Secondary Logo

Journal Logo

Research Reports

Childbearing Decisions in Residency: A Multicenter Survey of Female Residents

Stack, Shobha W. PhD, MD; Jagsi, Reshma MD, DPhil; Biermann, J. Sybil MD; Lundberg, Gina P. MD; Law, Karen L. MD; Milne, Caroline K. MD; Williams, Sigrid G. MD, MPH; Burton, Tracy C. MD; Larison, Cindy L. MA; Best, Jennifer A. MD

Author Information
doi: 10.1097/ACM.0000000000003549

Abstract

Female physicians and surgeons who desire children face unique challenges in deciding when to pursue childbearing. The average age of a matriculating medical student is 24 years.1 In the context of medical school, residency, and for many, fellowship, these years of training parallel declining fertility rates.2 For example, in a national survey of female obstetrics and gynecology residents, 29% reported diagnoses of infertility.3 Similarly, in a 2016 national survey of female physicians who graduated from medical school between 1995 and 2000, 24.1% experienced infertility.4 Another study comparing female trainees in procedural versus nonprocedural specialties showed that those in procedural specialties were older at first pregnancy, more likely to have prolonged time to conceive, and more likely to require assisted reproduction.5

Countering the risk of unintentional childlessness is the fear of the perceived stigma of childbearing. Often residents who become pregnant worry about the perception of not “carrying my weight”6–8 and subsequently creating resentment among other residents.9,10 This concern was substantiated by a national survey of general surgery program directors in which the majority reported that parenthood negatively affects a female trainee’s work and well-being.6 A smaller percentage also perceived a negative impact on scholarly activities, timeliness, and dedication to clinical work. Similarly, in a national survey of obstetrics and gynecology program directors, the majority believed parenthood negatively affects resident performance and well-being.11

Single-center peer surveys indicate similar attitudes. Among emergency medicine residents, 17.1% perceived pregnant colleagues as less efficient.12 Another study found that pregnant residents in internal medicine received lower peer evaluation scores than male residents whose partners had experienced pregnancy.13 Even as the number of women in medicine increases, the stigma of childbearing has persisted over time. This phenomenon has been demonstrated in longitudinal surveys of general surgery residents showing a consistent and substantial negative perception of their pregnant peers.14,15

No study to date has explored how competing desires to start a family and fulfill resident obligations influence a resident’s decision to delay or not delay childbearing during training. To better understand how female trainees make decisions regarding childbearing, we sought to evaluate how often residents across multiple specialties delayed childbearing, factors associated with the decision to delay childbearing, and satisfaction with a decision to delay childbearing.

Method

This study was deemed by the institutional review board of each participating institution as follows: approved for Emory University; exempt for the University of California, San Diego, University of South Florida, University of Utah, and University of Washington; and not regulated for the University of Michigan. All 6 participating academic medical centers represented urban, tertiary care teaching hospitals associated with large medical schools.

Female residents (n = 1,537) enrolled across 78 GME programs representing 25 unique specialties in these 6 academic medical centers were invited to participate in a voluntary, anonymous, 5- to 10-minute survey using REDCap, a secure web-based application.16

With the exception of one institution (University of Utah), a $5 gift card, not conditional on response, was provided with the email invitation. We collected data over a 6-week period per institution from May to October 2017, with 3 email reminders sent at 48 hours, 3 weeks, and 5 weeks.

Survey

We developed a survey tool based on a focus group of physicians (conducted in December 2015) with personal experience of parenthood during medical training and their experiences with parental leave and a literature review (covering the years 1993 to 2015) of pregnancy and parenthood in GME. A section of this survey was dedicated to the topic of delayed childbearing. Respondents who indicated they were married or living with a partner were asked if they planned to have children in the future. Those who responded affirmatively were then asked if they were choosing to avoid childbearing during residency. We defined “delaying childbearing” as planning to become pregnant but avoiding doing so during residency. Respondents delaying childbearing were asked to indicate up to 3 reasons for their choice from a list of 11 factors. Ten of these factors were identified from the literature review and pilot data from earlier versions of this survey. To account for other factors not previously considered, we included a free-text response as the 11th option. Finally, we asked residents delaying childbearing to indicate how satisfied they were with this decision using a 5-point Likert scale ranging from “very dissatisfied” to “very satisfied.”

At the end of the survey, we gave participants the option of a free-text response to provide their additional thoughts on pregnancy and parenthood in GME. These answers provided context for our quantitative results.

The survey underwent content validation followed first by cognitive interviews of a sample of female resident volunteers, then by pilot administration to 214 female residents at the University of Washington (May 2016).17 Based on these results, which showed an appropriate range of variance, we further refined the survey, including reasons for delaying childbearing. During a second round of content validation, 8 experts in survey design, or the topic at hand, from our participating institutions reviewed the survey, and we conducted cognitive interviews of 5 volunteers representative of our target population. The final version was subsequently distributed to our study population in 2017.18

Analysis

We generated descriptive statistics to characterize study participants. To assess if hypothesized factors contribute to childbearing decisions, we compared categorical variables using the Pearson χ2 test, and continuous variables using independent t tests. We performed a logistic regression analysis to determine associations using factors with a P value of < .5. Household income was normalized by the number of members supported by that income and adjusted to the site’s cost of living. Residency program specialties were categorized according to medical, surgical, and hospital-based specialties as designated by the Accreditation Council for Graduate Medical Education.19 Specialties were also categorized by “controllable” versus “uncontrollable” lifestyle as designated by Dorsey et al.20 Although this grouping does not precisely capture all resident experiences in every program, it was chosen as a rough estimate of the challenges perceived in controlling work hours in that specialty. Program size was categorized by tertiles based on the distribution of participating program sizes. Paid leave was normalized across institutions by calculating the percentage of base salary a resident could receive over a 12-week leave, not including sick leave or vacation, and regardless of the actual length of leave taken. For example, paid leave for an institution that provided 6 weeks of full salary support for a resident on maternity leave was categorized as 50% paid leave.

Satisfaction with the decision to delay childbearing was dichotomized for analysis as satisfied (“very satisfied,” “satisfied”) versus unsatisfied (“neither,” “dissatisfied,” and “very dissatisfied”). Stata SE 13.1 for Windows (Stata Corp, College Station, Texas) was used for the analysis, with P < .05 denoting statistical significance. To categorize the free-text responses obtained, S.W.S. and J.A.B. used a conceptual content analysis. For trustworthiness, all authors—each of whom represented GME leadership or attendings from 5 specialties—reviewed these categories.

Results

Among the 1,537 residents invited to complete the survey, 57% (n = 876) were medical, 23% (n = 351) surgical, and 20% (n = 310) hospital-based trainees. The overall response rate was 52% (n = 804) and ranged from 48% to 57% for institutions, 51% to 53% for program categories, and 33% to 89% for individual programs.

Table 1 shows characteristics of 447 respondents who were married or living with a partner and also planning to have children in the future. The distribution of these respondents by program type is similar to the distribution of those invited to participate: 57% (n = 254) medical, 25% (n = 111) surgical, and 18% (n = 82) hospital-based trainees. Within this group, 61% (n = 274) of respondents were delaying childbearing during residency and 39% (n = 173) were not. Both groups included residents who were already parents at the time of the survey.

Table 1 - Characteristics of 447 Married or Partnered Residents Who Reported Planning to Have Children and Delaying or Not Delaying Childbearing During Residency, From a Multicenter Survey of Female Residents on Childbearing Decisions, 2017
Characteristic Delaying (n = 274) Not delaying (n = 173)
Program category, no. (%)a
 Medical 165 (60) 89 (51)
 Surgical 68 (25) 43 (25)
 Hospital-based 41 (15) 41 (24)
Postgraduate year (PGY), no. (%)
 PGY-1 70 (26) 39 (23)
 PGY-2 82 (30) 46 (27)
 PGY-3 67 (25) 39 (23)
 PGY-4 41 (15) 37 (21)
 PGY-5 10 (4) 8 (5)
 PGY-6 or more 4 (2) 4 (2)
Relationship status, no. (%)
 Married 190 (69) 148 (86)
 Live with partner 84 (31) 25 (15)
Children (includes nonbiological children), no. (%)
 0 children 252 (92) 106 (61)
 1 child 17 (6) 57 (33)
 2 children 5 (2) 7 (4)
 3 or more children 0 (0) 2 (1)
Age of children, no. (%)b
 Infant (< 1 year) 5 (2) 27 (16)
 Toddler (1–3 years) 10 (4) 41 (24)
 Preschool (4–5 years) 7 (3) 4 (2)
 Elementary school (6–8 years) 4 (2) 3 (2)
 Age 9 and older 1 (0) 0 (0)
Other graduate education, no. (%)
 PhD 5 (2) 15 (9)
 Other graduate degree 31 (11) 19 (11)
Household income per household member in U.S. dollars, mean (SD)c 79,027 (36,741) 77,847 (62,738)
Abbreviation: SD, standard deviation.
aMedical programs include dermatology, family medicine, internal medicine, neurology, pediatrics, physical medicine and rehabilitation, and psychiatry. Surgical programs include general surgery, neurosurgery, obstetrics and gynecology, ophthalmology, orthopedic surgery, otolaryngology, plastic surgery, thoracic surgery, urology, and vascular surgery. Hospital-based programs include anesthesiology, emergency medicine, pathology, radiation oncology, and radiology.
bCategories are not mutually exclusive.
cAdjusted for cost of living.

The associations between delaying childbearing and trainee, program, and institutional characteristics are reported in Table 2. Respondents who were significantly more likely to delay childbearing were younger (P < .001), in a specialty with an uncontrollable lifestyle (P = .001), in a program with ≥ 75 trainees (P = .004), or not a parent (P < .001). Only the latter held true in a multivariable logistic regression model where respondents who were not parents were much more likely to delay childbearing (OR 7.61, 95% CI 3.84 to 15.08, P < .001).

Table 2 - Bivariable Associations Between Trainee, Program, and Institutional Characteristics and Delaying Childbearing, From a Multicenter Survey of Female Residents on Childbearing Decisions, 2017
Characteristic Delaying,a no. (% of 274) Not delaying,a no. (% of 173) P valueb Deltac (95% CI)
Trainee characteristics
 Age in years, mean (SD) 29.4 (2.4) 30.5 (2.5) < .001 1.06 (0.87 to 1.25)
 Currently a parent 22 (8) 67 (39) < .001 0.31 (0.12 to 0.50)
 Worked with a pregnant colleague 255 (93) 155 (90) .20 −0.04 (−0.24 to 0.15)
 Perception of pregnancy and maternity leave as a struggle 179 (65) 129 (75) .11 −0.04 (−0.23 to 0.15)
 Partner status
   In medical training 93 (34) 52 (30) .38 −0.04 (−0.23 to 0.15)
   Working full-time 248 (91) 151 (87) .30 −0.03 (−0.22 to 0.16)
 Plans .35
   Fellowship 154 (56) 91 (53) −0.04 (−0.23 to 0.15)
   Academic practice 39 (14) 24 (14) −0.004 (−0.19 to 0.19)
   Community, public, or private practice 34 (12) 26 (15) 0.03 (−0.16 to 0.22)
   Industry/health care administration/consultant 0 (0) 1 (1) 0.01 (−0.18 to 0.20)
   Undecided 37 (14) 29 (17) 0.03 (−0.16 to 0.22)
 Household income per household member in U.S. dollars, mean (SD)d 79,027 (36,741) 77,847 (62,738) .81 −1,180 (−1,180 to −1,179)
Program characteristics
 Category .16
   Medical 165 (60) 89 (51) −0.09 (−0.28 to 0.10)
   Surgical 68 (25) 43 (25) 0.00 (−0.19 to 0.19)
   Hospital-based 41 (15) 41 (24) 0.08 (−0.10 to 0.28)
 Lifestylee .001
   Controllable 62 (24) 61 (39) 0.16 (−0.04 to 0.36)
   Uncontrollable 199 (76) 94 (61) −0.16 (−0.36 to 0.04)
 Program size .004
   < 35 residents 81 (30) 62 (36) 0.06 (−0.13 to 0.25)
   36–74 residents 78 (29) 65 (38) 0.09 (−0.10 to 0.28)
   > 75 residents 115 (42) 46 (27) −0.15 (−0.34 to 0.04)
 Proportion of women
   Residents, ratio of women, mean (SD) 0.57 (0.19) 0.54 (0.19) .16 −0.03 (−0.22 to 0.16)
   Faculty, ratio of women, mean (SD) 0.46 (0.16) 0.45 (0.16) .69 −0.01 (−0.20 to 0.18)
   Program director, woman 161 (59) 95 (55) .42 −0.04 (−0.23 to 0.15)
Institutional characteristics
 Site .08
   Institution A 38 (14) 24 (14) 0.00 (−0.19 to 0.19)
   Institution B 28 (10) 11 (6) −0.04 (−0.23 to 0.15)
   Institution C 61 (22) 53 (31) 0.08 (−0.11 to 0.27)
   Institution D 23 (8) 6 (4) −0.05 (−0.24 to 0.14)
   Institution E 38 (14) 30 (17) 0.03 (−0.16 to 0.23)
   Institution F 86 (31) 49 (28) −0.03 (−0.22 to 0.16)
 Paid family leave (excluding sick leave or vacation)
   % of salary over 12 weeks, mean (SD) 36.4 (33) 42.1 (34) .08 5.77 (5.48 to 5.86)
Abbreviations: CI indicates confidence interval; SD, standard deviation.
aData are no. (%) unless otherwise indicated.
bBold type indicates statistical significance.
cMean difference for continuous variables, proportion difference for categorical variables.
dAdjusted for site cost of living.
eOf 25 specialties, 17 were categorized by controllable versus uncontrollable lifestyle. Controllable specialties include anesthesiology, dermatology, emergency medicine, neurology, ophthalmology, otolaryngology, pathology, psychiatry, and radiology (diagnostic). Uncontrollable specialties include family medicine, general surgery, internal medicine, obstetrics and gynecology, orthopedic surgery, pediatrics, and urology (n = 123 for controllable; n = 293 for uncontrollable).

While not statistically significant, the mean paid family leave was lower for residents choosing to delay childbearing compared with those who were not. Also, at least 90% of each cohort had worked with a pregnant colleague, and at least 65% of each cohort reported working with a resident who had struggled with issues around pregnancy and parenthood. These experiences and perceptions did not appear to affect childbearing decisions during residency.

Self-reported determinants of delaying childbearing, which were not mutually exclusive, are shown in Figure 1. The most frequently reported factor was “busy work schedule” (n = 255; 93%), with one respondent commenting, “I don’t care at all about extending residency, but it would break my heart to go back to work after 6 weeks.” The next most frequently reported factors, in order, were “desire to not extend my residency training” (n = 145; 53%), “lack of access to childcare” (n = 126; 46%), and “finances” (n = 116; 42%).

Figure 1
Figure 1:
Self-reported reasons for delaying childbearing among 274 female residents participating in a multicenter survey of female residents, 2017. Responses are not mutually exclusive; respondents indicated up to 3 selections. The survey is available as Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A984.

Many respondents cited among their top 3 reasons for delaying childbearing the concern that “parental leave would burden my colleagues” (n = 96; 35%). Twenty-seven percent (n = 74) of respondents cited the concern that “residency training might increase pregnancy complications” as a reason for delaying childbearing. Respondents who chose each of these reasons did not vary by program category, lifestyle, or size.

There were 35 free-text responses submitted by the 274 respondents who indicated they were delaying childbearing. The categories resulting from the analysis of these responses included not feeling ready for parenthood (n = 19; 7%), lack of family support (n = 5; 2%), concerns of maintaining healthy pregnancy in residency (n = 5; 2%), lack of time at home (n = 3; 1%), and an unsupportive program (n = 1; 0.4%). Career threat (n = 2; 1%) was also mentioned both with respect to pregnancy, which was seen as a disadvantage for physicians interviewing for future opportunities, and to parenthood, which could negatively affect a physician in the early years of establishing a career.

Overall, only 38% (n = 103) of respondents delaying childbearing were satisfied with this decision. In a multivariable logistic regression model, satisfaction decreased with increasing age (OR 0.85, 95% CI 0.74 to 0.97, P = .02) and was less likely if the respondent’s partner worked full-time (OR 0.41, 95% CI 0.14 to 0.96, P = .04). Satisfaction was more likely if the respondent was planning an academic career (OR 3.01, 95% CI 1.29 to 7.06, P = .01).

Discussion

In this large, multicenter study of female residents’ decisions regarding the timing of childbearing, most married or partnered residents indicated that they were delaying childbearing. Decisions to delay childbearing varied significantly by program lifestyle and size and by resident age and parental status. Many of the most commonly cited reasons for delay were related to work constraints, including the challenges of a busy work schedule, the need to extend training, concerns about the impact on colleagues, and worry about the impact of residency on pregnancy complications. Only a minority of those deciding to delay childbearing indicated that they were satisfied with this decision. These findings have important implications for how residency programs can address the concerns of residents considering childbearing.

For the first time ever in 2017, the number of female students matriculating at medical schools exceeded the number of male students.21 As the number of female medical school graduates continues to increase, more residents must determine how they will balance training and childbearing. The medical profession cannot ignore the collision of professional and biological demands that occurs for those pursuing the lengthy training necessary to achieve competence. The findings of the current study extend prior work exploring residents’ experiences and decisions in this context.

Prior research in single specialties or institutions has demonstrated that a similarly substantial proportion of trainees delay childbearing. Holliday et al discovered that the majority (54.2%) of female residents in radiation oncology were delaying having children (including pregnancy) due to the demands of residency.22 Blair et al reported that across 3 Mayo Clinic sites for graduate medical training, 44% of female residents were delaying childbearing until after training.23 Our findings demonstrate that in a much larger multicenter, multispecialty sample, the majority of female residents were delaying childbearing. Moreover, our findings are novel in exploring in detail the reasons underlying these decisions.

One key concern trainees identified was the potential need to extend training. Prior research has documented variability in the ways that different member boards of the American Board of Medical Specialties limit leave from training.24 For example, one study compared the effect of a 6-week parental leave on training extension and qualifying to sit for board certification exams across specialties. The authors found similar policy limits on how long a resident could be absent from training, but variable effects on board certification exam eligibility, from no impact to delaying the exam for up to 1 year.25 Studies have also demonstrated inconsistency in how resident training is extended, not only between but also within specialties.26

National medical specialty societies have issued statements calling for flexible solutions. For example, the American College of Obstetrics and Gynecology advocates for mechanisms to maintain board eligibility for residents taking more than 6 weeks of leave.27 Other statements encourage program flexibility by creating solutions to minimize extending training, such as home study or reading electives for those on leave.28–31 Nevertheless, the lack of clear and consistent maternity leave provisions from the American Board of Medical Specialties makes it difficult for programs to counsel residents on whether taking leave may jeopardize their board eligibility, causing significant uncertainty as residents consider family planning in the context of their careers.

Many residents worry about the effect their childbearing will exert on their colleagues, regardless of program size. This finding is consistent with data from a study of general surgery residents who became pregnant during residency, which indicated that respondents feared “being a burden on colleagues,” being perceived as “lazy or not carrying my weight,” and “being treated differently than my peers.”6 One-third of residents in radiation oncology expressed worry about how their pregnancy would increase the workload for their co-residents.22 Although our study focused on female residents, this concern is not restricted to the childbearing parent. Other studies have shown that male residents also describe guilt from taking parental leave, noting that “the good residents take as little time as possible.”6 Notably, respondents to our survey were limited to choosing 3 factors, and thus, it is possible that burdening colleagues is an even more prominent factor than our results demonstrate. This cultural factor could also explain why female residents delay childbearing, even in programs with large numbers of residents.

Prior studies have evaluated whether residency training increases the risk of pregnancy complications. One landmark national survey of obstetrics and gynecology residents found that female residents had higher rates of preterm labor, preeclampsia, and fetal growth restriction than the wives of male residents.32 Yet despite this difference, the frequencies of these complications for both groups were relatively low. Another national survey of family medicine residents found that one-third of reported pregnancies had unspecified medical complications.33 Many residents in the current study, whether or not fully aware of the results of such studies, cited concerns about pregnancy complications, regardless of program category or lifestyle. This finding reinforces prior research showing that pregnancy complications are a common concern among residents across specialties.9,23,34

Other key challenges for residents considering childbearing are finances and childcare, which must be considered in light of the unique nature of medical training. Those who pursue careers in medicine assume considerable debt and accept low salaries over many years of training before they reach their full earning potential. In 2018, 77% of residents reported medical school debt, with 47% reporting debt that exceeded $200,000. This level of debt is in the setting of an average resident salary of $59,300.35 For individuals with this financial burden, provisions for paid leave take on heightened importance. Unfortunately, at the time of this survey, only 3 states mandated paid family leave (California, New Jersey, and Rhode Island), and provisions for paid leave from residency training varied dramatically across institutions nationally.36 Indeed, among the institutions included in our study, paid leave ranged from 0% to 100% of resident salary for 12 weeks. Considerations of the financial ramifications of unpaid leave are compounded by the subsequent challenges of finding affordable childcare. Childcare is an infrequent benefit in residency: A national survey of residents in 2018 discovered that only 3% of institutions offered residents childcare benefits.35 A national survey of pediatric program directors found that 75% of available childcare facilities at their institutions did not reserve spaces for trainees.37

Concurrently, in a survey of residents and fellows on their childcare arrangements, less than half used a childcare facility (47%), followed by relying on a stay-at-home spouse (37%), a nanny (25%), or the help of extended family (10%).38 The stress of finances and childcare may also explain why respondents with partners who lacked full-time employment were more likely to be satisfied with delaying childbearing. Perhaps their satisfaction was not with delaying childbearing but rather with maintaining financial stability.

The majority of residents delay childbearing for reasons related to the residency environment, highlighting the need for programs to anticipate pregnancy, maternity leave, and postpartum well-being. To accommodate female physicians, particularly those in procedural and other specialties requiring longer lengths of training, we need to consider how to actively support both personal and educational objectives through structure and policy. For example, the uncontrollable lifestyles of certain specialties could be mitigated by options such as flexible schedules, shared residency positions, and a formalized structure for extended residency training. Rather than new parents returning directly to the 80-hour workweek of residency, programs should allow for alternatives such as reading electives, outpatient clinic rotations, research time, or other creative solutions that ease residents back into residency as they adjust to caring for an infant. Providing childbearing residents with mentorship in residency and beyond can help them navigate and counter stigma. Recognition of the postpartum period through easily accessible lactation accommodations and childcare resources has the dual benefit of providing support for the resident and demonstrating program awareness that parenthood is a life stage rather than a one-time event isolated to childbirth.

Implementing policies that address resident and program concerns is a key approach to improving the culture of physician parenthood.39 We recommend addressing parenthood as a whole rather than focusing only on maternity leave. This perspective has the potential to normalize resident parenthood, making it less of a sex-specific issue. It would also serve to mitigate the gendered division of domestic labor that persists long after childbearing by supporting the full engagement in parenthood of residents of all genders, rather than primarily emphasizing the role of the childbearing parent.40 All residents should have easy access to these policies without having to ask. This approach would allow residents contemplating parenthood to privately plan and also would effectively convey that a planned pregnancy will not disrupt a resident’s program.

To this end, policies must clearly address the workload expectations of covering peers. This approach has immense potential to reduce the discord that comes with an unknown burden on colleagues. To address the concern of many residents about length of training, policies should also explicitly state how length of leave affects training time and board eligibility so residents can make informed decisions.

Finally, while institution-level policies are beneficial in standardizing pay, leave, and childcare benefits across programs, program-level policies are necessary to address the board-specific requirements that determine if training must be extended when parental leave is taken. This uncertainty of program-level consequences appears to have contributed to residents delaying childbearing well into their 30s when we know that fertility declines and complications increase.

The results of this study are not intended to imply that all female residents should bear children during training. Rather, the study was intended to elucidate why some trainees delay childbearing in residency. By identifying obstacles, we can create a more sustainable path for residents to bear children if they choose. Such a change signals not only the inclusion of parenthood in training but also an appreciation for the personal lives, growth, and well-being of all residents.

Limitations of this study include its observational design, from which we cannot make definitive causal inferences. We attempted to avoid exclusion by designing the survey for both same- and opposite-sex partnerships and by distributing the survey to all residents who reported female sex to their institutions regardless of gender identity. To avoid selection bias, we presented questions regarding delaying childbearing before questions about pregnancy and maternity leave to capture residents who were neither pregnant nor parents, and responses from incomplete surveys were recorded. Also, questions on delaying childbearing were only asked of married or partnered residents due to confusion by single residents during cognitive testing of the pilot survey. As a result, we may not have captured unpartnered women who were delaying childbearing. Finally, because this survey was voluntary, there was a potential response bias toward residents with uncommon experiences that motivated their participation. Nevertheless, these concerns are mitigated by the high response rate for a physician survey and the lack of systematic differences between respondents and nonrespondents.

We also acknowledge the limitations of our survey. Self-reported reasons for delaying parenthood may have been underreported if there were respondents who did not find a choice matching their reason. We attempted to address this problem with an open-ended item but realize that there may be other reasons not yet addressed.

Conclusions

Decisions to delay childbearing are more common in certain medical specialties, with financial considerations and colleague burden weighing heavily in this process. Only a minority of residents who delay childbearing are satisfied with that decision. This finding suggests that greater attention is needed to promote policies and cultures that both anticipate and normalize parenthood in residency, thus minimizing the conflict between biological and professional choices for female residents.

Acknowledgments:

The authors gratefully acknowledge the project development support of Christy McKinney, PhD, MPH, associate professor of pediatrics and associate director of the Institute of Translational Sciences KL2 Career Development program at the University of Washington School of Medicine.

References

1. Association of American Medical Colleges. Age of applicants to U.S. medical schools at anticipated matriculation by sex and race/ethnicity, 2014-2015 through 2017-2018. https://www.aamc.org/download/321468/data/factstablea6.pdf. Accessed August 13, 2019.
2. American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. Female age-related fertility decline. Committee Opinion No. 589. Fertil Steril. March 2014;101:633–634.
3. Aghajanova L, Hoffman J, Mok-Lin E, Herndon CN. Obstetrics and gynecology residency and fertility needs. Reprod Sci. 2017;24:428–434.
4. Stentz NC, Griffith KA, Perkins E, Jones RD, Jagsi R. Fertility and childbearing among American female physicians. J Womens Health (Larchmt). 2016;25:1059–1065.
5. Davids JS, Scully RE, Melnitchouk N. Impact of procedural training on pregnancy outcomes and career satisfaction in female postgraduate medical trainees in the United States. J Am Coll Surg. 2017;225:411–418.e2.
6. Sandler BJ, Tackett JJ, Longo WE, Yoo PS. Pregnancy and parenthood among surgery residents: Results of the first nationwide survey of general surgery residency program directors. J Am Coll Surg. 2016;222:1090–1096.
7. Chow KH. Maternal health and leave policies during medical training. JAMA. 1997;277:766, 769.
8. Nickoloff EL, Brateman L. Proposition: A pregnant resident physician should be excused from training rotations such as angiography and nuclear medicine because of the potential exposure of the fetus. Med Phys. 1999;26:2517–2519.
9. Serrano K. Women residents, women physicians and medicine’s future. WMJ. 2007;106:260–265.
10. Cole S, Arnold M, Sanderson A, Cupp C. Pregnancy during otolaryngology residency: Experience and recommendations. Am Surg. 2009;75:411–415.
11. Hariton E, Matthews B, Burns A, Akileswaran C, Berkowitz LR. Pregnancy and parental leave among obstetrics and gynecology residents: Results of a nationwide survey of program directors. Am J Obstet Gynecol. 2018;219:199.e1–199.e8.
12. Vohra T, Farris S. Emergency medicine residents’ attitudes toward pregnancy during residency. Acad Emerg Med. 2011;18(suppl 1):S192.
13. Krause ML, Elrashidi MY, Halvorsen AJ, McDonald FS, Oxentenko AS. Impact of pregnancy and gender on internal medicine resident evaluations: A retrospective cohort study. J Gen Intern Med. 2017;32:648–653.
14. Mundschenk MB, Krauss EM, Poppler LH, et al. Resident perceptions on pregnancy during training: 2008 to 2015. Am J Surg. 2016;212:649–659.
15. Turner PL, Lumpkins K, Gabre J, Lin MJ, Liu X, Terrin M. Pregnancy among women surgeons: Trends over time. Arch Surg. 2012;147:474–479.
16. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–381.
17. Stack SW, McKinney CM, Spiekerman C, Best JA. Childbearing and maternity leave in residency: Determinants and well-being outcomes. Postgrad Med J. 2018;94:694–699.
18. Stack SW, Jagsi R, Biermann JS, et al. Maternity leave in residency: A multicenter study of determinants and wellness outcomes. Acad Med. 2019;94:1738–1745.
19. Accreditation Council for Graduate Medical Education. Data Resource Book, Academic Year 2015–2016. http://www.acgme.org/Portals/0/PFAssets/PublicationsBooks/2015-2016_ACGME_DATABOOK_DOCUMENT_Locked.pdf. Accessed August 1, 2017.
20. Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA. 2003;290:1173–1178.
21. Glicksman E. A first: Women outnumber men in 2017 entering medical school class. https://news.aamc.org/medical-education/article/first-women-outnumber-men-2017-entering-medical-s. Association of American Medical Colleges. Published December 28, 2017. Accessed August 13, 2019.
22. Holliday EB, Ahmed AA, Jagsi R, et al. Pregnancy and Parenthood in Radiation Oncology, Views and Experiences Survey (PROVES): Results of a blinded prospective trainee parenting and career development assessment. Int J Radiat Oncol Biol Phys. 2015;92:516–524.
23. Blair JE, Mayer AP, Caubet SL, Norby SM, O’Connor MI, Hayes SN. Pregnancy and parental leave during graduate medical education. Acad Med. 2016;91:972–978.
24. Jagsi R, Tarbell NJ, Weinstein DF. Becoming a doctor, starting a family—Leaves of absence from graduate medical education. N Engl J Med. 2007;357:1889–1891.
25. Rose SH, Burkle CM, Elliott BA, Koenig LF. The impact of parental leave on extending training and entering the board certification examination process: A specialty-based comparison. Mayo Clin Proc. 2006;81:1449–1453.
26. Alliance for Academic Internal Medicine. 2014—Program directors survey summary. https://www.im.org/viewdocument/2014-apdim-program-directors-survey. Accessed April 30, 2010.
27. American College of Obstetricians and Gynecologists. Paid parental leave, ACOG statement of policy, 2016. Accessed May 26, 2018. [No longer available.]
28. American Academy of Family Physicians. Parental leave during residency training, 2017. https://www.aafp.org/about/policies/all/parental-leave.html. Accessed May 26, 2018.
29. Justin I. Parental leave policies. Colo Med. 1994;91:22–23.
30. American Medical Association. Policies for parental, family and medical necessity leave H-405.960.https://policysearch.ama-assn.org/policyfinder/detail/family%20leave?uri=%2FAMADoc%2FHOD.xml-0-3580.xml. Published 2014. Accessed August 13, 2019.
31. Reed BR, Callen JP, Freedberg IM, et al. Position paper on family or personal leave, including pregnancy, during residency. J Am Acad Dermatol. 2001;45:118–119.
32. Gabbe SG, Morgan MA, Power ML, Schulkin J, Williams SB. Duty hours and pregnancy outcome among residents in obstetrics and gynecology. Obstet Gynecol. 2003;102(5 Pt 1):948–951.
33. Hutchinson AM, Anderson NS 3rd, Gochnour GL, Stewart C. Pregnancy and childbirth during family medicine residency training. Fam Med. 2011;43:160–165.
34. Willett LL, Wellons MF, Hartig JR, et al. Do women residents delay childbearing due to perceived career threats? Acad Med. 2010;85:640–646.
35. Medscape. Medscape residents’ salary & debt report 2018. https://www.medscape.com/slideshow/2018-residents-salary-debt-report-6010044. Accessed April 30, 2019.
36. Magudia K, Bick A, Cohen J, et al. Childbearing and family leave policies for resident physicians at top training institutions. JAMA. 2018;320:2372–2374.
37. McPhillips HA, Burke AE, Sheppard K, Pallant A, Stapleton FB, Stanton B. Toward creating family-friendly work environments in pediatrics: Baseline data from pediatric department chairs and pediatric program directors. Pediatrics. 2007;119:e596–e602.
38. Snyder RA, Tarpley MJ, Phillips SE, Terhune KP. The case for on-site child care in residency training and afterward. J Grad Med Educ. 2013;5:365–367.
39. Weinstein DF, Mangurian C, Jagsi R. Parenting during graduate medical training—Practical policy solutions to promote change. N Engl J Med. 2019;381:995–997.
40. Jolly S, Griffith KA, DeCastro R, Stewart A, Ubel P, Jagsi R. Gender differences in time spent on parenting and domestic responsibilities by high-achieving young physician-researchers. Ann Intern Med. 2014;160:344–353.

Supplemental Digital Content

Copyright © 2020 by the Association of American Medical Colleges