Pregnancy and Family Policies in Nephrology Fellowships

Introduction

Historically, there has been poor support for physicians wanting to start a family during their training.^1–5 For those pursuing parenthood, challenges include rigorous clinical schedules during pregnancy, limited time off for postpartum recovery, obstacles to breastfeeding, and stigma.⁴ Furthermore, female physicians experience a higher rate of infertility than the general population, likely because they often defer childbearing because of these barriers.¹

In 2022, the Accreditation Council for Graduate Medical Education mandated a minimum 6-week paid medical, parental, and caregiver leave for residents/fellows, and the federal government enacted workplace lactation protections.^6,7 The American Society of Nephrology (ASN)’s Data Subcommittee (including four training program directors/associate training program directors) surveyed US nephrology fellows to assess awareness of institutional family planning/caregiver policies (including support for lactating mothers) and whether such policies/program culture influenced fellows' choice of training program.

Methods

Questions assessing fellows' experiences with pregnancy and family planning were developed, validated, and disseminated in ASN's Nephrology Fellow Survey (Johns Hopkins IRB00205206). Adult, pediatric, and adult/pediatric fellows (N=954) were surveyed during May 2–23, 2023. Respondents could skip questions they preferred not to answer. Percentages were calculated using question-specific totals. Chi-squared tests for independence evaluated differences between subgroups aggregated by sex, binned age (<30, 30–35, and >35 years), fellowship (pediatric versus adult), and visa status.

Results

Four hundred fifty fellows (400 adult, 41 pediatric, and nine adult/pediatric) participated (47% response). A majority (59%) were international medical graduates, male (56%), either Asian or White (42% each), and non-Hispanic/Latina/Latino (84%), with a median age of 33 years (Table 1). Skip rates ranged between 0.5% (n=1) and 5% (n=11) per question.

Table 1.

Responding fellows’ demographics and results^a

Variable	Number of Respondents n (%)b
Demographics
Fellowship (N=450)
Adult	400 (89)
Pediatric	41 (9)
Adult/Pediatric	9 (2)
Citizenship status (N=450)
US citizen	266 (59)
Permanent resident	41 (9)
H-1, H-2, or H-3 visa	38 (8)
J-1 or J-2 visa	99 (22)
Other visa	3 (0.7)
Prefer not to answer	3 (0.7)
Years of training completed (N=450)
1	188 (42)
2	232 (52)
3	26 (6)
≥4	4 (0.9)
Gender identity (N=449)
Man	250 (56)
Woman	190 (42)
Gender nonbinary	1 (0.2)
Prefer not to answer	8 (2)
Ethnicity (N=449)
Hispanic/Latina/Latino	58 (13)
Race (N=450)c
American Indian or Alaska Native	5 (1)
Black or African American	40 (9)
East Asian (e.g., China, Japan, South Korea, Taiwan)	26 (6)
Pacific Islander	1 (0.2)
South Asian (e.g., India, Pakistan, Sri Lanka)	148 (33)
Southeast Asian (e.g., Philippines, Vietnam, Singapore)	15 (3)
White	190 (42)
Prefer not to answer	37 (8)
Did your plans to start/grow your family influence your choice of nephrology training program? (N=449)
Yes	122 (27)
No	327 (73)
Do you know your nephrology training program policies regarding family planning, parental leave, and available support for lactation and childcare? (N=447)
Yes	218 (49)
No	229 (51)
Please indicate which of the following benefits for family planning, parental leave, and available support for lactation and childcare are provided by your fellowship (N=207)
Minimum of 6 wk of paid leave (at 100% salary) for qualified medical, parental, or caregiver leave at any point during training	171 (83)
Clean and private facilities for lactation that have refrigeration capabilities	116 (56)
Clinic breaks for lactating mothers	86 (42)
Onsite childcare	37 (18)
Backup coverage for childcare emergencies	95 (46)
Insurance benefits for reproductive endocrinology services (e.g., intrauterine insemination or in vitro fertilization)	54 (26)
Other	6 (3)
Have you considered taking or have you taken parental leave during your nephrology training? (N=448)
Yes	83 (19)
No	365 (82)
How would you describe your training program leadership's response to your consideration of taking or decision to take parental leave? (N=83)
Extremely supportive	34 (41)
Very supportive	21 (25)
Supportive	15 (18)
Somewhat supportive	11 (13)
Not supportive at all	2 (2)

^aTotal number of respondents=450.

^bPercentages calculated using question-specific responses in denominator (indicated by “N=”) and may not sum to 100% because of rounding.

^cRespondents were allowed to select all relevant race options.

Family planning and childcare concerns influenced 27% (n=122) of respondents' training program selection, but only 19% (n=83) had considered taking/had taken parental leave. Forty-nine percent (n=218) indicated awareness of parental leave, lactation, and childcare policies. Of these, 83% (n=171) noted their programs offered 6-week parental/caregiver leave (Accreditation Council for Graduate Medical Education minimum). However, only 56% (n=116) reported availability of lactation facilities and 42% (n=86) reported clinic breaks for lactating mothers, both of which are mandated by federal law.

Of 83 respondents who had considered taking/had taken family leave, most (66%) felt their program's leadership were “very”/“extremely supportive.” However, 17 respondents (21%) perceived microaggressions and seven (8%) explicit bias as a result of considering or taking family leave during fellowship. Subgroup comparisons by sex, binned age, and fellowship were not statistically significant, although more US citizen/permanent resident fellows than fellows training on visas knew their program's pregnancy/family planning policies (53% versus 38%; P = 0.00515) and had considered taking/had taken parental leave (22% versus 11%; P = 0.00826).

Discussion

Our nationally representative study shows that family planning policies are important to nephrology fellows. Over a quarter of respondents, irrespective of sex, weighed these policies when selecting a training program. Unfortunately, more than half were unaware of their program's policies, including nationally mandated requirements—minimum 6-week paid leave for pregnancy/adoption and break time and secured private spaces for pumping breast milk.^6,7

Fellows' ignorance, or their program's failure to ensure fellows are fully informed, of these policies may drive this knowledge deficit. This underscores the responsibility of program leadership to ensure awareness, and enforcement, of family planning, caretaker, and lactation policies. Nevertheless, most respondents who considered taking/had taken parental leave felt that their programs were supportive. Although only a few respondents perceived microaggressions or explicit bias related to their decision to take leave, any such behavior is unacceptable.

This study is potentially limited by recall bias and does not evaluate individual programs' family planning/caregiver policies but rather fellows' awareness of them. Knowledge of state-specific laws mandating ≥6-week leave was not evaluated. Although we only asked about lactation breaks in clinics, federal law applies to all clinical and educational settings. The question skip rate was minimal, but because it was highest for the question about program-specific policies, this strengthens the hypothesis that many respondents were unaware of or could not remember them. Despite these limitations, the study offers key data to inform a national conversation about strategies to enhance awareness of mandated policies and implementation of others, including onsite childcare and insurance coverage for infertility treatments, noted by a minority of respondents. Furthermore, it demonstrates that family-friendly policies are valued by nephrology fellows regardless of sex or age—there were no significant subgroup differences, except for visa status. Respondents on visas were less likely to consider parental leave during training. Because a large proportion of our workforce trains on a visa, this disparity deserves further attention in future studies. Factors, such as program size, are practical barriers to implementation of these benefits. That is why innovative, collective problem solving by the nephrology community is key to creating work environments that attract, support, and sustain the next generation of nephrologists.

In conclusion, family-friendly policies are important to nephrology fellows. It is incumbent on institutional/training program leaders and organizations, including ASN, to close the knowledge gap regarding national parental leave and lactation policies and institute additional policies that support fellows who want to start/grow their family during training.

Disclosures

S.M. Boyle serves as a training program director. A.M. Burgner serves as a nephrology training program director. S.M. Halbach reports consultancy for Worldwide Clinical Trials and other interests or relationships with UpToDate. K. Jain serves as a nephrology training program director, serves as principal site investigator for the FSGSALLAGE (NCT04065438) and FSGS Pediatric (NCT02235857) clinical trials, and reports research funding from Visterra as PI for IgA trial (past) and from Kaneka as PI for liposorber study. K.A. Pivert is an employee of the American Society of Nephrology. D.K. Weidemann serves as an associate training program director and reports consultancy for UpToDate and role as an American Board of Pediatrics Pediatric Nephrology Sub-Board member (paid an annual honorarium of $3000 for volunteering to serve on the board and write/edit questions).

Funding

None.

Author Contributions

Conceptualization: Suzanne M. Boyle, Anna M. Burgner, Susan M. Halbach, Koyal Jain, Kurtis A. Pivert, Darcy K. Weidemann.

Data curation: Kurtis A. Pivert.

Formal analysis: Suzanne M. Boyle, Koyal Jain, Kurtis A. Pivert.

Investigation: Suzanne M. Boyle, Kurtis A. Pivert.

Methodology: Suzanne M. Boyle, Anna M. Burgner, Susan M. Halbach, Koyal Jain, Darcy K. Weidemann.

Project administration: Kurtis A. Pivert.

Resources: Kurtis A. Pivert.

Software: Kurtis A. Pivert.

Supervision: Suzanne M. Boyle.

Writing – original draft: Suzanne M. Boyle, Koyal Jain.

Writing – review & editing: Suzanne M. Boyle, Anna M. Burgner, Susan M. Halbach, Koyal Jain, Darcy K. Weidemann.