Pregnancy during Residency

A Literature Review

Abstract

Purpose 

It is estimated that by 2010 30% of U.S. physicians will be women. Pregnancy during residency can and does happen in all programs, and continues to provide problems for many. The author reviews the issues surrounding pregnancy during residency by evaluating published commentaries and research reports.

Method 

A literature search was conducted using Medline (January 1984–October 2001). Published articles were categorized as research or commentary. Research reports were sorted by content and summarized under three headings: mother and infant health, sources of stress and support for the pregnant resident, and reactions of colleagues to the pregnant resident.

Results 

A total of 27 research reports were located; two additional reports published before 1984 were added because they complemented included studies. The majority of the studies in this review used retrospective self-report questionnaires, mostly completed by female residents and physicians. All reports suggested an increased risk of complications, especially adverse late-pregnancy events, for pregnant physicians. Pregnant residents found the physical demands of residency and lack of support from fellow residents and their departments most stressful. Anger and resentment toward the pregnant resident were common among not-pregnant residents, feelings particularly associated with expectations of increased workload. Individual maternity/parental leave policies were inconsistent. Policy development is discussed.

Conclusions 

The studies in this review supported planning for residents' pregnancies, and the author advocates clear maternity/parental leave policies. The author comments on the use of existing data to make common sense changes and on the need for further studies to help clarify the issues and evaluate program changes.

The number of women in medicine has been increasing over the years.^1,2,3,4 Estimates suggest that by 2010, 30% of all U.S. physicians will be women.¹ In 1997, more than 21% of Canadian specialists, 50% of Canadian medical students,³ and 36% of all Israeli physicians were women.⁴ A 1990 American Medical Women's Association survey showed that the number one concern of its members was maternity and medicine.⁵

Many women in medicine want to combine career and family. One study showed that there was no difference between male and female physicians in the numbers of children they wished to have.⁶ A 1999 study of Israeli female physicians found that the mean number of pregnancies during residency per resident was 1.3, with smaller numbers for pregnancies in medical school and post training. Thirty-eight percent of female physicians surveyed had two or more pregnancies during residency. The mean age at the first delivery was 27 years, not significantly different from that of the general population.⁴

A study of residents and program directors of Harvard-affiliated programs found that pregnancy during residency was common (one in eight married female residents in 1983), and that these pregnancies were usually planned (77%).⁷ Similarly, a survey of 2,000 U.S. obstetrics and gynecology (ob/gyn), surgery, and psychiatry residents found that, while 28% of the residents' pregnancies were unplanned, most were wanted pregnancies.⁸ The residents who had unplanned pregnancies were more likely to experience conflict between the wish to have a baby and their career expectations. A study of female residents and spouses of male residents reported in 1990 found that 35% of residents' pregnancies were unplanned; 19% of residents' pregnancies occurred because they were not using birth control.⁹ So, as many studies have indicated, the majority of pregnancies during residency are planned, some are unplanned, and some residents leave the decision to chance.⁸

Clearly, pregnancy during residency is common. This is not a great surprise, considering that medical training is long and spans the main childbearing years. However, the demands of residency conflict with the realities of childbearing: the age limits of fertility, the time needed to develop a relationship with a partner, the time and energy needed to carry a baby, the need to eat and sleep properly to ensure health, the time needed for bonding and attachment, and for breastfeeding and caring for a baby, and the availability of child care.⁷ Society sees medicine and motherhood as two separate careers that require constant attention and availability.^2,8 Moreover, the medical profession still has negative attitudes toward pregnancy in residency. For example, in one study, a female obstetrician stated, “Becoming pregnant is not appropriate during this time period [residency]. If you [or they] want to conceive, they should do it on their own time and not inconvenience others.”⁸ “It is unacceptable to become pregnant during residency” was a comment made to the Advisory Committee on Equity Issues of the Royal College of Physicians and Surgeons of Canada regarding parental leave during residency.³

Why then do women choose to become pregnant during residency? The most common reasons include desiring a family, being of childbearing age, enjoying children, desiring pregnancy, and being concerned about decreasing fertility and a partner's age.^7,8

The residency years are particularly intense, characterized by long hours and psychological stress. Many residency programs rely heavily on residents' workloads to provide adequate medical services. In this context, a resident's pregnancy creates complications for the resident, her colleagues, and the program.

Three literature reviews have been published on this topic in the last decade.^2,10,11 One review was limited to why residents choose a pregnancy, and to mother and infant health, while another limited itself to one specialty.^10,11 The most comprehensive review was published in 1993, and its main emphasis was parental leave policies in the United States.² With the increased number of female residents and expected greater numbers of pregnancies during residency, it is important to review the progress made and how new literature has altered these issues. Leave policies have progressed, certainly in Canada, since then, and there are issues beyond leave policies that remain to be addressed.

METHOD

I conducted two separate Medline searches. One search covered articles published between January 1984 and December 1995, the other between January 1995 and October 2001. The search terms I used were resident pregnancy, pregnancy in physicians, and maternity and medicine. I screened publication lists by title and abstract for relevant articles and included those on the pregnant resident across specialties and in individual specialties. I classified all articles as research or commentary, considering an article research if it reported data that had been collected and analyzed. I searched the references in the research articles and the previous literature reviews for any research not discovered in the Medline searches.

Research articles, sorted by content, are summarized and discussed in this paper under three headings: mother and infant health, sources of stress and support for the pregnant resident, and reactions of colleagues to the pregnant resident. Some studies reported data relevant to more than one heading, and I discuss each one under the relevant heading. I excluded studies that presented data solely on institutional maternity/parental leave policies, because these have been reviewed elsewhere. Rather, I discuss the development of maternity/parental leave policies.

RESULTS AND DISCUSSION

My literature search yielded 27 studies published in or after 1984 that fit the inclusion criteria.^{4,7,8,9,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34} I later added two studies published before 1984 because they complemented articles under the heading “reactions of colleagues to the pregnant resident.”^35,36 Eighteen studies had participants across specialties,^{4,7,8,9,12,13,14,18,19,20,21,22,25,28,30,32,33,35} and 11 were specific to one specialty.^{15,16,17,23,24,26,27,29,31,34,36} Specialties represented were psychiatry with four articles,^23,26,27,36 ob/gyn with two,^15,31 pediatrics with two,^16,34 and surgery,²⁴ plastic surgery,¹⁷ and family practice²⁹ with one each.

Twenty-four of the 29 studies used self-report questionnaires,^{4,7,8,9,12,13,15,16,17,19,21,22,23,24,25,26,28,29,30,31,32,33,35,37} with 15 surveying female physicians,^{4,8,15,16,17,19,22,23,24,25,26,28,29,32,33} four surveying female residents and spouses of male residents,^9,12,13,21 three surveying female residents and faculty,^30,34,35 and one study each surveying all residents,³¹ and residents and program directors.⁷ Two studies were interview-²⁷ and observation-based³⁶ cohort studies, one was a controlled longitudinal study,²⁰ and two were retrospective chart reviews.^14,18

Mother and Infant Health

Thirteen of the studies in my review reported data on mother and infant health,^{4,12,13,14,15,16,17,18,19,20,21,22,32} nine of which reported outcomes of pregnancy during residency (see Table 1).^{4,12,13,14,15,16,17,18,19} The four remaining studies explored different aspects of mother and infant health, and I discuss them individually.^20,21,22,32

Table 1: Studies That Analyzed Outcomes of Residents' Pregnancies

Residency is fraught with factors that could complicate a healthy pregnancy, including potential increased exposure in hospitals to infectious and cytotoxic agents.⁴ Prolonged standing and strenuous physical activity are also characteristic of residency.

In 1998, Seguin³⁷ reviewed the relationship between pregnancy and working conditions in general. Although her results were inconsistent, she found increasing evidence that long working hours and prolonged standing may place a pregnancy at risk. Seguin's review suggested a relationship between increased physical stress and prematurity. She concluded that jobs requiring more than five hours of standing and walking per day should be modified during a worker's pregnancy, and also recommended that physicians counsel their patients about these risks and suggest early modification of employment activities.

Low socioeconomic status is a risk factor for pregnancy outcome, and physically strenuous work is often associated with low socioeconomic status, making it difficult to determine the primary cause of increased risk.^12,13 In order to clarify the risk to pregnancy outcome of residency, studies have analyzed the outcomes of residents' pregnancies specifically because residents are in a high socioeconomic status and have long work hours (see Table 1). An extensive study reported in 1990 used a questionnaire and compared the outcomes of pregnancy during residency among 1,293 U.S. female residents and 1,494 wives of their classmates.¹² On average, female residents in this study worked twice as many hours, stopped working 12 days versus 35 days before their deliveries, and perceived less support from supervisors and colleagues than did wives of male residents. The primary outcomes measured were incidence of preterm delivery and birth of a baby small for his or her gestational age. Neither of these outcomes differed for the two groups with the exception of a higher incidence of preterm delivery for residents working more than 100 hours per week. Based on these findings, the authors concluded that working long hours in a stressful occupation had little effect on outcomes of pregnancy in a healthy population of women of high socioeconomic status. However, the study also found residents to have a twofold increased risk of pre-eclampsia and premature labor requiring bed rest or hospitalization, which the authors explained as likely diagnostic bias. A number of researchers have rejected this explanation, and argued that the conclusions of the study are both inaccurate and overly broad.^{38,39,40,41,42} Another questionnaire-based study reported an increased incidence of preterm labor for female residents compared with wives of male residents.¹³

Two studies comparing physicians' pregnancies with pregnancies in the general population have suggested increased incidences of preterm labor, abruptio placentae, cesarean section, stillbirth, and premature delivery.^4,14 A comparison of births to obstetricians before, during, and after residency showed an increased incidence of low-birth-weight and IUGR (intra-uterine growth retardation) infants born to residents.¹⁵ A 36% complication rate was found in pediatrics residents' pregnancies, with preterm labor, pre-eclampsia and hyperemesis being the most common complications.¹⁶ Pregnant plastic surgeons had a high complication rate (57%) and a 26% elective abortion rate, and this group had a 33% infertility rate.¹⁷ A retrospective chart review study comparing pregnancies of physicians and non-physicians of similar socioeconomic status found that the physicians had a 1.86 relative risk of an adverse pregnancy outcome, with equal or greater frequencies for all adverse outcomes. Both preterm labor and preterm delivery were significantly increased. The authors of the study suggested that physicians should be considered and treated as a high-risk obstetric group.¹⁸

Phelan compared obstetric complications among 191 ob–gyn, 28 surgery, and 74 psychiatry residents' pregnancies.¹⁹ No difference was found among the residents, and pregnancy-induced hypertension was the only complication significantly higher than in the general population. The author suggested that this may have reflected the older maternity ages of the residents, because all three groups had similar rates.

Even though a definitive prospective study has not yet been done, all studies to date have suggested an increased risk of complications, especially adverse late pregnancy events, for pregnant physicians. There is evidence to indicate higher rates of preterm labor and delivery, pre-eclampsia, stillbirth, low birth weight, and abruptio placentae, the same constellation of risks associated with women who work at physically strenuous jobs. It has, thus, been suggested that these complications may be caused by a decrease in uterine blood flow, mediated by catecholamines (known to increase with physical and mental stress) and postural effect.⁴³ A small longitudinal study published in 1991 involving ten physicians, three ICU nurses, and 12 working control participants showed an increase in urinary catecholamines for working nurses and physicians of 58%, compared with catecholamine levels measured in non-work times, and 64% compared with the working control participants.²⁰

Little has been written about early adverse outcomes associated with physicians' pregnancies. A study that used a self-report questionnaire compared abortion rates for 1,284 residents' pregnancies and 1,481 pregnancies of partners of male residents.²¹ In spite of toxic exposures, female residents were not more likely to spontaneously abort. Female residents were about three times more likely to voluntarily terminate a pregnancy than were partners of male residents, and that significance persisted when only the married female residents and married partners of male residents were compared. The authors were reassured because pregnant residents were half as likely to terminate a pregnancy as were pregnant women in the general population. However, it seems likely that increased terminations among married residents are occurring due to the overall physical, psychological, and emotional environment of residency.

As many studies have noted, breast milk is the recommended primary nutritional source for infants. Resident mothers have characteristics associated with high rates of breastfeeding. A study of U.S. female physicians identified 60 respondents who gave birth during their residencies.²² Eighty percent initiated breastfeeding and continued breastfeeding during maternity leave (mean seven weeks). Half discontinued on return to work, and by six months the rate had dropped to 15% breastfeeding, well below the national goal (50% breastfeeding six months postpartum). The primary reason for discontinuing was the residency work schedule. For those who continued breastfeeding, difficulties included insufficient time and no appropriate place to pump at work, and mixed support from attending staff and colleagues.²²

Encouragingly, a study published in 2000 suggested that pregnancy may be a time of particularly healthy habits and productivity for female physicians. Using data from a U.S. national self-report questionnaire, 87 pregnant and 1,148 not-pregnant female physicians aged 30–40 were compared.³² The pregnant physicians ate healthier foods, exercised as much as, and reported better health status than the not-pregnant physicians. Work amount, desire to work less, perceived work control, career satisfaction, and work stress did not significantly differ by pregnancy status.

During a pregnancy, residents are exposed to increased cytotoxic, infectious, radiologic, and chemical agents.¹⁸ These exposures may be avoided because of the known risks to the fetus. However, in 1999 a debate was published about whether a pregnant resident should be excused from or have flexible scheduling around training rotations such as angiography and nuclear medicine.⁴⁴ Physical stresses may be more difficult to avoid. As physicians we feel comfortable recommending modified work hours to pregnant women in physically strenuous jobs.³⁷ However, no such recommendation has been made for physicians who are pregnant. Miller and Katz wrote, “It is ironic that we … feel compelled to document whether objective untoward outcomes occur with pregnancies during residency. Prudent obstetricians would not advise their pregnant patients to work 80 to 100 hours per week.”⁴¹

Sources of Stress and Support for the Pregnant Resident

Attitudes toward women in medicine are not always positive. These internal and external judgments become obstacles in a female physician's life. I identified 13 studies that analyzed pregnancy experiences and sources of stress and support for the pregnant resident.^{4,7,8,9,16,17,23,24,25,26,28,29,33} One study reported on feelings of discrimination,²⁴ and I discuss this study individually. Twelve of these studies have overlapping results and are summarized in Table 2.

Table 2: Studies That Analyzed Residents' Pregnancy Experiences

Table 2: Continued

A study of 459 Canadian female surgeons practicing in 1990 (response rate 91%) indicated that, during training, about half the respondents experienced discrimination (defined as the perception that female surgeons faced prejudice because they are women) from male attending physicians and nursing staff. Fifteen percent felt discriminated against during residency selection, and 17% felt that discrimination had affected their career development at least a fair amount.²⁴

Discrimination often is heightened during a resident's pregnancy, and female physicians are acutely aware of this, as reflected by the comments in one study of an ob–gyn resident and an obstetrician, neither of whom chose to have a pregnancy during residency: “As the first female resident in the program, I did not wish to color opinions against future women in the program;” and “Medicine/surgery specialties are geared to the feeling that anyone who doesn't work overtime and have essentially medicine as their life is sort of an oddity. If male, he is viewed with suspicion, as uncommitted or unreliable. If female, the sentiment is that she took a man's place who would have been a ‘real’ doctor.”⁸

With these pressures and the general lack of role models who have successfully combined their physician and mother roles, it is not surprising that pregnant residents feel guilty and vulnerable. Feelings of inadequacy due to physical and emotional limitations may lead a resident to deny these limitations and to overcompensate and overwork.² Some examples of this may be working right up to delivery, doing extra night call ahead of time to compensate for time missed during maternity leave, and taking shorter maternity leave than desired.

Table 2 summarizes 12 questionnaire-based studies that analyzed the pregnancy experiences of residents. Most pregnant residents in these studies took virtually no time off during their pregnancies, and returned to work full time following maternity leaves that ranged from 0 to 36 weeks.^{4,7,23,25,26,28} In two cross-specialty studies in the United States and Israel, about half the respondents (43% in U.S. and 51% in Israel) found pregnancy during residency “pleasant,” with 5% finding the experience “miserable.”^4,7 A third study of U.S. pediatricians found higher rates of “misery” (24%) during residents' pregnancies, with only 24% rating their experiences as “pleasant.” Nevertheless, two thirds of the U.S. pediatrician respondents felt they would have chosen again to have a pregnancy during residency, a rate even higher than that for the Israeli physicians (52%).

Several studies have shown that the timing of the pregnancy was important to reduce stress.^26,37,38 In one of these studies, Canadian psychiatrists who were pregnant during residency felt the best time was during the second or third year of residency, and recommended avoiding pregnancy during the first year.²⁶ Phelan found that 68% of a group of U.S. residents recommended pregnancy during residency but with the following qualifications: A program should have flexible elective time and a resident needs to time her pregnancy during residency. A program's size and the availability of personal support are also important factors to consider. The most common recommendation was that residents give birth in the last two or three months of residency, which would allow for continued insurance coverage, decreased clinical responsibility, and potentially extended maternity leave between jobs.²⁸ Several studies suggested that in hindsight, a significant percentage of women physicians would have preferred pregnancy after completing their residencies or would have changed the timing of their pregnancies during residency.

Several of the studies in Table 2 examined the sources of stress and support for pregnant residents.^{4,7,23,26,28,29} Stressful factors included frequency of call, fatigue, long hours, the emotional strain of residency, too little time with a partner, inadequate maternity leave, child care difficulties, breastfeeding problems, and work expectations during maternity leave.^23,26,28,29 Generally, partners, other residents, and medical staff (especially women) were considered supportive, but feelings of denial, resentment, and hostility from colleagues and program directors were stressful.^{4,7,23,26,28,29} A study conducted at Harvard found that the support of the program director, open discussion of pregnancy, and the ability to return to work part-time initially after maternity leave largely determined how “pleasantly” a resident experienced her pregnancy.⁷

Colleagues' Reactions to the Pregnant Resident

A resident's pregnancy will have an effect on her residency program and may generate conflicts with her colleagues. I identified six studies that addressed the reactions of colleagues to the pregnant resident.^{27,30,31,34,35,36} These are all discussed individually because the studies' designs and results differed significantly.

A questionnaire-based study published in 1983 surveyed 341 faculty and residents of the Medical College of Ohio and had a response rate of 42%.³⁵ The respondents felt that a pregnant colleague was an inconvenience to themselves (80%) and their departments (30%), but that pregnancy had a humanizing effect on the work environment (67%). Most felt pregnant physicians did maintain professional interests and efficiency, but one third believed women of childbearing age were a hiring risk. Opinions about the effects of pregnant physicians on departments often differed along gender lines, and depended on whether the respondent was a faculty member or a resident.³⁵ Generally, men were less receptive to a pregnant colleague, and women more than 40 years old were the most accepting of all.

Almost ten years later, another study was conducted at the Medical College of Ohio.³⁰ The response rate increased to 56% of 359 faculty and residents, and only a small minority described pregnant colleagues as a personal inconvenience. Physicians agreed or disagreed with 15 statements regarding attitudes toward pregnant physicians. Faculty members had only one item that showed a significant gender difference: “Females of childbearing age should be considered a risk to the optimum functioning of the department,” Eight of the 15 items showed significant gender differences among the residents. Female residents agreed that pregnant physicians maintained job performance, interest in departmental affairs, and interest in their chosen fields of medicine; they also agreed that pregnancy drew staff closer and endorsed flexible scheduling. Male residents, however, agreed far more often than female residents that pregnancy was disruptive to relationships with colleagues, and that women of childbearing age were a risk to the optimum functioning of the department.³⁰ The authors commented in the study and in a letter to the editor discussing the two studies that, overall, attitudes toward pregnant colleagues were more positive, and there was more support for parental leaves, especially from physicians less than 40 years old.^30,45 They concluded that it was the experience with pregnant physicians in the department that had led to less fear and more interest in this issue.

Staff responses to the pregnant psychiatrist were described by Benedek based on her observations during her own pregnancies. She observed displaced anger, sibling rivalry, and feelings of abandonment among staff. Later, she felt the majority denied the pregnancy and their feelings about it.⁴⁶ Other studies of cohorts of psychiatric residents where more than one resident was pregnant at a time described prominent anger and resentment.^27,36 One of these cohort studies observed and described events when three residents in a cohort became pregnant at once. The other cohort study was based on open-ended individual interviews with residents in a cohort in which five of nine residents were pregnant. Lines were drawn dividing women's rights from the burden the residents' absence would place on others.³⁶ Both pregnant and not-pregnant resident groups were found to mobilize primitive defenses of projection and denial to deal with emotions.²⁷ Both studies found that a schism developed in the groups as a result of the residents' pregnancies.^27,36

The main stressors for the pregnant resident are the unrealistic work demands of residency. In addition, there is an unstated expectation that an absent resident's workload will be shouldered by the other residents. These stressors are compounded by the lack of acknowledgement, dialogue, and problem solving on the part of program directors and departments. The stresses on the pregnant resident are recognized by the medical profession, as illustrated by a study published in 1990. Two thousand U.S. pediatricians were surveyed by self-report questionnaire, 1,000 receiving a questionnaire on the effects of residency on the fetus, and the other 1,000 receiving a questionnaire on the effects of other full-time work on the fetus. The study found that all subgroups of respondents (based on age and sex) judged residency to be more harmful to a pregnancy than other types of full-time work.³⁴ A study published in 1994 suggested that a change in curriculum can alter residents' attitudes and stress levels.³¹ Responses from two groups of ob–gyn residents (graduated in 1983–87 and 1988–92) at one site were compared. Adding a night call rotation in second year and an administrative rotation in the fourth year of the ob–gyn residency program was found to decrease workloads. Following this change, there was a reduction in residents' resentment of their pregnant colleagues and in the overall stress in the program.³¹

Maternity/Parental Leave Policies

Parental leave is a broad term that includes maternity leave, but also includes leave policies for the partner, and leave policies for parents who are adopting a child. Most programs and institutions are more likely to start with maternity leave policies and later build in broader parental leave policies. Numerous studies have indicated that many residency programs do not have maternity leave policies,^{1,7,9,29,47,48,49,50} that residents weren't aware of existing maternity leave policies,^9,29,48,50 that policies did not adhere to legal or professional guidelines and recommendations,^{1,7,25,28,29,48} that there was pressure to return from leave early,^{7,9,25,26,29,49,50} and that flexibility was limited in terms of meeting board certification requirements and completing residency^{1,7,9,25,28,29,49} Although there seems to be ongoing improvement,⁵⁰ a study published in 1995 showed that many residents still took less than four weeks of maternity leave.²⁹

In spite of inconsistent maternity/parental leave policies in residency programs throughout the United States, legal and professional guidelines have been established. In 1978, the Pregnancy Discrimination Act was added to the Civil Rights Act of 1964.^1,49 This banned workplace discrimination on the basis of pregnancy with regard to job termination, refusal to hire, promotion, and reinstatement. Pregnant employees are to be treated the same as disabled employees for employment purposes.^48,49,51 Similarly, the Canadian Human Rights Act protects pregnant women and women of childbearing age from employment discrimination, because sex discrimination is prohibited.⁵²

In 1989, a position paper by the American College of Physicians suggested that a residency program that anticipates pregnancies and develops parental leave policies would be better equipped to support the mental and physical health of all residents and their families.⁵³ These programs would be more likely to allow flexible rotations while maintaining appropriate patient coverage, and would reduce residents' resentments and gender conflict.^2,53 These programs would, thus, be more able to recruit residents.

In 1991, the American Medical Association adopted a new maternity leave policy that encourages residency programs, specialty boards, and group practices to develop written policies that allow a minimum six-week maternity leave. Policies must not discriminate against child-bearing physicians, should comply with federal law, and should not overburden colleagues or neglect patient care or quality of education.¹ Medical schools and residency programs are encouraged to establish policies that outline insurance benefits and salary adjustments, that address leave for birth and adoption, and that indicate how leave can be made up.² Specialty groups such as the American Academy of Pediatrics and the American College of Gastroenterology are offering specific guidelines to be included in an individual residency program's written parental leave policy while still allowing flexibility for the program and individual situation.^54,55

In Canada, professional residents' associations in each province establish an agreement with the province that specifies residents' rights such as salary, sick leave, parental leave, maximum work hours, and benefits. These contracts clearly state the parental leave policies for each resident in that province regardless of the resident's specialty, hospital, or university affiliation. Moreover, the policies of the different professional organizations are similar to each other. For example, the residents' agreement with Ontario has established a parental leave policy that includes up to 17 weeks of pregnancy leave, and up to 18 weeks of parental leave after the birth of the child. No physician will be required to return to her duties sooner than six weeks after delivery, and pregnancy cannot be cause for termination. In addition, upon completing leave, a resident is entitled to work to complete his or her year; leave will be covered financially by the employment insurance through the hospital until the end of leave or end of training, whichever comes first. All these conditions apply to the birth or the adoption of a child.⁵⁶ Contracts are renegotiated on a regular basis, which allows ongoing improvements in residents' quality of life.

Additional recommendations have been made in the literature to help minimize the stress felt by pregnant residents, and their colleagues and departments. Some of these recommendations include flexibility in rotations and on-call scheduling, breastfeeding and daycare support, external coverage during absences, mutual timely communication with program directors, support groups, and having mentors and role models.^2,4,5,6,7,8

With the increased numbers of residents taking parental leave come concerns about continuity of their education. It has been suggested that videotaping educational sessions or using new technologies such as telemedicine and the Internet could provide flexible learning options.³ At the 1997 Royal College of Physicians and Surgeons of Canada conference on residents' education, some innovative suggestions were made to support quality of life in medicine, such as incorporating practice and stress management into the core curriculum, ascertaining whether leave policies are being followed as part of accreditation approval, and incorporating management of one's personal life into criteria for promotion in university departments.³

Some of these recommendations would require money to implement, and many departments are already strapped financially. On the other hand, a number of changes can be made with minimal financial outlay by changing attitudes rather than structures. It should be recognized that medical residents are highly motivated, hard-working people, and a decrease in workload may actually increase productivity and learning.

CONCLUSIONS

Pregnancy during residency is a complex, multifaceted issue closely linked to other issues in medicine. Residents will become pregnant whether it is convenient or not. Although the data on pregnancy complications are not completely consistent, a clear trend toward an overall increased risk of late pregnancy adverse outcomes, especially premature labor, is present. A more definitive, large prospective study might outline more clearly the specific risks for pregnant residents. It does not seem necessary to wait until then to acknowledge that extremely long work hours with excessive standing and physical exertion would not be recommended. Probably the best indicator to date of the risk to pregnancy posed by the psychological stress of residency is an increased rate of voluntary terminations among married female residents.

Stresses related to pregnancy during residency affect all the residents, staff, and directors of the pregnant resident's department. Further studies would help to clarify specific conflicts, and initiatives aimed at addressing these directly could be developed. It would be interesting to see more studies of attitudes toward pregnancy during residency before and after a department has adopted appropriate policies.

The establishment of written, well-defined parental leave policies is important to support residents and their families. Additional recommendations have been made to ease the stress of being a resident with a family, in addition to easing the stress of the pregnancy itself. Implementing measures to improve residents' quality of life raises concerns about meeting education and service goals. Studies looking at levels of residents' education, service provision of departments, and the competency of graduating specialists after their working conditions improve would be most revealing.

Certainly pregnancy and parenthood can be a valuable learning experience for a resident and can be humanizing for a medical department. Most physicians who are parents bring to both their roles valuable experiences that can enhance all their relationships.