Pregnancy and Parenthood Remain Challenging During Surgical Residency: A Systematic Review : Academic Medicine

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Pregnancy and Parenthood Remain Challenging During Surgical Residency: A Systematic Review

Todd, Anna R. MD, PhD; Cawthorn, Thomas R. MD, MSc; Temple-Oberle, Claire MD, MSc, FRCSC

Author Information
Academic Medicine 95(10):p 1607-1615, October 2020. | DOI: 10.1097/ACM.0000000000003351

Abstract

Challenges and barriers to pregnancy and parenthood are pervasive throughout medicine and residency programs.1 Although women currently represent the majority of medical school graduates, they remain underrepresented in surgical specialties.2 In 2015, only 20% of surgeons in the United States were female, and rates were as low as 5% in orthopedic surgery.2 Previous research indicates that difficulty with family planning and work–life balance during surgical training deter women from choosing surgical residency programs.3

In 2003, Susan Finch conducted a comprehensive review and found that female surgical residents delayed childbearing, experienced higher rates of obstetrical complications in pregnancy, and self-reported more voluntary terminations than the general population.4 Additionally, she noted that the prevailing perceptions of pregnant residents were negative.4

Our impression is that many of the research reports published since 2003 on the topic of pregnancy in surgical residency have reiterated these concerning findings; therefore, we undertook a review of the literature to examine common themes and synthesize data surrounding pregnancy and parenthood during surgical residency training. The objective of our review is to expand on Finch’s groundbreaking work by examining the data published since the publication of her review. We hope to examine whether female surgical residents continue to delay pregnancy, whether obstetrical complications still remain high, and how pregnancy and parenthood are perceived and accommodated in the surgical world. The findings of this current review may provide an impetus to discuss what is working and what is not, and may help move the surgical community toward a culture supportive of pregnancy and parenthood during residency training.

Method

We performed a systematic review, following the Preferred Reporting Items for Systematic Review and Meta-Analyses principles.5

Search criteria

Two of us (A.R.T., T.R.C.) created a preliminary search strategy, which a medical librarian subsequently refined. We searched the following databases for articles published from January 2003 to December 2018: Ovid MEDLINE, Embase, and Scopus. We conducted the search on March 17, 2019. We used the following medical subject headings, plus keywords and synonyms derived from them, for MEDLINE and Embase:

  • pregnancy, parental leave, education, medical, graduate; or
  • internship and residency; and
  • specialties, surgical.

See Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/A873 for full search strategy. In Scopus, we used only keywords for our search.

Inclusion and exclusion

We selected studies for inclusion if the data therein reflected the experience of pregnancy and/or parenthood during surgical residency training in the United States or Canada, if they were reported in English, and if they were published within the past 15 years (2003–2018). We excluded the following: editorials, letters, commentaries, abstracts, and articles or reports commenting on nonsurgical programs. If 2 of us (A.R.T., T.R.C.) could not agree whether to include a particular article, then all 3 of us (A.R.T., T.R.C., C.T-O.) reviewed it as a group and reached a consensus.

From studies providing both medical and surgical resident results, we extracted the outcomes pertaining to only the surgical residents whenever possible. We included studies that surveyed board-certified staff surgeons only if they commented on the residency experience or sequelae thereof. We excluded studies focusing exclusively on obstetrics and gynecology (ob/gyn) programs since the baseline demographics, as well as the reported outcomes, of the ob/gyn programs varied considerably from the other surgical specialties. Ob/gyn programs have greater female representation among staff and residents, institutional maternity leave policies that are more conducive to parenting and pregnancy, and a culture that is generally positive toward childbearing during residency.6–8 Further, the rates of infertility among ob/gyn residents are similar to the general population.6–8 In their study, comparing surgical residents and ob/gyn residents, Mundschenk and colleagues reported that surgical residents experienced significantly more stigma toward pregnancy, less flexibility, and prolonged training as compared with ob/gyn residents who reported a positive environment and supportive faculty and coresidents.9

Our search strategy returned 642 records, and we identified 8 additional publications by reviewing the references cited by these articles (see Figure 1). After removing duplicates, we identified 523 publications. After screening the titles and abstracts of these, we had 53 publications. We excluded 12 of these based on the study inclusion/exclusion criteria: 7 were editorials or commentaries, 2 focused primarily on radiation safety in fellowship programs, and 3 were published abstracts. We selected the remaining 41 publications for full review. We excluded 2 articles because their authors had mixed medical and surgical specialties, and we were unable to extract the surgical results. Five articles did not comment on the experience of pregnancy or parenthood during residency training. Four articles focused on the experiences of either medical students or staff surgeons exclusively. Finally, we excluded 3 articles focusing only on ob/gyn residency programs as they were not generalizable to the core study population, as discussed above.

F1
Figure 1:
Article search and selection process for a systematic review of the literature on the experience of pregnancy and parenthood during a surgical residency. The authors conducted the search on March 17, 2019.

Data extraction and analysis

One reviewer (A.R.T.) assessed all of the included studies, entering data into a data extraction table (that had been created a priori); a second reviewer (T.R.C.) confirmed the extracted data. We recorded information, including author, year of publication, population studied, number of participants, geographic region, and sources of bias (see Appendix 1). We developed further table headings based on predicted outcome measures and findings from previous reviews surrounding pregnancy and residency: percentage of females becoming pregnant during their surgical residency training, duration of parental leave, use of assisted reproductive technology (ART), obstetrical complications, and subjective perceptions of pregnancy in surgical residency.

In addition, we assessed the generalizability of each study based on its applicability to residents in surgical programs. Descriptors of the content were recorded in the data collection table as detailed above, and together 2 of us (A.R.T. and T.R.C.) organized these into 5 themes. We have reported our summary of both the qualitative and quantitative outcomes by theme. Meta-analysis of the quantitative data was not possible due to the variability of the data and the heterogeneity of the study designs; therefore, we have provided a narrative synthesis for qualitative data and have presented quantitative data as ranges.

Results

In the end, we selected 27 articles for final quantitative and qualitative analysis (Figure 1).9–35 The majority of studies reported survey-based results, and survey respondents included surgical residents, attending surgical staff, and program directors (PDs). Collectively, the 27 articles represented 14,498 survey responses (14,144 responses from residents and surgical staff; 354 responses from PDs). We organized data into 5 major themes: (1) barriers to pregnancy and parenthood during residency, (2) effect on training, (3) fertility, (4) obstetrical complications, and (5) attitudes and perceptions.

Demographics of surgical residents

The articles indicated that the average age of a first-year surgical resident was 27.7 years old.26 Surgical residents worked in general surgery, orthopedic surgery, cardiothoracic surgery, otolaryngology, plastic surgery, and urology.9–35 Fewer female residents than males had children during their residency (18%–28% as compared with 32%–54%).9,10,13,18,20–22,26,27,29,31,32,34 Female surgical residents were, on average, 10 years older than their peers in the general U.S. populationat the time of the birth of their first child (30.2–34.3 years old vs 24.6 years old),23–25,28–31,33 and they had fewer children overall (0.6–2.1 vs 2.7).9,24,25,29,33 Duration of leave varied between Canadian and U.S. programs: on average, maternity leave was 2 to 12 months in Canada and 1 to 14.6 weeks in the United States.10–13,15,19,21,25,26,28,29,34,35 Paternity leave ranged from 1 to 4 weeks across both the United States and Canada, and most frequently ranged from 1 to 2 weeks.11,19,21,25,31,34

Theme 1: Barriers

Here we have synthesized outcomes regarding barriers to pregnancy during residency, as well as difficulties identified by surgical residents once they had a child. Despite being aware of the potential complications of delayed child bearing,36 48% to 98% of female residents voluntarily delayed childbearing.10,25,30 The primary reasons cited for this delay included (1) a desire to avoid disruption or prolongation of training; (2) a belief that childbearing would adversely affect their career; (3) fear of potential obstetrical complications secondary to high stress and workload; and (4) personal factors such as relationship status, age, and finances.9,10,25 Additionally, 61% of female surgical residents, as compared with 16% of their male peers, felt they would be viewed unfavorably if they had a child during residency. Further, 82% of females and 60% of males felt childbearing would adversely affect their career.25

We reviewed any accommodations made for pregnant or child-rearing residents. The 7 studies examining parental policies in surgical residency programs reported that only 34% to 80% of programs had formal guidelines in place.10,11,13,16,18,19,21 Even among the policies that were available, many neglected to specify call requirements, define work expectations based on weeks of gestation, or provide options for call coverage or flexible rotation schedules.11,16,18 A lack of formal policies was associated with more unexpected call coverage by colleagues.14

Less than 12% of pregnant residents had reduced duty hours while pregnant,23 and 95% continued overnight call before going on maternity leave.13 In a Canadian study, 70% of pregnant general surgery residents stopped overnight call by 35 weeks gestation and 65% discontinued clinical duties between 36 and 40 weeks.28 Residents who had given birth and taken maternity leave identified issues with either having to make up missed call before going on/after returning from maternity leave or having to find coverage for the call missed.19,35

One study identified returning to work as a very difficult part of having children during surgical residency.15 Mothers who returned to their residency training identified breastfeeding and breast pumping at work as barriers.13,16,21,24,28 Between 42% and 67% of mothers reported that they would have wanted to breastfeed longer.13,16,31 One article reported that 63% of the programs examined had designated lactation facilities, but that 85% of female residents felt uncomfortable leaving the operating room to pump and 79% felt their colleagues would not be supportive if they did.13

Establishing adequate childcare was frequently identified as a barrier since childcare is expensive and daycare center hours are often inflexible and not available at hospital sites.12,13,16,21,34 Approximately 18% of medical centers offered childcare on-site, but the hours were inconvenient and not amenable to the surgical residency schedule.13 Interestingly, female residents with children were more often the primary caregiver at home on weeknights and weekends than their male colleagues (47% vs 17%).12 More than half of male residents with children had a spouse at home for primary childcare, whereas female residents were 10-fold more likely to require childcare from a nanny, family member, or daycare center (91% of females vs 48% of males).12

Theme 2: Effect on training

Attrition rates were similar between male (18%) and female (19%) surgical residents across U.S. and Canadian sites, and, notably, they were not higher amongst residents with children as compared with those without children.26 Overall caseload was similar between female residents who did and did not have children.26,35 One study reported that 31% of female general surgery residents who returned to work after maternity leave had a 10%–20% decline in their American Board of Surgery In-Training Exam scores, as compared with their pre-maternity leave scores.15 Pregnancy and child-rearing, however, did not affect board pass rates, and residents who had children during residency had higher rates of obtaining fellowship positions.26 Fifteen percent of female trainees altered their plans for fellowship training due to perceived difficulties in balancing career with parenthood.14 A range of 39%–84% of female surgical residents worked on research or graduate degrees while on maternity leave.28,31 Two studies examined female residents’ subjective views of how pregnancy and maternity leave affected their training.15,28 One reported that 74% of female residents did not perceive pregnancy or maternity leave to have a negative effect on their training,28 but the other reported that 50% of female residents felt that their knowledge and technical skills had fallen behind by the time they returned to work.15

Theme 3: Fertility

The reported rates of infertility ranged from 30%–32% amongst female surgeons and female surgical residents as compared with 10.9% in the general U.S. population.24,29 For 33% of residents reporting infertility, the reason was unknown and not accounted for by advanced maternal age, anovulation, polycystic ovary syndrome (PCOS), or male infertility.24 A range of 18%–28% of female surgeons sought fertility support through ART, as compared with 5.2%–12% in the general U.S. population.24,25,29,33 The percentage of children conceived amongst female surgeons with ART was 8%–13%,24,25,29,33 whereas currently 1.7% of children born in the United States are born with the support of ART.37 Amongst surgeons surveyed after residency, fewer female than male surgeons had children (63.8% vs 91.3%).34 More than half of women surveyed without children would have liked to have a child.24 Female surgeons were more likely to be single or divorced than their male counterparts (20.5% vs 5.9%).34

In 1995, Eskenazi and Weston reported a high number of voluntary terminations amongst plastic surgery residents (26%).38 Since then, there have been few additional reports on this topic. In 2012, Hamilton and colleagues reported an abortion rate of 2.7% (6/223 orthopedic surgeons), and of the 6, 3 were due to congenital abnormalities noted on screening.29 Merchant and colleagues reported in 2013 that 43% of pregnancies amongst general surgery residents ended in miscarriage or termination, but did not distinguish between the two.28 Other articles have reported miscarriage rates at 11% to 28% amongst female surgical residents,23,25,28,29,31 which together with the findings by Merchant et al may imply the termination rate is similar to the 26% reported in 1995.

Theme 4: Obstetrical complications

Overall, we noted a wide range of obstetrical complication rates—from 25% to 82% of pregnancies amongst female surgical residents as compared with a rate of 5% to 15% in the general U.S. population.23,25,28,29,33 Behbedani and Tulandi reported on specific complication rates of surgical residents compared with a control group of pregnant women in the general population; the surgical residents experienced higher rates of preterm labor (10.5% vs 5.9%), intrauterine growth restriction (10.5% vs 3.9%), involuntary miscarriage (13.3% vs 4.2%), and placental abruption (5.2% vs 0%).23 These results were consistent with other studies, as per Table 1.23,25,28,29,33

Table 1 - Rate of Obstetrical Complications Among Female Residents and Surgeons Compared to a National Control of U.S. Womena
Complications Female surgical residents and surgeonsb (%) Control (%)
Overall complication rate23,25,28,29,33 25.3–82 4.9–19
Preterm labor/delivery23,28,29,33 5.9–10.5 5.9
Early induction29,33 16–31.8 21.7
Intrauterine growth restriction23,29 3.9–9.2 3.9
Placental abruption23,28,33,45 2.0–5.2 1.2
Miscarriage23,25,28,29,31 11.0–28.0 4.2–13
Gestational diabetes mellitus23,29 1.6–10.5 9.5
aThese data were compiled from 27 studies included in a systematic review of the literature (2003–2018) on the experience of pregnancy and parenthood during surgical residency training.
bCompiled quantitative data are presented as ranges.

Higher rates of complications were noted among residents working more than 6 overnight call shifts per month (49% vs 26.4% for those working 6 or fewer overnight call shifts, P < .001) or more that 8 hours per day (41.7 vs 8.9% for those working 8 hours or fewer per day, P < .001).23 Hamilton and colleagues additionally observed an increased risk of preterm labor and delivery amongst female surgeons who reported working more than 60 hours per week (odds ratio 4.95, 95% confidence interval, 1.4 to 36.6).29

Theme 5: Attitudes and perceptions

We compiled a narrative synthesis of subjective data reported in the included studies—specifically the attitudes and perceptions identified by pregnant residents, colleagues, and PDs. Female surgical residents who had become pregnant identified experiences of discrimination and guilt.16,21,25,27,28,35 The degree of support women felt after having a child varied. In one study, female study respondents indicated that they felt more overwhelmed and less supported once they had a child, whereas male surgical residents reported feeling more supported by faculty after having a child.27 Although 4 studies reported that female surgical residents who had been pregnant during residency felt supported by their program,10,15,28,35 the majority of female residents felt there was a negative bias and perception toward experiencing pregnancy and parenthood during surgical residency training.9,10,13,14,16,21,25 Rangel and colleagues reported that 39% of women who were pregnant during their residency training strongly reconsidered a career in surgery based on their experience, and 30% would advise female medical students against surgical residency.14 Professional dissatisfaction was specifically associated with (1) negative perceptions of pregnancy during residency, (2) a lack of formal policies, and (3) difficulty balancing work and motherhood.14 Two-thirds of female residents with children reported that they would have found a mentor helpful.14,16

Many female residents who had children expressed significant feelings of guilt around burdening their colleagues, primarily with increased call coverage.21,25,28,35 Male surgical residents endorsed feeling little influence by colleagues’ opinion in regards to the timing of children.9,27 Male residents did, however, report feeling increased family strain once they had a child.27

Data on the topic of colleagues’ perceptions toward childbearing residents varied. In a study by Mundschenk and colleagues, residents reported that they did not feel burdened by pregnant female colleagues.9 Coresidents agreed that there is a stigma toward pregnant residents and felt being pregnant during residency would not be easy.28,31 Other studies reported that 19%–50% of resident colleagues felt their workload increased if a coresident became pregnant,28,31 and 33%–35% of 107 surveyed PDs felt that becoming a mother placed an increased burden on coresidents.11,21 The perception of stigma associated with pregnancy during training decreased from 76% of respondents who had graduated from medical school 30 years ago (1990) to 67% among more recent graduates (2010).30

The idea of a flexible-track residency program, which allows residents to complete their training in 6 years as opposed to 5 years, was supported by residents and PDs in large part to accommodate child bearing (69% of residents, 58% of PDs) and child-rearing (63% of residents, 44% of PDs).32

Overall, 38%–61% of PDs felt that becoming a parent negatively affected a female trainee’s work, whereas only 12%–34% of PDs felt that parenthood negatively affected male trainees’ work.11,21 In one study, 66 PDs were surveyed, of whom 30% were female.21 Of the male PDs, 54% (n = 25) had a child while in residency, whereas only 5% of the female PDs (n = 1) had a child during their residency training.21

Discussion

Fifteen years ago (in 2003), a comprehensive literature review of pregnancy during surgical residency training identified multiple concerns.4 Our contemporary review has indicated that female surgical residents continue to voluntarily delay childbearing, still have fewer children than the general population, continue to have high rates of obstetrical complications, and still experience feelings of guilt around childbearing and increased colleague workload. The delay in childbearing appears to be influenced by surgical culture and negative perceptions of female surgeons who become pregnant and have children during residency training.

Recent reported rates of infertility among female surgical residents remain elevated; the rates of 30% to 32% are largely unchanged from prior reviews. Substantial data indicate that fertility declines with age: only 7% of women desiring a child at age 39 will successfully become pregnant.39 Despite this evidence, the majority of residents overestimate the age of fertility decline, misjudging the time they have available to have children.36 This misperception is likely one contributing factor to the decrease in fertility amongst surgical residents.

An interesting finding was that over 30% of infertility cases were unexplained and not related to advanced maternal age, PCOS, or anovulation.24 One hypothesis is that the physical and psychological demands of surgical residency influence fertility. Another possibility is that female surgical residents simply are not having intercourse with sufficient frequency to achieve pregnancy. Aghajanova and colleagues found that only 23% of female residents were having intercourse regularly (i.e., at least 2 to 3 times a week during a fertile period).6 Finally, female surgical residents were more likely to be single or divorced than their male counterparts,34 and even though marriage is not necessary for pregnancy, relationship status may negatively affect opportunity.

According to the 2003 review by Susan Finch, the overall rate of obstetrical complications was significantly higher than that observed in the general public.4 This discrepancy seems to be largely unchanged in this updated review; the majority of publications report an overall rate of obstetrical complications in about 30% of pregnant female residents.23,25,28,29,33 Prior meta-analyses have shown that prolonged duty hours, prolonged standing, and shift work increase the risk of premature labor.40 Indeed, Hamilton and colleagues found that residents who worked more than 60 hours a week throughout their residency had increased rates of complications.29 Their finding is consistent with a 1990 study showing that female residents who worked more than 100 hours a week in the first trimester were twice as likely to go into preterm labor than those who worked less.41 Behbedani and Tulandi found that more than 6 overnight call shifts a month also significantly increased obstetrical complication rates.23 These findings provide guiding principles for creating and updating policies.

In 1995, Eskenazi and Weston reported that 26% of pregnant plastic surgery residents voluntarily terminated a pregnancy during their training.38 Klebanoff and colleagues (1991) reported the rate of voluntary termination at 8.2% amongst female residents as compared with 2.7% of matched controls.42 Since the publication of these 2 concerning reports, few researchers have investigated rates of voluntary terminations by surgical residents. Merchant and colleagues reported that 43% of pregnancies amongst general surgery residents ended in miscarriage or termination.28 If we estimate miscarriage rates amongst residents at 11% to 28%, this would suggest that the termination rate is similar to that reported in 1995. Although the impetus is unclear, the very fact that female surgical residents may still consider voluntary termination at a higher rate than that of the general population43 is concerning.

In 1995, a reported 36% of plastic surgery PDs actively discouraged pregnancy among residents.38 In 2016, Sandler and colleagues reported that 15% of PDs would still advise against having a child during residency.21 In a recent survey of applicants to orthopedic surgery residency, 62% reported inappropriate questions during their interviews, many regarding pregnancy and plans for marriage during residency.44 There was no perceived change in the number of inappropriate interview questions between 1971 and 2015.44 Still, the majority of female surgical residents feel supported by their programs,10,15,28,35 and more than 80% of female surgeons report feeling happy in their career choice.25,34 However, many female residents who became pregnant reported experiencing feelings of guilt about work and their colleagues’ increased workload, as well as discrimination and resentment from colleagues and administrators.16,21,25,28,35 This finding suggests that although surgical programs may be improving guidelines and the training structure for pregnant residents, there remain cultural undertones that inherently lag behind policy changes.

Ob/gyn programs remain an exception despite the fact that residents in these programs still experience the pressures and workload of a surgical residency program. While Gabbe and colleagues report that pregnant obstetrical residents worked up to 80 hours per week until their leave and had increased rates of complications as compared with the general population,8 pregnancy and parenting seem generally to be more accepted and supported within these programs. Ob/gyn residency programs are more likely to have formal maternity policies and accommodations for leave, longer duration of leave, and less stigma toward those residents who become pregnant.6–8 In a comparison of ob/gyn residents with other surgical residents, surgical residents reported experiencing significantly more negative attitudes toward pregnancy, less flexibility, and prolonged training.9 In turn, ob/gyn residents reported a positive environment as well as supportive faculty and coresidents.9 Larger female representation amongst residents, staff mentors, and PDs may be a contributing factor. These factors may also have worked to shift the culture toward a more positive and accepting environment. An in-depth analysis comparing ob/gyn programs with other surgical programs may be warranted.

Future direction

Unfortunately, many surgical residency programs continue to be inadequately equipped to deal with the issues of pregnancy and parenthood during residency. Willett and colleagues found that amongst medical and surgical residents, having a policy positively affected a female resident’s plan to have children during residency.36 However, an in-place policy was outweighed by factors such as prolonging residency, a perceived negative effect on career trajectory, and possible obstetrical complications.36 Discussion with residents as primary stakeholders is paramount when designing program policies. In the literature, residents frequently commented on the benefits of flexible rotation schedules to accommodate lighter rotations in the third trimester of pregnancy.11,16 Many felt that a contingency plan, such as contracting with paid associates or extenders, should be in place in case of illness or unexpected pregnancy complications.11,16,18 Residents frequently requested designated locations within the hospital premises for breastfeeding and pumping, as well as on-site, affordable childcare facilities.11,16,21,28,29,36 Finally, many felt that having a mentor would be helpful for navigating the experience of returning to work, dealing with the negative perceptions of others, and managing the challenges of maintaining a work–life balance.14,16 Open discourse and continued dialogue on these issues and how to best address them is of vital importance.

Limitations

This systematic review is limited by the lack of formal numerical quality assessment of the studies included; however, we assessed each study for generalizability and bias before inclusion. The main contributors to bias were (1) English language bias and (2) recall bias secondary to the survey format of studies included. We also acknowledge selection bias, as the response rate for the surveys ranged widely, and those individuals responding may have had opinions that are not representative of the general population being examined. Additionally, we were limited by the inability to perform a formal meta-analysis due to the heterogeneity of the study designs and results. The use, instead, of quantitative ranges allowed for the most concise presentation of relevant findings. Finally, we compiled the control data cited from the publications reviewed and added standard population control data (from the Center for Disease Control and Prevention37), where available.

Conclusions

Fifteen years after the review by Susan Finch,4 many of the issues she identified still persist in surgical residency training programs. Female surgical residents delay childbearing and have fewer children overall—in large part due to concerns of being viewed negatively by their colleagues and other staff, or to concerns of pregnancy/parenthood adversely effecting their careers. Surgical residents also experience higher rates of infertility and obstetrical complications than women in the general U.S. population. Recent reports are still calling for clearly outlined maternity and parental guidelines for residency programs that may help mitigate some of the issues that persist in surgery. Simple steps in the direction of supporting surgical residents who wish to have children can be made with policy changes and guidelines, but open discussion, genuine support, and a frank recognition of the issues regarding pregnancy during a surgical residency will be invaluable in making progress in this domain.

Acknowledgments:

The authors thank Helen Lee Robertson, Medical Librarian, University of Calgary, for her support in the development of the search strategy and methodology.

References

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    Appendix 1 Summary of Studies Included in a Systematic Review of the Literature (2003–2018) on the Experience of Pregnancy and Parenthood During Surgical Residency Training

    -
    First author (year) Population surveyed No. of PDs No. of residents/staff RR (%) Country Major themes Comments
    Mulcahey (2018)10 Female orthopedic surgery residents 190 32 USA • Barriers
    • Attitudes/Perceptions
    Single specialty
    Tang (2018)11 Otolaryngology residency PDs 41 40 USA • Barriers
    • Attitudes/perceptions
    Single specialty
    Kin (2018)12 Medical and surgical residents and fellows 435 56 USA • Barriers
    • Attitudes/perceptions
    Medical and surgical
    Rangel (2018)13 Female general surgery residents who had had children during residency 347 n/aa USA • Barriers
    • Attitudes/perceptions
    Single specialty
    Rangel (2018)14 Female general surgery residents who had had children during residency 347 n/aa USA • Barriers
    • Attitudes/perceptions
    • Effect on training
    Single specialty
    Shifflette (2018)15 Female general surgery residents who had had children during residency 22 37 USA • Barrier
    • Effect on training
    Single specialty
    Rangel (2018)16 Female general surgery residents who had had children during residency 347 n/aa USA • Barriers
    • Attitudes/perceptions
    Single specialty, qualitative data
    Davids (2017)17 Female postgraduate trainees in procedural (221) and nonprocedural specialties (517) 738 16 USA • Complications
    • Fertility
    Garza (2017)18 Plastic surgery PDs 54 61 USA • Barriers
    • Attitudes/perceptions
    Single specialty
    Mundschenk (2016)9 Surgical, GIM, ob/gyn, anesthesia residents 203 (107 in 2008 and 96 in 2015) 74.8 (2008)
    50.5 (2015)
    USA • Barriers
    • Attitudes/perceptions
    Medical and surgical
    Weiss (2016)19 Orthopedic surgery PDs 45 31 USA •Barriers Single specialty
    Stephens (2016)20 Cardiothoracic surgery residents 354 100 USA • Demographics Single specialty
    Sandler (2016)21 General surgery PDs 66 26 USA • Barriers
    • Attitudes/perceptions
    Single specialty
    Verheyden (2015)22 Plastic surgery PDs 59 587 66 USA • Barriers
    • Attitudes/perceptions
    Single specialty
    Behbehani (2015)23 Pregnant female medical (19) and surgical (219) residents 238 n/aa North America • Barriers
    • Complications
    Medical and surgical
    Phillips (2014)24 Staff surgeons in 9 surgical specialties 1,021 n/aa USA • Barriers
    • Fertility
    Pham (2014)25 Thoracic surgeons 113 18 USA • Barriers
    • Complications
    • Fertility
    • Attitudes/perceptions
    Single specialty
    Brown (2014)26 General surgery residents from one site (graduates from 1999 to 2009) 85 100 USA • Effect on training Single institution/site
    Chen (2013)27 General surgery residents, PGY-1 and PGY-3 4,028 82 USA • Barriers
    • Attitudes/perceptions
    Prospective longitudinal study, single specialty
    Merchant (2013)28 General surgery residents and PDs across Canada (the Canada PREGS study) 8 176 50 (PDs)
    30 (residents)
    Canada • Barriers
    • Complications
    • Effect on training
    • Attitudes/perceptions
    Single specialty
    Hamilton (2012)29 Residents and staff within 9 surgical specialties 1,021 n/aa USA • Barriers
    • Fertility
    • Complications
    Turner (2012)30 Female staff surgeons, American College of Surgeons, and Association of Women Surgeons 1,950 35 USA • Barriers
    • Attitudes/perceptions
    Merchant (2011)31 General surgery residents across Canada (the Canada PREGS study, pilot [1997–2009]) 53 65 Canada • Barriers
    • Complications
    • Effect on training
    • Attitudes/perceptions
    Single specialty
    Abbett (2011)32 General surgery residents and PDs 81 748 34 (PDs)
    14 (residents)
    USA • Attitudes/perceptions Single specialty
    Lerner (2009)33 Board-certified urologists 243 69 USA • Fertility
    • Complications
    Single specialty
    Troppman (2009)34 Board-certified staff surgeons 895 26 USA • Barriers
    Cole (2009)35 ENT residents who had delivered within 12 months 3 100 USA • Barriers
    • Complications
    • Attitudes/perceptions
    Single specialty, small number
    Abbreviations: PD, program director; RR, response rate; USA, the United States; n/a, not available; GIM, general internal medicine; Ob/gyn, obstetrics and gynecology; PGY; postgraduate year; PREGS, pregnancy among residents enrolled in general surgery; ENT, ear, nose, and throat.
    aThe authors could not calculate the response rate due to an unclear denominator in the original report.

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