Provincial agreements for pregnant and parenting orthopedic surgery residents: a call for a national residency guideline

Summary

In Canada, orthopedic surgery residents who identify as women face unique challenges regarding family planning during training. We investigated provincial policies on pregnancy, parental leave, and return to work in 8 provinces across Canada. We also explored the British Orthopaedic Association (BOA) guideline as a potential model for improving support for Canadian orthopedic surgical residents during pregnancy, parental leave, and professional development. Our analysis reveals disparities in duty hours, parental leave benefits, and pregnancy-related restrictions. For instance, Quebec allows relief from call duties at 20 weeks’ getation, while Manitoba, Nova Scotia, and Saskatchewan mandate waiting until 28 weeks. Duty-hour restrictions vary across provinces, with British Columbia setting a limit of 12-hour shifts and Quebec setting it at 8 hours. Pay during parental leave also varies, with top-ups ranging from 84% to 100%, inconsistently available to nonbirthing or adoptive parents. Current agreements fail to support informed family planning decisions and lack robust strategies for risk mitigation. We propose implementing a standardized national guideline based on the BOA model. This guideline would offer clear policies for trainees during pregnancy, parental leave, and return to work, along with strategies to minimize occupational hazards. Adoption of such a guideline would empower trainees, promote inclusivity, and encourage more women to consider careers in orthopedic surgery.

More than 60% of graduating medical students in Canada identify as women, yet there continues to be an underrepresentation of women in surgical specialties.¹ Several studies have outlined that the surgical training environment can be a deterrent for residents looking to start a family.² Most medical school graduates are in their mid to late 20s and, thus, pursuing a surgical residency often coincides with a critical time for family planning.³ However, many women who pursue surgical residency programs decide to delay childbearing until the completion of their training.² Reasons cited for delaying childbearing include fear of obstetrical complications secondary to high stress and workload, a lack of program support, and financial insecurity.² This delay is not without risk; advanced age has been linked to adverse outcomes in pregnancy, as have increased workload and stress.⁴ Furthermore, surgeons are at higher risk of infertility and pregnancy complications (e.g., miscarriage, ectopic pregnancy, fetal growth restriction) than their colleagues in nonsurgical specialties.⁵

Although barriers to family planning are pervasive across surgical specialties, orthopedic surgical residency represents a unique challenge, given its long history as a male-dominated profession, the physical demands of select subspecialties, exposure to radiation, and exposure to toxic chemicals.⁶ Women report experiencing discriminatory comments and biased opinions regarding their professional reputations owing to pregnancy and parental responsibilities.⁶ Prolonged standing, heavy lifting, and long operative cases are not infrequent in orthopedic surgery, and have been shown to correlate with a higher risk of complications during pregnancy.⁶ Radiation exposure is also common and can have toxic effects on the developing fetus, especially during early development.⁶ Bone cement, which contains methyl methacrylate, is frequently used in arthroplasty and, occasionally, trauma procedures. Methyl methacrylate is a fetotoxic chemical that is linked to skeletal growth disturbance.⁶ In a survey of orthopedic surgeons, 70% of respondents agreed with the statement, “If policies were in place to support women who desire to have children during residency, more women would choose orthopedic surgery as a career.”⁷ Orthopedic workplace culture and the conditions of the work environment may be important deterrents for residents considering pregnancy or parenthood.

Evaluation of current policy

Given the unique challenges and barriers faced by orthopedic surgery residents, evaluation of the current policies available to those who are considering family planning is essential. In Canada, residents are governed by their respective provincial association agreements (Appendix 1, available at www.canjsurg.ca/lookup/doi/10.1503/cjs.015623/tab-related-content). On Oct. 20, 2023, we reviewed 8 available provincial agreements for terms, conditions, and recommendations related to pregnancy (Table 1), parental leave (Table 2), and return to work (Table 3).

Table 1.

Stipulations related to pregnancy in provincial agreements

Province	Work hours	Call	Risk management	Medical care
British Columbia	< 12 duty h after 24 WG	Shifts < 12 h after 24 WG	Pregnant residents should comply with all occupational health recommendations including opting out of work in circumstances that would affect mother or fetus.	Eligible for paid sick leave
Alberta	No night shifts (0000–0600) after 24 WG	No call in excess of 12 h or between 00:00–06:00 after 24 WG	NS	Eligible for paid sick leave
Saskatchewan	No night shifts after 28 WG	No call after 28 WG	NS	Eligible for paid sick leave
Manitoba	NS	No overnight call between 2200–0800 after 28 WG	NS	Eligible for paid sick leave
Ontario	Accommodation plans are developed on a case-by-case basis	No call after 27 WG	NS	Eligible for paid sick leave
Quebec	Work hours should not exceed 8 h/d, except for call	No call after 20 WG	Involve program director and establish modifications	Eligible for paid sick leave; additional 4 d paid leave for pregnancy-related visits
Nova Scotia	NS	No overnight call after 28 WG or earlier if recommended by a physician	NS	Eligible for paid sick leave
Newfoundland and Labrador	No in hospital duties after 1700 after 32 WG	No call after 1700 or on weekends after 27 WG	NS	NS

NS = not specified; WG = weeks’ gestation.

Table 2.

Stipulations related to parental leave in the provincial agreements

Province	Leave eligibility	Leave start	Leave duration	Leave pay
British Columbia
Maternity leave	Birthing parent	Up to 13 wk before expected DOD, and no later than DOD	17 wk	EI + top-up equal to 90% of salary for 16 wk
Paternity leave	Nonbirthing parent	NS	2 d to attend birth of child	2 d paid leave
Parental leave	Birthing parent	Within 78 wk of DOD	61 wk (78 wk inclusive of maternity leave)	EI
	Nonbirthing parent or adoptive parent	Within 78 wk of DOD	62 wk	EI
Alberta
Maternity leave	May require medical certificate confirming pregnancy and estimated DOD	Up to 8 wk before expected DOD, and no later than DOD	17 wk	EI + top-up equal to 90% of salary, for 17 wk
Paternity leave	See parental leave	NS	See parental leave	See parental leave
Parental leave	Birth or adoption where a resident has not been granted maternity leave	Within 52 wk following DOD or adoption	61 wk for parent also taking maternity leave (78 wk inclusive) 62 wk for parent not granted maternity leave	EI + top-up equal to 100% of salary for 2 wk (if taking parental leave only)
Saskatchewan
Maternity leave	Birth or adoption of a child		16 wk	EI + top-up equal to 90% of salary for 1–16 wk
Paternity leave	See parental leave	NS	NS	NS
Parental leave	Either parent, includes birth or adoption of a child	NS	Up to 78 wk	5 d with full pay (within 30 d of DOD), then EI only
Manitoba
Maternity leave	A resident who adopts or becomes a parent of a child and employed for at least 7 consecutive mo	Up to 17 wk before expected DOD, and not later than 17 wk after the DOD	17 weeks	EI + parental leave benefit equivalent to 60% of earnings, up to $1400 per wk, for 20 wk
Paternity leave	A resident whose spouse or common-law partner has given birth to a child	NS	2 d	NS
Parental leave	A resident who adopts or becomes a parent of a child and employed for at least 7 consecutive mo	Up to 17 wk before expected DOD, and not later than 52 wk after child is born or comes into care of parent. If taken in addition to pregnancy leave, must commence immediately on expiry of pregnancy leave	63 wk	EI + parental leave benefit equivalent to 60% of earnings, up to $1400/wk for 20 wk
Ontario
Pregnancy leave	Applies to birth parent or surrogate	17 wk before expected DOD, and not later than the DOD	17 wk	EI + top-up equal to 84% of salary for 15 wk
Paternity leave	See parental leave
Parental leave	Applies to all new parents, birth parent, adopting parent, or person in a relationship with a parent of a child and plans to treat the child as their own	Up to 17 wk before expected DOD, and no later than 78 wk after child is born or comes into care of parent	35 wk for a birth parent who also takes pregnancy leave 37 wk for all new parents who do not take pregnancy leave (e.g., nonbirth parents and adoptive parents) Extended parental leave can be taken for a maximum of 18 mo total	EI + top-up equal to 84% of salary for 12 weeks If taking both pregnancy and parental leave, maximum of 27 wk of top-up (15 wk pregnancy leave, 12 wk parental leave)
Quebec
Maternity leave	A resident who gives birth to a child	Anytime during pregnancy (paid benefits as of 24 WG)	21 wk	QPIP (basic and special plan), with employer top-up to 95% of salary (if employed at least 20 consecutive wk)
Paternity, same-sex spouse, or adoption leave	A male resident who becomes a parent through the birth of his child A female resident whose spouse gives birth, if she is designated as one of the child’s mothers A resident who adopts a child	DOD or within 15 d of adopted child coming home	6 wk	QPIP (basic and special plan), with employer top-up to 100% of salary (if employed at least 20 consecutive wk)
Parental leave	A resident who has taken maternity, paternity, or adoption leave	Immediately after maternity, paternity, or adoption leave	Up to 2 yr	Portion paid as per QPIP (basic and special plan); rest unpaid
Nova Scotia
Maternity leave	Resident who becomes a parent through the birth of the child	Not sooner than 16 wk before the expected DOD, and not later than the DOD	17 wk	EI + top-up to 93% of salary for 7 wk
Paternity leave	See parental leave	NS	See parental leave	See parental leave
Parental leave	Resident who becomes a parent through the birth of a child, or through the placement of a child in the care of the employee for the purpose of adoption of the child	For adoption leave, must be employed for at least 1 yr	61 wk for birth parent also taking pregnancy leave (78 wk inclusive) 78 wk for parent not taking pregnancy leave Up to 35 wk (may be combined with maternity leave). For adoption, up to 78 wk, or more, if required by adoption agency.	EI+ top-up to 93% of salary, up to a maximum of 12 wk If taking both pregnancy and parental leave, maximum of 17 wk of top-up (7 wk pregnancy leave, 10 wk parental leave)
Newfoundland and Labrador
Maternity leave	Resident giving birth	May begin 8 wk before expected DOD	NS	NS
Paternity leave	See parental leave	NS	See parental leave	NS
Parental leave	Birth or adoption of a child	NS	Up to 52 wk for all parents	NS

EI = employment insurance; DOD = date of delivery; LOA = leave of absence; NS = not specified; QPIP = Quebec Parental Insurance Plan; top-up = additional salary provided on top of EI.

Table 3.

Stipulations related to return to work found in the provincial agreements

Province	Lactation and feeding	Child care	Special circumstances	Make-up time
British Columbia	NS	NS	Up to 3 paid d of compassionate leave for loss of child, including miscarriage after 20 WG	NS
Alberta	AHS is responsible for providing private space to breastfeed; resident must submit a form requesting accommodation to AHS	NS	Entitled to maternity leave due to miscarriage after 24 WG	NS
Saskatchewan	NS	NS	Maximum of 3 d compassionate leave for death of a child, miscarriage NS	NS
Manitoba	NS	NS	Compassionate benefit of up to 1 mo for stillbirth, death soon after birth, or pregnancy loss after 19 WG	NS
Ontario	The hospital must make accommodations (private space, secure fridge for storage) so that resident may breastfeed, chestfeed, or express milk for child Extended health care benefits include coverage for lactation pumps	NS	NS	NS
Quebec	NS	NS	Special leave available after spontaneous or therapeutic abortion before 20 WG if recommended by treating physician (5 d sick leave then salary insurance benefits) Entitled to maternity leave in event of pregnancy termination as of 20 WG (and 5 d paid leave for partner)	NS
Nova Scotia	NS	NS	Compassionate leave of 7 d for death of a child, miscarriage NS	NS
Newfoundland and Labrador	Commitment to providing appropriate environment for breastfeeding and lactation	NS	Compassionate leave of 3 d for death of a child including miscarriage	NS

AHS = Alberta Health Services; NS = not specified; WG = weeks of gestation.

There is considerable variability in the recommendations for duty hours, as well as the ability to access parental leave pay. For example, residents in Quebec may request to be relieved from call duties at 20 weeks’ gestation, while residents in Manitoba, Nova Scotia, and Saskatchewan must wait until 28 weeks’ gestation. Furthermore, surgical residents in British Columbia and Alberta are limited to 12-hour shift maximums, while Quebec has an 8-hour shift limit, and the remaining provinces have no duty-hour restrictions. Regarding parental leave pay, employment insurance (EI) is available to residents in all provinces except Quebec, which has its own Quebec Parental Insurance Plan (QPIP). Most provinces provide a top-up beyond the 55% of wages or maximum $650 per week provided by EI. This top-up, however, ranges from 84% to 100% of wages, and is not universally available for the nonbirthing parent or adoptive parents. Lastly, there are no provincial agreements that outline the unique occupational hazards that specifically pertain to orthopedic residents such as radiation, long work hours, and toxic chemical exposure.

Comparison with policy in other countries

It is imperative that orthopedic surgery trainees have access to clear and consistent policies that protect trainees from potentially hazardous conditions of the orthopedic work environment, and these should be standardized across Canada. The evaluation of current policy in this study demonstrates substantial variability among provinces. This is similar to the United States, where calls for a unified parental leave policy have also been made.⁸ In England, the British Orthopaedic Association (BOA) has published a national guideline.⁹ It is a 14-page document containing recommendations that include but are not limited to notification of pregnancy, time off for antenatal care, mandatory risk assessment, strategies for risk mitigation, suggestions for return to work, and options for less than full-time training. For example, the guideline suggests that pregnant residents be offered the opportunity to alter their rotation schedule such that they limit time spent on rotations with high radiation and cement exposure. The guideline also requires that pregnant residents wear a dosimeter, with a maximum exposure of 1 mSv of radiation. For reference, the average radiation exposure during a femoral intramedullary nailing procedure ranges from 0.08 to 0.108 mSv, without lead protection.¹⁰ In contrast, radiation safety is not discussed in any of the current Canadian provincial agreements.

Conclusion

There is substantial variability among the provinces regarding policies for residents who are pregnant during training. The current provincial agreements do not adequately support Canadian orthopedic surgery trainees to make informed decisions about family planning, nor do they adequately address risk mitigation strategies for pregnant orthopedic surgeons. We suggest that orthopedic surgeons warrant unique consideration and should have access to national guidelines that specifically address the orthopedic work environment. The BOA guideline should be regarded as an exemplar in the creation of a Canadian residency guideline. Having a national policy that is clear and consistent will allow future trainees who are considering starting a family during training to feel adequately supported. This may, in turn, encourage more women to consider orthopedic surgery as a career.