Nearly half of female surgeons (42%) who were recently surveyed have had a miscarriage or stillbirth — twice the rate of women aged 30 to 40 years in the general population — according to an article published online on July 28 in JAMA Surgery.
The authors, led by Erika L. Rangel, MD, metformin safety Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, also found that after the losses, the women took little or no time off.
Of 692 surgeons surveyed, 347 female surgeons had experienced a pregnancy loss. Of those, 244 had had a miscarriage at less than 10 weeks’ gestation, 92 had had a miscarriage between 10 and 20 weeks’ gestation, and 11 had had a stillbirth (loss at 20 weeks or later).
Most Took No Time Off After Miscarriage
After a miscarriage, 225 of 336 women (75%) took no time off work, and after a stillbirth, 5 of 11 (45%) took off 1 week or less, the authors found.
The study addressed an issue that people have talked about anecdotally or on social media, Rangel told Medscape Medical News.
“This was finally an opportunity to do a study of enough magnitude to show that there is a very quantifiable difference in complication rate, use of IVF [in vitro fertilization], and the age at which we have children. These are not just anecdotal stories,” she said.
For the study, a self-administered questionnaire was distributed electronically. Answers were collected from November 2020 to January 2021 through multiple US surgical societies and social media among attending and resident surgeons with children. The control group for the study was a group of 158 male surgeons who answered questions regarding their partners’ pregnancies.
Female surgeons had fewer children compared with male surgeons and their female partners (mean [SD],1.8 [0.8], vs 2.3 [1.1]; P < .001) and were more likely to delay having children because of surgical training (450 of 692 [65.0%] vs 69 of 158 [43.7%]; P < .001).
Additionally, Rangel and colleagues found that 57% of female surgeons worked more than 60 hours a week during pregnancy and that 37% took more than six overnight calls.
The data show that female surgeons who operated 12 or more hours per week during the last trimester of pregnancy were at higher risk compared with those who operated fewer hours (odds ratio, 1.57; 95% CI, 1.08 – 2.26).
“Pregnant surgeons should not be operating more than 12 hours a week when they are in the third trimester,” Rangel said.
“That is a modifiable risk factor,” she told Medscape Medical News. “It’s a very brief period of support — a couple of months of support for a woman who may do 25 to 30 more years of serving the public with surgical skills.”
She said that training programs should be organized so as to have colleagues cover operating room (OR) shifts to reduce the operating hours for pregnant colleagues. In addition, advanced practice healthcare professionals should be paid to take up the paperwork and perform non-OR care to reduce the stigma associated with pregnant trainees overburdening other surgical trainees.
“It’s Too Big an Ask”
Obstetrician-gynecologist Maryam Siddiqui, MD, told Medscape Medical News she was particularly struck by the number of female surgeons who experience involuntary childlessness.
“That’s a big ask for people who want childbearing to be a part of the fulfillment of their life. It’s too big,” said Siddiqui, who is also a gynecologic surgeon at UChicago Medicine, in Chicago, Illinois.
She said that the amount of detail in the article and the large number of participants were persuasive factors that can support establishing a more humane system than one in which one person at a time has to ask for change.
Pointing to the finding that three fourths of the women in the study who had had miscarriages didn’t take time off, she said, “That’s not really humane. But they’re afraid to ask or they don’t want to reveal they’re trying [to get pregnant]. Why should you be afraid of building your family?”
The authors also found other adverse outcomes. Female surgeons were more likely to have musculoskeletal disorders compared with female nonsurgeon partners (36.9% vs 18.4%; P < .001), and they were more likely to undergo nonelective cesarean delivery (25.5% vs 15.3%; P = .01) and to experience postpartum depression (11.1% vs 5.7%; P = .04).
Siddiqui said the conditions that surgeons encounter on their return to work after childbirth are “a perfect storm” for postpartum depression among women who are not accustomed to being reliant on others.
Women often feel coerced into returning to work before they are physically or emotionally ready, then toggle back and forth from night shift to day shift, losing sleep, she added.
“We can do better,” she said.
One of the solutions, she said, is to provide better work coverage for the surgeon while pregnant and when she returns to work. That includes properly compensating the person covering for the surgeon by giving that person extra pay or additional time off.
“You have to value both people,” she said. “If both people are valued, there’s still collegiality.”
She acknowledged that that kind of compensation may be more readily available at large academic centers.
At UChicago, she said, they are creative with scheduling in training. For women at the height of pregnancy, rotations are less intensive, and trauma rotations are avoided.
Siddiqui said one of the most important aspects of the article is the authors’ list of two dozen ways, both big and small, to improve conditions.
Adopting such changes will become increasingly important for hiring and retaining female surgeons. “You want to work someplace you’re respected as a whole person,” she said.
Sarah Blair, MD, a surgical oncologist at University of California, San Diego (UCSD), told Medscape Medical News that the number of miscarriages in particular provides disturbing proof of a problem women in surgery frequently discuss.
For nearly a decade, she led a women in surgery committee at UCSD in which they discussed such issues regarding pregnancy and medicine.
She hopes these data can help push for change in flexibility in residency so that women can graduate on time and have the families they want.
“There’s a movement away from time-based training to competency-based training, so maybe that will help women,” she said.
“We Have to Figure This Out”
“We will have to figure this out, because more than half of the people in medical school are women, and there are a lot more women in surgery than when I trained more than 20 years ago. It’s not a problem that’s going away,” she said.
One sign of improvement happened at the beginning of this month, Rangel said.
As Medscape previously reported, according to the American Board of Medical Specialties, as of July 1, residents and fellows are allowed a minimum 6 weeks away for medical leave or caregiving once during training, without having to use vacation time or sick leave and without having to extend their training.
“That’s huge,” she said. “But we still have a long way to go, because the residency programs still don’t have to have policy that abides that. It merely says you can take 6 weeks off and take your boards. It doesn’t say that the residency program has to allow you to take 6 weeks off.”
The authors note that the United States and Papua New Guinea are the only countries in the world without federally mandated paid parental leave.
“Most US female surgeons rely on their employer for this benefit, but only half of top-ranked medical schools offer paid leave, and 33% to 65% of US surgical training programs lack clear maternity leave policies,” she said.
Funding for the study was provided by the Brigham and Women’s Hospital Department of Surgery. The study authors, Blair, and Siddiqui have disclosed no relevant financial relationships.
JAMA Surg. Published online July 28, 2021. Abstract
Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune and Nurse.com and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.
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