Childbearing and Training
Men were significantly more likely than women to have had children before age 30, although both women and male respondents’ partners were equally likely to get pregnant before residency. In contrast, during training, women were significantly more likely to avoid pregnancy or to have no more than one child if they did get pregnant than were the co-residents’ female partners (Table 2). Compared with men, women were significantly more likely to delay having children because of the demands of training, although both women and men cited long work hours as the most significant reason for a delay (Tables 3 and 4).
Miscarriages and Pregnancy Terminations
Miscarriage rates were similar among all respondents, as were elective abortion rates. None of the 81 female respondents electively terminated a pregnancy, but six partners of the 170 male respondents did. In this small sample, the demands of training influenced two-thirds of these terminations (Table 2).
Ten percent of pregnant residents felt they worked harder during their pregnancy, and only 1.2 percent reported working less. Just over 40 percent of women felt their pregnancy increased workloads for their colleagues, yet nearly the same percentage believed their colleagues’ workloads were not increased. Just under half of women respondents had a complication of pregnancy during training, the most common being preterm labor, followed by a baby that was small for gestational age (Table 5).
Over 80 percent of pregnant residents worked until initiation of labor, and just under one-third took 1 month or less of leave. Of all plastic surgeons who had children during training, men were much more likely to state their program had maternity and paternity leave policies, and women were more likely to state that neither existed. Nearly all respondents felt surgery programs should have comprehensive parental leave policies (Table 6).
In a survey question regarding desired changes in the American Society of Plastic Surgeons, 37 women wrote comments. Although the question did not mention parental leave, nine respondents urged American Society of Plastic Surgeons support of pregnancy, breastfeeding, and onsite childcare in residency, at conferences, for faculty, and at hospitals. Of the 14 comments from men, two addressed those issues (Table 7).
Most mothers breastfed or expected to do so. Nearly half of respondents breastfed or planned to do so for 6 months or less. Work forced two-thirds of women to curtail breastfeeding sooner than they wished, with contributing factors including the unpredictability of the workday, difficulty breaking scrub to pump breast milk, and time constraints (Table 8).
Involvement with Children
Among those who had children, over twice as many women were dissatisfied with their level of involvement with their children compared with men (Table 2).
Support for Pregnancy in Training
Women were significantly more likely to support a co-resident’s pregnancy during training than were men. Conversely, a significantly higher percentage of women felt their program director/chief/chair would not support their decision to have a child during training (Table 9).
In the late nineteenth century, William Halsted (1852 to 1922) erected the scaffolding of the rigorous U.S. surgical training structure in which unmarried, childless men resided in the hospital around the clock. Halsted himself delayed marriage until he approached 40, and he never had children.40 The rules eased with time, allowing male residents to marry, have children, and live outside the hospital. The few women accepted into surgical training programs adopted the no-pregnancy reproductive model of the male resident. Although much of that structure still stands, more recent improvements in plastic surgery training programs include a 4-week annual leave allowance averaged at each program director’s discretion and 2 additional extended-leave weeks allowed the last 2 plastic surgery training years.41
Until recently, women were minorities not only in surgery but in all specialties. Understanding surgical training’s unique impact on women begins with examining medical school populations, which are the raw material of training programs. In 1979, women constituted just 23 percent of medical school classes.42 By 1997, that number had risen to 41 percent, and by 2016, women had become the majority at 52 percent.1 , 42 During those same decades, the percentage of female plastic surgeons rose dramatically, from 2.1 percent in the 1970s, to 13.5 percent in the 1990s, to 23.5 percent in this incomplete decade.2 , 12 These numbers indicate that despite their current majority numbers in medical schools, women remain a significant minority in plastic surgery residency programs.
Female and male plastic surgeons receive the same training and pass the same board examination, but they differ in their reproductive lives. With women having fewer children later in life or none at all, disparities have persisted over time3 , 13–15 , 20–23 , 43–46 (Tables 2 and 10). One possible reason for this childbearing gap is that women plastic surgeons are less interested in having children. In fact, among respondents without children, women were 11 times more likely than men to not want children (Table 3). Historically, however, both female and male physicians have desired a similar number of children,46 indicating that surgery’s training structure and culture likely serve as major deterrents to women from choosing a surgical career, particularly if they desire children. In fact, female medical students wanting families are less likely to choose a surgical career based on perceptions of longer training, poor maternity support, risks of advanced-maternal-age pregnancy, and infertility.3–6 The marked gender disparity among those not wanting children indicates that our specialty may be losing excellent candidates by thwarting talented medical students who also want to achieve motherhood from considering a career in plastic surgery.
Given the conflict between adequate maternity leave provisions and the annual 48-work-week requirement of residencies, it is no surprise that in the present study only 30 percent of women plastic surgeons felt their program directors supported their choice to have a child. A young mother’s maternity leave typically results in increased workloads borne by sometimes resentful co-residents,24 , 26 , 47–50 which may explain why the men in this study were less likely than the women to support a pregnant co-resident (Table 3). Historically, women residents have avoided having children during residency, sometimes quietly undergoing elective abortions during training to do so.16 , 23 , 45 , 47 , 51–53
Survey respondents who agreed that the problems associated with maternity leave and service coverage could be solved by delaying pregnancy until after training emphasized the elective nature of pregnancy as justification. Certainly, birth control and abortions prevent childbearing during training, but a woman cannot change her intrinsic biology. Her ovaries and uterus undergo involutional changes as she ages, lowering her fertility. Age-related infertility can result in depression, anxiety, and stigmatization, affecting women more than men.43 , 54–57 Even if she is able to conceive, an older pregnant woman faces heightened health risks to both her fetus and herself, including intrauterine fetal death and perinatal mortality.13 , 15 , 16 , 26 , 58–60 Reflecting these age-related biological changes, women in this study were significantly more likely than men to experience infertility, to have fewer children, and to be childless (Tables 2 and 3 and Fig. 1).
Some survey respondents suggested having a child during a research year as a suitable alternative to postponing pregnancy until completion of training. Although this option works well for some, women in their 30s can experience escalating difficulty conceiving, potentially sabotaging attempts to time a pregnancy during a given calendar year.58 Furthermore, unplanned pregnancies occur, and to assume otherwise ignores the reality implied by the historically high surgical residents’ abortion rate.16 , 26
None of the women respondents in the current study had an abortion during training, indicating that antipregnancy pressures may be abating. This plunge from a rate of 26 percent in 199516 may be the result of improved birth control methods or a greater acceptance of pregnancy among women residents (Table 10). Interestingly, the partners of six male respondents did terminate pregnancies, with four doing so in part because of the demands of the respondent’s training (Table 2). Men hoping to be active fathers may be postponing fatherhood until completion of residency or their partners may be hard-working residents or other professionals postponing motherhood.16 Both possibilities are associated with evolving gender roles.
If a woman gets pregnant during clinical training, the guilt arising from taking maternity leave and burdening co-residents with extra work may pressure her to take extra call. That additional call may explain why 10 percent of respondents who were pregnant during training said they worked harder during pregnancy, and only 1.2 percent of respondents felt they worked less. Although pushing through fatigue and physical discomfort may be lauded in surgery, an increase in clinical responsibilities during pregnancy can come at a cost, as long cases, heavy workloads, and extra call put both mother and baby at risk.24 , 26 , 61–68 In fact, nearly half the respondents who were pregnant during residency in this study experienced complications, with 22.9 percent experiencing preterm labor/birth, compared with a 9.6 percent U.S. national average. In addition, 14.5 percent of respondents had babies that were small for gestational age, compared with 8.1 percent nationwide.68
After delivery, the vast majority of mothers in this study breastfed, but over two-thirds stopped before they wished. The respondents cited several contributing factors: unpredictable days, difficulty breaking scrub, lack of time, and the absence of a place to pump breast milk. Of the mothers who did breastfeed, nearly half did so for 6 months or less, falling short of the American Academy of Pediatrics’ recommended 12 months for babies’ medical and neurobiological benefits.69 , 70
A minority of men and even fewer women in this study were aware that their program had a parental leave policy with clear expectations (Table 6). At first glance, it may seem surprising that women, who require physical recovery after delivery, are less likely to be aware of clear parental leave policies. However, this lack of awareness likely reflects the significantly higher number of women respondents who had no interest in having children (one in five). Furthermore, programs with historically few pregnant residents, poorly defined maternity policies, short leave durations, absent on-site daycare, and poor breastfeeding allowances discourage residents from getting pregnant without explicitly stating so.71 , 72 In contrast, male residents, who more commonly have children during residency, would be more likely to inquire about a paternity leave policy.
Comments from some respondents stated that residency is about sacrifice. Indeed, residents sacrifice their time in long work hours and extended years of training; their mobility while working and taking call; and the forfeiture of opportunities arising outside of training. However, women desiring children potentially sacrifice their ability to conceive, as indicated by their higher infertility and lower birth rates (Tables 2 and 3).
Some of those who commented in this study viewed pregnancy as elective, selfish, and indicative of a woman’s lack of commitment, consistent with the perceptions of some faculty members, both female and male24 , 26 , 62 , 71 (Tables 4, 7, and 8). When a pregnant surgical resident is stigmatized by faculty and resented by co-residents, she can experience a decline in well-being.16 , 18 , 19 , 21 , 24 , 73 Both the guilt associated with pregnancy and the heartbreak of infertility may be conditions unknown and unfamiliar to a woman’s superiors.7 , 18 , 24 , 27 , 28 , 71
The specialty’s lack of recognition of women’s biological limitations perpetuates the disparity in gender reproductive outcomes. Pregnancy is almost never convenient, regardless of a mother’s job or circumstance, but many plastic surgeon mothers have demonstrated that it is possible to combine maternity leave, surgical training, and motherhood successfully. One study of pregnant general surgery residents showed that despite taking maternity leave, mothers’ case numbers and board pass rates were comparable with those of residents who took no leave.71 Similarly, a study of obstetrics and gynecology residents showed that pregnancy and delivery did not negatively impact their surgical training experience.72
Regardless of our institutions’ level of preparation, pregnancy rates among surgical residents are increasing.8 , 9 , 48 In the words of Dr. Linda G. Phillips, “Pregnancy or the potential for pregnancy clearly makes women different from men.”73 Continuing to pressure women to ignore their biology because it conflicts with a regimented training structure deprives them of a basic human right. This lack of pregnancy support will also continue to deter talented women from pursuing a career in plastic surgery.
This study had several limitations. A response rate of 15 percent is low. However, the authors determined that the best means to survey all North American plastic surgeons was through the American Society of Plastic Surgeons, which has an even lower average survey response rate of 12 percent (range, 6 to 24 percent). In fact, statistical analysis confirmed that a response rate of 15 percent was acceptable for statistical significance. Another limitation was the disproportionate response rate of men compared with women; approximately 80 percent of American Society of Plastic Surgeons and resident members are men, a significantly greater percentage than the 59 percent of male survey respondents. Consequently, a weighted adjustment was used to account for the potential selection bias. Analysis of reproductive differences among age groups might have lent insight into evolution over time, but individual age groups were not sufficiently robust to yield statistical significance. In addition, questions could have been better aligned with previous studies for temporal comparison. Nonetheless, the volume of responses is comparable to other studies, and the results offer insight into the varying reproductive outcomes of women and men plastic surgeons.
Looking Forward to the Future of Plastic Surgery
Plastic surgery requires a lengthy training period that conflicts with women’s limited window of fertility. To allow women to enjoy the same reproductive options as men, our specialty must accept and welcome pregnancies among female plastic surgery trainees. We must work with the American Board of Plastic Surgery, the American Council of Graduate Medical Specialties, and parent institutions to develop comprehensive parental support within training programs and institutions, including adequate leave, flexible scheduling through hiring locum tenens personnel, on-site daycare, and accommodations to facilitate and encourage breastfeeding.26 Maternity support during peak fertility years will lower health risks to both mother and infant, decrease age-related infertility, broaden the pool of talented candidates, and improve resident well-being not only in plastic surgery but across all specialties.7 , 9–11 , 26 , 67–69 , 74–80
We will succeed in our support of women’s reproductive lives when women plastic surgeons desiring children can bear them during their prime fertility years and when female medical students choose their specialty based on a keen level of interest and are not dissuaded by surgery’s antipregnancy culture. Greater diversity in our specialty will enhance our talent pool, which is the raw material for greater successes and improved outcomes.
Dr. Kevin C. Chung is currently receiving the Midcareer Investigator Award in Patient-Oriented Research (2 K24-AR053120-06) from the National Institutes of Health. The authors would like to thank Christopher Simmons and Keith Hume for providing assistance with the American Society of Plastic Surgeons survey used in this article.
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