Abstract
Background
Nearly half of graduating medical students today are women, with many having children early in their careers, necessitating thoughtful consideration of practices and policies. The short duration of maternity leave for physician mothers often means that most who choose to breastfeed must return to work while still breastfeeding their infants.
Objective
To characterize the experience of physician mothers and identify facilitators and barriers related to breastmilk pumping upon return to work.
Design
Cross-sectional nationwide survey study administered to physician mothers electronically via REDCap™ to broadly characterize their personal experiences with family leave and return to work.
Participants
Physician mothers in the USA (n=724).
Approach/Main Measure
Demographic data and survey responses related to experiences during family leave and return to work, including free-text response options when participants indicated “other” experiences not captured by the survey response options and one open-ended question asking, “What do you think are the most important factors contributing to a positive maternity/family leave experience?” For this study, we searched free-text responses across the entire survey for keywords related to breastfeeding and pumping and thematically analyzed them to summarize key features of physician mothers’ experiences.
Key Results
Lack of time, flexibility, dedicated and hygienic locations for pumping breast milk, disrespect and lack of support from others, and concerns about financial consequences of productivity changes were the most common barriers to pumping breastmilk reported by physician mothers.
Conclusions
Flexibility in scheduling, adjusted productivity targets, and clean, private, and well-equipped pumping rooms would likely provide the greatest support to help physician mothers thrive in their careers while simultaneously allowing them to provide the nourishment needed for their developing infants.
Supplementary Information
The online version contains supplementary material available at 10.1007/s11606-021-07388-y.
KEY WORDS: family leave, physician mothers, breastfeeding, lactation, pumping
INTRODUCTION
As the proportion of women graduating from medical school rises to greater than half of all medical graduates,1 challenges surrounding pregnancy and childbearing are increasingly identified as threats to the well-being and gender equity of the physician workforce 2–9. Despite more than a decade of acknowledgement of these challenges, policies regarding family leave after childbirth remain inadequate for both trainee and attending women physicians.3,7,10–12 Further, after family leave, challenges continue upon return to work, particularly regarding breastfeeding and expressing breastmilk. One study supporting the impact of work-related challenges on breastfeeding found that, despite 64% of physician mothers intending to breastfeed for at least 12 months and 97% of them breastfeeding at birth, only 41% continued to provide breastmilk to their infants at 12 months.13 Another reported that longer maternity leave and laws to support breastfeeding were associated with a longer duration of breastfeeding.14
Survey studies of women physicians across multiple settings, specialties, and levels of training have quantitatively described the inadequacy of lactation facilities at academic medical centers, often preventing mothers from meeting recommended and individual breastfeeding goals. 14–23 In our own study of physicians’ experiences of return-to-work after parental leave using a rigorously developed and nationally administered survey, insufficient time and inadequacy of space for lactation needs were the most frequently reported negative experiences after returning to work.24 However, while prior studies have quantitatively examined physician mothers’ lactation experiences in the context of known barriers and outcome measures, they lack a description of how physician mothers experience these challenges. More recently, compelling narratives describing individuals’ experiences pumping at work suggest that the true impact of challenges to breastfeeding on the physical and mental health of physician mothers may extend beyond that conveyed by statistics on achievement of breastfeeding goals.25–27 As supervising bodies increasingly acknowledge the challenges associated with lactation for physicians and call for supportive practice environments,28–31 a more nuanced understanding of barriers to and facilitators of lactation, specific to physicians, can inform creation of a better breastfeeding environment to support physician mothers early after childbirth.
To this end, we sought to describe physician mothers’ perceptions of barriers and facilitators related to breastfeeding and pumping breastmilk through presentation of both quantitative and qualitative responses on a survey about their experiences.
MATERIALS AND METHODS
Design
This study presents both quantitative and qualitative results from a secondary analysis of a large, national anonymous survey study of physician mothers across the USA. Details about the survey, recruitment, and participants were previously described.24 The University Institutional Review Board approved this study as exempt, though all participants provided assent before completing the survey.
Participants and Recruitment
We collected anonymous survey data electronically via REDCap™. Participants accessed the survey through a web-link distributed to the American Medical Women’s Association email list-serve and posted to multiple Facebook™ groups for physician mothers, Twitter™, LinkedIn™, and publicly on personal social media accounts. After brief screening for inclusion, participants indicated consent to participate. Inclusion criteria for the parent study were identifying as a mother, being a physician, and being fluent in English. A further inclusion criterion for this analysis was conceiving or adopting their first child after completing medical school. Of 1459 respondents who met eligibility criteria, 844 were confirmed as unique respondents with valid and complete survey data in the parent study. We previously described a detailed breakdown of recruitment and survey responses.24
Measures
We developed a comprehensive survey about physician mothers’ experiences with pregnancy, adoption, family/maternity leave, and return to work, with direct input from a panel of experts, including physicians from a number of subspecialty disciplines, academic medical center leadership, and legal, administrative, and advocacy professionals with expertise in family leave policies .24 For the present study, descriptive analysis was conducted on a section of the survey focusing on physician mothers’ experiences with breastfeeding/pumping breastmilk. All survey items included in this study are presented in the first column of Table 1. Items had either multiple choice, yes/no, or multiple checkbox response options. Open-text response options were available whenever the “other” option was selected. The survey also included one open-ended question asking, “What do you think are the most important factors contributing to a positive maternity/family leave experience?” For qualitative analysis, we included open-text comments made in response to any question across the entire survey (see Supplemental Table 1 for a summary of the number of comments from each type of survey question). We searched comments for the following terms: lactation, pump*, milk, and breast* to identify potentially relevant comments.
Table 1.
Descriptive statistics from quantitative survey data
| Personal and professional characteristics | All (n=724) | Trainees (n=120) | Attending (n=604) |
|---|---|---|---|
| Age (years; mean (SD)) | 35.5 (4.3) | 31.2 (2.3) | 36.1 (4.1) |
| Currently practicing | 711 (98.2%) | 118 (98.3%) | 593 (98.2%) |
| International physician | 68 (9.4%) | 12 (10.0%) | 56 (9.3%) |
| Employed full-time | 593 (81.9%) | 111 (92.5%) | 482 (79.8%) |
| Practice setting | |||
| Private practice | 139 (19.2%) | 9 (2.5%) | 131 (22.6%) |
| Hospital-based practice | 200 (27.6%) | 9 (7.5%) | 191 (31.6%) |
| Academic setting | 335 (46.3%) | 107 (89.2) | 228 (37.7%) |
| Other | 42 (5.8%) | 1 (0.8%) | 41 (6.8%) |
| Carried at least one pregnancy to term | 714 (98.6%) | 119 (99.2%) | 595 (98.5%) |
| Adopted at least one child | 7 (1.0%) | 0 (0%) | (1.0%) |
| Number of children | |||
| One | 421 (58.1%) | 109 (90.8%) | 312 (51.7%) |
| Two | 251 (34.7%) | 11 (9.2%) | 240 (39.7%) |
| Three or more | 52 (7.2%) | 0 (0%) | 52 (8.6%) |
| Pregnancy and leave for first child | |||
| Years family leave was taken for first child | |||
| 2001–2010 | 85 (11.7%) | 0 (0%) | 85 (14.1%) |
| 2011–2018 | 639 (88.3%) | 120 (100%) | 519 (85.9%) |
| Pregnancy | 721 (99.6%) | 120 (100%) | 601 (99.5%) |
| Adoption | 3 (0.4%) | 0 (0%) | 3 (0.5%) |
| Return to work after first child | |||
| Required to make-up time off | 265 (36.6%) | 67 (55.8%) | 198 (32.8%) |
| How long after delivery/adoption until return to work | |||
| 0–4 weeks | 26 (3.6%) | 15 (12.5%) | 11 (1.8%) |
| 5–8 weeks | 247 (34.1%) | 61 (50.8%) | 186 (30.8%) |
| 9–12 weeks | 354 (48.9%) | 39 (32.5%) | 315 (52.2%) |
| 4–6 months | 66 (9.1%) | 4 (3.3%) | 62 (10.3%) |
| >6 months | 7 (1.0%) | 1 (0.8%) | 6 (1.0%) |
| Had limitations in performing job upon return to work | 43 (5.9%) | 12 (10%) | 31 (5.1%) |
| Difficulty managing nursing supply | 37 (86.0%) | 9 (7.5%) | 28 (4.6%) |
| Believed health was at risk upon return to work | 59 (8.1%) | 14 (11.7%) | 45 (7.5%) |
| Inability to maintain nursing supply | 36 (61.0%) | 7 (5.8%) | 29 (4.8%) |
| Mastitis | 15 (25.4%) | 6 (5.0%) | 9 (1.5%) |
| Worsening depression | 21 (35.6%) | 8 (6.7%) | 13 (2.2%) |
| Worsening anxiety | 31 (52.5%) | 7 (5.8%) | 24 (4.0%) |
| Fatigue | 40 (67.8%) | 11 (9.2%) | 29 (4.8%) |
| Unable to follow physician’s recommendations upon return to work | 90 (12.4%) | 20 (16.7%) | 70 (11.6%) |
| Unable to pump/feed every 3 h | 66 (73.3%) | 15 (12.5%) | 51 (8.4%) |
| Negative experiences upon return to work | |||
| Inability to acquire adequate facilities for pumping | 221 (30.5%) | 48 (40.0%) | 173 (28.6%) |
| Inadequate time for pumping | 341 (47.1%) | 66 (55.0%) | 275 (45.5%) |
| Inadequate frequency for pumping | 310 (42.8%) | 69 (57.5%) | 241 (39.9%) |
| Positive experiences upon return to work | |||
| Adequate facilities for pumping | 229 (41.3%) | 43 (35.8%) | 256 (42.9%) |
| Adequate time for pumping | 212 (29.3%) | 29 (24.2%) | 183 (30.3%) |
| Adequate frequency for pumping | 175 (24.2%) | 20 (16.7%) | 155 (25.7%) |
| Breastfeeding/pumping breast milk at work | |||
| Breastfed/pumped breast milk at work | 690 (95.3%) | 116 (96.7%) | 574 (95.0%) |
| Aware of federal laws pertaining to nursing/pumpingemployee requirements | 502 (69.3%) | 87 (72.5%) | 415 (68.7%) |
| Items below were asked only of those who breastfed/pumped milk at work | n=690 | n=116 | n=574 |
| Who paid for breast pump? (multiple selections possible) | |||
| Self-paid | 286 (41.4%) | 31 (26.7%) | 255 (44.4%) |
| Insurance | 508 (73.6%) | 108 (93.1%) | 400 (69.7%) |
| Employer | 4 (0.6%) | 0 (0%) | 4 (7.0%) |
| Borrowed | 28 (4.1%) | 1 (0.9%) | 27 (4.7%) |
| Free | 2 (0.3%) | 0 (0%) | 2 (0.3%) |
| Did not have appropriate facilities for breastfeeding/pumping | 236 (34.2%) | 42 (36.2%) | 194 (33.8%) |
| <21 employees (not legally required) | 8 (3.4%) | 8 (6.8%) | 8 (1.4%) |
| No space available | 90 (38.1%) | 11 (9.5%) | 79 (13.8%) |
| Space too far away | 162 (68.6%) | 38 (3.3%) | 124 (21.6%) |
| Other | 30 (12.7%) | 5 (4.3%) | 25 (4.4%) |
| Did not have enough time for breastfeeding/pumping | 381 (55.2%) | 73 (62.9%) | 308 (53.7%) |
| Inability to maintain RVUs if pumping was scheduled | 64 (19.8%) | 3 (2.6%) | 61 (10.6%) |
| Inconvenience for patients | 180 (47.2%) | 24 (20.7%) | 156 (27.2%) |
| Need to be present for cases/trainees | 158 (41.4%) | 41 (35.3%) | 117 (20.4%) |
| Unpredictable schedule | 270 (70.9%) | 55 (48.7%) | 215 (37.5%) |
| Pumping difficulties | 35 (9.2%) | 3 (2.6%) | 32 (5.6%) |
| Difficulty accessing pumping facility within time frame | 142 (37.3%) | 30 (25.9%) | 112 (19.5%) |
| Difficulties with pumping equipment | 10 (2.6%) | 1 (0.9%) | 9 (1.6%) |
| Other | 22 (5.8%) | 1 (0.9%) | 21 (3.7%) |
| Experienced discrimination due to breastfeeding/pumpingwhile at work | 176 (25.5%) | 40 (34.5%) | 136 (23.7%) |
| Inappropriate comments by others or made to feel uncomfortable regarding breastfeeding/pumping | 215 (31.2%) | 48 (41.4%) | 167 (29.1%) |
Data Analysis
This study presents descriptive statistics to characterize our sample and participant experiences related to breastfeeding. To account for potential historical effects in practices and policies that may uniquely affect trainees, we also separately characterized those who were trainees (residents or fellows) and those who were attending physicians at the time of taking the survey. All quantitative analyses were conducted using SPSS™ for Windows v26.
We conducted a thematic analysis of the qualitative data, following steps outlined by Nowell and colleagues for establishing trustworthiness in thematic analysis, to summarize key features of physician mothers’ experiences with breastfeeding and breastmilk pumping on return to work.33 Three researchers comprised the coding team. Following COREQ guidelines (Supplemental Table 2), the team discussed their positionality, biases, and expectations regarding the study. The coding team ranged in age from 26 to 42 years old and were from diverse backgrounds, with respect to both academic credentials, and experiences and beliefs regarding breastfeeding and pumping. S. J. is a physician who values breastfeeding and personally experienced challenges with pumping in a healthcare setting after returning from maternity leave. For coding, she was paired with S. N., who is a rehabilitation counselor with no personal experiences with pumping in any setting. The lead author, S. B. J., who generated the codebook and supervised the analysis, is a certified rehabilitation counselor and PhD-trained scientist who personally values breastfeeding and, while not a physician, did have experience pumping in an academic medical setting upon returning to work after childbirth. While the researchers were not directly involved in soliciting comments from participants, since these were derived from anonymous survey responses rather than interviews, we believe that this team with varied experiences and values regarding pumping brought richness to our interpretation and analysis of the participant responses.
One investigator (S. B. J.) first generated an initial codebook, through review of 20% of the qualitative responses. She then trained two other investigators (S. J., S. N.) who independently coded all responses and made notes for adding to or modifying the initial codebook. All three investigators iteratively met to discuss discrepancies in coding and to modify the codebook. Two additional codes were added, recoding was completed, and coders continued to iteratively code until reaching thematic saturation and final consensus on codes.32 The study team then categorized the codes into distinct overarching themes to produce this report. Detailed notes tracking this iterative process were maintained, as recommended, for transparency and replicability.33
RESULTS
In Table 1, we summarize characteristics for all participants who met the eligibility criteria (n=724), grouped by trainee (n=120) versus attending status (n=604) at the time of survey response. Unsurprisingly, most trainees (90.8%) had only 1 child, whereas attendees were more likely to have ≥2 children. Also, 14.1% of attendees had their first child (to whom all survey responses reported herein apply) over 10 years ago. A larger proportion of trainees (40%) reported difficulties accessing adequate facilities or time for pumping than attendees (28%), even with a similar percent breastfeeding or pumping breast milk at work (55% of trainees vs 45% of attendees), though whether this is due to actual differences or effects of recall bias for attendees reflecting back on experiences longer ago cannot be determined. Trainees (56.2%) reported needing to be present for clinical training as a time barrier more frequently than attendees (38.0%), whereas attendees (50.6%) reported inconvenience to patients being a more common barrier than trainees (32.9%). Trainees reported experiencing discrimination (34.5%) and/or inappropriate comments (41.4%) more often than attendees (23.7% and 29.1%, respectively). Overall, 72% of survey respondents rated “protected locations for nursing/pumping breast milk” as an extremely important factor (on a 5-level ordinal scale ranging from not important to extremely important).
Thematic Analysis
We analyzed n=221 distinct open-ended comments for this thematic analysis; distinct comments could receive multiple thematic codes. The final codebook contained 14 minor themes. Of the 221 comments, 1 could not be coded (it was unclear to what the participant was referring in her comment), 168 received one code, 41 received two codes, and 12 received three codes.
We categorized the 14 minor themes into four overarching groups: Attitudes and Support, Time and Facilities, Health and Wellness, and Financial and Legal. A description of each of the 14 minor themes and representative comments coded for each theme are presented in Table 2. Overall, the results of our thematic analysis indicated four broad groups of challenges and consequences for female physicians who pump on returning to work after childbirth. These themes highlight areas deserving the highest attention from division and institutional leaders and policymakers:
Lack of support from leaders to accommodate pumping and disrespectful, and at times blatantly harassing, behavior from peers constitutes an unsupportive culture for pumping mothers.
Inadequate time and unsanitary, inconvenient, and crowded lactation spaces make it physically challenging for physician mothers to pump at work.
Barriers of time, support, and space that impede pumping have consequences on physical and mental health of breastfeeding mothers.
Absent or sub-optimal legal and financial accommodations for pumping at organizational and government levels exacerbate the gender pay gap.
Table 2.
Thematic analysis results
| Theme | Description | n | Quotes |
|---|---|---|---|
| Attitudes and support | |||
| Support/lack of support from colleagues/leadership/others for time needed to pump | Schedule for pumping not supported in general or by specific people (Chair, supervisor, schedulers, colleagues, nurses, etc.) | 39 |
“Any changes to schedule needed to be approved by chair. There was no way he was going to approve pumping slots.” “Needed to finish rotation before leaving or didn't get credit for rotation for the first 2 weeks and would've had to make it up. However, when [I] got burnt out they let me do half days. I was exclusively pumping due to baby in NICU and they allowed me to pump as well” |
| Insufficient information or communication | Information about how much time off was available, location of pumping facilities, etc. | 12 | “During my pregnancies I had a difficult time finding a good contact person or resources to help educate me on maternity leave, FMLA and information about lactation rooms. I felt like I was getting information that may or may not be correct. This made me very anxious leading to my due date because I worried I didn't fill out the correct paperwork or didn't have enough vacation time to take maternity leave” |
| Others dictating how much time was needed to pump | Others stating that a certain amount of time (e.g., 15 min) was sufficient for pumping or stating that amount of time requested was not needed | 5 | “Never given enough time to allow letdown to happen/pump adequately; was told 20 mins to pump would have to work. At home it took me 30” |
| Inconvenience to others | Pumping as inconvenient to others (e.g., colleagues, patients); feeling guilty over inconveniencing others or taking too much time | 5 | “The service was sometimes very busy and there was always work to be done. It was obvious that when I said, "I have to go pump," my colleagues were frustrated with me.” |
| Disrespect from others (supervisors, colleagues, staff) | Harassment, inappropriate humor, disparaging, or inappropriate comments | 25 |
“One specific nurse would always page me or send someone to get me when I went to pump. I talked to her about it multiple times. She was nice to my face but then kept doing it. If I ignored a page for even 2 minutes she would pound on the door until I came out or [have] someone else pound on the door. Literally none of the pages were urgent for the two weeks she did this. It got to the point where I would get anxious waiting to be harassed every time I went to pump and couldn't let down. My milk dried up and I wasn't able to pump at all after subsequent pregnancies.” “My chief resident thought it was funny to 911 page me while I was pumping - or knock on the door telling me to get back to work!” |
| Challenges self-advocating | Uncertainty, challenges, and/or lack of (chose not to) self-advocating, asking for time or space | 3 |
“I never asked and just pumped in call rooms.” “I was interviewing for residency when my daughter was 8 weeks old. I did not feel comfortable asking to leave during the interview day to pump on any of my interviews.” |
| Time and facilities | |||
| Schedule could/could not accommodate time needed to pump | Full schedule/no room in schedule for flexibility/time available/protected time | 67 |
“Protected TIME for pumping. Having a room for it is useless if you never have time to use it” “Protected time for pumping upon return to work” |
| Unpredictable nature of clinical schedule as a barrier to pumping | Unpredictable schedules due to the setting (e.g., ER), duties (e.g., on call), or other factors (e.g., patient appointments running late) | 6 | “Clinic times were frozen so I could pump but patients came later and clinic ran late which got into my pumping times. Unpredictable nature of the OR and floor can make it difficult to have scheduled pump breaks. However, I was grateful for the attempt to block of my schedule during some clinics” |
| Inappropriate, inadequate/appropriate, adequate facilities | Facilities were not accessible (e.g., locked, too far away), equipped for pumping or for working while pumping, or otherwise appropriate (e.g., pumping in a shared office). | 52 |
“[I was] not always-in hospital; I had space but at many rotations there was not a place to pump that was comfortable, had water and a seat and power. I often went to the car and pumped.” “It was the resident call room that was frequently occupied by the residents-I was A fellow. By the end of my fellowship this room was infested with bed bugs so was unusable. Other pumping areas were too far away.” |
| Facilities were overbooked | Facilities in use during scheduled pumping time, too many women needing to pump for the number of facilities available | 17 | “[The] hospital system with more than a thousand employees only had one pumping room and it only had 2 chairs. The tiny room was frequently crowded with women standing in every corner pumping while standing up” |
| Health and wellness | |||
| Breastfeeding/pumping/feeding challenges | Experienced challenges with pumping/breastfeeding/feeding (e.g., supply issues, changes in diet) and associated challenges/consequences (e.g., exhaustion from cluster feeding, pain, guilt) | 9 |
“Severe food allergies- had to completely alter my diet during breastfeeding/pumping” “Feeding q3 hours (triple feeds) until 4 months of age. I spaced it out at that point [because] I could not physically keep up with this schedule. I was exhausted from working and all the nighttime feeding.” |
| Unsanitary or unsafe/sanitary or safe facilities | Facilities were dirty, in unsanitary locations (e.g., bathroom) | 15 | “A place to pump. I pumped 2 years on a hospital bathroom floor.” |
| Financial and legal | |||
| Legal factors | Laws not yet in place related to pumping/break time for pumping; breaks not covered for contract employees, etc. | 11 | “In [my state] the law is two 15min breaks. Not enough. Plus no lunch [time] built in. All the time pumping was added at the end of the day anyways.” |
| Affected RVUs/pay/financial | Pay disparity, financial consequences, RVU concerns | 19 | “Finding a way to compensate for leave and breastmilk pumping time. I lose quite a bit of my pay due to pumping milk because I am paid strictly on RVU. I chose this for my family, but the pay disparity is pretty high” |
DISCUSSION
In this nationwide survey study of physician mothers, we elucidate the experiences of physician mothers regarding challenges and facilitators of pumping breastmilk at work. Three-fourth of the survey respondents rated protected locations for nursing/pumping breast milk as an extremely important factor to an all-around positive family/maternity leave experience. Survey respondents, overall, reported full schedules in clinic and operating rooms, substantial patient loads, and productivity requirements as barriers to successfully pumping at work. Almost one-third of pumping physician mothers experienced inappropriate comments or were made to feel otherwise uncomfortable in the workplace as a direct result of their pumping, and a quarter experienced discrimination. Besides the presence of pumping rooms in proximity to work locations, respondents indicated that pumping room cleanliness, accessibility of rooms to physicians, and availability of equipment to allow charting during pumping sessions would provide a supportive pumping environment. Qualitative comments provided more detailed and nuanced insight into these experiences. Four broad themes emerged from these qualitative data to characterize breastfeeding/pumping experiences. These themes were the need for systemic (e.g., legal, financial) supports to be in place, adequate time and facilities for pumping, consequences to physician mothers’ physical and mental health, and support from others.
The Affordable Care Act of 2010 necessitates that employers provide a “reasonable break time” to allow women to pump breast milk while they are at work.34 Unfortunately, the unique constraints of medicine often prevent physician mothers from such opportunities.35,36 Similarly, for trainees, while the ACGME has recently included providing time for lactation as a requirement, the lack of stipulations about its adequacy leaves room for ambiguity at the institutional level.37 Our analysis highlights that the time mandated legally and by local institutions was insufficient without also making accommodations for work responsibilities. Another factor less highlighted in the current policy discussion about time for lactation that was reflected in our findings was the potential of unaccommodated time for pumping to further exacerbate the existing gender pay-gap. University of California San Francisco is one of the first in the country to establish lactation credits to circumvent financial penalties for pumping mothers;38 however, no such policies exist at a national level across institutions and specialties.
While space for pumping has been recommended by both ACGME and US labor laws, our findings highlight the need to address adequacy of these spaces. The current policies state that pumping space should have “proximity appropriate for safe patient care.” However, our findings highlight that lactation spaces need to account for factors like privacy and hygiene that are important to physician well-being in addition to being proximate to patient-care locations. Respondents frequently commented on being driven to using unsanitary facilities like their car or bathroom floors for pumping in the absence of adequate pumping spaces. Furthermore, there are no institutional obligations to ensure availability of lactation spaces beyond their presence. Our findings highlight how space, even when present, can be unavailable if not accounting for the needs of physician mothers who often share it with other hospital staff.
Another key theme in our study that has received very little attention in the current policies is the impact of lack of support from colleagues, supervisors, and leaders for pumping. Comments like “my colleagues were frustrated with me,” “If I ignored a page for even 2 minutes she would pound on the door until I came out or had someone else pound on the door…... It got to the point where I would get anxious waiting to be harassed every time I went to pump and couldn't let down,” and “My chief resident thought it was funny to 911 page me while I was pumping” highlight the impact of such harassment on not only success of breastfeeding but also on mental health of physician mothers who are already meeting grueling demands of work and childcare. The survey participants uniformly echoed a common desire for cultural acceptance of pumping in the workplace so that mothers could pump without discrimination or intimidation.
While the challenges of adequate “time” and “space” to pump identified in our results are consistent with prior work,12,15–17,19–23,31,36,39 our study adds to the literature by highlighting the nuanced and specific needs in these areas. Future policies and mandates must take these details into consideration beyond requiring institutions to check boxes of “time” and “space” to allow for an effective breastfeeding environment for physician mothers. Our findings also illuminate the scope and type of harassment that physician mothers can face when pumping and advocate for the need to create policies to actively combat such discrimination.
We also found that experiences may differ for residents and fellows versus attending physicians. Trainees more frequently reported difficulty finding adequate facilities and time for pumping, with greater demands of being present for training, worse access to lactation spaces in proximity to work environment, and more experiences of discrimination related to pumping compared to attendees. However, attendees reported more often than trainees that inconvenience to their patients was a barrier to pumping, indicating that more experienced physicians who are also likely more deeply integrated into their practice setting may experience more internally driven pressures (e.g., responsibility to patients) that could require individual-level(rather than system-level) supports.
Limitations
We previously described limitations of the parent survey study, which included unavailable survey response rate, the length of the survey and effects of survey fatigue, and sampling bias from relying largely on email lists and social media for recruitment.24 For this analysis, only a portion of participants from the overall survey study provided qualitative responses, though this subset did not differ from the full sample (see Supplemental Table 3 for characteristics of those who did and did not provide qualitative comments on the survey). Those motivated to share their experiences in open-text responses may not represent all physician mothers and therefore we should exercise caution when inferring how frequently these experiences occur. However, the substantive feedback provided by survey participants provides a foundation for improving policy and practice to support physician mothers. Though qualitative study design may introduce bias based on motivation to share personal stories, a strength of this study is the substantive responses provided by survey participants. Additionally, we selected quotes for each theme that were representative of multiple qualitative comments, rather than sharing the extreme or rarer experiences women reported. For this study, our survey included both positively and negatively framed questions not always related to breastfeeding and pumping experiences specifically (see Supplemental Table 1 for how many comments were obtained from why types of questions), which is a limitation to fully capturing the lived experiences of these women related to breastfeeding/pumping upon return to work. Also, since it was an anonymous electronic survey, we did not have the opportunity to probe participants’ comments further nor to solicit feedback from our participants on the results of our thematic analysis. Though thematic analysis was appropriate to our purpose and data, thematic analysis has several disadvantages relative to other qualitative research methods (e.g., grounded theory approach), so results should be interpreted as a summary of physician mothers’ experiences rather than a specific theory or phenomenon underpinning their experiences. Lastly, our survey preceded some policy changes (e.g., ACGME policy changes in 2018) that could have had an effect on physician mothers’ experiences; however, whether and how lactation environments have changed in response to these already insufficient policies remains unknown and requires investigation.
Conclusions
The nuances of which policies and institutional practices across practice settings, institutions, and medical specialties can most effectively support physician mothers who choose to breastfeed have been unclear, though physician mothers clearly want policies that specifically require a space to breastfeed while also being able to work. They understand the demands of their career choice but are also entitled as mothers to have the time, space, and support to be able to breastfeed/pump. One physician mother in our study summarizes this best:
“The medical establishment needs to come to terms that its workforce is now half female. There needs to be some slack in the system to accommodate for the inevitable reality that these young women will birth children.”
Simple changes like providing adequate lactation workspaces, blocking off times in schedules, and adjusting productivity requirements could make substantial and meaningful progress towards allowing physician mothers to remain productive in their workday without sacrificing the decision to breastfeed and pump.
Supplementary Information
(DOCX 30 kb)
Acknowledgements
We would like to acknowledge the contributions of all our study participants who shared what were often very personal experiences.
Funding:
This study was supported by a small grant ($1,000) from the University of Texas Southwestern Medical Center, Department of Physical Medicine and Rehabilitation. Data collection via REDCap was supported by CTSA NIH Grant 1ULTR003163-01A1.
Declarations
Conflict of interest
The authors declare that they do not have a conflict of interest.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
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