This work is based substantially on the publication named Medicine and Motherhood: Can We Talk? authored by the task Force on the Accommodation of the Pregnant Physician, published by the Physician Health Program of British Columbia. The original report can be found at www.physicianhealth.com/medicineandmotherhood.
Executive Summary The increasing importance of women in the Canadian physician labour force raises important questions about how to accommodate the workplace needs of women when they are pregnant and become parents. The extent to which the needs of physician mothers are - or are not - accommodated is recognized as a significant influence on:
• Maternal and fetal health
• Mother and child well-being during pregnancy and postpartum
• Female physicians’ career progression, career choices and practice patterns.
Accommodation of pregnant physicians is also a key issue in human resources planning. This consensus statement tries to make recommendations on how best to respond to and plan for the improved integration of the pregnant physician in the workplace.
The physician labour force in Canada is changing dramatically. Not only are there more women graduating as physicians but increased training requirements mean that women are older before they achieve ‘practice-readiness’. In order to effectively utilize the contributions that women make to the physician labour force, stakeholders within practice groups, health-care entities, educational settings, professional associations, policy makers and employers need to engage in a constructive dialogue about improving the working conditions for pregnant physicians and parents of young children. The potential costs of not having this conversation are significant and include dysfunctional practice patterns and educational settings and lower rates of retention in a profession that already faces a labour shortage.
This paper provides a summary of the current evidence regarding the impact of work on maternal and fetal health, including the implications for women who delay pregnancy until later in life. It also highlights workplace conditions that may need to be modified for the pregnant physician. It is intended to serve as a guide to assist the pregnant physician and her colleagues with conversations about workplace accommodation as set out in the Human Rights Code of Canada.
It is essential that physician associations, educators, employers, practice groups and policy makers find ways to accommodate female physicians through workplace planning and related measures. Without such accommodation, these mothers may either place themselves or their children at risk, or may exit the profession at a time when society most needs their expertise.
For women pursuing a career in medicine, juggling professional education and personal plans can lead to delays in starting a family. Age of admission into medical school has been increasing steadily... Given that it takes a minimum of six years of training to practice as a family physician and nine to fourteen years to be licensed as a specialist, it is clear that career and parenting priorities can clash. It is recognized that after age 35 women face a decline in the number and quality of eggs they produce, leading to increased rates of infertility, in-vitro fertilization, miscarriage and birth defects associated with chromosomal aberrations and disorders. There are also increased risks to maternal health, including hypertension, diabetes, increased rates of caesarean section and even perinatal mortality. Thus for every year a woman defers childbirth, the risk of complications increases - something that medical students and physicians are well familiar with due to their training.
Impact of Work on Maternal and Fetal Health
As with all expectant mothers, a pregnant physician’s ability to safely continue working during pregnancy may be compromised by complications of pregnancy, pre-existing maternal medical conditions, or problems associated with pregnancy such as back and pelvic pain, sleep disruption, nausea, preterm labor and gestational hypertension (16).
The impact of reproductive health for the pregnant physician can be briefly summarized into three broad categories: harmful exposures, physical demands and stress and a lack of social support.
Depending on the workplace and practice patterns, pregnant physicians may be exposed to violence, toxins, radiation, biological and chemical agents, infectious diseases and other conditions that are recognized as risks to maternal and fetal health (16).
Research has pointed to the risks for pregnant women and their fetuses from exposure to chemicals including organic solvents, anesthetic gasses and heavy metals (17). These agents can act as teratogens or fetotoxins at levels much lower than those at which they exert mutagenic or gametotoxic effect (18). In addition, training or practicing medicine in certain fields such as psychiatry and emergency medicine may expose pregnant physicians to risks of violence in the workplace (19).
Risk of exposure to infectious diseases is a consideration for pregnant physicians working in areas such as emergency medicine, family practice, internal medicine, surgery and anesthesia. Different infectious diseases pose different risks and appropriate responses can range from standard infection control precautions to avoiding contact all together where circumstances dictate. As a peer-reviewed article in the Journal of the American Academy of Family Physicians advised in 2007: “...Each physician must find his or her own level of comfort with the inherent risks of the job. In circumstances that increase the risk of pregnancy-related complications, pregnant physicians should feel comfortable about asking non pregnant colleagues for assistance.” (20)
Research indicates that some physical activities are generally contraindicated by the physiological changes that accompany pregnancy. (18) The demands include: physician schedules, long periods of time spent standing, physical exertion, heavy lifting and shift work (16, 17, 21-26)..
Croteau, Marcoux and Brisson (27) found that the risk of bearing a ‘small for gestational age’ infant increased for working pregnant women with an irregular or shift-work schedule alone and with a cumulative index of the following occupational conditions: night hours, standing, lifting loads, noise, and high psychological demand combined with low social support at work. Risk was also fund to increase with the number of physically stressful conditions to which a woman was exposed during pregnancy. intervention to reduce exposures earlier in pregnancy was found to result in a decrease in risk.
A 2000 meta-analysis of working conditions and adverse pregnancy outcomes found a statistically significant relationship between pre-term birth and both prolonged standing and shift and night work (21). In general, physically demanding training rotations have been shown to cause additional strain for pregnant residents and those newly returned to work after child-bearing (28, 29). Evidence also suggests that exposure to excessive noise may be contributors to complications such as low birth weight, (30) preterm birth and intrauterine growth restriction (31) as well as high-frequency hearing loss in newborns (32).
In Quebec, the negative impact of shift work has been recognized in the collective agreement of the residents’ association. It states: “A pregnant resident’s basic regular schedule shall not exceed eight hours per day, from Monday to Friday, with the exception of call duty. In the twenty weeks prior to the expected date of delivery, the resident shall be entitled to exemption from call duty. If the resident’s work is organized in shifts, she shall also be entitled on a weekly basis ... to two consecutive days of leave; moreover, she is also entitled to exemption from any night shifts, where applicable.” (17)
Stress and social support
A common source of stress for the pregnant physician arises from the high psychological demands that can be related to certain aspects of medical practice, particularly when long work hours or shift work are involved (33).
A 2003 review of the research literature on pregnancy during residency training (2) found that major stressors for the pregnant resident included the sometimes onerous work demands of residency and an often-unspoken expectation that the absent resident’s workload will be shouldered by other residents. This is compounded by a lack of acknowledgment, dialogue and problem-solving on the part of program directors and departments (34). Also noted by this literature review was evidence of stressors such as frequency of call, fatigue, long hours, emotional strain, too little time with partners and real of perceived feelings of denial, resentment and hostility from colleagues and program directors.
Consequences for Maternal and Fetal Health
As outlined above, the evidence examining three key elements of physician work on maternal and fetal health suggests that “bearing a child during residency or practice may be associated with adverse pregnancy outcomes.” (29) According to a comprehensive 2003 literature review of pregnancy during residency, (34) these outcomes include:
• A higher than normal overall complication rate, including incidences of preterm labour, abruptio placentae, hypertension, hyperemesis and preeclampsia. • A higher than normal miscarriage rate, and increased relative risks of still birth, preterm labour and delivery and caesarean section. • Significantly increased incidence of low birth weight and intrauterine growth restriction.
Physician work can also lead to longer-term health outcomes that include sexual dysfunction for the mother, sterility, genetic or chromosomal defect, intrauterine growth retardation, spontaneous abortion, fetal death, premature birth, congenital defect, behavioral problems and certain infant cancers or other diseases.
This daunting list must be considered in context, since even at an increased level of incidence overall, the absolute risks of some of these complications remain quite low. None the less, the demands of residency and clinical practice do conflict with the psychosocial realities of childbearing. These include fertility concerns, the time needed to develop a relationship with a partner, the time and energy needed to carry a baby to term, the need to eat and sleep properly, the time needed for bonding and attachment, the need for breast feeding and the juggling of demanding schedules to accommodate child care needs. (34)
Postpartum Issues Important for the Pregnant Physician
Postpartum issues also need to be taken into account when developing and implementing accommodation policies. These include the impact of physician work on breast feeding, the need for leave related to complications arising from childbirth, challenges associated with securing safe infant child care and the impacts of maternal sleep deprivation and fatigue. Evidence relating to the risks of each of these is summarized below.
The Canadian Paediatric Society recommends breast feeding exclusively for the first six months after birth for healthy, term infants. The society further asserts that breast milk, being the optimal food for infants, may continue for two years and beyond (35). However, research shows that female physicians do not maintain breast feeding at the rates recommended, citing return to work, diminished milk supply and a lack of space and time to pump (36). This occurs despite the fact that research has demonstrated the benefits of breast feeding for at least six months postpartum for child health and maternal and child bonding. For employers, providing workplace support to help mothers maintain breast feeding results in higher workplace satisfaction for the mother and therefore enhanced recruitment and retention of employees. (37).
Complications arising from birth
Given that female physicians generally have children later in life, it is important to take into account the risk of complications, such as a caesarean section or preeclampsia or, for the infant, low birth weight or pre-term birth. This can have an impact upon the timeline for a physician’s return to work.
Obtaining infant child care
Long hours, unpredictable work demands, guilt because of absences from work, increased workload for colleagues and high personal expectations cause pregnant residents and physicians severe stress. This stress continues upon returning to work, as finding adequate child care can be difficult. (28).
Fatigue and sleep deprivation
There is a significant interaction between sleep and both perinatal and postpartum mood disorders for hormonal and psychosocial reasons. Napping does not result in restorative REM sleep (38). Sleep deprivation also has a negative impact on emotional and cognitive functions. The effect cumulates over time when sleep is regularly less than seven hours per night. This impacts mood, cognitive performance, working memory, executive function and attention. Sleep deprivation leads to deficits in neurocognitive performance and results in fatigue, loss of vigor and confusion. The impact is even more evident when multi-tasking and flexible thinking are required (39).
By choice, default or tradition, women physicians, like other women, tend to take on more than their share of child care and parenting responsibilities. Female residents are more likely to have a spouse who works outside the home - often another resident or physician - than their male peers. (40, 41).
‘Role overload’ is common among women physicians (42) who suffer from an increased likelihood of stress and burnout and who have a higher tendency to work part time to try to achieve improvements in their work and life balance (4). Some observers argue that the combination of managing a medical career and parenting levies an unusually high price on women physicians, pointing to higher divorce and suicide rates compared to women who are not physicians. (12)
In a 1999 report on physician numbers in Canada, “the pattern of practice is changing for all physicians - male and female. Increasingly, physicians are recognizing the need to balance work with family and community needs. The long hours that house staff have traditionally worked are being questioned. These efforts have resulted in changes in employment contracts for residents.” Moreover, the same report notes that the general public is increasingly “beginning to question the appropriateness of medical care being delivered by physicians working excessive hours.” (3)
In summary, these three main issues: working conditions, postpartum concerns and the longer-term impact of combining a medical career with parenting, point to the necessity of ‘getting it right’ early on in the career of female physicians. Providing career options, modifications, accommodations and solutions early on can set the stage for a fruitful career that benefits not only a female physician but her family and the health care system overall.
Medicine and Motherhood: The Current Experience
In recalling her own pregnancy, one physician exemplifies the current experience for many pregnant doctors: “I was able to decrease my call [but] I felt guilty about that. I felt like I really let everyone down, [even though due to pregnancy complications] I could not physically go on.” (3) Unfortunately, this type of experience is all too common; a physician requests changes to her work environment such as her call schedule but feels guilty about it and anticipates resentment from her colleagues. She therefore delays putting her request forward and pushes herself on to carry on until her situation becomes extreme.
Impact of medical culture Even though more attention than ever is paid to issues of physician health, medical practice is still embedded in a culture that values professional achievement and scientific mastery over personal, family, and relationship needs (47). This culture carries such hidden messages as ‘push yourself to succeed’ and ‘pay your dues,’ (28) leaving doctors reluctant to acknowledge their needs privately, let alone discuss them with colleagues.
Haidet and Stein (43) recently listed some of these themes and the unspoken assumptions underlying them. These include:
• Doctors must be perfect; they never make mistakes.
• Uncertainty and complexity are bad - avoid them.
• The outcome is more important than the process.
• Medicine takes priority over everything else.
• Hierarchy is necessary.
Many doctors see medicine as a “higher calling” and interpret the need to attend to their own needs as a sign of weakness. This can lead pregnant physicians to postpone discussion of their physical and emotional requirements until the need is dire.... Another extreme: a pregnant physician would like to continue working, but leaves practice altogether at a point early in her pregnancy because of the difficulty of negotiating suitable accommodation with her colleagues. These situations occur all too frequently, and neither ensures “the healthy and sustainable growth of the number of women in medicine.” (48)
To achieve this growth, the medical profession must find a way to meet the needs of the pregnant physician and her fellow doctors. The medical profession and society in general will gain much by optimizing the contribution to the medical workforce that female physicians make during their reproductive years. As even greater numbers of women enter the medical profession, this challenge will only grow. Policy makers and leaders must therefore act now to prevent suffering, conflict, and lost productivity.
Cultural Change: Reframing the Conversation
Collective efforts must focus on a cultural change. While legislation enables and shapes institutional policy, neither it nor policy guarantees implementation (50) without a supportive culture. Strong and persistent cultural norms, such as those found in medicine, are slow to change. Shifting cultural norms takes time, patience, persistence, intelligence and insight (54,55). We suggest three simple strategies to current practice that should make meaningful differences. These are:
Start talking early There are many reasons why a pregnant physician might want to postpone discussions with colleagues. These include a need for personal privacy and the relatively high rate of fetal loss in the first trimester. However, the earlier the discussion starts, the less pressure there is to reach a satisfactory solution and the more time there is to ensure that everyone’s feelings and needs are heard and understood. For those who work in medical specialities where exposure to radiation and chemicals is high, this might involve having a preconception conversation. Each physician must make her own decision about when to initiate the discussion with her colleagues. If a physician feels she needs help initiating the topic of accommodation with her colleagues (or her employer), she can consult first with her local Physician Health Program or with another trusted resource.
Understand everyone’s needs before proposing strategies to meet them. One of the reasons we suggest starting a conversation early is because satisfactory solutions can take some time to emerge. Bringing up the subject of how a pregnant physician might meet her needs can trigger strong reactions among colleagues who may have struggles silently with their own needs. Physicians are oriented towards quick solutions. Putting forward a solution too early tends to invite others to say “no”. Saying and hearing “no” too early in the conversation can present its own difficulties, especially when there are asymmetries of positional power involved. Try to take an approach that will minimize, but not eliminate, the chances of hearing “no” too early in the conversation. Several short conversations will likely be needed, as most physicians will need time to reflect on what their needs are. When the stakeholders’ needs have been articulated and heard, the process of generating potential solutions can begin. Consensus about which solution to try first should be reached in a free-flowing discussion.
Pay attention to the conversation. With everyone’s needs heard and several solutions presented, a longer series of conversations should continue. As each solution is tried, stakeholders should be given the opportunity at regular meetings to say what is working for them and what isn’t. Ensure that the conversations are conducted in a spirit of mutuality and respect. This is more important that the outcome of each conversation (51).
Editor’s Note: This article including references will be continued in our next issue in January