Advocating For a Culture of Support for Lactating Medical Residents in Hawai‘i

Abstract

Lactating medical residents face unique barriers due to intense clinical work schedules, limited support in the clinic and hospital workspaces, and competing pressures between career development and childcare. The objective of this project was to explore the perceived culture of breastfeeding support among medical trainees and design an action plan to improve support for lactating residents in Hawai‘i. Resident and faculty representatives from the Hawai‘i Residency Programs and the University of Hawai‘i John A Burns School of Medicine participated in an 8 month national learning collaborative to review the existing resident lactation policy and resident perception of lactation support.

In a pre-survey, the majority of residents (88%) agreed that 20-30 minutes every 2-3 hours should be allowed to express milk but only 18% felt comfortable asking for a change in schedule to accommodate time to pump. An action plan was created with the following objectives: (1) revamping the existing policy to address protected pumping times, lactation spaces, and responsibilities of administration, faculty, and residents; (2) improving lactation space through uniform provision of educational material on available facilities and efficiency tips for new parents, and (3) improving awareness of the unique challenges lactating residents face and empowering faculty and trainees to advocate for lactating residents through department and educational presentations. Medical residents in Hawai‘i recognize the importance of breastfeeding but perceive a lack of support in the workplace. A comprehensive action plan to revamp the resident lactation policy and improve faculty and resident education may foster an increased culture of lactation support and healthy development of the physician workforce.

Introduction

“Liquid gold”, the thick golden colored colostrum produced in the first few days post-partum for a new parent before their breast milk matures to an opaque white color, is aptly named for the valuable precious benefits for both baby and parent. Infants who receive breast milk have reduced risk for sudden infant death syndrome (SIDS), respiratory or gastrointestinal infections, allergies, asthma, and obesity. Lactating persons have reduced risk of breast and ovarian cancer, type 2 diabetes, and hypertension. Thus, major medical organizations including the American Academy of Pediatrics (AAP) and American College of Obstetrics and Gynecologists (ACOG) recommend that infants exclusively receive breast milk for their first 6 months and continue breastfeeding for at least the first year of life.1,2

Medical students and resident physicians (defined as individuals with an MD, DO or MBSS degree who are participating in a graduate medical education program) are educated about these benefits of breastfeeding during their training and are expected to support lactating patients. However, many fall short of meeting these recommendations when it comes to their personal lactation goals and experiences. A 2018 study of 927 members of the AAP Section on Medical Students, Residents, and Fellow Trainees found that the 33% did not meet their goal for exclusive breast milk and 24% did not meet their lactation duration goal due to the intense work schedules of residency, lack of perceived support among peers and staff, and feelings of guilt from conflicting expectations between career development and infant support.3 Similarly, another survey of resident physicians in 2020 revealed that 73% felt residency limited their ability to lactate, 37% stopped before their goal, and 40% reported that faculty and peers made them feel guilty for their decision to lactate.4

Like many states, Hawai‘i law entitles all employees to reasonable break times during the workday to express milk for 1 year after the birth of a child and to a private, non-bathroom space to express milk. However, the practical logistics of achieving these legal rights is left to the employer. The Hawai‘i Residency Program, which comprises the largest graduate medical education residency programs in the state of Hawai‘i, has only has a two-sentence lactation policy in its resident handbook that simply states, “For up to one year after the child’s birth, any resident who is breastfeeding her child may take breaks to express breastmilk for her newborn. [Contact Human Resources for information].” Additionally, the diversity of health care systems involved as training sites for residents adds a degree of complexity to this issue from the perspective of space sharing with other staff. The aim of this project was to explore the perceived culture of breastfeeding support among Hawai‘i Residency Program resident physicians and design an action plan to improve support for lactating residents based on the American Academy of Family Physicians Model Policy Breastfeeding and Lactation for Medical trainees.5

Methods

Kapi‘olani Medical Center for Women and Children (KMCWC), a major training hospital site for the Hawai‘i Residency Program, was one of 10 medical residency institutions selected to participate in an 8 month learning collaborative “Supporting Breastfeeding Medical Residents Project’’ sponsored by the AAP and the American Academy of Family Practice. The goal of the program was to evaluate each site’s written policy and culture around breastfeeding support for trainees through anonymous resident surveys and facilitate each site’s creation of an action plan for improvement. The KMCWC local collaborative group was composed of resident representatives from pediatrics, obstetrics and gynecology, and family medicine residency programs (which comprise the majority of residency programs utilizing KMCWC as a training hospital site) as well as a faculty member from the University of Hawai‘i John A Burns School of Medicine Department of Pediatrics and administrative member from the Hawai‘i Residency Program.

A pre-work survey link provided by the learning collaborative was distributed to all residents from the pediatrics, obstetrics and gynecology, and family medicine programs. After reviewing the institution’s survey results, the KMCWC group met virtually every month with representatives from 5 other national hospital sites to review and share strategies towards effecting policy change. The KMCWC group also engaged in monthly internal meetings to develop a local action plan.

Results

Pre-work Survey Results

Thirty-three resident physicians from the Hawai‘i Residency Program completed the pre-work survey, including 7 from obstetrics and gynecology, 18 from pediatrics, and 8 from family medicine. Thirty-six percent were aware of the resident lactation policy and 58% knew who to contact if they or another resident had breastfeeding/pumping needs. While 88% agreed that medical residents should be allowed to take 20-30 minutes every 2-3 hours to express milk, only 18% felt that they or another resident who had breastfeeding/pumping needs would feel comfortable asking for a change in their schedule to accommodate time to pump. Of the respondents, 18% had personal experience breastfeeding or pumping. Of those with experience, 83% of them pumped or breastfed during residency and met their personal breastfeeding goals.

KMCWC Action Plan

Revised Resident Lactation Policy

A suggested revised lactation policy was submitted to the Hawai‘i Residency Program Graduate Medical Education Council for consideration. The revised policy significantly expanded upon the existing two-sentence policy in the resident handbook to a more comprehensive policy document, which defines minimum times for protected breaks, minimal components of lactation space, and outlined specific responsibilities for program administrators, supervisors, and trainees. This document was reviewed and approved by the Graduate Medical Education council and will be included in the resident handbook. The updated handbook is provided to every resident annually.

Improved Efficiency of Lactation Space

A document was created to be given to residents, which provides practical tips to achieve success in lactation during residency, including suggested supplies and tools such as hands-free breast pump accessories that allow residents to multi-task discreetly, milk storage tips, and links to local lactation consultant resources. The KMCWC group continues to collaborate with residents from other programs to create a comprehensive listing of lactation spaces available at various Hawai‘i Residency Program training sites based on feedback from residents. The hope is chief residents will provide these documents to all residents, especially those returning from maternity leave and planning to continue lactating during their training.

Improved Culture of Support: Faculty and Resident Education

The KMCWC group created a 20 minute presentation that outlines the unique barriers to lactation success that medical residents face. The presentation also includes our tips on how faculty, staff, and other residents can be pro-active in fostering a culture of support by finding creative ways for clinical coverage during pump breaks. For example, checking-in with the resident regarding preferred pump schedule timing, altering the start time or flow of medical rounds, offering to hold pagers, and being cognizant of offering breaks during prolonged uninterrupted work periods, such as extended rounds or surgical cases. This presentation was given at multiple resident and faculty meetings in the John A. Burns School of Medicine Departments of Pediatrics, Obstetrics, Gynecology, and Women’s Health, and Family Medicine and Community Health in the inaugural year with hopes of continuing annually. The hope is also to provide a brief educational presentation each year at the annual resident orientation.

Conclusion

While medical residents in Hawai‘i recognize the importance of breastfeeding, a majority do not feel there is adequate support in the workplace conducive to achieving success in lactation. Such perceptions of inadequate support in the clinical training environment are similar to survey results published from other US institutions. 3,4 Conflicting pressures between lactation and clinical demands are a significant stressor for medical trainees who face significant barriers to achieve lactation success. Through a comprehensive action plan to revamp the resident lactation policy and improve faculty and resident education, the goal is to foster an increased culture of lactation support for medical residents in Hawai‘i. Supporting lactating residents is essential to the healthy development of the physician workforce as the proportion of women in the physicians has increased from only 28.3% in 2007 to 36.3% in 2019.6 Additionally, a greater number of female medical resident trainees are planning to become pregnant (from 13% in 1983 to 30% in 2016).7 The number of female medical resident trainees choosing to become pregnant and breastfeed during training may be expected to rise further as greater attention has been called to the problems with fertility among physician women who choose to delay their pregnancies beyond training.8 Furthermore, physicians who are successful in their own personal lactation goals are more likely to promote breastfeeding for their patients and families. This practice benefits both physician and non-physician parents, their children and families. In promoting a culture of support for breastfeeding in the Hawai‘i community, physician faculty and medical education leadership must commit to not only “talking the talk” in clinical didactics for trainees on breastfeeding benefits but also “walking the walk”: check in regularly with lactating colleagues or trainees to see how they are doing and create a safe, protected space for lactation breaks in the clinical training site. Anyone interested in joining the mission of advocacy for lactating medical trainees are invited to contact the authors.