskformenstrualdisorders(17) and ortheriskofmiscarriages.

1 Divisionof Occupationaland EnvironmentalMedicineand Psychiatric Institute Medi-

of Laboratory
Epidemilogy,
Hospital,Lund,Sweden.
cine,University
2 Sectionof OccupationalMedicine,Institute Hospital,Göteborg,Swe-
of InternalMedicine,SahlgrenskaUniversity
den.

Correspondenceto: Dr AnnaAxmon,Department
of Occupationaland Environmental Hospital,SE-
Medicine,University
221 85 Lund,Sweden.[E-mail:anna.axmon@med.lu.se.]

Scand J WorkEnvironHealth 2006, vol 32, no 1 51

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 among female hairdressers
Fertility

andmethods
population
Study tothegroupsofwomenbornin 1960orlateras thehair-
dressercohortandthereference cohort.
Study populationandquestionnaire Self-administered timeto
questionnaires
regarding
In 1996,a cohortof womenwho had graduated from pregnancy and pregnancyoutcomeweresentby mail
anyofthe29 Swedishvocationalschoolsforhairdress- tothewomeninthehairdresser (N=5289)(figure1) and
ersbetween1970and 1995andwhowerebornin 1946 reference (N=5299) cohorts.The questionnaires were
orlaterwas established
(25). Forcomparisons, a refer- designed in sucha waythatfactors
that to
applied preg-
encecohortofwomenfromtheSwedishgeneralpopu- nancyin general(eg,use oforalcontraceptives priorto
lation was created.The referentswere frequency trying to conceive)wereaskedaboutonlyonceandre-
matchedto thehairdressersby calendaryearof birth, latedto thetimepriorto whenthewomanstarted her
buttheywereotherwise randomly In
selected. 2000,the attempts to become pregnant.Other factors thatmay
subgroups,consistingofthewomenin theoriginalco- changeovertime(suchas smoking habits,butalso in-
hortswhowerebornin 1960 or later,wereinvitedto cludingoccupational exposurespecificto hairdressers)
thecurrent study(73% of thehairdressersand72% of were determined foreach 3-monthperiodduringthe
thereferents).
Althoughthewomenwhograduated to
from yearprior conception and foreach trimesterduring
vocationalschoolsforhairdresserswerenotnecessari- the pregnancy. From thewomenwhoneversucceeded
lyworking as hairdressers
in 2000,we henceforth refer in conceiving,or werecurrently tryingto conceive,

Hairdressers Referents
N=5289 N=5299

i[ ''

Respondents Respondents
N=2626 N=2860

Neverbeen Everbeen Neverbeen Everbeen

pregnant pregnant pregnant pregnant
N=758 N=1845 N=1017 N=1829

Evertriedtoget Atleast1 planned Evertriedtoget Atleast1 planned

pregnant pregnancy pregnant pregnancy
N=88 N=1615 N=95 N=1527

I
N^84
N=1594
/
/ !
!
! I 7 •
N=*83 '
/ ;
!
/ N=1456 i N=J495
/ I / N=1380

i / 4r ▼ / V
Information available Information
available Information available
available Information
outcome
outcome on timetopregnancy on pregnancy
on timetopregnancy on pregnancy
N=1678 N=1456 N=1578 N=1380

Certainexposure Certainexposure
as hairdresser as hairdresser
N=1418 N=1256
in some of the questionnaires,
Figure 1 . Women included in a studyon reproductiveoutcomes among hairdressers.Due to missing information
the numbersdo not always add up to 100%.

52 Scand J WorkEnvironHealth2006, vol 32, no 1

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 Axmon et al

informationwas collectedfortheperiodduringwhich job title(forgainfully employed womenonly)andhair-

theytriedto conceive.It was notspecifiedif thean- dresserworkduringthetimewhenthewomantriedto
swersshouldrelatetothebeginning orendofthisperi- conceivemadeit possibleto establisha subcohort of
od. womenwho,withcertainty, wereexposedbeforeand
The responseratesto thequestionnairewere50% duringtheirpregnancies. Thesewomenrepresented ap-
(N=2626) and 54% (N=2860) forthehairdressers and 60%
proximately (N=1534) of thewomenin thetotal
referents,
respectively(figure1). hairdresser cohort.Oftheremaining 40%, onlya fourth
hadclaimednotto havebeenworking as a hairdresser
prior to or the
during pregnancy. For the otherwomen,
Outcome variables information was missingon whether theywerework-
ing as a hairdresser during therelevant timeperiods, ei-
The mainoutcomevariable,timeto pregnancy forthe
therbecausetheywerenotgainfully employedduring
firstplannedpregnancy, was assessedbythefollowing
thisperiodor theychose notto answerthisquestion.
lineof questions:"Did youbecomepregnant thefirst
monthof trying? If not,did youbecomepregnant the Amongthe 1534 womenwithcertainhairdresser ex-
posure, 1418 had provided information on time to
secondmonth oftrying? Ifnot,inwhichmonth didyou
and 1256 on outcome
becomepregnant?" Withthismethod ofinquiring about pregnancy pregnancy (figure
timeto pregnancy, 1).
theuncertainty concerning women
Within thehairdresser cohort,numbers oftreatments
who conceivedin theirfirstcycle was reduced(26).
of permanent waving, hair bleaching,oxidativehair-
However,it mayhave introduced othersourcesof er-
for-
coloring formulations, direct-reacting hair-coloring
ror.For example, 14 hairdressersand 12 referents
mulations(supertones),and directnonreactive hair-
checkedthe"no"boxesforachievingpregnancy in the
formulations (mousse,tones),as wellas theuse
firstorsecondmonth, butdidnotprovidea timetopreg- coloring
ofhairspray,wereconsidered as measuresofexposure,
nancy.Themedianrecalltimefortimetopregnancy was
as was thenumber of hours in a standing
7 [1 (2.5 percentile)- 18 (97.5 percentile)] working posi-
years. tion,a self-perceived stressful worksituation, andself-
The womenwho had neverbeen pregnantwere
askediftheywere,orat somepointhadbeen,trying to employment (comparedwithbeingemployed).
conceive,and,if so, forhow long.Thesetrying-times
wereincludedinthetimetopregnancy analysesas cen-
soredtimestopregnancy. Potential confounders
Miscarriage riskwas usedas a secondary outcome. The distributions of potentialconfounders fortimeto
Forthewomenwhohadhadat leastoneplannedpreg- arepresented
pregnancy forthehairdressers andrefer-
nancy,theoutcomeofthefirstplannedpregnancy was entsin table1.
establishedand classifiedas miscarriage, stillbirthor Menstrualcyclelengthwas availableonlyforthe
live birth(including multiple birth);at thesametime, womenwho
actuallybecamepregnant, whowereasked
inducedabortions (8 ineachcohort), extra-uterine preg- abouttheirnormalmenstrual
nancies(10 hairdressers cycle length priorto the
and8 referents), andpregnan- A smallfraction of thewomen(3% of the
pregnancy.
cies thatwerestillongoingwhenthewomenanswered hairdressers and 4% of thereferents) claimedto have
thequestionnaire (87 hairdressersand65 referents) were
veryshortmenstrual cycles(<14 days).It was assumed
excluded. thatthesewomenhadmistaken menstrual cyclelength
In theanalysesoftimetopregnancy, 1678hairdress- formenses
duration, and theirmenstrual cycle length
ersand 1578referents wereincluded(figure1), where- was setas
as 1456hairdressers missing.
and 1380referents wereincluded All ofthewomenwereaskediftheyusedanymed-
in themiscarriage analyses. ication,vitamins, or foodsupplements regularly prior
to or duringpregnancy, and,if so, whatproduct(s).A
physicianwentthrough thelistof productnamesand
Exposure variables classifiedthemas eithermedication or vitamin, miner-
Thehairdresser cohortwascompared withthereference al, or ironsupplements. Unfortunately, it was notpos-
cohortin an evaluationof thepossiblereproductive sibleto makea distinction betweenuse of medication
healthrisksofworking as a hairdresser.
In themainco- andvitamins priorto andduringthepregnancy.
hortcomparisons, noconcernwas giventoworking sta- Afterconception, thefrequency of smokers was re-
tus(hairdresser,otherwork,unemployed). However,as ducedin boththehairdresser (N=206, ie, reducedto
alreadystated,someof thewomenin thehairdresser 18%) and reference (N=203, ie, reducedto 19%) co-
cohortdid notnecessarily workas a hairdresser when horts,as was thefrequency of womenwhoconsumed
theyweretrying toconceive.Nevertheless, questions on alcohol [90 hairdressers (ie,reduced to 8%), 97 referents

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 among female hairdressers
Fertility

Table 1. Potentialconfounders
forthe 1678 hairdressers
and 1578 referents
includedin a studyon the effectofworkas a hairdressei
on timeto pregnancy.

Hairdressers Referents
N % Median95% range N % Median 95% range
Agewhenincluded instudy(years) . . 32 24-39 . . 33 23-39
Ageatfirst
menstruation (years) ■ . 13 10-15 ■ • 13 10-I6
Education
Elementaryschool(9 years) 34 2 ■ • 146 9
Highschool 1490 90 ■ 884 57
Collegeoruniversity 131 8 533 34
Ageat conception
(years) 25 19-34 ■ ■ 25 19-34
Whenstartingtoattempt pregnancy
Length ofmenstrualcycle(days)a 28 23-36 ■ . 28 23-35
Oralcontraceptives
as lastcontraceptive
method 1167 74 ■ . 969 67
Nulliparous 1258 79 • ■ 1081 73
Heavylifts 388 29 ■ 664 52
Employment
Full-time
employment 607 43 ■ 943 68 ■ ■
Part-time
employment 125 9 ■ . 240 16
Self-employed 577 41 31 2 ■ ■
Housewife 11 1 36 2 ■ ■
Student 50 4 ■ ■ 105 6 ■■
Unemployed 18 1 56 4 ■ .
Other 13 1 29 2 ■ ■
workhoursb
Irregular 251 21 • ■ 509 45
b
Nightshirt 18 2 - - 86 8
Workplace smokingb 468 39 . 355 34
Smoking forsmokers)
(cigarettes/day 408 30 10 2-20 348 27 10 2-20
Partner's
smoking forsmokers)
(cigarettes/day 260 20 15 2-30 248 20 15 3-30
Alcohol
consumption (yes) 846 62 ■ ■ 720 57
Partner's
alcoholconsumption (yes) 1050 81 ■ 875 73
Usemedicationregularly0 96 6 ■ • 127 8
vitamins,
Taking mineralsorironsupplements0 401 24 ■ . 318 20
a Excluding
womenwithmenstrual
bOnlyamongthose cycles14 daysorshorter.
employed orself-employed.
c Information
onlyavailable
fortheentire fromtheyearbefore
period to delivery.
conception

(ie, reducedto 9%)]. The otherfactorswere similarto Nonrespondentsand missinginformation

the corresponding factors(data not
prepregnancy _ , ^ ... u „ of. the
shown' The dateofbirthwas ,known£ forall , womenwho
receivedthequestionnaire, anditwas foundthatthere-
and
spondents nonrespondents to thequestionnaire did
Potentialeffect modifiers notdiffer in age (medianyearof birth1969 forboth
Thehairdressers wereaskedabouttheventilation d thereferentS)*
Datafr°mtheSwed"
inthe ^ ^f*? f
salonwheretheywereworking lsh MedlCal Birth ReglStry was available fora11of the
priortoandduring their
en wh°
or whentheyweretrying gave birth between 1973 and 1994'which
pregnancy to conceive.Spe- W0Ifll t0 the
P°SSlble COmpare ^respondents with
theywereaskedaboutpassiveventilation
cifically, and ^
theabsence-presence theresPondents withresPect t0severalreproductive out-
of generalventilation and local
exhaustventilation. ™meS- N°te thatthe informationfrom the Medical Bi*h
The different ventilationmethods
weregroupedso thatno ventilation ReglStry nOtUSedin any of theotheranalyses'
or passiveventila- uwas
*e therewereslightly more
tiononlywas regarded as low ventilation,thepresence Am°ng ^respondents,
WOmen'nduded *n BirthRegÍStry than
ofeithergeneralorlocalexhaustventilationwasregard- the ^f™1 3?% °f
ed as medium andthepresenceofbothgen- amOng P° ^ ^
ventilation, f 38% versus^T*
eralandlocal exhaustventilation and 35% of thereferents>' The
was regarded as high dreSTSerS
ventilation ^ nOt reC°rded * **
(ifeither
generalorlocalexhaustventilation ^ f ÍB'rth
fo W°T1IT
was present, ReglStry untl11982' Among the women
passiveventilationwas disregarded). All MuedlCal
oftheresultsconcerning wh° birth thisdate'therewas a lowerfrac"
hairtreatments werestratified gfe fer
onthelevelofventilation tlOn°f amonSthenonrespondents than
thatwas usedin thesalon. nu°nsmokers
the
among respondents (66% versus 74% amongthe
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 Axmon et al

and 63% versus74% amongtherefer-

hairdressers outthequestionnaire or at thetimetheystoppedtrying
ents). to conceive.Moreover, the14 hairdressers and 12 ref-
erentswho had checkedthe"no" boxes forachieving
pregnancy inthefirst orsecondmonth, butdidnotgive
Statistics a timeto pregnancy wereincludedin thetime-to-preg-
Information on exposure,potentialconfounders, and nancyanalysis,butcensoredat 2 months.All of the
effectmodifiers was collected.For thewomenwhose womenwhostatedthattheirpregnancy was a resultof
timeto pregnancy was shorter than12 months, thein- medicaltreatment (84 hairdressers and 69 referents)
formation corresponding to thetimewhentheystarted wereincludedin theanalysis.Forthesewomen,itwas
theirattempts to becomepregnant was used.Forwom- assumedthatthetimeto pregnancy was longerthan12
enwhosetimetopregnancy was longerthan12 months, monthseven if timeto pregnancy was missing,since
theinformation concerning the10thto 12thmonths prior thisis normally theearliesttimepointwhenmedical
toconception was used.Forthewomenwhowerecen- treatment is introduced. In orderto controlbias due to
soredat 2 months,theinformation concerning the 3 birth control failure (29), we repeatedtheanalysesaf-
months to was
prior conception used, since we did not ter theexclusion of data on first-cycle pregnancies.
knowtheexacttimeto pregnancy. In themiscarriage Odds ratioscalculatedusinga logisticregression
analyses,theinformation concerning thefirsttrimester wereusedto estimate miscarriage risks.
ofthepregnancy was used. Multivariate analysescomparingthehairdressers
For each of thespecifichairdresser exposures, the with thereferents werecarried outthatincluded thecon-
hairdresser cohort was split into two subgroups - those founders in table 1. When selecting confounders forthe
whohadexposure below the median and those who had multivariate analyses, we used the stepwisemethod sug-
exposureequaltoorabovethemedian.Thesetwosub- gestedby Greenland (30). Variableswereentered into
groupswerecompared withthereference cohort. Since themodeliftheychangedtheeffect estimateby >10%
it is fairto assumethatthelevel of ventilation in the and excludedif exclusionchangedtheeffectestimate
salonaffects theexposure levels,analyseswerealsocar- by<5%.
riedoutthatincludedonlyhairdressers withno or low
ventilation.
AllofthedatawereanalyzedusingSPSS (SPSS Ine,
Results
Chicago,IL, USA).
A logisticregression of thesurvivaldatawas car-
riedoutto estimate theeffects of thecohortaffiliation Timetopregnancy
andhairdresser exposureon timetopregnancy. Thera- The fractionof womenwho needed morethan 12
tionaleforusingthelogisticregression modelcomes months toconceivewas slightly higheramongthehair-
fromthediscretelinearlogisticmodel(27), whichis dressers(N=113; 7%) thanamongthereferents (N=91;
applicablewhensurvivaltimeis discrete (28). Foreach 6%). When time to pregnancy as a continuous variable
comparison, a fecundability ratiowas calculatedfrom was considered, thehairdressers wereless successful in
theoddsratio(OR) ofeachtimeinterval (1-1.9, 2-2.9, conceiving than the referents (fecundability ratio= 0.91,
etc).Themodelassumption thatoddsratiosaresimilar 95% confidence interval 0.83-0.99). The mediantime
foreachtimeinterval was checkedusingan interaction to pregnancy was, however,2 monthsin bothgroups
termbetween timeandinterval. Fecundability ratiosare (excluding women whowerecensoredat 2 months; see
similarto effectestimatesobtainedfroman analysis thestatisticssection).The decreasedconceptionrate
basedontheproportional hazardsmodelwhentheevent seemedinparttobe aneffect ofbirth controlbias.When
ratesaresmallin eachinterval andthefollow-up peri- an analysiswas carriedout withthewomenwho got
od is relatively short(28). Notethatsincethefecunda- pregnantthefirstmonthof trying[515 hairdressers
bilityratio measures positiveevents(wantedpregnan- (31%) and 554 referents (36%)] excluded,thediffer-
cies),a valueoflessthanoneindicates a prolonged time ence betweenthecohortswas reduced(fecundability
to pregnancy as comparedwiththatof thereference ratio0.96,95% CI 0.87-1.07).Theresultschangedless
group. than10% whenthepotential confounders fromtable1
To avoid interference frommedicaltreatment for wereincludedin thebivariatemodels.Thusno adjust-
infertility(24), we censoredtimeto pregnancy at 12 ed effectestimates are presented. Whenthesubcohort
months(113 hairdressers and 91 referents). Further- of hairdressers whowereexposedwithcertainty com-
more,timeto pregnancy forthewomenwhohad cur- pared withthe referencecohort(fecundability ra-
rently (59 hairdressers and 65 referents) or previously tio=0.95,95% CI 0.87-1.03), the were
results similar
(23 hairdressers and 18 referents) beentrying to con- to thosefoundwhentheentirehairdresser cohortwas
ceivewerecensored at 12months, atthetimetheyfilled comparedwiththereference cohort.

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 Fertilityamong female hairdressers

Thespecific exposureanalyseswereperformed only potentialconfounders changedtheeffectestimatesby

forthehairdressers who wereexposedwithcertainty less than10%.
priorto theirpregnancy (N=1418).Due to missingex- Ventilationlevelwasconsideredas no-low(N=348)
posuredata,thenumber ofwomenincludedintheanal- or medium-high (N=754). When theanalysesregard-
ysesdiffered slightly(table2). ingspecificexposurewererestricted
tohairdresserswith
On thebasisoftheresultsfromthecohortcompari- no or low ventilation,
theeffectswereslightlylarger
son,it was to be expectedthatthespecificexposure thanwhenall thehairdressers
wereincludedintheanal-
analyseswouldalso showreducedfecundability. In- yses. However,thissubgroupwas rathersmall,and
deed,forsomeof theexposuresinvestigated (setting hencetheconfidence intervals
wererelativelywide.
permanent waves,oxidative hair-coloring formulations,
hairdyes,working
direct-reacting ina standing position,
self-employment, and stressfulwork there
situation),
Miscarriages
wereindications of a dose-response relationbetween The number of womenwhosefirstplannedpregnancy
exposureand fecundability (table 2). Adjustingfor endedin a miscarriage
was 157 (11%) in thehairdresser

Table 2. Timeto pregnancy

forthewomenworkingas hairdressers
whenstarting
theirattemptsto conceive.Fecundability
ratiosforthe
womenwithexposureabove or belowthe mediancomparedwiththose ofthe referents
fromthe generalpopulationare presentedwith
their95% confidenceintervals(95% CI).

ExP°sure Allhairdressers Hairdresserswithlow or no ventilation

Womenwith Fecunda- 95% CI Womenwith Fecunda- 95% CI

exposure bility exposure bility
information ratio information ratio
(N) (N)

Settingpermanentwaves
Referents 1578 1.00 •• 1578 1.00
Below median(4 treatments/week) 493 0.91 0.80-1.04 146 0.84 0.68-1.05
Above median(4 treatments/week) 581 0.86 0.76-0.97 172 0.83 0.68-1.01
Hairbleaching
Referents 1578 1.00 •• 1578 1.00
Below median(4 treatments/week) 530 0.88 0.78-0.99 170 0.81 0.66-0.99
Abovemedian(4 treatments/week) 536 0.89 0.79-1.01 142 0.86 0.69-1.07
Oxidativehair-coloring
formulations
Referents 1578 1.00 •• 1578 1.00
Below median(2 treatments/week) 535 0.94 0.83-1.06 169 0.86 0.70-1.05
Abovemedian(2 treatments/week) 522 0.83 0.73-0.94 140 0.83 0.66-1.03
hairdyes
Direct-reacting
Referents 1578 1.00 ■• 1578 1.00
Below median(3 treatments/week) 452 0.92 0.80-1.05 146 0.86 0.69-1.07
Above median(3 treatments/week) 585 0.86 0.76-0.96 158 0.82 0.67-1.01
Nonreactive
dyes or tones
Referents 1578 1.00 •■ 1578 1.00
Below median(2 treatments/week) 558 0.89 0.79-1.01 170 0.85 0.69-1.03
Abovemedian(2 treatments/week) 431 0.90 0.79-1.03 116 0.95 0.75-1.20
Hairspray
Referents 1578 1.00 ■• 1578 1.00
Below median(30 treatments/week) 472 0.89 0.79-1.02 148 0.81 0.65-1.00
Above median(30 treatments/week) 540 0.87 0.77-0.99 154 0.84 0.68-1.04
Workingin a standingposition
Referents 1578 1.00 •• 1578 1.00
Below median(8 hours/day) 334 0.97 0.82-1.15 58 0.97 0.70-1.35
Above median(8 hours/day) 927 0.84 0.76-0.93 249 0.77 0.65-0.91
Self-employment
Referents 1578 1.00 •• 1578 1.00
Employedhairdressers 732 0.90 0.80-1.01 126 0.86 0.68-1.07
hairdressers
Self-employed 577 0.82 0.73-0.93 192 0.77 0.63-0.93
Stressfulworksituation
Referents 1578 1.00 •■ 1578 1.00
Hairdresserswithoutstress 472 1.00 0.87-1.15 102 0.88 0.68-1.13
Hairdresserswithstress 819 0.78 0.70-0.87 205 0.71 0.59-0.86

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 Axmon et al

cohortand 135 (10%) (OR 1.12,95% CI 0.88-1.42)in permanent waves,hairbleaching, oxidativehair-color-

thereferencecohort.The effectestimatechangedless ing formulations,nonreactivedyes,hair spray,and
than10% whenthepotential confounderswereinclud- working in a standing
position(table3). However,all
ed in thebivariatemodels.Similarresultswerefound of theserisksdisappearedwhenadjustment was made
forthesubgroupof hairdressers who had hairdresser forpotentialconfounders.
Hairdressers witha self-per-
exposurewithcertainty, andwhenwomenwhosepreg- ceivedstressfulworksituationweremorelikelyto ex-
nancieswerenotdetermined by a pregnancy test(21 a
perience miscarriage, but also thisriskdisappeared
hairdressers
and 19 referents)
wereexcluded(datanot whenpotential confounderswereadjustedfor.
shown).
Theanalysesofspecificexposureswerecarriedout
onlywiththe1256hairdressers whowereexposedwith
certaintyduringpregnancy. to missingexposure
Due Discussion
data,thenumberof womenin thedifferent analyses
variedslightly
(table3). Our studygivessomeindications
of a prolonged time
Thecrudeoddsratiosindicated dose-response rela- to pregnancyamonghairdressers
when theyare com-
tionsbetweenexposureand miscarriageforsetting pared with women fromthe general population.

Table 3. Exposurevariablesand numberoffirstplannedpregnancymiscarriagesforSwedishwomenwho wereworkingas hairdress-

ers duringtheirfirstplannedpregnancy. The odds ratios(ORs) wereadjustedforyearof birth,
age at conception,performance
ofheavy
lifts,use oforalcontraceptives
priorto pregnancy, menstrualcyclelengthpriorto pregnancy,partner'ssmokinghabits,and workplace
smokingand presentedwith95% confidenceintervals(95% CI).

Exposure N Crude
OR 95% CI OR
Adjusted 95% CI

Settingpermanent waves
Referents 1381 1.00 ■■ 1.00
Belowmedian(4 treatments/week) 419 1.06 0.73-1.52 0.72 0.45-1.17
A ovemedian(4 treatments/week) 487 1.25 0.90-1.73 0.88 0.57-1.37
Hairbleaching
Referents 1381 1.00 ■■ 1.00
Belowmedian(4 treatments/week) 458 1.08 0.76-1.53 0.77 0.48-1.21
Abovemedian(4 treatments/week) 441 1.26 0.90-1.77 0.79 0.50-1.24
Oxidative formulations
hair-coloring
Referents 1381 1.00 •• 1.00
Belowmedian(2 treatments/week) 488 1.05 0.75-1.48 0.75 0.48-1.18
Abovemedian(2 treatments/week) 399 1.35 0.96-1.91 0.88 0.56-1.40
hairdyes
Direct-reacting
Referents 1381 1.00 •• 1.00
Belowmedian(3 treatments/week) 396 1.30 0.92-1.85 0.87 0.54-1.40
Abovemedian(3 treatments/week) 474 1.11 0.79-1.56 0.79 0.51-1.23
Nonreactivedyesortones
Referents 1381 1.00 ■• 1.00
Belowmedian(2 treatments/week) 481 1.14 0.82-1.60 0.74 0.47-1.15
Abovemedian(2 treatments/week) 356 1.23 0.85-1.78 0.95 0.59-1.53
Hairspray
Referents 1381 1.00 •■ 1.00
Belowmedian(30 treatments/week) 417 0.98 0.68-1.42 0.65 0.39-1.07
Abovemedian(30 treatments/week) 438 1.24 0.89-1.75 0.93 0.61-1.43
Working ina standingposition
Referents 1381 1.00 ■• 1.00
Belowmedian(8 hours/day) 259 1.03 0.66-1.60 0.69 0.40-1.19
Abovemedian(8 hours/day) 744 1.17 0.88-1.57 0.89 0.61-1.30
Self-employment
Referents 1381 1.00 •■ 1.00
Employed hairdressers 626 1.26 0.93-1.70 0.85 0.57-1.28
Self-employedhairdressers 470 1.07 0.76-1.52 0.78 0.50-1.21
Stressful
worksituation
Referents 1381 1.00 ■■ 1.00
Hairdressers
withoutstress 381 0.73 0.48-1.12 0.57 0.34-0.95
withstress
Hairdressers 668 1.46 1.10-1.93 1.01 0.70-1.46

Scand J WorkEnvironHealth 2006, vol 32, no 1 57

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 among female hairdressers
Fertility

However,itcannotbe ruledoutthatthis,in part,is an It is probablethattheconditions havebeen similarin

effectof birthcontrolbias. Withinthehairdresser co- Sweden.However,eventhoughalmostall hairdressers
hort,a self-perceived stressfulworksituation, butnot in Swedenhaveusedgloveswhenmixingandapplying
chemicalexposurebased on thenumberof hairtreat- hairdyes,notall haveusednewglovesforeverytreat-
mentsper week,was foundto decreasefertility by ment, andonlyfewhaveusedgloveswhenapplying per-
meansofprolonging thetimetopregnancy. manent waving(Birgitta Meding,personalcommunica-
Therewas no increasedmiscarriage riskamongthe tion,2004).Thusdermaluptakemaystillhaveoccurred.
hairdressers versuswomenfromthegeneralpopulation. Nineteen ofthesalonswerevisitedbyoccupational
However, within thehairdresser cohort, a self-perceived hygienists, andventilation velocitiesweremeasured. A
stressfulworksituation indicatedan increasedriskof comparison with the answers in the self-administered
miscarriage. A raised,butnotstatistically significant, questionnaire showedthatthehairdressers knewifthere
miscarriage riskwas found for most of the hair treat- was onlypassive ventilation.However, there was a ten-
ments. dency for the hairdressersin small salons to overesti-
Fertilitywas measured using time to pregnancy, as mate the ventilation levels,whereas the hairdressers in
wellas frequency ofmiscarriages. Ithasbeenfoundthat big salons underestimated theventilation levels. Al-
timeto pregnancy is a usefultool whenreproductive thoughthisdifference mayhavelead to somemisclas-
effectsarebeingassessed(23) andthatdatacanbe col- sification, it was notlikelytobe associatedwiththeout-
lectedretrospectively (23) by using self-administered comes time to pregnancy andmiscarriage.
questionnaires A
(31). major criticism concerning ret- In addition to the use of chemicaltreatments and
rospective time-to-pregnancy studies has been the ex- work in a standing position, we examined self-employ-
clusionof womenwhoneverconceived.By askingall mentand a self-perceived stressful workingsituation.
womenwhohad neverbeenpregnant iftheyhad ever Withrespectto self-employment, theriskofmisclassi-
triedtobecomepregnant, we wereabletoincludewom- ficationshouldbe minimal.However,a self-perceived
en whohadtriedtoconceivebutso farhadfailedtodo stressful worksituation was determined bytheuse ofa
so. singleyes-noquestionand,therefore, be consid-
must
For thewomenwho had yetto becomepregnant, eredas a verycrudemeasureof stress.
information was collectedfortheentireperiodwhen The responserateto thequestionnaire was rather
they tried to conceive.Thisperiodcouldcoverseveral low. However,we had substantial information regard-
years,andthusthequalityofthesedata,andespecially ing boththereproductive and lifestyle factorsof the
thatofthedichotomous variables,maybe biasedwhen nonrespondents to enable satisfactory nonrespondent
compared withthatofwomenwhosetimetopregnancy analyses.Theresultsfromtheseanalysesspeakagainst
endedin a pregnancy. However,thefraction ofwomen anysizeableselectionbias due to noneor onlysmall
whohad notyetconceivedwas verylow (5% in each differences in theoccurrence ofpotential confounders.
cohort),and theimpacton thefecundability estimates Moreover,the minordiscrepanciesbetweenthe re-
shouldtherefore be slight,at most. spondents andnonrespondents werenondifferential be-
Eventhoughinformation concerning timeto preg- tweenthehairdressers andthereferents.
nancyis probably recalledcorrectly bythewomen(23), Whenmiscarriage riskwas assessed,theinforma-
therecallconcerning work-related factorsin thehair- tionrelatedtothefirst trimesterofpregnancy wasused.
dresser cohortwas notnecessarily as good.A subsam- The reasonforusingthisvariable,rather thana long-
pleofthehairdresser cohorthadpreviously beenexam- termexposure,was thea prioriidea thatmiscarriages
inedwithrespectto reliability forself-reported expo- relatedto hairdresser exposurewouldbe theresultof
sure(25). It was foundthat,ifa misclassification was an effecton thefetus,ratherthan,forexample,dam-
introduced bythequestionnaire, itprobably resultedin aged ovarianfunction. Furthermore, availabledatado
underestimations oftheeffects of specificexposure.A notsupport long-term biologicalhalf-times forthepo-
further concernwithrespectto exposureclassification tentialhazardouschemicalsin thehairdresser worken-
is thatit is a crudeone,basedon thenumber of treat- vironment.
mentsperweek,and no information was collectedon We choseto use womenfromthegeneralSwedish
whether thehairdressers wereusinggloveswhenapply- population as thereference group.Thischoicemayhave
ingchemicalsto thecustomers' hair.Personalandsta- resulted in someofthereferents beingexposedto oth-
tionary measurements in Norwegian hairdresser salons er,to us unknown, reproductive hazardsin worklife.
have shownlow meanair concentrations of isopropa- Indeed,someof thereferents mayhavebeenexposed
nol,ethanol, andammonia, whereasphenylenediamine to chemicalsand workconditions thatweresimilarto
anddiamionotolouene werenondetectable (32). Theex- thoseof thehairdressers. Thispossibility is unavoida-
posurelevelwas significantly lowerin salonswithlo- ble whenthegeneralpopulation is used as a compari-
cal exhaustventilation thaninthosewithnoventilation. son groupand maylead to thetrueriskdifferences

58 Scand J WorkEnvironHealth2006, vol 32, no 1

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 Axmon et al

beingattenuated. On theotherhand,selecting"unex- andRegionSkâne.

MedicalFacultyatLundUniversity,
posedgroups" from thegeneralpopulation forcompar- Noneoftheauthors haveanycompetinginterests.
isonsmayresultin uncontrolled bias fromdifferences The studywas approvedbytheEthics
Committee at
in socioeconomic andlifestyle factors. LundUniversity.
Whenall pregnancies (firstmonth conceptions also)
wereincluded,therewas approximately a 10% less
chanceof a hairdresser conceivingthanthereferents
each month ratio0.91). Theanalysescar- References
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