Plastic surgery has traditionally been a male-dominated specialty. The number of women entering the field has increased substantially, from less than 2 percent 50 years ago to women now constituting 38.1 percent of plastic surgery residents.1,2 Women’s fertility decreases by 50 percent from their early 20s to their late 30s, which is also the period when plastic surgeons undergo residency and fellowship training.3 As a greater number of women endure lengthy and rigorous plastic surgery training, the importance of understanding the impact on childbearing, breastfeeding, childcare, and fertility is becoming more recognized.
A survey of program directors in 1995 revealed that 36 percent of program directors actively discouraged residents from becoming pregnant and 26 percent of plastic surgery trainees had undergone an elective abortion during training. The same study reported a complication rate of 57 percent, and 33 percent suffered from infertility.4 More recently, a survey of program directors revealed that only 36.5 percent of training programs have a formal maternity leave policy, and of those, only 20 percent defined allowances for breastfeeding on return to clinical duties.1 Rates of obstetrical complications are higher in female physicians than in the general population,5 and female orthopedic surgeons are twice as likely to suffer from complications during pregnancy as women in the general population.2 There are currently no published data collected directly from plastic surgery trainees elucidating barriers to starting a family, obstetrical health, parental leave, breastfeeding, and infertility.
The aim of this study was to provide baseline information about reproductive issues in plastic surgery trainees, specifically focusing on obstetrical complications, parental leave, breastfeeding, childcare, and infertility. The data presented in this study are essential for identifying areas of concern and providing guidance for formulating solutions.
Following approval by the Institutional Review Board at the University of Pittsburgh (PRO17120572), an anonymous, electronic survey was distributed to all plastic surgery residents and fellows in the United States. An electronic, Web-based survey was created using Qualtrics Survey Software (Qualtrics, Provo, Utah) and distributed by program coordinators at each institution. The link to the survey and three reminder e-mails were sent to all plastic surgery residents participating in Accreditation Council for Graduate Medical Education–accredited programs (1064 residents) and all plastic surgery hand, craniofacial, body contouring, aesthetic, and microsurgery fellows.
The survey encompassed questions regarding demographic information, level of training, obstetrical complications, parental leave, breastfeeding, and use of assisted reproductive technology. The full survey can be viewed in supplemental material. (See Figure, Supplemental Digital Content 1, which shows the survey sent to plastic surgery residents and fellows, http://links.lww.com/PRS/D781.)
Data were analyzed in JMP Pro 13 (SAS Institute, Inc., Cary, N.C.) throughout. Age data, being continuous, were analyzed using analysis of variance followed by Tukey honestly significant difference post hoc after confirmation of normality and homoscedasticity. Ordinal data were analyzed using proportionality testing, reporting chi-square and p values, where any condition with an expected n < 5 was excluded from the analysis; post hoc testing from chi-square testing was performed with corresponding Bonferroni correction.
The survey was completed by 307 respondents (54.3 percent female and 45.7 percent male). The overall resident response rate was 27.0 percent (39.3 percent of female and 20.3 percent of male resident trainees). Mean age was 31.7 ± 3.8 years. Fifty-nine percent were married. Of the respondents who were married, 44.2 percent of women and 33.3 percent of men were married to another physician. There was no significant difference in age or marital status between genders; however, respondents in more advanced years of training were more likely to be married (p < 0.001). The majority of respondents were integrated residents, with junior residents (postgraduate years 1 through 3) constituting 41.8 percent and senior residents (postgraduate years 4 through 6) representing 37.3 percent of respondents. Fifteen percent of respondents were independent residents. Trainees in fellowships including hand, craniofacial, microsurgery, aesthetics, and body contouring represented 5.6 percent of respondents, and 0.7 percent were completing a research year (Fig. 1).
Thirty-five percent replied that they or their partner had experienced at least one pregnancy. Pregnancy significantly correlated with older age (p < 0.0001) and more advanced level of training (p = 0.005), but not gender (p = 0.500). Seventy-one percent of pregnancies resulted in a live birth, 24.4 percent resulted in miscarriage, and 5.0 percent were terminated (Fig. 2). Two percent of live births had a congenital malformation, specifically, cleft lip and palate, horseshoe kidney, and congenital heart disease.
The maternal age at first pregnancy was 30.3 ± 3.6 years. The majority of both women (76.5 percent) and men (67.4 percent) reported intentionally postponing having children because of demands of their career (Fig. 3). Both men and women agree there is a negative stigma attached to being pregnant during residency; however, women were significantly more likely to report stigma (70.4 percent versus 51.1 percent; p = 0.003) (Fig. 4). Male and female respondents who were married to another physician responded similarly about when they plan to have children, with 50.0 percent planning to start a family during training and 50.0 percent planning to wait until completion. In contrast, female trainees married to a nonphysician were significantly more likely to plan to wait until after training to have children compared with men married to a nonphysician (64.7 percent versus 21.1 percent; p = 0.007) (Fig. 5).
Fifty-six percent of female trainees reported a complication during pregnancy. The most common complication was hyperemesis gravidarum, which was experienced by 16.7 percent of female plastic surgery trainees. Preterm labor was reported at 9.7 percent; low birthweight, 5.6 percent; preeclampsia, 4.2 percent; and gestational diabetes, 4.2 percent. All complications are listed in Figure 6. Ten percent of female trainees were put on bedrest.
The mean maternity leave taken by female plastic surgery trainees was 5.5 weeks (range, 1 to 12 weeks). Nearly half (44.4 percent) took less than 6 weeks, and 62.2 percent reported dissatisfaction with the amount of leave they took. Satisfaction was significantly correlated with the length of leave (p = 0.011).
Paternity or non–child-bearing parental leave averaged 1.2 weeks (range, 0 to 4 weeks). Sixty-eight percent took less than 2 weeks’ leave. More than half (51.4 percent) were dissatisfied with the amount of time they took. Satisfaction was again significantly correlated with the length of leave (p = 0.033).
Forty-seven percent of trainees reported that their program had a formal parental leave policy (21.4 percent reported no policy, and 32.1 percent did not know). Trainees at institutions with formal policies did not differ in amount of leave taken (p = 0.377) or satisfaction with leave (p = 0.286).
Thirty-nine percent of female trainees breastfed for less than 6 months (compared to 21.9 percent of partners of male trainees). Only 19.5 percent of female plastic surgery trainees breastfed for 12 months (compared to 62.5 percent of partners of male trainees) (Fig. 7). Female trainees were significantly more likely to be dissatisfied with their length of breastfeeding (35.6 percent versus 5.9 percent; p = 0.004). Satisfaction was significantly correlated with length of breastfeeding for female respondents (p = 0.009).
Fewer than one-third (29.4 percent) of respondents reported lactation facilities in close proximity to operating rooms. Female trainees were significantly more likely to disagree with the statement “attending surgeons and resident colleagues are supportive of pumping during clinical duties” compared with male trainees (31.3 percent versus 8.2 percent, respectively; p < 0.001) (Fig. 8). Twelve percent reported their program had a formal lactation policy.
On-site childcare was available at the institution of 10.7 percent of respondents. Thirty-four reported no available on-site childcare and 52.6 percent did not know.
Assisted reproductive technologies were used by 19.6 percent of trainees, implying difficulty conceiving. Use of assisted reproductive technology was significantly correlated with female gender (p = 0.039) and older age (p = 0.023). The most common techniques used were clomiphene (5.2 percent), in vitro fertilization (5.2 percent), and intrauterine insemination (4.0 percent). Figure 9 displays all techniques used.
Five percent of female plastic surgery trainees underwent oocyte cryopreservation. Undergoing this procedure was significantly correlated with older age (p = 0.030). Sixty-three percent reported cost as a significant barrier to undergoing oocyte cryopreservation. The most common reason reported by women undergoing this procedure was “completion of my education” (38.9 percent). Other reasons included “stability and/or advancement of career goals” (16.7 percent), “time needed to find a suitable long-term partner” (16.7 percent), and “need to achieve financial stability” (16.7 percent).
This is the first study directly exploring barriers to plastic surgery trainees who choose to start a family. Our results demonstrate that the plastic surgery training environment discourages women from becoming pregnant during residency or fellowship. Women who are married to nonphysicians are more likely to plan to have children after training compared to men; however, this difference disappears when comparing men and women who are married to another physician. This implies that the pressure women feel to complete training before childbearing is not unique to plastic surgery. The maternal age at first pregnancy was 30.3 ± 3.6 years, which is 5 years older than maternal age at first pregnancy for the general U.S. population (24.6 years) but similar to that of other women with a master’s degree or higher level of education.6,7
Plastic surgery trainees reported a higher number of miscarriages compared with the general population (24.4 percent versus 17.0 percent).8 We can only speculate that this may be related to advanced maternal age and stress. In 1995, plastic surgery program directors reported that 25 percent of pregnancies were electively terminated.4 Our results demonstrated only a 5.0 percent abortion rate, which is lower than previously reported and lower than in the general U.S. population (18.6 percent).9 This suggests that the majority of women who do become pregnant feel they will be able to successfully carry their pregnancy to term. The decrease in abortion rates in trainees compared to 23 years ago may be attributable to the 80-hour work week, greater acceptance of pregnancy during training, or heightened awareness of potential infertility if childbearing is delayed until the completion of training.
Sleep deprivation is correlated with complications and adverse outcomes in pregnancy.10 Therefore, it is not surprising that a greater number of nights on call is correlated with a greater incidence of obstetrical complications.11 Furthermore, working more than 60 hours per week and more operative hours per week correlate with higher rates of pregnancy complications.6,11–13 Risk of preterm labor is increased in women working more than 42 hours per week or standing more than 6 hours daily.14 Furthermore, plastic surgery residents may be exposed to methylmethacrylate, anesthetic gases, blood-borne pathogens, and radiation, in addition to emotional and physical stress and sleep deprivation.
Female plastic surgery trainees reported a complication rate nearly four times higher than in the general population.6 The most common complication was hyperemesis gravidarum, which was experienced by 16.7 percent of female plastic surgery trainees compared with a rate of 0.3 to 2.0 percent in the general population.15 It is encouraging that some complications, including low birthweight, gestational diabetes, and hypertension, were actually lower in plastic surgery trainees than in the U.S. general public (5.5 percent versus 8.2 percent, 4.2 percent versus 7.5 percent, and 0.8 percent versus 9.1 percent, respectively).6,16–18 This may be because plastic surgery trainees have lower rates of obesity and smoking and better access to medical care than the general population.
The health benefits of paid parental leave include decreased infant mortality, improved maternal mental health, improved child developmental milestones, and improved breastfeeding practices.19 Economic benefits include improved worker morale, increased worker retention with decreased turnover, increased income, and increased productivity.20–22 Taking less than 9 weeks of maternity leave compared to more than 12 weeks negatively impacts maternal well-being and is correlated with increased rates of depression and anxiety, loss of general positive affect, and decreased life satisfaction.23 Female urologists report significantly higher satisfaction with maternity leave of 9 weeks or longer; however, only 30 percent take a leave of this length, and residents are more likely to take shorter leave.24 The American College of Obstetricians and Gynecologists recommends at least 6 weeks of paid parental leave.22 Forty-four percent of plastic surgery trainees are taking less than 6 weeks maternity leave and 62 percent are dissatisfied with the length of their leave. This demonstrates that changes are needed.
The American Board of Plastic Surgery requires 48 working weeks per year, which allows for only 4 weeks of annual leave. Recently, the American Board of Plastic Surgery has provided an allowance for leave to be averaged, allowing for greater flexibility. In addition, in the final 2 years of training, plastic surgery residents may have an additional 2 weeks of medical leave.25,26 Furthermore, the residency review committee is moving toward competency-based rather than time-based residency training. The American Board of Obstetrics and Gynecology has led the way in formulating flexible parental leave policies, allowing for a total of 20 weeks, and demonstrated no significant impact on surgical experience.27
Breastfeeding has significant health benefits for infants, including decreased rates of hospitalization, infections, allergies, obesity, and sudden infant death syndrome, in addition to improved gastrointestinal health and neurodevelopment. Maternal benefits include less postpartum blood loss; lower rates of depression; more rapid weight loss; and lower rates of diabetes, cardiovascular disease, and breast and ovarian cancer. Economic benefits to breast feeding include reduction in company health care costs, lower employee turnover, and increased employee morale and productivity.28 For every $1 invested in creating lactation facilities and support including appropriate breaks for lactating mothers, there is a $2 to $3 economic return.28
The American Academy of Pediatricians recommends exclusive breast feeding for 6 months, with continued breast feeding with complementary foods for 12 months.28 Despite these recommendations, only 20 percent of female plastic surgery trainees reported continuing breast feeding for 12 months. General surgery residents in Canada report barriers to breastfeeding including being too busy, not having a place to pump milk, and feeling unsupported by attending surgeons and resident colleagues.29 The majority of female physicians across both medical and surgical specialties who breastfed for less than 6 months report problems with accessibility and/or time for breastfeeding after their return to work.6
Delays in expressing milk can have negative consequences, including pain, leakage, infection, and decreased milk supply. Under the Fair Labor Standards Act of 2009, employers are required to provide a “reasonable break time for an employee to express breast milk for her nursing child for 1 year after the child’s birth each time such employee has need to express milk.” Furthermore, employers are required to provide “a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public, which may be used by an employee to express breast milk.”25 Despite these regulations, only 29 percent of trainees reported that lactation facilities were located in close proximity to operating rooms. Furthermore, one-third of women felt colleagues and attending physicians did not support pumping and therefore they may be reluctant to interrupt clinical duties or scrub out of long cases to express milk.
Women who have difficulty arranging child care report worse mental health status, less vitality, and more limitations to role functioning.23 General surgery residents report frustration with limited availability of on-site childcare centers and that drop-off and pick-up times are incompatible with a residency schedule.30 Only 10.7 percent of respondents from this survey reported the availability of on-site childcare. Currently, expense, long waiting lists, and limited hours of operation make on-site childcare an impractical option for residents even if it is available. As 40 percent of plastic surgery trainees are married to another physician, coordinating childcare can be extremely difficult and stressful.
Fertility in women decreases by nearly 50 percent from their early 20s to their late 30s, which reflects the period female trainees are in residency for plastic surgery.3 Furthermore, physical and psychological stress and working long hours negatively impact pregnancy rates.31
Thirty-two percent of female surgeons across surgical specialties reported difficulty with infertility, 84 percent of whom underwent an infertility workup, and 76 percent of these women used assisted reproductive technology. Women with advanced degrees who delay childbearing are most at risk for involuntary childlessness.32 Female residents across all specialties are more likely than their male colleagues to delay childbearing until after training because of concern regarding how they will be perceived by fellow residents, faculty, and leadership.33 Surgeons have fewer biological children (1.4), compared with 2.6 in the general population, and age at first pregnancy is later than in the general population.31,34 Therefore, it is not surprising that the number of plastic surgery trainees who reported using assisted reproductive technology was nearly four times that of the general U.S. population.35
Female plastic surgery trainees, and partners of male trainees, may choose to delay childbearing and may want to undergo oocyte cryopreservation. Sixty-three percent of plastic surgery trainees reported that cost is a significant barrier.
Limitations to this study include response bias, with a higher percentage of female plastic surgery trainees completing the survey compared with male trainees. Residents and fellows without children or with uncomplicated pregnancies may have been less likely to respond. Comparison data from the general U.S. population does not account for confounding variables such as education, socioeconomic factors, age, and smoking status.
Plastic surgery training is long and occurs during childbearing years. The increase in gender diversity within plastic surgery promises to improve the specialty. Exceptional women and men who wish to have a family may be discouraged from entering this field if changes are not instituted to accommodate healthy pregnancies, reasonable parental leave, and childcare options. A recent survey of practicing general surgeons reported that 39.0 percent strongly considered leaving surgical residency because of the difficulty of balancing pregnancy and demands of residency and 29.5 percent would discourage female medical students from a surgical career, specifically because of the difficulties of balancing pregnancy and motherhood with training.36
- Allow for flexible rotation schedules so that trainees can schedule rotations with a lighter workload during pregnancy, and provide the option to pursue research time during pregnancy and postpartum periods.
- Include paid parental leave in resident and fellow standard benefit packages and explicitly include paid and unpaid parental leave policies in employment contracts.
- Parental leave policies at each institution should include contingency plans for service coverage if a woman is unable to work because of pregnancy-related complications or being put on bedrest. In the ideal case, coverage would be provided by paid clinical associates rather than placing an increased burden on other residents, which leads to resentment and decreased morale within the program.1
- Do not require physicians to make up call missed when on parental leave.
- Provide mechanisms to allow residents to become board-eligible if they take greater than 6 weeks of parental leave.
- Provide lactation facilities that are quickly and easily accessible from the operating rooms. These should be furnished with refrigeration, a chair, an outlet, a phone, and a computer so that residents can answer pages and put in orders or write notes while pumping.
- Integrate breaks in clinical duties for lactation.
- Programs should promote a culture that is supportive of pregnancy, breastfeeding, and childcare.
- Provide affordable on-site childcare at teaching hospitals with 24-hour availability and options for when children are sick.
- Include education on the impact of delaying childbearing on fertility and options such as oocyte cryopreservation as part of resident and fellow orientation.
- Health insurance policies available to plastic surgery trainees should cover oocyte cryopreservation and assisted reproductive technology at a reasonable cost.
Plastic surgeons are well recognized for their ability to innovate and solve difficult problems. Current emphasis on wellness and preventing physician burnout must encompass not only the physician in the workplace, but also family, if effective change is to be realized. Creating a supportive environment for childbearing is challenging. Developing effective strategies to support plastic surgeons at all stages within their career who wish to start a family will require innovation and resources. The effort will result in improved job satisfaction and lower rates of burnout, and help to recruit preeminent people into plastic surgery, ultimately improving the specialty.
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