Perspectives of US General Surgery Program Directors on Cultural and Fiscal Barriers to Maternity Leave and Postpartum Support During Surgical Training

This qualitative study describes the perspective and experience of US surgical program directors regarding maternity leave and postpartum support.

Key Points

Question

What is the perspective and experience of US surgical program directors regarding maternity leave and postpartum support?

Findings

In this qualitative study of 40 surgical program directors, fiscal barriers and complex interpersonal and social issues within the surgical training culture were reported as obstacles to program directors providing support to pregnant residents.

Meaning

The findings suggest that promotion of a surgical culture that normalizes pregnancy and motherhood during training is needed and that surgical program leadership should provide written maternity leave policies, defined lactation support, and structured mentorship and coaching programs.

Abstract

Importance

Although pregnancy during surgical residency is increasingly common, studies of surgical residents have identified challenges associated with pregnancy and motherhood. These include perceptions of different maternity leave policies among institutions, lack of mentorship, stigma, and desire for greater lactation support.

Objective

To describe the perspective and experience of US surgical program directors regarding maternity leave and postpartum support for surgical residents.

Design, Setting, and Participants

This qualitative study included surgical program directors of US general surgery residency programs who were selected using purposive-stratified, criterion-based sampling. Transcripts were collected from semi-structured interviews, which were audio-recorded and transcribed verbatim, from October 21, 2018, to June 1, 2019.

Exposures

Maternity leave and postpartum support.

Main Outcomes and Measures

Perspectives of program directors regarding maternity leave and postpartum support were categorized into common themes identified using content analysis.

Results

A total of 40 US general surgical programs directors (28 [70.0%] male; mean [SD] age, 49.7 [6.8] years) were interviewed, of whom 36 (90.0%) were from university-based programs. All reported having maternity leave policies allowing a duration of leave of 6 weeks or longer. Analysis of program director interviews identified 5 themes: (1) residents are reluctant to extend training despite being offered multiple leave options; (2) childbearing negatively impacts the quality of work of certain residents; (3) lack of formal lactation policies creates practical challenges in supporting residents who are nursing; (4) resentment from coresidents who are asked to provide maternity leave coverage varies based on the prepregnancy reputation of the resident on leave; and (5) lack of salary support limits the practicality of extended leave options. Complex interpersonal issues affected residents differently, including stigma, reluctance to change established surgical training patterns, and challenges with work-life balance.

Conclusions and Relevance

This qualitative study found that sociopolitical issues within surgical training culture and fiscal constraints created obstacles against program directors supporting pregnant residents. These findings suggest that a multidimensional approach to supporting residents through written maternity and lactation policies, structured mentorship and coaching programs, and efforts by leadership to enforce family priorities is needed to promote a surgical culture that normalizes pregnancy and motherhood during training.

Introduction

Up to 50% of physicians plan to become parents during clinical training,¹ a life event that has important implications for career development, work-life balance, and burnout.² Studies of surgical resident perceptions on childbearing have described stigma and negative attitudes against parenthood, guilt over the burden placed on peers to cover leave, variable presence of maternity leave policies, a paucity of mentorship on balancing family priorities and work duties, and deficits in breastfeeding and childcare support.^3,4 These difficulties may have negative implications for the surgical workforce, with nearly 40% of women who had a child during training reporting that they seriously considered leaving their training program and 30% reporting they would counsel a female medical student against a surgical profession owing to the challenges of becoming a mother during training.⁴

The American Board of Medical Specialties and the Accreditation Council for Graduate Medical Education (ACGME) convened at a cosponsored Parental Leave Workshop in February 2020 to discuss optimization of parental leave nationally, demonstrating a commitment of national stakeholders to improve family wellness for residents. Similarly, the American Board of Surgery (ABS) revised its leave policies to maximize flexibility for new parents and allow “surgical residents/fellows to exceed their professional goals without sacrificing their personal ones.”⁵ Despite recent focus on policy change and studies characterizing the concerns of surgical residents having children, information on the challenges that program directors face is needed to inform practical changes at the institutional level. The purpose of this study was to describe the perspectives of US program directors regarding maternity leave, pregnancy, and postpartum support during training to help provide the basis for building programmatic support for pregnant residents.

Methods

Study Design and Setting

In this qualitative study, transcripts were collected from semi-structured interviews with US surgical program directors from October 21, 2018, to June 1, 2019. The institutional review board from the Partners Human Research Committee determined that this project met the criteria for exemption §45 CFR. Moreover, verbal informed consent was obtained from each participant at the beginning of their interview. This study followed the Standards for Reporting Qualitative Research (SRQR) reporting guideline.

Participants

To maximize diversity among participants and equal geographic distribution, purposive, stratified, criterion-based sampling was used to select program directors from the general surgery ACGME-accredited training programs throughout the US. This method emphasizes obtaining information-rich feedback from particularly knowledgeable or experienced individuals over probabilistic or random sampling.⁶ With criterion-based sampling, participants from all geographic regions and varied program sizes were sought to identify shared patterns and to understand how program directors have adapted to diverse conditions and training cultures. A description of the study and an invitation to participate in the interviews was electronically sent to potential participants. No participation incentive was offered.

Interview Guide

The interview guide was constructed using a comprehensive approach including a literature review and an expert panel. A preliminary conceptual framework was developed with a literature review to identify major themes related to maternity leave during residency training, with particular focus on surgical and procedural-based training programs. A primary interview guide was constructed using the most relevant themes, with open-ended questions tailored to program directors and narrowed to key questions through our consensus. The final interview guide included 15 questions focused on leave policies, obstacles faced by the program director in providing leave, perceived consequences of leave for a resident’s quality of work, and challenges in providing career guidance, lactation support, and childcare support for the pregnant resident. The guide was refined through a process of constant comparison as new themes and concepts arose from the interviews. This interview approach allowed flexibility to identify and explore topics not included in the original interview guide.

Interview Procedures

Program directors who responded to the initial invitation were contacted to set up a 30-minute interview. One of us (M.C.-A.) with advanced qualitative research training conducted all interviews from October 2018 to April 2019. After verbal informed consent, a period of 5 minutes was used to explain the study and answer questions, and the remaining time was used for the interview. Interviews were reviewed in real time to assess for new concepts and themes being discussed by each participant. All interviews were audio recorded with permission, transcribed verbatim, and evaluated shortly after completion to continuously update the interview guide and to assess for content saturation. Content saturation occurs when no new major concepts or ideas are being introduced during the interviews, ensuring that there are no unidentified ideas and that additional interviews are not likely to add substantially to the conceptual framework.⁷

Statistical Analysis

Descriptive statistics are reported using the mean for continuous variables and frequencies and percentages for categorical variables. Data were analyzed using qualitative content analysis, which facilitates interpretation of the content of text data through a systematic process of coding and identifying themes or patterns. Two of us (M.C.-A., E.L.R.) read all data repeatedly to achieve immersion and identify codes. Codes were discussed by us on several occasions, disagreements were resolved by consensus until 100% agreement was achieved, and a finalized codebook was built. Codes were sorted into categories or themes, and emergent themes were discussed among us to resolve any discrepancies. Illustrative quotations were identified for each theme. Thematic saturation was defined by the lack of new themes after 3 consecutive interviews. Atlas.ti 8 (Scientific Software Development, GmbH) software was used to organize the qualitative data.

Results

Participant and Program Characteristics

Of 80 program directors invited to participate, 40 (50.0%) were interviewed, representing 40 of the 264 ACGME-accredited general surgery residency programs (15.2%). Of these participants, 28 (70.0%) were male, 36 (90.0%) were married, and 31 (77.5)% had at least 1 child, of which 25 (51.1%) were born outside of surgical training; the mean (SD) age was 49.7 (6.8) years. Mean (SD) time in the role of program director was 7.65 (5.13) years (Table 1).

Table 1. Demographic Characteristics of Program Directors.

Characteristic	Program directors, No. (%)
Sex
Male	28 (70)
Female	12 (30)
Marital status
Single	4 (10)
Spouse or partner	36 (90)
Works	27 (75)
Does not work	9 (25)
Divorced	0
Widowed	0
Children
Yes	31 (77.5)
No	9 (22.5)
Stage of training during which children were born
Medical school	2 (4.1)
Residency	13 (26.5)
Fellowship	11 (22.4)
Attending	23 (47.0)
Duration in practice, mean (SD), y	16.05 (7.11)
Duration as a program director, mean (SD), y	7.65 (5.13)

Most participants (36 [90.0%]) were from larger university-based programs with a mean (SD) of 6.67 (2.16) chief residents per program. All 4 regions of the country were represented, with the fewest programs from the South (6 [15.0%]). Most programs demonstrated sex parity in composition of residents, with 29 program directors (72.5%) reporting a proportion of female residents of 41% to 60%. However, in a substantial proportion of programs, a minority of residents were parents (0%-20% residents with children: 16 [40%]) (Table 2). All program directors reported having maternity leave policies allowing a duration of leave of 6 weeks or longer.

Table 2. Residency Program Characteristics.

Characteristic	Residency programs
Chief residents, mean (SD)	6.67 (2.16)
Type of program, No. (%)
Independent	4 (10)
Academic	36 (90)
Geographic region, No. (%)
Midwest	11 (27.5)
Northeast	14 (35.0)
South	6 (15.0)
West	9 (22.5)
Female residents, No. (%)
0%-20%	0
21%-40%	10 (25.0)
41%-60%	29 (72.5)
61%-80%	1 (2.5)
81%-100%	0
Residents with children, No. (%)
0%-20%	16 (40.0)
21%-40%	18 (45.0)
41%-60%	3 (7.5)
61%-80%	3 (7.5)
81%-100%	0

Themes

Five major themes emerged from the interviews: (1) residents are reluctant to extend training despite being offered multiple leave options; (2) childbearing negatively impacts the quality of work of some residents; (3) lack of formal lactation policies creates practical challenges in supporting residents who are nursing; (4) negative attitudes and resentment from coresidents asked to cover leave varies with the prepregnancy reputation of the resident on leave; and (5) lack of salary support limits the practicality of extended leave options. Table 3 includes illustrative quotations for each described theme.

Table 3. Representative Quotes for Each Theme.

Theme	Illustrative quotations
Desire to not extend training	Well I’ve offered it [5 in 6 leave policy] to several of the residents who are pregnant, but no one has wanted to take it because there is a really…there is an imperative to finish your training and move on to fellowship. I think the 2 things that drive people’s desire not to extend their training are: one, not to be away when their peers have to work, and I think the second is they don’t want to extend their training and overlap with residents coming up.
Brief maternity leave negatively impacts the quality of work of some residents, but it varies by resident	I have had female residents say, “I feel like I should be home,” and they are distracted at work, and the faculty have come to me to say, “your resident X is really conflicted. Is there something we can do for her?” I’ve seen women come back and having [a] child has actually focused them and I think made them better residents; they have stepped up their game in terms of time management, efficiency, you know all those things. And I’ve also seen women struggle when they come back.
Lack of a formal lactation policy makes it difficult to support pumping during surgical procedures	We had one incident with a faculty member where a resident broke scrub to go pump, she told the faculty member where she was going and he said ok great…go pump and then 5 min into being gone, he called her. “Ok I need you back now,” and it wasn’t an emergency. It was just, “you know I need you back now,” and I think he just, I don’t know, maybe he didn’t realize how much time had elapsed or not, or maybe he didn’t know how long it takes to pump. I don’t think the residents feel comfortable asking many faculty members for that accommodation. I am confident that my faculty would accommodate it; I think that there probably is a reticence though on their [residents] part to ask.
Mismatch between leave policy options and financial logistics	So the biggest challenge that we’ve had, that has now been sort of ameliorated by our local GME office, was how we have to work [out] payment, like salary [during maternity leave]. There is an issue of salary. Even though the board allows 5 y to be done in 6, there is not going to be salary continuation through the year they are off.
Resentment by coresidents varies on a case-by-case basis	You might get some resentment. Do they like that resident? Is that resident someone they feel like has really worked hard the whole residency? Are they a real team player?…Then they are more likely to cover for them and not worry. But if it is a resident perceived as weak or someone who is a little more likely to take advantage, then they get a little more resentful. I think a lot of it depends on the individual who is having maternity leave. If that person is viewed as strong and collaborative and goes out of their way, then there are almost never any issues. If that person is already viewed as someone who is not one of the stronger residents or who sometimes dumps on other residents, then it can be a problem….

Abbreviation: GME, Graduate Medical Education.

Desire Not to Extend Training

Although all program directors reported discussion of multiple leave options during resident orientation and again when their residents communicated their pregnancies, many described residents’ reluctance to lengthen leave by extending training. The recently revised ABS leave policy allows multiple options for time away from training including the ability to postpone completion by up to 8 weeks while remaining admissible to the certification process, extending training by up to 12 months, or adding an additional 2 weeks of leave up to 2 times during residency.⁸ However, most program directors reported little interest in these options based on pressure to start a fellowship on time, not wanting to be away while peers had to work, and reluctance to overlap training experiences with more junior residents.

Consequences for Residents’ Quality of Work

The program directors described marked variability in how childbearing affected residents’ quality of work, with many describing returning residents as conflicted and distracted. Faculty complaints about lower work quality and weak performance were reported to some program directors. Such feedback prompted 2 program directors to recommend extension of leave to the affected residents to reduce work-home conflict and improve subsequent performance. Conversely, other program directors reported that some residents returned more focused, thorough, organized, and detail oriented after returning from maternity leave.

Lack of Formal Lactation Policies

Program directors reported that faculty members were generally supportive of the need for nursing residents to step out of the operating room to pump milk. However, 2 common obstacles included residents’ discomfort in making the request and poor understanding by faculty of the practical logistics and time needed for the process. One program director described a situation in which an attending expected the resident to be back within 5 minutes even though she was not missing a critical portion of the procedure. The faculty did not seem to understand the time needed to express milk, highlighting the need for education. Program directors felt that such misunderstanding of residents’ personal needs compounded awkwardness and reluctance in making requests for accommodations. Creation of a written lactation policy was recommended to reduce trainee apprehension, provide clear guidelines describing resident needs, and set expectations for lactation breaks during cases.

Resentment by Coresidents

Program directors reported that some residents taking maternity leave experienced resentment from coresidents asked to cover their work. However, many reported that the way in which a resident was perceived before taking maternity leave was associated with the reaction of their coresidents. If the resident was viewed as a hard worker, requests for coverage would be met collaboratively. However, if the resident was previously perceived as weak, more animosity would result from shifting of clinical duties.

Mismatch Between Leave Options and Financial Logistics

Program directors reported that the lack of salary support limited the practicality of extended leave options. Few had resources, such as extra funding or workforce, to support all of the extended options permissible for residents by the ABS. In exceptional cases in which residents took a full year of leave, program directors were able to offer salary compensation by involving the resident in research and educational activities, but this option occurred rarely. However, most described difficulty providing remuneration to residents who decided to take more than 6 weeks of leave.

Discussion

The long duration of surgical training means that it coincides with the critical years of starting and raising a family. Recent focus on the challenges of female residents having children during training^4,9,10,11 has galvanized efforts to create national mandates regarding family leave during training.⁵ This study reports perspectives of program directors and provides insight on the challenges of implementing changes at the institutional level, which include cultural and practical obstacles.

Four of the 5 themes highlighted by this study demonstrate the need for culture change to normalize maternal and postpartum needs and cease the narrative that time away is equivalent to weakness. Traditional surgical resident identity is based on independence, grit, a strong work ethic that requires completion of tasks without assistance, and a commitment to the profession that avoids personal responsibilities that may interfere with hospital work.^12,13 Sociologists have described the challenges of violating such traditional identities, with guilt on the part of those attempting change¹⁴ and disapproval by senior members of the hierarchy who protect the status quo.¹⁵ The former is described in a prior study¹⁶ that described fear of stigma deterring residents from requesting work accommodations despite health concerns during pregnancy or for the desired time off after the birth of a child. Hierarchy is well established in surgical training, with a paradigm that relies on support, guidance, and instruction from senior residents and faculty.¹² Pressure to maintain this pyramidal structure forms a political barrier to residents asking for support. In the absence of written program policies limiting strenuous rotations close to term, outlining cross-coverage schedules, and defining lactation needs, pregnant or postpartum residents may be reluctant to approach more senior residents for coverage of clinical responsibilities. To avoid discord from inconsistencies in departmental policies, reduce anxiety for the expectant resident, and reduce resentment from colleagues asked to cover unplanned absences in an ad hoc fashion,¹⁷ policies for maternity leave and postpartum support should be transparent and openly disseminated.

Similar to the obstacles that program directors experienced after ACGME work hour reductions, upcoming national mandates for parental leave present a paradigm shift and culture change that are likely to be met with resistance by both pregnant residents struggling to preserve their reputation and more senior members of the surgical team who trained under an older system. Such barriers to culture change were demonstrated by the illustrative quotes seen in this study, which include peer and faculty descriptions of new mothers as “weak,” “distracted,” or “dump[ing] on other residents.” Similar to interventions that facilitated the transition to reduced resident work hours,¹² a top-down campaign by surgical leadership is needed to affirm and encourage time away from training to establish healthy behaviors and work-life balance, thereby establishing legitimacy for a surgeon’s identity that prioritizes family well-being. Initiatives with support and dissemination by the chair and program director, such as the formal lactation policy at the University of Michigan,¹⁸ highlight the needs of new parents, educate nonchildbearing faculty on the time requirements for pumping, and reduce barriers to implementation. Formal and informal communication from faculty and senior residents should be frequent and should enforce that becoming a parent is a celebratory event, time for parental bonding is an expectation and not reflective of a resident’s worth, and lactation in a postpartum woman is a basic body function that must be supported during the clinical work day.¹⁸

We further call on training programs to adopt a culture of mentorship as a strategic priority by highlighting the measurable benefits, including increased career satisfaction, productivity, personal development,¹⁹ and decreased burnout.²⁰ National studies^4,21 of surgical residents have demonstrated that women are uniquely challenged to reconcile the dual roles of being a mother, partner, and surgeon. The demands of having and raising children while meeting the rigorous expectations of a surgical resident, such as long hours, maximizing educational opportunities, and obtaining sufficient operative experience, may contribute to higher rates of burnout and poor psychological well-being among women. Qualitative work suggests that like-gendered leadership and mentorship is associated with mitigating stress, increasing advocacy, and reducing feelings of disenfranchisement.^21,22,23 At our institution, residents are asked to identify a “pregnancy mentor” from a list of faculty volunteers when they communicate their pregnancy to the program director. These volunteers are both mothers and surgeons and are committed to providing a coaching relationship, a safe setting to discuss challenges, and experience-based advice on balancing domestic and professional commitments. Although mentorship by leaders of a different sex are still encouraged, shared viewpoints with fellow surgeon mothers may increase the resident’s willingness to talk openly and address vulnerabilities without fear of judgment or misunderstanding. Such connections are important when discussing sensitive topics that can threaten identity and may help residents receive feedback in a constructive manner.

The fifth theme identified addressed lack of funding to support longer maternity leave. Financial barriers to extramural opportunities are not unique in surgical training, with research efforts and resident benefits²⁴ also constrained by high costs, limited grant funding, and graduate medical education resources threatened by Medicare spending cuts.^25,26 With waning federal support, individual departments may bear greater costs internally for discretionary funding. Innovative solutions to maximize fiscal support should be tailored to institutional needs but may become increasingly important, as previous research suggests that medical students consider quality of life among the most important factors in selecting a program.^27,28 As parenthood becomes more common during training,^3,4 benefits, such as paid leave, may influence the decisions of the most competitive applicants.

Limitations

This study has several limitations. First, although efforts were made to capture a diverse sample, community and military programs were underrepresented, and viewpoints expressed may not reflect the experiences of these programs. Second, program directors from institutions with more experience with maternity leave or stronger benefit packages may have been more inclined to respond to our request for interviews, leading to response bias. Targeted efforts to evaluate smaller, community-based and independent programs may demonstrate additional needs. Third, it is not clear based on existing data how strongly culture change would improve wellness for residents having children during training. Although literature⁴ shows that the challenges of pregnancy and motherhood during residency contribute to professional dissatisfaction, caring for a new child and training to become a surgeon are inherently sleep-depriving, all-consuming endeavors that may be difficult to undertake simultaneously regardless of the support provided. Future research investigating burnout and wellness before and after implementation of programmatic changes would be helpful to better understand the direct impact of residency support. In addition, details of nonmonetary assistance to resident mothers, such as health plans and moonlighting opportunities, were not explored in this study and may impact overall financial strain and merit future research.

Conclusions

The findings of this qualitative study suggest that, despite increasing recognition of the need for more support for women having children during residency, sociopolitical issues within surgical training culture present obstacles. Surgical program directors reported complex interpersonal issues, including stigma, reluctance to change established surgical training patterns, and struggles with work-life balance that affected residents differently. A multidimensional approach to supporting residents through written maternity and lactation policies, structured mentorship and coaching programs, and iterative efforts by leadership to enforce family priorities appear to be necessary to promote a surgical culture that normalizes motherhood during surgical training.