Survey documents difficulties of pregnancy, motherhood during surgical training

By Liz Meszaros, MDLinx
Published April 6, 2018

Key Takeaways

Female surgical residents encounter significant issues surrounding pregnancy and childbearing, according to results from a national survey of general surgery residents published in JAMA Surgery. The majority may work unmodified schedules until they give birth, leading to fears that their intense work schedules could adversely affect both themselves and their unborn babies.

Although women comprise more than 50% of current medical school graduates, they represent 40% of general surgery residents and only 18% of faculty members throughout the country.

Researchers from the Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, conducted a national survey to assess the experiences of childbearing women during residency training, and help identify more effective interventions.

“Overall, women were very excited to have this issue studied formally. There have been publications reporting a growing number of female surgeons having children during residency, but this is the first national study to look at the actual perspectives of general surgery residents who were pregnant,” said lead author Erika L. Rangel, MD, MS, Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School.

In January 2017, Dr. Rangel and colleagues electronically distributed a self-administered survey to members of the Association of Women Surgeons and the Association of Program Directors in Surgery listserv, as well as to targeted social media platforms. They included 347 female surgeons (mean age: 30.5 years; 452 pregnancies) with one or more pregnancies during a US general surgery residency program accredited by the Accreditation Council for Graduate Medical Education. The surgeons completed training in 2007 or later.

Dr. Rangel and her fellow researchers identified important themes to include in the survey through surgeon focus groups with participants who had been pregnant during training in the past 7 years. In addition, they used MEDLINE searches from January 2000 to July 2016 to identify additional topics.

More than 25% of respondents had more than one pregnancy during residency, and most occurred during or after postgraduate year 3; 83.0% had at least one pregnancy during clinical training.

Disturbingly, a full 85.6% reported working an unmodified schedule until they gave birth, while 63.6% had concerns that their work schedules could adversely affect their own or their unborn child’s health.

In all, 34.9% reported on their residency program maternity leave policies, of whom 78.4% were given a maternity leave of 6 weeks or less. A full 72.0% considered the length of their maternity leave inadequate. In addition, 82.2% reported that the American Board of Surgery’s (ABS) maternity leave policy was a major barrier to their desired length of leave.

“There is a misconception that the ABS is an obstacle to getting longer maternity leave. In general, about 78% of women were getting 6 weeks or less of maternity leave, and about 72% thought this wasn’t enough time. Most people thought it was because ABS didn’t allow more time. However, the goal of the Board is to ensure the adequate training of surgeons to be prepared to take care of patients, and they offer several leave options to make this feasible for everyone, even with longer maternity leave.”

A full 72.9% of respondents reported hearing faculty members and other residents make negative comments about pregnant trainees or childbearing during training, and 60% reported a negative stigma towards pregnancy as a surgical resident. More than 50% felt pressured to plan pregnancies during nonclinical time.

Since these results were presented, the ABS has clarified its leave policy on its website. The Association of Program Directors in Surgery will meet in May to discuss how to improve the training experience for pregnant residents.

“There are a lot of low-hanging fruit—smaller modifications that can be made to make the overall training experience much better for this group of women. If you don’t have a maternity policy, make one. It can reduce the stigma of having to ask for help,” said Dr. Rangel.  

They also found that 95.6% of respondents cited breastfeeding as important, but 58.1% stopped earlier than they wanted due to poor access to lactation facilities and challenges in leaving the operating room to express milk. Institutional support for childcare was reported by 18.4% of respondents, primarily comprised of preferential daycare enrollment, discounted daycare, or access to backup childcare services.

The majority (85.9%), however, reported that the available childcare options did not offer hours that accommodated a surgical resident’s schedule. Most (75.4%) reported that additional childcare support would have helped them focus more on their surgical training. A full 66.8% reported a desire for greater mentorship in integrating their surgical career with motherhood and pregnancy.

Finally, Dr. Rangel and colleagues found that 39.0% of respondents considered leaving their surgical residency, and 29.5% would discourage other female medical students from pursuing a surgical career due to the difficulties of balancing pregnancy and motherhood with training.

According to study co-author Douglas Smink, MD, surgical residency program director, Brigham and Women’s Hospital Department of Surgery is creating an equitable work environment for surgical trainees, and organizing discussions facilitated by female faculty members centered on gender issues and disparities faced by residents.

“At BWH, we have accommodated a variety of maternity leave requests for our surgical residents, considering their various needs. Each maternity leave is managed on a case by case basis, depending on what the resident’s wishes are,” said Dr. Smink.

Dr. Rangel added: “We are also putting together support documents including information on lactation support, childcare assistance, and examples of various maternity leave options so that residents are well informed. Additionally, we have a group of female faculty who meet routinely in a social setting with the resident mothers to provide mentorship and support as well.”

Such efforts are vital for the proper recruitment and training of skilled surgeons.

"There is no good reason why the goals of training in surgery and starting a family should feel mutually exclusive. Understanding what that experience has been like for recent trainees is a next step in the continuous improvement of surgical training. Developing effective, progressive employment practices for our surgical residents will help us to recruit, to retain, and to deliver the most prepared surgeons to society," said Gerard Doherty, MD, chair, Department of Surgery, and surgeon-in-chief, Brigham and Women’s Hospital.

Dr. Rangel agreed.

“Over half of medical school graduates are women. If we want to educate and retain the best surgeons, we need to create a better training experience for women who wish to start families during their training,” she concluded.

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