Parental-leave policies and perceptions of pregnancy during surgical residency training in North America: a scoping review
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* Josephine S. Jakubowski
* Heather Baltzer
* Joan E. Lipa
* Laura Snell

## Abstract

**Background:** The number of surgical residents experiencing childbearing during residency training is increasing, and there is an absence of clarity with respect to parental-leave, lactation and return-to-work policies in support of residents. The aim of this review was to examine parental-leave policies during residency training in surgery and the perceptions of these policies by residents, program directors and coresidents, as described in the literature.

**Methods:** We performed a scoping review of the literature based on the following themes: maternity or parental-leave policies; antepartum work-restriction policies and obstetric complications; accommodations for training absences; support for, and perceptions of, maternity or parental leave during residency training; and challenges upon return to work, namely resident performance and breastfeeding.

**Results:** Parental-leave policies during surgical residency training have historically lacked clarity and enforcement. Although recommendations for parental leave are now in place, this may have historically contributed to a lack of perceived support for surgical residents and may result in variable leave permitted to residents. Unclear policies may also contribute to career dissatisfaction among resident parents, which may deter qualified individuals from selecting surgical subspecialties.

**Conclusion:** A call for a cultural shift is required to inform policies that would better support residents across all surgical specialties to pursue success in their dual roles as parents and surgeons. With increased awareness, progress in policy and guideline development is under way.

In North America, the cohort of surgical residents has diversified over the last 20 years with respect to gender.1,2 Yet, institutional parental-leave policies, and historical enforcement of these policies, has been slow to adapt to this landscape.3,4 As such, childbearing during residency training was historically discouraged owing to perceived or actual demands of training, burdens to colleagues5,6 and the impact on personal finances.7–9 Residents who are pregnant may also perceive variable support from program directors,10,11 and that pregnancy is a negative threat to their career.3,7,12–14 As a result, a female resident is more likely to feel sad about the prospect of having children13 and delay childbearing when compared with male colleagues.8,14,15

When comparing across all specialties, we found that the female surgical resident is more likely to delay childbearing16 and, when maternal age is controlled for, is more likely to use assisted reproduction to achieve pregnancy16 and face greater obstetric complications.17 This, combined with a lack of similar gender role models,18–21 may support ongoing gender disparities and slow down the culture shift required for full support of parenthood during a surgical residency.

In Canada, residents who meet certain requirements (600 working hours per qualifying period, not including call) are eligible for paid maternity leave (up to 52 weeks),22 although this may necessitate an extension of training. Recently, in July 2020, the American Board of Medical Subspecialties (ABMS) updated its policy to include maternity and parental leave as an explanation for leave during training.23,24 Similarly, in March 2020, the American Board of Plastic Surgery instituted a policy that allows for 12 weeks of maternity or paternity leave, medical leave, foster care, adoption or family leave, without exhaustion of vacation time or extension of training.25

Despite the presence of these universal parental-leave policies, there is less clarity when it comes to phased return-to-work policies.23,26 As the number of pregnant residents increases,1,27–30 there is a timely need to improve consistent implementation of universal parental leave, and to introduce phased return to work and lactation support for residents. The goal of this article is to provide a scoping review of the literature to inform prospective and current surgical residents of the existing policies and current perceptions of parenthood during residency training. We strive to inform policy changes to better support surgical residents in pursuing success in family and their academic careers.

## Methods

We performed a scoping review of the literature according to the following topics: maternity or parental-leave policies; antepartum work-restriction policies and obstetric complications; accommodations for training absences; support for, and perceptions of, maternity or parental leave during residency training; and challenges upon return to work, namely resident performance and breastfeeding (Table 1). We consulted library services at Sunnybrook Health Sciences Centre to develop the search terms to best explore the chosen topics. We performed an electronic search of the Ovid database (MEDLINE, Embase, PsycINFO and Cochrane Library), using the following terms: Internship and Residency/ or Resident.mp., exp/ Education, Medical Graduate/., Family leave/or Parental leave., Maternity leave .mp., Paternity leave.mp., Child-bearing. tw,kf., ((sug* or female or medical) adj2 residen*). tw.kf. We assessed publications between January 1980 and February 2019 and retrieved 201 articles. Duplicates (*n* = 24) were removed and titles and abstracts were reviewed by 1 research staff member (J.S.J.). We removed non-English articles, review articles, editorials and letters to the editor (*n* = 36), as well as nonrelevant articles (*n* = 83). Data were extracted and amalgamated into topics (J.S.J. and L.S.). This scoping review discusses the findings of the resulting 58 articles.

View this table:
[Table 1](http://canjsurg.ca/content/66/2/E132/T1)

Table 1 
Themes discussed

Of note, we recognize that not all pregnant individuals or individuals who give birth identify as female. Throughout this manuscript, we use only gendered language as per our references.

## Results

### Parental-leave policies affecting surgical residents in North America

In Canada, all employed birthing parents are eligible for financial support during 17 weeks of maternity leave and 35 weeks of parental leave after the birth of a child.31 Financial support during maternity leave is offered by Canada’s Employment Insurance Program (EI), which provides 55% of total salary, up to $547/week.22 In addition to EI, a resident may be topped up by their provincial residency contract (Table 2).22 To qualify for the financial benefits of EI, roughly 15 weeks of work (excluding call) is required to incur the 600 hours during the qualifying period.31 Consequently, a resident in their first postgraduate year or a resident who begins their training while pregnant will not qualify for this type of financial support.31 A graduated resident enrolled in a fellowship program will likely also not qualify for this support.31 Financial support programs in place do not necessarily reflect program-level parental-leave policies in surgical residency programs.32 Therefore, despite the available financial support, not all residents participate in the full period of parental leave for which they are eligible.33 Of those surveyed by Augustine and colleagues,33 92% of residents and 86% of staff surgeons who gave birth to a child took maternity leave.33 However, among male respondents, 24% of residents and 33% of staff surgeons fathered a child during residency and only 50% of residents and no staff surgeons took parental leave.33

View this table:
[Table 2](http://canjsurg.ca/content/66/2/E132/T2)

Table 2 
Canadian leave provisions as of 2016 – Canadian’s employment insurance program and provincial residency contract top-up

In the United States, the maximum duration of leave from residency for any reason (vacation, sick leave, parental leave) that will not require extension of training is defined by the ABMS.24 As late as 2018, there remained variability between surgical specialties (Appendix 1, Table 1, available at [www.canjsurg.ca/lookup/doi/10.1503/cjs.009321/tab-related-content](http://www.canjsurg.ca/lookup/doi/10.1503/cjs.009321/tab-related-content)), yet most pregnant residents reported 5–8 weeks of maternity leave during training,8,34,35 with proceduralists being more likely to report maternity leaves of shorter durations (< 8 wk).7 Encouragingly, in July 2020, the ABMS announced progressive leave for residents and fellows, which provides more flexibility to create a parental, family or medical leave protocol that best suits the training required for a specialty or subspecialty, with a minimum duration of leave for this purpose to be 6 weeks.24

For practising surgeons, there are no regulatory guidelines for maternity-leave benefits. The mean paid child-bearing leave in 2016–2017 for faculty physicians at 12 high-ranked US medical schools was 8.6 weeks.36 In 2021, the American College of Surgeons published a bulletin in support of healthy pregnancy outcomes.37 The bulletin suggested that the terms of parental leave should be outlined in all employment contracts, payment should be negotiated, accommodations to duty hours and call schedule should be considered, and parental leave should not affect career progression.37 Therefore, financial support during leave may vary by institution, full- or part-time status and duration of employment before leave.38

### Antepartum work policies and obstetric complications

Antepartum work restrictions are better outlined at the provincial level for Canadian surgical residents (Table 3). Of the 8 Canadian provinces with surgical residency training programs, each endorses a reduced workload policy for pregnant residents31 (Table 2). These recommendations define the gestational week at which a pregnant resident is relieved of call duty and is not required to work extended shifts.31 Augustine and colleagues33 observed that Canadian plastic surgery residents and staff surgeons were concerned regarding how far into pregnancy a resident should be expected to take call, despite the existence of guidelines. The higher risk of obstetric complications among surgical residents compared with the general population — including miscarriage, hypertension in pregnancy, placental abruption and intrauterine growth restriction17 — highlights the importance of follow-through with respect to the antepartum work-restriction guidelines. Behbehani and colleagues17 observed a higher rate of obstetric complications in residents working 6 or more nights per month on call compared with those working 6 or fewer nights per month on call. The authors also observed that the complications rate was higher among surgical residents operating 8 or more hours compared with those operating 8 or fewer hours (42% v. 9%).17 Similarly, Hamilton and colleagues39 observed that the risk of preterm delivery was higher among orthopedic surgeons than in the general population, and residents working more than 60 hours per week had an even greater risk.39 A recent survey of Canadian plastic surgery residents found that of those who became pregnant, 42% experienced complications.33 Accordingly, in a 2011 study, 70% of pregnant Canadian general surgery residents stopped overnight call at 35 weeks, and 65% stopped clinical duties at 36 weeks.40

View this table:
[Table 3](http://canjsurg.ca/content/66/2/E132/T3)

Table 3 
Canadian antepartum leave provisions as of 2016

In contrast, in the available literature,15,41–43 it appears that many residents in the US continued to work an unmodified schedule until labour.30,44 Several pregnant residents reported an unmodified work schedule until birth,41 and many believed this adversely affected their health or the health of their child.17,39,42,45

To address this, in August 2021, the American College of Surgeons published recommended accommodations to call schedule, duty hours and operative schedule late in the third trimester.37 The recommendation also included flexibility for new mothers who intended to continue breastfeeding to express breast milk during work hours.37

### Accommodations for training absences

In Canada, a surgical resident may be granted an extended parental leave, and benefits can be paid up for to 61 weeks.46 The benefit rate is 33% of the resident’s average weekly insurable earnings, and when the second parent (non–birth parent) takes a minimum of 5 weeks of parental leave, the parental benefit increases by up to 8 weeks for a total of 69 weeks.46 Of note, in Canada, parental leave benefits are shared per family.46 In doing so, the resident is not obliged to “make up” missed call accrued from their training absence but may have to extend their training to satisfy the requirements of the Royal College of Physicians and Surgeons of Canada.

In the US, it has been reported that surgical residents may have had to make up missed call47,48 in addition to extending their training49,50 if they exceed maximum leave set by the ABMS-member Board.51 As of 2018, the median leave among all specialties was 6 weeks,31 but differences exist among programs (Appendix 1, Table 1). The maximum allowable time away from training per year without having to add additional training time varies among specialties.23 In addition, the capacity to accumulate leave over the duration of training varies by program.23 These inconsistencies have resulted in discrepancies in formalized maternity or parental-leave policies and in the permitted duration of leave. In these environments, most female surgical residents report that returning to work is the most difficult aspect of their pregnancy,52,53 when they may have to overcome obstetric complications or the challenges of parenthood or both, and continue to fulfill time-based training requirements.

### Perceptions of parental leave

Often, the work of pregnant colleagues is covered by coresidents, without compensation or schedule rearrangements.5,44 The necessity of co-residents to cover parental leave may be the result of scheduling inflexibility or inadequate service coverage.54 Nonetheless, the increased load on co-residents may contribute to negative perceptions of the resident parent.40 Notably, pregnant residents themselves perceive the negative impact of their pregnancy on co-residents.53 Significantly more female than male resident parents (63% v. 43%) felt that childbearing placed a burden on their colleagues.13 This perceived stigma from co-residents is associated with female surgical residents’ desire to revisit their career choice.9 Notably, parenthood during residency training is not an issue exclusive to child-bearing residents, but rather one that affects co-residents as well as the residency program and, for this reason, supporting institutional policies that alleviate scheduling burdens are necessary.

As few as 30% of plastic surgery residents said they felt supported during their pregnancy by their program directors,15 and 65% felt supported by their attending surgeons.6 Among all specialties, surgical residents report the lowest support for pregnancy from male residents and faculty.55 In a nationwide survey of general surgery residency program directors, 15% said they would advise against having a child during residency.10 In a recent assessment of gender diversity and equity policies among Canadian plastic and reconstructive surgery programs,32 our group observed that these programs had an approach for paid maternity, paternity or caregiver leave, but only 2 had approaches to support trainees as parents.32

As many as 39% of pregnant surgical residents surveyed by Rangel and colleagues41 considered leaving surgery, and 29% would discourage students from a surgical career, specifically because of the difficulties of balancing pregnancy and motherhood.41 Interestingly, the duration of maternity leave may mediate career satisfaction and perceived support,41 and so longer maternity leave may alleviate some of these stressors, resulting in residents who are more satisfied with parenthood and breastfeeding.8

### Challenges upon return to work: resident performance, well-being and breastfeeding

In 2 surveys of program directors — obstetrics and gynecology5 and general surgery10 — it was observed that 83% and 61%, respectively, asserted that pregnancy during training decreases performance.5,10 In studies evaluating the average American Board of Surgery In-Training Exam scores as a metric to compare performance before child-birth with performance after pregnancy, Shifflette and colleagues52 report that 31% scored lower after pregnancy compared with their prepregnancy scores, whereas others did not report fewer pass rates.52,56 It is possible that lower scores may be explained by the added workload and disproportional parenting duties of female resident parents.57 Physician-parent survey respondents revealed that males were more likely to miss family activities owing to work demands, whereas females reported missing more work activities owing to family responsibilities.57 To the best of our knowledge, no group has examined the effect of parenthood during training on either ABMS or Royal College of Physicians and Surgeons of Canada certifying examination pass rates.

Despite an increase in parenthood among residents, it appears that residents of all genders are equally pursuing academic endeavours and careers.58 General surgery residents who were pregnant during their training were more likely to pursue fellowships than nonparents.56 The academic achievements of childbearing residents may be comparable with those of nonparents because many residents pursue graduate degrees, mentor students and prepare manuscripts while on maternity leave.30 Recently, Merchant and colleagues6 observed that 39% of female general surgery residents who took 6–12 months of leave engaged in graduate work or research so as to not lose time from training, remain intellectually challenged and receive pay. Thus, financial incentives or burdens, as well as support or lack thereof from program directors, are 2 factors that may influence the duration of maternity leave taken by residents.59

Regardless of the resident’s productivity during their leave, upon return to work they are more likely to feel that childbearing during training negatively influenced professional perceptions60 and adversely affected their career.13 A resident may also face sleep deprivation, difficulties arranging child care and the agony of leaving a newborn child.61

On top of these challenges, a resident may face barriers to breastfeeding, which is of concern given that breastfeeding for less than 8 weeks is associated with postpartum depression.62 The resident may not be guaranteed time or adequate facilities to breastfeed,6 be too busy, not have a place to pump close to the operating room, or feel unsupported by an attending surgeon and co-residents.6 This may result from a lack of formal lactation policies and unavailability of on-site lactation facilities, which have been reported by only 58% of program directors.10 In Canada, provision of longer maternity leave may alleviate some of the obstacles associated with breastfeeding, yet there are not enough lactation services to support breastfeeding during training.6,10

Implementing policies to support lactation during training is critical. Fortunately, progressive lactation policies exist, such as described in Gordon and colleagues,54 which protect 30 minutes of breastfeeding every 4 hours.54 The provision of dedicated lactation rooms with hospital-grade pumps may improve the efficiency of postpartum residents through reduced pumping time and increased mean milk volume.63 Storage capabilities are also essential.63 The ability to breastfeed during training may, however, be influenced by medical subspecialty.64 For example, a surgical resident may find it difficult to leave the operating room to pump, and the lactation facilities, if present, may be far removed from the operating room.40 Combined with the time needed to pump and store the milk, this requires the resident to be away from a patient for a substantial amount of time.40 This prolonged absence, along with a lack of understanding regarding the necessity to consistently pump, may contribute to surgical residents terminating breastfeeding earlier than they wished.64

## Conclusions and future directions

A recent survey from the American Society of Plastic Surgeons found that 73% of women and 39% of men delayed starting a family because of the demands of training.15 Trends in Canada are similar, as 72% of residents did not want to become pregnant during residency.33

In the face of obstetric complications among pregnant residents17,39 and a lack of contingency plans for service coverage by co-residents,27 clearer antenatal, parental and return-to-work policies are needed. Encouragingly, progress is being made, as illustrated by recent ABMS and American Board of Plastic Surgery policies, as well as by American College of Surgeons guidelines.37 Specific examples of progressive policies in other specialties — such as that put forth by Gordon and colleagues54 for emergency medicine residents at a renowned teaching hospital — suggest that parental leave, return-to-work and breastfeeding policies to support resident parents are feasible. These policies should include accessible infrastructure for pumping and program-wide education on the importance of breastfeeding.27,65 The absence of universal policies for parental leave, antenatal work modification and postpartum modifications at the program level is not unique to North American surgical-residency programs. In countries in the European Union, policies exist that provide surgical residents with varying levels of support for parental leave26 (Appendix 1, Table 2). Of note is the fact that several countries endorse a mandatory maternity or parental leave.26 This concept does not currently exist in North America. A mandatory leave period may help with enforcement of policy and encourage the requisite cultural shift necessary to support parenthood in the surgical training environment. In short, as the number of childbearing residents increases, there is a call for a cultural shift of residency training programs to better support their trainees as parents.

## Footnotes

*   **Competing interests:** Joan Lipa reports reimbursement for travel expenses for the American Board of Plastic Surgery and the American Society for Reconstructive Microsurgery. Dr. Lipa is director and chairelect of the American Board of Plastic Surgery and president, American Society for Reconstructive Microsurgery. Laura Snell is co-lead of equity, diversity and inclusion at the Department of Surgery, University of Toronto. No other competing interests were declared.

*   **Contributors**: All of the authors contributed to the conception and design of the work. Laura Snell contributed to the acquisition of data. Laura Snell and Joan Lipa contributed to the analysis and interpretation of data. Josephine Jakubowski, Heather Baltzer and Laura Snell drafted the manuscript. Heather Baltzer, Joan Lipa and Laura Snell revised the manuscript critically for important intellectual content. All of the authors gave final approval of the version to be published and agreed to be accountable for all aspects of the work.

*   Accepted June 21, 2022.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: [https://creativecommons.org/licenses/by-nc-nd/4.0/](https://creativecommons.org/licenses/by-nc-nd/4.0/)

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