Supporting Breastfeeding Physicians Across the Educational and Professional Continuum: A Call to Action : Academic Medicine

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Scholarly Perspectives

Supporting Breastfeeding Physicians Across the Educational and Professional Continuum: A Call to Action

Ortiz Worthington, Rebeca MD1; Adams, Dara R. MD2; Fritz, Cassandra D.L. MD3; Tusken, Megan MD4; Volerman, Anna MD5

Author Information
Academic Medicine 98(1):p 21-28, January 2023. | DOI: 10.1097/ACM.0000000000004898
  • Open

Abstract

The benefits of breastmilk and lactation are well established for both infants and women. 1,2 Among infants who are breastfed, benefits include reduced incidence of infectious diseases including otitis media, reduced rates of sudden infant death syndrome, and reduced rates of metabolic diseases. 1 Maternal benefits of breastfeeding include reduced rates of breast and ovarian cancer, diabetes, hypertension, and cardiovascular disease. 2,3 Breastfeeding is a public health initiative, and various professional organizations provide recommendations to promote breastfeeding among mothers. 1,2,4

Lactation exists on a spectrum that ranges from direct breastfeeding (feeding a child with milk directly from the breast or chest) to pumping (expressing breastmilk, typically via a breast pump, to feed the child with a bottle). We will use the term breastfeeding to refer to the practice of directly feeding on the breast or chest, pumping, or a combination of both. The American Academy of Pediatrics and American College of Obstetricians and Gynecologists recommend exclusively breastfeeding for the first 6 months of life and continued breastfeeding for the first 1–2 years of life or longer as mutually desired. 1,2 The recommended intervals for breastfeeding, and therefore pumping when away from an infant, range from every 2 to 4 hours during the first several months of life to longer intervals as solid foods are introduced. 5

For women who work outside of the home, employers play a critical role in supporting a woman’s likelihood of maintaining breastfeeding after returning to work. 6 Supporting lactation in the workplace is an issue of reproductive justice, along with other evolving issues such as parental leave and fertility treatments. Creating work conditions that facilitate pumping allows lactating employees to participate equitably in the workplace. 7

For physicians, childbearing years often coincide with key periods of training and their early career. As such, it is critical to systematically examine policies and practices to support breastfeeding across the clinical educational and professional continuum, which includes medical students, residents, fellows, and attending physicians. The goal of this article is to (1) describe experiences of breastfeeding physicians across the clinical educational and professional continuum; (2) review current policies about breastfeeding across this continuum; and (3) provide recommendations to individuals, institutions, and professional organizations about how to better support breastfeeding physicians. We will use the term physicians to refer collectively to attending physicians, fellows, residents, and medical students on clinical rotations unless otherwise stated.

Breastfeeding Experiences

Decades of both qualitative and quantitative data capture the experiences of breastfeeding physicians and describe the structural and systemic barriers encountered by breastfeeding physicians. While a handful of institutions have created evidence-based policies to improve breastfeeding support for physicians, 8–11 the majority of the literature strongly suggests that there has been limited system-wide progress to meaningfully support breastfeeding.

Physician mothers have high rates of initiating breastfeeding but low success in maintaining breastfeeding. In the 1990s, a national study of third-year residents found that half discontinued breastfeeding upon returning to work, and breastfeeding rates dropped to 15% by 6 months post-partum. 12 This trend has persisted: a study conducted in 2007 found that 24% of physicians did not reach their breastfeeding duration goal. 13 A 2020 study found that, despite 87% and 27% of residents intending to breastfeed for 6 and 12 months, respectively, only 74% and 13% met these goals. 14

The etiology of breastfeeding discontinuation among physicians is multifactorial, with the most frequently cited reasons including inadequate access to pumping rooms, insufficient workplace and coworker support, and constrained schedules. 15,16 A common recurring theme involving barriers to pumping at work is a lack of access to “dedicated lactation rooms which were clean, private and fully equipped … in accessible locations.” 14 Problems with pumping facilities include inconvenient location (e.g., long walk to dedicated space, limited availability of facilities), absence of computers to continue working while pumping, lack of sink and refrigerators for sanitation and milk storage, limited or no access to hospital-grade pumps, and deficient locks on the doors. 14,16,17 Breastfeeding physicians spend considerable time and effort planning their days to incorporate time to pump, clean pump parts, and find storage for milk. Consequently, challenges to pumping at work can create significant stress, contribute to reduced milk supply due to infrequent pumping, and negatively impact both duration of breastfeeding and maternal mental health. 17–19

Beyond the necessary structural features to overcome barriers to pumping, supportive social relationships in the workplace have been described as critical to the success of women continuing to breastfeed while working. 14,20–24 Unfortunately, studies show that 25%–50% of physician mothers report experiencing breastfeeding discrimination. 16,25 A key issue is that pumping time is perceived to burden teammates. 14,26,27 The lack of clear policies to support breastfeeding physicians and their teams compounds these challenges. 9,13,14,17–19,28 A number of studies chronicle actions and comments that target physicians who seek time to pump, including reports by physicians who were told by colleagues and superiors that they lack dedication to their work and that they are not working as hard as their colleagues. 14,26 This conflict is illustrated by a pediatric resident’s description of being explicitly told by coresidents that spending time to pump appeared to be an effort to avoid work, despite the resident reportedly taking only one pump break every 12–14 hours. 27 The same study also captured the perspectives of nonbreastfeeding residents, who were quoted as feeling as though they were left with additional responsibilities not performed by residents with children, which interfered with achieving their own career and life goals. 27 This tension is further exacerbated by the long hours and limited support for residents in general. 27 Similar issues about being perceived as a burden are described by breastfeeding physicians in relation to their superiors. For example, among surgical residents, 85.2% expressed discomfort asking attending surgeons to allow them to step away from the operating room to pump, and 78.8% felt attendings would not have supported pumping if the resident asked. 20

The lack of official policies and an institutional culture that support breastfeeding places the burden on the breastfeeding physician to navigate relationships with peers and superiors. From our own experiences, substantial planning, communication, and flexibility are required to find time to pump that does not significantly impact patient care or inconvenience colleagues. As a result, the breastfeeding physician endures the physical consequences of long periods in between pumping sessions as well as the mental health consequences of managing work expectations and workplace relationships. For example, many breastfeeding physicians report significant physical consequences stemming from inadequate breastmilk expression. These consequences were quantified in one study and include, but are not limited to, diminished supply (64%), clogged ducts (26%), and mastitis (16%). 14 Another study reported that over half (52%) of resident physicians indicated they experienced low milk supply. 26 In terms of mental health, studies have shown that breastfeeding cessation is associated with postpartum depression, 29 and postpartum depression was more likely in mothers who intended to breastfeed but did not. 30

Employers play a key role in a physician’s success in breastfeeding, yet many employers do not perceive supporting breastfeeding as a core responsibility. 24 In 2018, 49% of surveyed physician mothers in the United States would have increased their duration of breastfeeding “if their job had been more accommodating.” 18 In fact, studies show a negative association between breastfeeding continuation and employment for both physician and nonphysician working mothers. 18,24 Furthermore, most employers lack explicit policies to support breastfeeding employees. 19,24

Inflexible work schedules and lack of time are frequently cited by physicians as significant barriers to breastfeeding. 18–20 Residents—who have notoriously less flexible schedules than attending physicians—breastfeed for shorter durations than staff physicians, with inflexible work schedules correlating to this trend. 19,31 In 1996, 80% of residents returning from maternity leave did not continue breastfeeding due to a lack of time. 12 Despite the increasing female physician workforce 32 and a national requirement for adequate time and space for breastfeeding, 33 more than 80% of U.S. physicians continue to cite time as a significant barrier to breastfeeding and pumping success. 18 While attending physicians have more autonomy over their schedule, they may be compensated based on productivity or be required to meet rigid clinical productivity metrics that can make it complicated and financially detrimental to rearrange clinical responsibilities for pumping. 16 In addition, some institutions or departments require physicians to make up pumping time used during duty hours. For example, physicians with procedural and surgical responsibilities report inflexibility in scheduling procedures, the need to pay back time used for pumping when on call and during procedures, and requirements to extend their clinic time to make up for pump breaks. 28

It is important to note that the short maternity leave typically afforded to physicians likely also contributes to shorter breastfeeding duration. Indeed, longer maternity leave has been shown to support maintenance of breastfeeding during employment. 8,18,19,24 Nevertheless, comprehensive parental leave policies are not in place for medical trainees, and parental leave policies for attending physicians vary widely across institutions. 15,34–36

The subjective experiences of breastfeeding physicians may not reflect the full scope of perspectives on this topic. For example, breastfeeding physicians may perceive a higher burden on teammates than what is reported by their teammates. In one study, 80% of obstetrics and gynecology nonpumping residents reported that pumping did not burden the team. 26 Similarly, while 80% of breastfeeding residents at one institution felt that pumping burdened their teams, only 10% of nonpumping coresidents agreed. 17 These findings suggest that physician colleagues are open to the idea of thoughtful policies for pumping that accommodate the needs of breastfeeding and nonbreastfeeding physicians alike. This divergence warrants further exploration, including thorough studies of physicians across a variety of specialties. The experiences of breastfeeding physicians, the opinions of their colleagues, and the clinical environment are also likely influenced by gender balances or imbalances across specialties and institutions.

Outside of their institutions, breastfeeding physicians also face barriers during certification exams, which are required for professional advancement. The United States Medical Licensing Examination (USMLE) introduces many obstacles to breastfeeding physicians who need to pump during these daylong exams. Breastfeeding trainees and physicians must complete a 4-page request form and obtain a qualified physician signature to validate their need for additional break time for breastfeeding. 37 The form also requires photographic documentation of the breast pump that will be used. Important details about the length of these additional breaks, the cost of this request, the next steps in the approval process, and the percentage of applications approved, among other things, are not readily apparent on the USMLE website. Anecdotal reports describe breastfeeding applicants paying an extra $895 to potentially be granted additional break time. 38 This lack of transparency places extra burden on trainees who are uncertain about the approval process and unable to plan for any related additional constraints, such as saving money for the additional cost and determining their approach to taking the test. Also, the breastfeeding physicians’ ability to schedule the exam is delayed while the National Board of Medical Examiners (NBME) puts the scheduling permit for the exam on hold for 30 days to consider the request; thus, a breastfeeding examinee may have fewer choices available for their preferred testing time and site. For residents, fellows, and attending physicians, board certification exams have similar approval processes for lactation, which may include required documentation by a physician, with variable transparency about the timeline for requests, the accommodations provided, and the cost of such requests. 39–42 Furthermore, exam testing sites do not guarantee any reasonable parameters about the pumping space, such as cleanliness or privacy. 43,44 Anecdotal reports by physicians have described pumping in bathrooms, closets, or break rooms during their exams. 45–47

Current Breastfeeding Policies

In 2018, the Accreditation Council for Graduate Medical Education (ACGME) explicitly made providing time and space for lactation a core requirement for all residency and fellowship programs. 48,49 While an important first step, this policy is vague in outlining how training institutions must comply with the requirement. The absence of concrete expectations for implementation hinders the ability to enforce compliance and thus limits the impact of the policy. Beyond the ACGME, other accreditation bodies have yet to outline lactation policies. The Liaison Committee on Medical Education (LCME) has not provided medical schools with policies on breastfeeding accommodations. Furthermore, the LCME’s Independent Student Analysis, which includes medical student survey questions on resources and facilities, does not define or assess adequate breastfeeding or pumping resources as part of the medical school review and accreditation process. 50

For licensing exams, detailed accommodations provided by testing centers are not standardized. The USMLE, NBME, and specialty boards allow accommodations for pumping but create barriers to making accommodation requests for exams. Further, these organizations do not have mechanisms to guarantee or enforce reasonable pumping spaces for physicians taking these career-defining exams, because the testing centers are not governed by the medical licensing or specialty organizations.

Few professional organizations have focused on how best to support breastfeeding trainees and physicians. The American Academy of Family Physicians (AAFP) has taken the lead in outlining the minimal requirements per the law, along with recommending additional considerations breastfeeding policies for medical trainees should encompass. 51 The AAFP clearly defines the minimal adequate time for milk expression as 20–30 minutes every 2–3 hours. The AAFP further details the minimum requirements for lactation rooms, based on federal workplace laws: the room should be private, comfortable, and sanitary with access to a secure place for milk and pump storage. 33,51 The specific and inclusive AAFP policy leaves minimal room for varying and inappropriate interpretations of adequate lactation facilities or protected time. Further, it emphasizes the need for policies that clearly outline roles and responsibilities to build a culture of support for breastfeeding physicians across the educational and professional continuum.

Addressing the Problem

Pilot studies aimed at creating lactation-friendly workplaces have been trialed in a variety of medical specialties spanning diverse training environments. These programs have focused on 2 main goals: providing physicians with a place and time to pump and fostering a culture to support breastfeeding.

Several initiatives describe how they identified convenient, private locations to transform into lactation rooms, often providing tools to aid in completing clinical work (e.g., computer, telephone, dictation system) and in pumping more efficiently (e.g., hospital-grade breast pumps, vending machine with pumping parts). 8–11 For example, a study in one residency program evaluated the efficacy of supplying hospital-grade pumps by measuring pumping time and milk yield. They found that use of the hospital-grade pump versus the double electric pump decreased time per session by a mean of 8.5 minutes, while simultaneously increasing milk volume by 2.8 ounces. 8

Another critical way that employers can support breastfeeding physicians is by mitigating schedule constraints. Successful solutions to allow for protected time include blocking off clinic appointments for pumping and implementing a cross-cover system for surgical residents to cover for one another during noncritical portions of surgical cases. 9,11 Solutions that work in one specialty may not be as successful in others. For example, one anesthesia program analyzed surgical case lengths and found only 39% lasted long enough for a resident to receive a break in the middle of the case without missing the critical induction and emergence stages. 52 As a result, this program advocated for scheduling breastfeeding anesthesia residents to longer cases. In contrast, surgical residents who are lactating may prefer shorter cases that allow for more frequent breaks in between operations.

Innovative programs or policies to support lactation should be tailored to the unique needs of each specialty, department, or division and accommodate relevant work locations and physician schedules. For instance, an emergency department’s policy may specify the impact on overnight shifts, a gastroenterology division’s program may address procedure slots that are protected for pumping, and an otolaryngology division’s policy may address time in between surgical cases. Also, we recognize that many hospitals face physical space constraints that affect the ability to locate lactation spaces within a reasonable walking distance from a variety of work areas. Creating a lactation policy and finding dedicated lactation space may involve reconfiguring existing spaces, identifying and repurposing work areas that are underused, and/or creating new rooms in areas with large open spaces. If a permanent lactation space cannot be found or created near physician workspaces, portable lactation pods or providing physicians with portable pumps are innovative approaches to consider.

A unifying theme among pilot programs that successfully improve lactation policies is the creation of formal guidelines that are championed by leadership and disseminated to trainees and attending physicians within a particular program, department, or institution to encourage open communication regarding pumping. 9–11 By creating a supportive work environment and a positive pumping culture, barriers to breastfeeding—both actual and perceived—are reduced. Funding is also a necessary component of any successful initiative, and institutions should be thoughtful about funding sources to support initiatives that create a lactation-friendly workplace. One successful department partnered with an institutional initiative to become a “Mother’s Room Owner” through a shared ownership model, with funding shared between the department and institution to support breastfeeding physicians. 10 Notably, while several pilot studies focused on creating a lactation-friendly environment have been successful in single institutions, none of these published initiatives bridge institutions or examine impact at a regional or national level.

Recommendations

Given the experiences of many breastfeeding physicians across the educational and professional continuum, including our own, it is critical to make system-wide changes to improve the culture, resources, and support for breastfeeding in medicine. The medical field has researched and established the benefits of breastfeeding, and it is time to realize these benefits for those working in the field. Individuals should not have to choose between breastfeeding their child and meeting their professional obligations. Systemic policies and practices are necessary to make this a reality. As such, we propose several recommendations to improve the environment, support, and resources for breastfeeding physicians with a focus on what individuals, institutions, and professional organizations can do (List 1).

List 1

Recommendations to Improve the Environment, Support, and Resources for Breastfeeding or Chestfeeding Physicians

Individuals (e.g., trainees, faculty, divisional or departmental leaders)

  • Request accommodations
  • Perform needs assessment of existing lactation accommodations
  • Help create or improve institutional policies
  • Discuss and normalize experiences with breast/chestfeeding
  • Ask someone who is breast/chestfeeding about how to support them
  • Be flexible about rounding, clinic, and cases
    •  o Allow individuals to take time to pump
    • Adjust rounding times to facilitate pumping
    • See patients alone while an individual pumps
  • Cover for peers, colleagues, or trainees who need time for lactation

Institutions (e.g., clinics, hospitals, health systems, medical schools, residency and fellowship programs)

  • Create and implement lactation policies in educational and training programs, clinical settings, and academic departments
    •  o Include stakeholders of all genders, parental statuses, and training levels in committee
    •  o Fund work of committee members
    •  o Tailor policies to specific clinical and learning environments
  • Create policies to protect flexible rounding times, case coverage for surgical and procedural specialties, and blocked clinic slots for pumping without making up time
    •  o Ensure policies reflect each specialty, department, or division and its specific structure for clinical care and schedules
  • Create a supportive environment for lactation
    •  o Disseminate information about lactation (insurance coverage, room locations, etc.)
    •  o Share information with current trainees, faculty, and other employees as well as with those being recruited
  • Create virtual educational options for physicians to participate in while pumping
  • Create an ideal environment for pumping
    •  o Design spaces for lactation in different buildings
    •  o Support development and upkeep of lactation rooms or spaces with designated funding
    •  o Provide hospital-grade pumps in lactation rooms or spaces
  • Provide option for wearable pumps through employer-provided insurance free of charge or at same cost as other preferred pumps
  • Support flexibility in scheduling for all parents during early postpartum period
  • Present lactation accommodations and policies as part of a family-centered package of benefits for physicians
  • Include dedicated lactation rooms when creating or remodeling buildings

Professional organizations (e.g., ABMS, ACGME, LCME, NBME, USMLE, specialty organizations)

  • Update core requirements to include detailed expectations for lactation spaces and clinical coverage for pumping (ACGME)
  • Create core requirements for lactation spaces in medical schools and training facilities (LCME)
  • Require institutions to create policies to guarantee adequate lactation spaces and coverage during educational and clinical work (all organizations)
  • Require proof of lactation policy at training institutions for accreditation (ACGME, LCME)
  • Minimize barriers to pumping during licensing and board certification exams (ABMS, NBME, USMLE)
    •  o Remove review requirements for pumping time requests
    •  o Remove financial costs for testing accommodation application
    •  o Clearly and publicly state requirements for submitting a request on website
    •  o Require test centers to meet minimum requirements for lactation spaces
  • Require time allowance for pumping during educational sessions (all organizations)
  • Advocate for stronger federal and state laws to protect lactation in the workplace (all organizations)
  • Advocate at national and state level for insurance coverage of optimal pumping equipment, including hospital-grade and wearable pumps (all organizations)

Abbreviations: ABMS, American Board of Medical Specialties; ACGME, Accreditation Council for Graduate Medical Education; LCME, Liaison Committee on Medical Education; NBME, National Board of Medical Examiners; USMLE, United States Medical Licensing Examination.

Individuals

Everyone—regardless of gender or prior parenting and breastfeeding experience—has an important role in facilitating changes to support breastfeeding physicians. We encourage women who are currently breastfeeding or have previously breastfed to talk about their experiences with breastfeeding to normalize the practice. Individuals of all genders can support a woman who is breastfeeding by being as flexible as possible and covering for them while they pump, such as adjusting the time of rounds, finishing a case independently, or seeing a patient alone. Further, an individual can simply ask the breastfeeding physician how they can help to show that they recognize the woman’s professional and personal responsibilities and are available to support as needed. While seemingly simple, these practices facilitate a breastfeeding-friendly culture and remove undue burden from the breastfeeding physician.

Physicians in need of lactation accommodations should first and foremost request accommodations. Without accommodation requests, institutional leadership may fail to appreciate this important need. Physicians who have, are, or will be lactating should consider creating, improving, or advocating for lactation policies at their institutions (Table 1). Likewise, divisional or departmental leaders should prioritize needs assessments to review the current state of lactation among physicians and use the results to inform new or revised policies.

T1
Table 1:
Elements to Include in Institutional Lactation Policies 53 , 54

Institutions

Clinics, hospitals, health systems, medical schools, residency programs, and fellowship programs can facilitate logistical and technical changes to support breastfeeding physicians. An important first step is to create and implement a lactation policy in educational and training programs, clinical settings, and academic departments (Table 1). Policy development should include stakeholders of all genders, training levels, and parental statuses and come with appropriate funding to support initiatives. Lactation policies should include specific solutions related to the clinical environment, such as flexible rounding times, case coverage plans, and blocked clinical slots that do not require time to be made up.

Beyond a written policy, it is critical to create a culture that is welcoming to those with families and to breastfeeding physicians. Institutions should compile up-to-date information about lactation (e.g., insurance coverage for pumps, lactation room locations) and share it widely, including with individuals being recruited as well as with current trainees, faculty, and other employees. Support for lactation, including optimal lactation rooms and protected time for pumping, can be presented as part of a set of family-centered benefits offered by an institution, which ultimately benefit physician parents of all genders. Institutions can also create options for physicians to balance education and pumping (e.g., offering virtual platforms for didactics or conferences such as those adopted during the COVID-19 pandemic), make wearable pumps and hospital-grade pumps readily available at work, and allow for flexibility in scheduling early in the postpartum period. Further, institutions should create and maintain optimal lactations rooms or spaces with the necessary equipment and resources for pumping (List 2) as a sign of investment in family-friendly workplaces.

List 2

Minimum Requirements and Recommended Key Elements for Lactation Spaces

Minimum requirements

  • Private (door must be able to be locked) 33
  • Reliable accessibility 33
  • Not a bathroom 33
  • Sanitary 48
  • Refrigerator available for milk storage 48
  • Proximity to clinical responsibilities 48
  • Comfortable 51
  • Pump storage available 51

Recommended key elements

  • Permanent space, meaning it is dedicated solely to pumping
  • Comfortable chair
  • Table
  • Door lock on inside of room
  • Functioning outlet
  • Sink for cleaning pump parts
  • Microwave for sterilization
  • Computer in room with reliable Internet service
  • Phone in room connected to hospital system
  • Online scheduling system available to reserve the space
  • Less than a 5-minute walk from workspace, which often requires that there be multiple dedicated lactation spaces throughout a building
  • Hospital-grade pumps
  • Preplanning for number of lactation rooms needed by considering appropriate proportion of lactation rooms to number of employees of reproductive age capable of breastfeeding or chestfeeding

We recognize that health systems are under an unprecedented amount of pressure due to the COVID-19 pandemic. Likewise, health care professionals and leaders are facing extraordinary stressors and challenges at work. Support for lactation in the workplace should be viewed by institutions as one of many ways to support and retain physicians and other employees.

Professional organizations

Educational, accreditation, and specialty-based professional organizations have a fundamental role in creating and implementing policies and programs at a national level that support breastfeeding physicians in training and practice throughout the United States. Namely, all organizations can design policies to guarantee adequate lactation spaces and coverage for breastfeeding physicians during clinical work. The ACGME core requirement (see above) is a starting point; however, it should provide additional details regarding expectations for lactation spaces and clinical coverage to help make the requirement specific, measurable, and enforceable. The LCME should also create enforceable core requirements that medical schools and training facilities must meet to create adequate lactation spaces and accommodations for clinical medical students. The ACGME and LCME should also require that training institutions provide documentation of an institutional lactation policy for accreditation. Further, the ACGME and LCME should create policies that allow flexibility for breastfeeding trainees to attend educational sessions in person or remotely. These changes will help hold training institutions accountable for supporting lactating physicians and can spur change within institutions.

Licensing and medical specialty organizations have a unique role to better support breastfeeding physicians during licensing and certification exams and in the registration process for these exams. While these exams only encompass a few days, they are high stakes in terms of what they mean for progression to the next stage of training and thus have a fundamental impact on career paths. As such, these organizations should make maximal efforts to remove barriers to breastfeeding during these exams, remove financial and scheduling barriers to requesting pumping time during exams, and publicly enumerate the policies for applying for and using pumping time during exams. Licensing bodies should require testing centers to provide adequate lactation accommodations in compliance with the Fair Labor Standards Act at a minimum and ideally to meet suggestions for optimal lactation spaces (List 2) to continue administering physician licensing exams.

All medical-related professional organizations should advocate at national and state levels for laws that provide stronger lactation protections in the workplace, which would contribute to lasting, enforceable improvements in equity in the workplace. Professional organizations should also advocate for full insurance coverage for optimal pumping equipment, including hospital-grade and wearable pumps.

Conclusions

The breastfeeding experience of physicians across the educational and professional continuum is well described, captured by decades of both qualitative and quantitative data. Yet, barriers to breastfeeding persist, which negatively affect breastfeeding physicians in terms of professional advancement, working relationships, and physical and mental health. These barriers lead to early discontinuation of breastfeeding among physicians. The implementation of policies and practices to support breastfeeding are necessary at multiple levels. Everyone from individuals, to institutions, to professional organizations has an important role in fostering a lactation-friendly environment. Creating lactation policies that allow breastfeeding physicians equitable participation in the workplace is a matter of reproductive justice. Improving the collective awareness and support for breastfeeding trainees and physicians is a critical step in recruiting, retaining, and supporting women in medicine.

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38. @cer_scott. Unsurprisingly, @TheUSMLE hasn’t made it easy to be a mum and a resident physician. You’ll be shocked to learn that 45 minutes per 7-9 hour test day isn’t enough time to express breast milk, so I needed my OB to write a letter documenting my medical need for extra time. https://twitter.com/cer_scott/status/1415827677181878273. Published July 15, 2021. Accessed June 28, 2022.
39. American Board of Internal Medicine. Pregnant and Nursing Mother Accommodations. https://www.abim.org/certification/exam-information/test-accommodations-nursing-mothers. Accessed June 28, 2022.
40. American Board of Radiology. Provisions for Special Requests Regarding ABR Examinations. https://www.theabr.org/wp-content/uploads/2017/06/Provisions-for-Special-Requests.pdf. Published October 18, 2013. Accessed June 28, 2022.
41. American Board of Pediatrics. Test accommodations. https://www.abp.org/content/test-accommodations. Accessed June 28, 2022.
42. American Board of Surgery. Testing center accommodations for nursing mothers and candidates with other medical conditions. https://www.absurgery.org/default.jsp?policyaccommodations. Accessed October 2, 2021.
43. Pearson VUE. Test accommodations. https://home.pearsonvue.com/Test-takers/Accommodations.aspx. Accessed October 4, 2021.
44. Prometric. Test accommodations for breastfeeding candidates. https://www.prometric.com/sites/default/files/Test_Accommodations_for_Breastfeeding_Candidates.pdf. Accessed June 28, 2022.
45. @BeyondTheCoat. To all the #PHOdocs taking boards! Smash it. You got it. I have (not) so fond memories of my 30 min break eating, hydrating, and pumping breast milk in a gross prometric break room. #AcademicMom we can do anything..but can we get more support while we’re taking names? https://twitter.com/BeyondTheCoat/status/1379816499976802304. Published April 7, 2021. Accessed June 28, 2022.
46. @HritaniRama. I had to pump breastmilk in the bathroom during my ABIM exam for my 3 month old baby. It was exhausting and stressful. Nursing & pregnant physicians should get appropriate accommodations during their exams..let’s start with a pumping room with a chair @ABIMFoundation @WomenAs1. https://twitter.com/HritaniRama/status/1304154459434614794. Published September 10, 2020. Accessed June 28, 2022.
47. @ACLU_DC. Medical Licensing Organization Tells Med Student Bathroom Is Suitable for Pumping Breastmilk During Exam. https://twitter.com/ACLU_DC/status/612002581984976896. Published June 29, 2015. Accessed June 28, 2022.
48. Accreditation Council for Graduate Medical Education. ACGME Common Program Requirements (Residency). https://www.acgme.org/globalassets/PFAssets/ProgramRequirements/CPRResidency2020.pdf. Accessed June 28, 2022.
49. Accreditation Council for Graduate Medical Education. ACGME Common Program Requirements (Fellowship). https://www.acgme.org/globalassets/pfassets/programrequirements/cprfellowship2019.pdf. Accessed June 28, 2022.
50. Liaison Committee on Medical Education. Checklist of Requirements for Completing the Independent Student Analysis (ISA) for Provisional/Full Accreditation. https://lcme.org/publications. Published January 2021. Accessed June 28, 2022.
51. American Academy of Family Physicians. Breastfeeding and Lactation for Medical Trainees. https://www.aafp.org/about/policies/all/breastfeeding-lactation-medical-trainees.html. Accessed June 28, 2022.
52. Titler S, Dexter F, Epstein RH. Percentages of cases in operating rooms of sufficient duration to accommodate a 30-minute breast milk pumping session by anesthesia residents or nurse anesthetists. Cureus. 2021;13:e12519.

References cited only in Table 1

53. U.S. Department of Health & Human Services, Office on Women’s Health. What employers need to know. https://www.womenshealth.gov/supporting-nursing-moms-work/what-law-says-about-breastfeeding-and-work/what-employers-need-know. Accessed June 28, 2022.
    54. Mamava. How to write a workplace lactation accommodation policy. https://www.mamava.com/why-buy-blog/how-to-write-a-lactation-accommodation-policy. Accessed June 28, 2022.