CORR Insights®: What Are the Challenges Related to Family Planning, Pregnancy, and Parenthood Faced by Women in Orthopaedic Surgery? A Systematic Review

Where Are We Now?

I got away with it. I birthed three healthy girls when I was 36, 39, and 43 years old. I married at 21, but I opted to wait to have children to avoid facing any bias barriers to being hired or promoted. What biases specifically? The perception that I wouldn’t work as hard as men or I would have conflicting priorities arising from family responsibilities—not to mention adjustments in the call schedule and patient coverage because of maternity leave after delivery. Sociologists call this the “motherhood penalty” [1]. Working mothers encounter disadvantages in pay, perceived competence, and benefits relative to childless women and men. This is not so different from the concerns other women orthopaedic surgeons feel that have led to delays in building a family, as outlined in a systematic review in this month’s Clinical Orthopaedics and Related Research® [4]. It’s strange. If someone has an unexpected illness or accident, we step up to help cover and serve patients. If pregnancy is planned, it is perceived as optional, more “personal,” and less situational.

We know fewer than 15% of practicing orthopaedic surgeons are women. We know that gender discrimination issues stop excellent medical students from applying to orthopaedic surgery. We know women orthopaedic residents and attendings continue to experience workplace harassment [8]. But the systematic review in this month’s CORR® [4] looks at a different issue. The authors reviewed the best-available evidence with excellent scientific rigor and reported the health facts about pregnancy-related issues for women in orthopaedic surgery. Like me, many women orthopaedic surgeons delay pregnancy such that pregnancies occur up to 10 years later than they do in control populations (33.1 versus 24.6 years); women surgeons delay pregnancy for many of the same reasons I noted above.

But with delays come consequences. The ability to become pregnant begins to decrease at 32 years old (63%), and this challenge continues to decline steeply at 35 to 39 years (52%) [2]. This CORR article [4] identified a number of risks to the mother and fetus if the woman is an orthopaedic surgeon, including environmental exposures known to be detrimental to the health of the pregnancy like exposures to blood, chemicals (such as methacrylate cement), anesthesia gases, and radiation. The authors found that women orthopaedic surgeons are more likely to have complications with their pregnancies, even after adjusting for age, than are typical for women in the United States. Lastly, the authors identified a lack of accommodations for postpartum needs including maternity leave, family leave, child care, and physical plant modifications such as lactation facilities, despite state policies supporting these necessities for a healthy mother–child environment.

Where Do We Need to Go?

This study reinforces the conversations I have with medical students, orthopaedic residents, and early-career faculty. I say, “don’t wait!” If you plan to have a family, fulfill your dream. Biologically, environmentally, and emotionally, this article [4] supports this statement, which suggests women orthopaedic surgeons have children earlier in life.

Unfortunately, despite having legislature such as the Pregnancy Discrimination Act of 1978, which prohibits discrimination based on pregnancy, childbirth, or related medical conditions, we are still facing barriers in the workplace when we become pregnant. These barriers include bias in hiring pregnant women and salary discrimination: the “motherhood penalty” [1]. Pregnancy discrimination is defined as treating an individual––an applicant or employee––unfavorably in any aspect of employment, including hiring, firing, pay, job assignments, promotions, layoffs, training, fringe benefits (such as leave and health insurance), and any other terms or conditions of employment [6]. These laws, which try to protect pregnant working women, are not enough. Our orthopaedic training and professional practice opportunities need to enact cultural and organizational changes that reduce gender inequity in the workplace, specifically regarding pregnancy and related child health needs. Women orthopaedic surgeons need to have confidence that they will be hired for the same pay, have the same promotion and professional growth opportunities, and be afforded an environment that respects women regardless of whether they decide to start a family.

How Do We Get There?

Denmark guarantees a child care spot for every child and dedicates up to 25% of funding support [3]. Denmark also guarantees this space until the child is up to 10 years old, with the option of after school care. If a nanny works best for a family in Denmark, the government is flexible enough to use this contribution to partially support hiring a nanny. The United States, in contrast, is the outlier for child care spending with the lowest contribution among most other countries [3]. Trying to convince our government to support this endeavor has been unsuccessful for years. We will have to consider other more local options.

We need to break down the barriers for women in orthopaedic surgery who hope to get pregnant and have children. We need to have collaborative discussions with partners and administrators regarding solutions to pregnancy and health needs for the mother and child. Coronavirus-19 highlighted the option of telehealth, which expands work-from-home opportunities. Clinic hours might be held at night so a mother can leave clinic to pick up her child at the bus or from daycare. Job share options may provide flexibility for the right practice. Regarding doing the “right thing” to support the working woman orthopaedic surgeon, there are a variety of state laws requiring businesses to provide time and facilities for breast feeding [5, 7]. We should provide the same lactation break options for women surgeons and find ways to do this that alleviate the perception that this delays surgery or reduces operating room efficiency. Finally, we need to understand what each mother-surgeon hopes to achieve both at home and professionally and to align resources to help her accomplish these goals. Child care hours are often not surgeons’ hours. Supplementing support with child care resources with local facilities near the hospital or clinic, earlier hours or later extension hours, or financial incentives can help bridge the gap of time or pay.

To assess whether we have “moved the bar” by improving pregnancy rates and lowering the barriers to women considering families, we need to unify as a specialty and “measure it to manage it.” On the professional side, we should follow metrics like promotion, tenure, leadership profile, or Association of American Medical Colleges salary; and on the health side, future studies might track pregnancy attempts and success and age at the time of pregnancy among women orthopaedic surgeons.

It is interesting that at academic institutions, we can take 6 months full pay sabbatical to work to advance our academic goals, yet we have only 6 to 12 weeks (depending on policy) of full pay to recover from a life-altering health condition that results in lifelong change. Something has got to give.