Parental postpartum depression among medical residents

Abstract

The study aimed to quantify and compare rate of parental postpartum depression (PPD) among medical residents to that of the general population and identify potential areas of further support for resident parents. Our team, University of Nebraska Medical Center (UNMC) OB/GYN and Creighton Psychiatry departments, developed and disseminated 22 item anonymous survey distributed via email link to targeted specialties as well as the “Physician Mom’s Group” on Facebook. The survey included both quantitative and qualitative measures on medical resident and resident partner mental health, demographics, specialty, year in residency, support from residency program, parental leave, and an open comment section. Seventy-two resident parents, 64% of whom were female, completed the survey. 42% of female respondents reported feeling they suffered from PPD symptoms, representing more than four times the rate of PPD within the general population (11%). Only 12% of these women reported having sought treatment or were diagnosed with PPD. Male residents did not report an increased rate of depressive symptoms; however, 19% of respondents believed their partner’s symptoms were consistent with PPD. Responses from the survey and open-ended questions emphasized need for emotional support, transparency in programmatic leave policy, breastfeeding accommodations, and additional parental leave time. This is the first study of its kind to examine PPD among both male and female medical resident parents. Limitations of the study included small sample size, which impacted statistical significance. The data and commentary are nonetheless useful in highlighting risk of PPD amongst medical residents and indicate further study is warranted.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00737-022-01271-3.

Introduction

Medical residents play a vital role in the care of patients in hospitals around the country. Their well-being has been at the forefront of ongoing dialogue concerning medicine and healthcare for the past decade (Mata et al. 2015; Golob et al. 2018; Dean 2016). Resident mental health has been further brought to light with the recent COVID-19 pandemic bringing with it increased work demands, compassion fatigue, burnout, and unfortunately resignation for some before they begin their careers. Rates of depression among medical residents across all medical specialties has been well documented over the course of the past ten years. A meta-analysis in 2015 of 17,560 residents estimated the rate of depression at 28.8% of all trainees (Mata et al. 2015). Physicians are at a significantly higher risk of depression as well as suicide compared to the general population. The rate of suicide among male physicians is 1.41 times higher, and female physicians are 2.27 times higher than their counterparts in the general population (Goldman et al. 2015). These staggering statistics of higher rates of both depression and for some suicide emphasize why resident emotional wellness is of critical importance. Resident physicians are at risk of significant mental illness with potentially catastrophic outcomes. In a 2008 study, depressed residents were 6 times more likely to make a medication error than non-depressed residents (Golob et al. 2018; Dean 2016). Focusing on improving wellness not only benefits the resident but their department and the healthcare system in ensuring safe patient care. Ultimately, resident physician mental health impacts patient safety and quality of care and it is imperative that steps are taken to ensure long-lasting careers in medicine.

Rigorous hours, prolonged stress exposure, stressful life transitions, and work-family conflict residents experience during residency training impact their mood, depression rates, and the ability to cope affecting their long-term careers. The rate of depression among resident physicians compared to other professional graduate students of similar age was significantly higher 7–49% compared to 8–15%, respectively (Golob et al. 2018). One stressful transition central to both resident well-being as well as work-family conflict that has not been well studied or quantified is the transition to parenthood while in residency (Guille et al. 2017; Fried and Nesse 2015). Most resident physicians are of childbearing age, with the vast majority 25 to 35 years of age, making this life transition of particular interest. While this transition is likely to affect many residents, particularly as the rate of female trainees increases, there is a paucity of research surrounding mental health and the transition to parenthood for medical residents. In evaluating postpartum depression among the general population, the rate is approximately 11–15% for women (Leung et al. 2017) and 8.4% for men (Cameron et al. 2016; Edmundson et al. 2010). Studies have also shown the greatest lifetime risk of depression for both women and men is in the first year after the birth of their child (Leung et al. 2017). While this at-risk time has been evaluated within the general population, little research has been done to evaluate this transition among medical resident parents. We hypothesize that the increased risk of the postpartum period coupled with the stressful demands of residency training may increase medical residents’ rate of postpartum depression.

Objective

Our objective is to quantify and compare the rate of maternal and paternal postpartum depression among medical residents. In defining the risk of depression among residents, we also hope to identify areas to improve support for resident parents.

Materials and methods

Our study completed a thorough literature review and found two well-validated postpartum depression tools to assist with survey design. In initial development of the survey, we utilized both the PHQ-9 screening questionnaire as well as the Edinburg Postnatal Depression Scale (EPDS). These tools were used to help identify validated themes of interest. These themes were then used to brainstorm and develop more generalizable questions as to not limit survey to any particular time in the postpartum period. Collectively, resident parents make up a small portion of all medical residents and it was felt that further restrictions to the targeted population would be both confusing to the resident responding to the survey as well as very limiting to the sample size for survey distribution. A collaborative effort was then conducted between all researchers to further develop a novel survey.

The survey included 22 items to assess demographics, medical specialty, history of depression, year in residency during childbirth, support from residency program, NICU stay, time off for family leave, and open-ended comment section. The finalized survey was then piloted to 5 resident parents in both psychiatry and OBGYN programs for timing, relevance, and comprehensibility of the survey. The survey took on average 5 min to complete. After IRB approval, program coordinators for OB/GYN, family medicine, internal medicine, pediatrics, and psychiatry both at UNMC as well as Creighton University were contacted for distribution of anonymous email link. The link was distributed with details of the study including “a survey to evaluate the stress associated with the resident physician transition to parenthood. We have created a survey in an attempt to gain a deeper understanding of depressive symptoms amongst resident parents within the first year postpartum. We welcome both female and male resident parents who have had children during residency to complete the survey.” The survey was anonymous with no identifying information. Completing the survey indicated consent to participate per protocol in the IRB application. The survey was also distributed through a national Physician Mom’s Group on Facebook. An NPI number is required for acceptance into the group to ensure only residents and physicians are in the group. Response to the survey was not incentivized. After survey results were received, the responses were summarized using frequencies and percentages for all survey items. Bivariate comparisons of responses to one survey item by responses to another survey item were then evaluated using Fisher’s exact tests. All analyses were conducted using STATA v17 (StataCorp LLC, College Station, TX).

Results

There were 72 surveys returned, but one person left the survey blank. This survey was not included in final analysis, 71 records for analysis. This was a 5-min survey; 83% of respondents finished within the 5 min, and 96% finished within 10 min. It is likely that the remaining 3 respondents were interrupted while completing the survey.

Demographics of the respondents are listed in Table 1. The complete survey and all results are available in the Appendix (Supplementary information). Most (88%) were between 25 and 35 years old, and 65% were female. Just over a third (35%) listed OB/GYN for their specialty, followed by internal medicine (20%), psychiatry (17%), and a variety of others. UNMC (39%) and Creighton (39% — includes one respondent from their Phoenix campus) were the most frequently listed institutions.

Table 1.

Demographics of respondents

Demographics
Variable	Characteristics	Frequency (N = 71)	Percent
Sex	Female Male	46 25	64.7 35
Age	< 24 25–30 30–35 35–40	0 31 32 7	0 43 45 9
Specialty	Anesthesiology Family Practice Internal Medicine OB/GYN Pediatrics Psychiatry Radiology Surgery Other	3 6 14 25 4 12 2 1 2	4.2 8.4 19.7 35.2 5.6 16.9 2.8 1.4 2.8
Institution	U. Nebraska Medical Center Creighton University Other	28 27 9	39.4 38 12.6
Lifetime history of clinical depression?	Yes No	12 59	17 83
History of counseling or psychotherapy during residency	Yes No	16 55	22.5 77.5
History of being prescribed antidepressants during residency	Yes No	7 64	10 90
Number of children	1 2 3	43 20 8	60.5 28.2 11.2
More than 1 pregnancy during residency	Yes No	15 56	21 79
Partner is also a medical resident	Yes No	12 59	17 83
Gestational age at time of delivery	> 37 weeks 34–37 weeks  < 28 weeks	62 (66) 3 1	94 4.5 1.5

In evaluating female residents and diagnosis of depression versus feeling they suffered from postpartum depression, there is an interesting difference. Only 12% were diagnosed (Table 2); however, a staggering 42% reported feeling that they suffered from postpartum depression (Table 3), and 9% felt their partner suffered from postpartum depression (Table 4). Of those female respondents that reported feeling that they suffered from postpartum depression, 16% reported feeling their spouse/partner also suffered. In examining male residents, no male residents were diagnosed with PPD. However, when evaluating their female partners, 9% were diagnosed with PPD and 19% felt their partners suffered from PPD.

Table 2.

Diagnosis–of PPD among male and female respondents

Were you ever diagnosed with postpartum depression?
	Male	Female	Total
No	22 100.00	38 88.37	60 92.31
Yes	0 0.00	5 11.63	5 7.69
Total	22 100.00	43 100.00	65 100.00

Boldface highlights relevant data referenced in the main text

Table 3.

Reported PPD among male vs. female respondents

Do you believe you suffered from postpartum depression?
	Male	Female	Total
No	21 100.00	25 58.14	46 71.88
Yes	0 0.00	18 41.86	18 28.13
Total	21 100.00	43 100.00	64 100.00

Boldface highlights relevant data referenced in the main text

Table 4.

Respondents to reported PPD among their partners

Do you believe your partner suffered from PPD?
	Male	Female	Total
No	17 80.95	39 90.70	56 87.50
Yes	4 19.05	4 9.30	8 12.50
Total	21 100.00	43 100.00	64 100.00

Boldface highlights relevant data referenced in the main text

The next analysis, shown in Table 5, compared whether the respondent believes that they suffered from postpartum depression by the amount of maternity or paternity leave taken. In considering risk factors for depression, one variable of interest for the study was the amount of maternity or paternity leave time that was given. For Table 5, responses were limited to females who said their pregnancy did not result in fetal loss or miscarriage and who did not respond “Not Applicable” to the respective question regarding the amount of leave taken. Given small sample size, Fisher’s exact test was utilized to evaluate statistical significance between the two variables (i.e., leave time vs. reported depression) and the P-values for Fisher’s exact tests are under each table (Table 6) .

Table 5.

Amount of maternity leave compared to reported depression

Amount of maternity leave taken after live birth?	Do you believe you suffered from postpartum depression?
	No	Yes	Total
2–4 weeks	1 100.00 4.76	0 0.00 0.00	1 100.00 3.03
4–6 weeks	9 60.00 42.86	6 40.00 50.00	15 100.00 45.45
6–8 weeks	9 75.00 42.86	3 25.00 25.00	12 100.00 36.36
8–10 weeks	0 0.00 0.00	2 100.00 16.67	2 100.00 6.06
12 + weeks	2 66.67	1 33.33 8.33	3 100.00 9.09
Total	21 63.64 100.00	12 36.36 100.00	33 100.00 100.00
Fisher’s exact = 0.356

Boldface highlights relevant data referenced in the main text

Table 6.

Ranking of reported stressors

Rank	Stressor	Point total
1	Fatigue	56
2	Emotional distress in leaving infant	53
3	Breastfeeding/pumping accommodations	37
4	Concern about partner wellbeing	24
5	Daycare/childcare issues	16
6	Feeling academically behind coworkers	13
7	Guilt associated with colleagues covering your caseload	13
8	Concern regarding potential exposure to COVID-19	11
9	Single parenthood	2
10	Physical discomfort	0
11	Financial concerns	0
12	NICU visits	0

The most common amount of leave taken was 4–6 weeks. In females with 4–6 weeks of leave, 40% reported that they felt they suffered from postpartum depression compared to the 6–8-week group reporting 25% felt they suffered from postpartum depression. This was not noted to be statistically significant. Most commonly, 1–2 weeks of paternity leave was taken. There was no difference in reported rate of postpartum depression among resident fathers, all being 25%, between the three groups, given no difference between amount of leave table (Table 7) was omitted but included in the Appendix. The amount of paternity leave did not appear to correlate to rate or risk of postpartum depression.

Table 7.

Amount of paternity leave to rate of perceived postpartum depression

Amount of paternity leave taken after delivery?	Do you believe you suffered from postpartum depression?
	No	Yes	Total
0 weeks	2 50.00 13.33	2 50.00 28.57	4 100.00 18.18
1–2 weeks	6 75.00 40.00	2 25.00 28.57	8 100.00 36.36
2–4 weeks	3 75.00 20.00	1 25.00 14.29	4 100.00 18.18
4–6 weeks	3 75.00 20.00	1 25.00 14.29	4 100.00 18.18
6 + weeks	1 50.00 6.67	1 50.00 14.29	2 100.00 9.09
Total	15 68.18 100.00	7 31.82 100.00	22 100.00 100.00
Fisher’s exact = 0.958

Boldface highlights relevant data referenced in the main text

It was felt in evaluating families in which both parents were medical residents they may be predisposed or at a higher risk for postpartum depression for either parent. However, on all analyses of both diagnosis as well as feeling as though they suffered from postpartum depression, this was not statistically significant, and in fact, only one resident of the eleven, 5%, with a partner in medicine felt their partner suffered from postpartum depression. Tables 8 and 9 detailing this analysis is included in the Appendix.

Table 8.

Partner medical resident to diagnosis of postpartum depression

Is your partner also a medical resident?	Were you ever diagnosed with postpartum depression?
	No	Yes	Total
Yes	11 100.00 18.33	0 0.00 0.00	11 100.00 16.92
No	49 90.74 81.67	5 9.26 100.00	54 100.00 83.08
Total	60 92.31 100.00	5 7.69 100.00	65 100.00 100.00
Fisher’s exact = 0.579

Table 9.

Partner medical resident to perceived postpartum depression

Is your partner also a medical resident?	Do you believe you suffered from postpartum depression?
	No	Yes	Total
Yes	10 90.91 21.74	1 9.09 5.56	11 100.00 17.19
No	36 67.92 78.26	17 32.08 94.44	53 100.00 82.81
Total	46 71.88 100.00	18 28.13 100.00	64 100.00 100.00
Fisher’s exact = 0.159

Finally, respondents were asked to rate the top three most stressful aspects of returning to work following parental leave. There were 38 respondents who appeared to have completed this task as expected, and analysis has been limited to those persons. The overall ranking of the listed stressors was determined using a point system, where 3 points were given for a first place (most stressful) vote, 2 points were for a second-place vote, and 1 point was given for a third-place vote. The sums of the points given by all 38 respondents to each stressor were calculated and arranged in descending order below. Fatigue and emotional distress in leaving infant were the two most stressful aspects, while no one indicated physical discomfort, financial concerns, or NICU visits as one of their three most stressful aspects (Table 6).

Discussion

This study works to understand and quantify the risk and reality of parental postpartum depression among residents. The study evaluated both female and male resident parents. Residency is a challenging time in any physician’s career compounded by the fact that it occurs during reproductive years for the majority of residents. The greatest strength of this study comes in its novelty. There have been no other studies evaluating or examining postpartum or perinatal depression among resident parents, let alone one that includes both female and male residents. While historical studies have clearly demonstrated the effect of rigorous training on the mental health of its trainees (Mata et al. 2015; Goldman et al. 2015), never has parenthood and the stressors associated been considered. So, while a small sample size is the greatest limitation of this study, there remains value in the findings. In planning for this study, sample size was an expected obstacle given resident parents represent a small subset of residents overall, as well as limited access to residents for distribution of the survey given resident privacy protections in place. Despite these challenges, it was still felt to be worthwhile given the risk of depression among residents, as well as the potential benefit in identifying support for the intended population, resident parents. In examining these analyses, it is felt that the small sample size is the primary reason for no statistically significant results. An additional confounding factor may also be that most results are from a limited number of medical specialties within Nebraska. However, when examining the statistical analysis, there is value in the trends within the results as well as in the resident commentary emphasizing reported experiences, stressors, and options for support in the open-ended comments section.

In examining the rate of postpartum depression among female respondents a staggering 42% felt that they suffered from PPD while only 12% were diagnosed. Interestingly, only 12% sought treatment and were diagnosed with postpartum depression. Despite knowing how to both identify, diagnose, and treat mental health disorders, physicians are historically less likely to seek treatment or mental health services (Golob et al. 2018). Within our study, female residents report a four-fold increase in suffering from postpartum depression, compared to the rate of 11% among the general population (Cameron et al. 2016). This emphasizes that while perhaps not statistically significant, new resident moms are a group at particular risk for postpartum depression and in need of support. A recent study in 2022 looked at childcare stress during the COVID-19 pandemic. The study showed that women are 22% more likely to experience burnout, anxiety, and depression compared to their male counterparts regarding childrearing demonstrating an increased risk to mental health does not likely stop with the postpartum period (Harry et al. 2022). No male residents studied reported diagnosis or believing they suffered from postpartum depression compared to a rate of 8.4% within the general population (Cameron et al. 2016). However, male respondents did report that 9% of their partners were diagnosed with PPD and they felt that 19% suffered from PPD, showing some risk to the partners of male medical residents. Maternal depression prevalence has been shown to be a moderator of paternal well-being and depression rates during the transition to parenthood (Cameron et al. 2016).

Allocating leave time for both maternity and paternity leave has been difficult to accommodate for all residency programs for several decades. It represents the delicate balance of upholding Family Medical Leave Act (FMLA) requirements while covering needed services within the residency program and meeting requirements for residency graduation. The most common maternity leave documented was 4–6 weeks with a reported 40% rate of depression. In comparing the next most common leave of 6–8 weeks showed an improved rate of 25%, there may be some benefit in allowing additional time for this transition. In asking resident parents if they felt prepared to return to service, 68% reported they did not feel ready. In further evaluating the commentary from the open-ended questions from resident respondents the most frequent response in response to “what could your program do to better support you during your transition to parenthood” residents persistently responded, “allowing for additional time for family leave”. Program directors of all specialties should heavily consider allocating additional time to assist resident families through this transition. Under national FMLA standards, parents and families of the general population are allowed 12 weeks of leave per year after the birth of a child (Family and Medical Leave Act of 1993 2022), yet in medicine a field that at its core understands the impact of wellness of the family unit, our trainees are expected to return to 80-h work weeks with nightly and 24-h calls predominately within 4–6 weeks. In addition, respondents strongly desire transparency in the policies and available time off: “want concrete information about maternity leave options free of guilt.” Paternity leave time was not any different between categories and did not show an association with increased rate of postpartum depression; however, there were several comments regarding allowing additional paternity time and time to be home to help support partner with this transition.

It may be helpful to target the most common stressors reported by residents experiencing this transition. The most common stressors included fatigue, emotional distress in leaving infant, and stress associated with breastfeeding and accommodations. These themes continued to present themselves in the open-ended comments in the desire for additional time off to have more time caring and supporting their infant and family at home. Fatigue was referenced in the desire to transition back to less demanding rotations or more flexibility upon return, in an effort to acclimate to the new role as both parent and resident. Breastfeeding accommodations should be an expectation of all programs. The American Academy of Pediatrics, Center for Disease Control, World Health Organization, and American College of Obstetricians and Gynecologists all recommend exclusively breastfeeding as the best option for infant nutrition for at least 6 months of age. Yet regardless of these recommendations, resident mothers continue to report both breastfeeding time and accommodations as a primary stressor in returning to work as a resident physician. Comments included “hospital wide private areas for residents to pump,” “pumping accommodations,” “time and a place to store my breastmilk,” “not be required to do notes while pumping,” and “I had mandatory noon conference and all day clinic, as an intern I didn’t feel like I could ask for accommodations.” This is medicine, and if breastfeeding is recommended by multiple governing bodies of medicine, there must be flexibility and options for returning resident mothers. Support for these resident physicians comes in many forms. Many times support does not require much time or resources. Several residents specified they wish they would have had emotional support from their program, co-residents, and specifically, their program director had “explicitly checked in to see how they were doing” and “acknowledge what I am going through.”

Conclusions

Medical training is rigorous, stressful, and a necessary steppingstone to licensure as a physician. This training historically spans reproductive years for the majority of trainees. The transition to parenthood, if desired, is unavoidable and should be expected in a portion of residents during their training. This is the first study of its kind evaluating the transition to parenthood within residency training and highlights an at-risk population particularly for postpartum depression among female residents. Future research would be beneficial to further define the prevalence of peripartum mood disorders among resident parents by capturing a larger sample size and increasing applicability to a national level. There is more power in numbers, and this would be helpful to further drive policy change and support among residency programs across the country. This study emphasizes a need for emotional support, transparency in policy, breastfeeding accommodations, and additional time to help adjust to their complex, demanding new role of both parent and resident.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Funding

This project was supported by the Olson Center for Women’s Health, Department of Obstetrics and Gynecology, University of Nebraska Medical Center.

Declarations

Conflict of interest

The authors declare no competing interests.