Call to Action: Universal Policy to Support Residents and Fellows Who Are Breastfeeding

Breastfeeding confers a multitude of health benefits to women and children, and it improves workplace productivity.¹ The World Health Organization recommends exclusive breastfeeding for 6 months and continued breastfeeding combined with complementary foods for at least 2 years. Unfortunately, many working women face challenges that limit the duration of breastfeeding, and female physicians are no exception.

A survey of 2363 US physician mothers found that nearly half of the respondents would have breastfed for a longer period of time if their jobs had been more accommodating.² Overall, only 28% reached their personal breastfeeding goals. Junior faculty (less than 4 years in practice) and physicians in procedural specialties were less likely to report breastfeeding for at least 12 months. On adjusted analyses, women with a longer maternity leave, dedicated space to express breast milk, and a more flexible schedule were more likely to report reaching breastfeeding milestones.

Residents and fellows face additional and unique challenges. Female trainees report more barriers to successful breastfeeding than their faculty counterparts, including insufficient time to express breast milk, lack of appropriate physical spaces to pump, and lack of a supportive team.³ Barriers to successful breastfeeding vary across training specialties, with obstetrics and gynecology residents reporting greater access to adequate lactation facilities and achieving a longer duration of exclusive breastfeeding compared with residents in other surgical or nonsurgical specialties.⁴ A recent study of 347 female surgeons who were pregnant during general surgery residency found that breastfeeding was important to almost all (95.6%), but more than half (58.1%) stopped breastfeeding earlier than they wished due to poor access to lactation facilities and challenges leaving the operating room to express milk.⁵ Asking a faculty physician for a break from rounds, conferences, or surgery to pump can be intimidating and uncomfortable; trainees may fear that they will be seen as less committed to patient care than their colleagues if they ask for scheduled breaks.

Trainees and junior faculty who are breastfeeding may also face challenges during the specialty board examination process. Some testing centers restrict women requesting lactation accommodations to a single regional testing location, which may require an otherwise unnecessary overnight trip away from their children.⁶ Furthermore, when examinees arrive at the testing center, a private space to pump is not always available. Additional testing time is not consistently provided, despite pretesting approval by a specialty board (personal written communication, members of Dr. MILK support network, January 2019).⁷

In June 2018, the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements approved revisions to instruct that residency and fellowship training sites

… must provide private and clean locations where residents may lactate and store the milk within a refrigerator [which] … should be in close proximity to clinical responsibilities. It would be helpful to have additional support within these locations that may assist the resident with the continued care of patients, such as a computer and a phone … the time required for lactation is also critical for the well-being of the resident and the resident's family.⁸(p6)

To date, few institutions have established standard protocols to support breastfeeding residents. One exception is the University of Michigan, where surgical residents and departmental leaders have developed guidelines that outline specific accommodations for a lactating resident, with the stated objective of minimizing disruption in clinical activity while creating a “welcoming and inclusive environment for a diverse workforce.”⁹ These efforts have been shared on social media, and residents at other programs are now seeking to draft and adapt similar policies at their respective institutions. However, it should not be the responsibility of residents to ask for this support; rather, it is our charge as clinicians and educators to create an environment and system that support trainees who are breastfeeding.

We applaud the ACGME for its recent steps to facilitate breastfeeding for residents and fellows. Given the emerging evidence illustrating the prevalence of these challenges for women in medical and surgical training, we are advocating for a call to action to establish a universal policy to support and protect the breastfeeding trainee. This policy should be one that can be implemented at every training program and adhere to expert guidelines and best practices. It should include specific requirements for both physical and temporal accommodations. Trainees should be provided access to designated lactation spaces that meet minimum standards established by federal law, state organizations, and professional societies. As frequent expression of breastmilk is essential for maintaining milk supply and avoiding complications,¹³ trainees and programs should work together to identify opportunities for flexibility in daily clinical schedules. For example, residents in procedural specialties might elect to utilize a wearable breast pump intraoperatively or scrub out to express breast milk; either personal choice should be supported. Finally, the universal policy should emphasize the expectation that programs create and maintain an institutional culture supportive of residents and fellows who are breastfeeding. Through focused efforts, we can improve the well-being of the mother and child, minimize disruptions in patient care, and eliminate trainees' concerns about how breastfeeding may impact their clinical evaluations or perceived dedication to patient care. In the Table, we outline 3 primary goals with specific action steps to serve as an initial guide for program directors and institutional leaders interested in effecting institutional change around this issue.

Table.

Supporting Trainees Who Are Breastfeeding: Suggested Goals and Action Steps for Program Directors and Institutional Leadership

Goal	Action Steps
1. Cultivate a supportive workplace culture	Circulate written departmental expectations for a supportive work culture Disseminate information about the importance of supporting breastfeeding in the workplace10 and increase awareness of implicit bias11 during annual occupational health training Implement a policy that outlines the responsibilities of coresidents and attendings in actively supporting breastfeeding residents Designate avenues for safe reporting of policy violations or concerns Indicate that the program is breastfeeding-friendly on its website
2. Promote access to appropriate, accessible lactation facilities	Identify whether the institution currently has lactation rooms Tour these rooms to assess their locations and amenities Elicit feedback from trainees on their experiences accessing and using these rooms Advocate to institutional leadership for necessary modifications of current rooms and/or designation of new rooms1,12
3. Ensure adequate time for breastfeeding or breast milk expression	Meet with breastfeeding trainees prior to their return to clinical duties to discuss their personal needs for milk expression13 Communicate needs to clinical teams and establish expectations for adequate breaks from clinical duties Maximize efficiency of breast milk expression by installing a hospital-grade breast pump and lockers for storage of personal supplies in each lactation room Facilitate multitasking (eg, computer, telephone, teleconference options) to alleviate trainees' concerns about missing educational opportunities or patient care Support trainees who elect to pump during conferences/didactics, on rounds, or in the operating room

In writing this statement, we recognize that this issue may not be relevant to all residents and fellows and acknowledge that it is only one of many potential opportunities for reducing gender disparities in medicine. Nevertheless, supporting trainees and young faculty who are breastfeeding remains an important issue that must be addressed to support women in all clinical specialties. Normalizing and respecting the most basic human need of breastfeeding should be a priority in every workplace, including our own.