Introduction:
While there are multiple barriers that may discourage women from choosing a career in orthopaedic surgery, one area of concern is pursuing pregnancy during residency training. This study's primary purpose was to determine the most prominent barriers to pursuing pregnancy during orthopaedic surgery residency.
Methods:
A 63-item survey designed to evaluate multiple aspects of childbearing during orthopaedic surgery residency was distributed through email and a targeted Facebook platform to female orthopaedic surgeons and orthopaedic trainees in the United States. Given the study design, statistics were largely descriptive in nature. Multivariate logistic regression was also used to determine independent factors associated with professional dissatisfaction as it related to pregnancy during orthopaedic residency.
Results:
A total of 328 women responded to the survey. The 3 most prominent barriers to pursuing pregnancy during orthopaedic residency were concerns about the ability to balance clinical and maternal duties (67%), fear of how the resident would be viewed by those in the program (60%), and being unable to ensure optimal prenatal and postpartum care for the mother and child given an unpredictable schedule (38%). On univariate analysis of those who reported ≥1 pregnancy during residency (n = 71), maternity leave ≤6 weeks was statistically associated with “revisiting career choice” (p = 0.02) and “lack of resources and support” (p = 0.01).
Conclusion:
The results raise concern that qualified female applicants may be deterred from the field of orthopaedics given perceived difficulties associated with pregnancy as a resident. If policies are created to support women who desire to have children during residency, more women may be encouraged to pursue a career in orthopaedic surgery.
Level of Evidence:
V
Introduction
There continues to be a large gender imbalance when it comes to orthopaedic residency programs. There are now more women in medical school than men; however, women represent only 14% of orthopaedic trainees1. Women are also least represented in orthopaedic surgery compared with all other surgical subspecialties with only 5.3% faculty who are female2. These statistics highlight the question, “Why are there so few women in orthopaedic surgery?”
While there are multiple barriers that may discourage women from pursuing a career in orthopaedic surgery, one area of concern is starting a family during residency training. A 2018 article written by de Costa et al. highlighted many of the deterrents to choosing a surgical career among women3. The authors noted that women can be subjected to perceptions that the surgical lifestyle is not compatible with the disproportionate burden that women face regarding care-giving responsibilities3. They suggest that these gendered expectations can steer women away from a career that could take time away from starting a family. In addition, in a 2019 study conducted by Larsen et al., women reported significantly more concerns about finding time during residency to have a child, taking maternity leave, and being too old after residency to have a child4. This perceived pregnancy bias is a potential barrier to attracting qualified women into the field and to equalizing the profound gender imbalance of orthopaedics.
This study's primary purpose was to determine the most prominent barriers to pursuing pregnancy during orthopaedic surgery residency. By recognizing barriers that pose challenges for women to have children during residency, specific targets for intervention can be identified. This is particularly important in the field of orthopaedics, which has the smallest proportion of women when compared with all other surgical subspecialties2.
Methods
Study Design and Sample
This study was a self-administered, 63-item survey designed to evaluate multiple aspects of childbearing during orthopaedic surgery residency. Female orthopaedic surgeons, including current residents and those who had completed training in an Accreditation Council for Graduate Medical Education (ACGME)–accredited US orthopaedic surgery training program, met inclusion criteria. The survey was distributed electronically through email to residency program coordinators and through a targeted Facebook platform, “The Women of Orthopedics” Facebook group (1,700 members). The members of this private group must be a current orthopaedic trainee, faculty, retiree, or matched into an orthopaedic residency training program. Program coordinators were asked to forward the survey to current female trainees and faculty. The survey was distributed in September 2021 and was available for 8 weeks. One reminder for completion was posted in the Facebook group 1 week before closure of the survey. Responses were anonymous, and participants were not remunerated. This study was granted exemption status by the authors' institutional review board and was not funded.
Survey Instrument
The survey included questions consisting of basic demographic information, resident pregnancy history, maternity leave policies, and questions regarding attitudes and opinions toward pregnancy in female orthopaedic trainees. Survey questions used in the final analysis are included in Supplement 1 (http://links.lww.com/JBJSOA/A448).
Respondent attitudes regarding the impact of various program-specific factors on pregnancy were assessed using a 5-point Likert scale from “not at all impactful” to “extremely impactful,” with an option for “not applicable.” Participants were asked their opinion regarding the utility of standardized maternity leave policies, whether standardized policies would encourage greater female interest in orthopaedic surgery, and whether current work-life balance deters female applicants from entering the field.
Outcome variables included 3 statements developed to assess professional dissatisfaction with their surgical career5. Participants were reported to be at least temporarily dissatisfied with their career if they indicated agreement with the statements: (1) “Given the opportunity, I would consider choosing a nonsurgical career more accommodating of motherhood” (“revisit career choice”); (2) “I do not feel that I had the resources/support available to have a child during residency” (“lack of resources/support”); and (3) “I considered quitting due to difficulties associated with having children as a resident” (“considered quitting”)5. Multivariate logistic regression was used to determine independent factors associated with agreement with each of these 3 statements. Covariates with a p value of 0.20 or less on univariate analysis were included in the multivariate models. A p value of 0.05 or less was accepted as statistically significant, and p values were 2-sided. Data were analyzed using Graphpad Prism, version 9.0 (Dotmatics).
Results
A total of 328 women responded to the survey and met inclusion criteria. Forty-two percent (138/328) reported a desire to have children during residency; however, only 22% (71/328) reported at least 1 pregnancy as a resident. The average age of first pregnancy was 32.9 years (±3.1 years) with a range from 24 to 45 years. In addition, 68.6% (223/325) reported that they intentionally delayed childbearing secondary to the demands of residency training. Demographics, attitudes, training experiences, and expectations regarding pregnancy during residency are listed in Table I.
TABLE I.
Patient Demographics
| Participant Characteristics (N = 328) | N (%) |
|---|---|
| Current role | |
| Resident | 124 (37.8) |
| Fellow | 23 (7.0) |
| Practicing surgeon (≤10 yrs in practice) | 134 (40.1) |
| Practicing surgeon (>10 yrs in practice) | 45 (13.7) |
| Residency program size | |
| 1-3 chief residents | 54 (16.5) |
| 4-6 chief residents | 210 (64.0) |
| ≥7 chief residents | 64 (19.5) |
| Level of training during pregnancy (N = 176) | |
| Medical student | 4 (2.3) |
| Resident | 69 (39.2) |
| Fellow | 25 (14.2) |
| Faculty | 76 (43.2) |
| Other | 2 (1.1) |
| No. of children during residency (N = 71) | |
| 1 | 60 (84.5) |
| 2 | 10 (14.1) |
| Other (adoption) | 1 (1.4) |
| Residency program characteristics | |
| Designated number of weeks allotted for maternity | |
| Yes | 78 (23.7) |
| No | 155 (47.3) |
| Unsure | 95 (29.0) |
| Written policies in place regarding maternity leave | |
| Yes | 64 (19.5) |
| No | 147 (44.8) |
| Unsure | 117 (35.7) |
| Lactation rooms near clinical spaces | |
| Yes | 57 (17.4) |
| No | 206 (62.8) |
| Unsure | 65 (19.8) |
| Refrigerators to store breast milk | |
| Yes | 22 (6.7) |
| No | 226 (68.9) |
| Unsure | 80 (24.4) |
| Other female residents in the program with children | |
| Yes | 150 (45.7) |
| No | 176 (53.7) |
| Unsure | 2 (0.6) |
| Experienced miscarriage as a resident | 22 (6.7) |
| Intentionally delayed childbearing secondary to residency demands | 223 (68.6%)N=325 |
| “There should be a standardized policy across all orthopaedic surgery residency programs for maternity leave” | |
| Agree | 264 (80.5%) |
| Disagree | 24 (7.3) |
| Unsure | 41 (12.5) |
| “If policies were in place to support women who desire to have children during residency, more women would choose ortho as a career” | |
| Agree | 230 (70.1) |
| Disagree | 22 (6.7) |
| Unsure | 76 (23.2) |
| “Difficulties with work/life balance as an orthopaedic resident deter qualified female applicants from entering the field” | |
| Agree | 260 (79.3) |
| Disagree | 24 (7.3) |
| Unsure | 44 (13.4) |
| “A smaller program makes it more difficult for a woman to have a child during residency” | |
| Agree | 240 (73.2) |
| Disagree | 30 (9.1) |
| Unsure | 58 (17.7) |
Sixty-seven percent of all respondents (220/328) agreed with at least 1 statement of professional dissatisfaction: 12% (39/328) considered quitting because of difficulties associated with having children as a resident, 59% (194/328) felt they did not have the resources/support available to have children during residency, and 5% (16/328) would consider a nonsurgical career more accommodating of motherhood. In addition, 63.1% (207/328) reported that concerns about long working hours and an unpredictable schedule were “very impactful” or “extremely impactful” in their decision regarding pregnancy during orthopaedic residency. Complete results of the Likert response frequencies are presented in Table II and Figure 1.
Fig. 1.
Complete results of the Likert response frequencies for the question, “To what extent do/did each of these factors impact your decisions regarding pregnancy and child-rearing during pregnancy?”
TABLE II.
Survey Likert Response Frequencies (“To What Extent Do/Did Each of These Factors Impact Your Decisions Regarding Pregnancy and Child-Rearing During Pregnancy?”)
| Question | Extremely Impactful | Very Impactful | Moderately Impactful | Mildly Impactful | Not at all Impactful |
|---|---|---|---|---|---|
| Resident treatment | 60 (18.3) | 63 (19.2) | 54 (16.5) | 63 (19.2) | 31 (9.5) |
| Faculty treatment* | 86 (26.3) | 57 (17.4) | 62 (19.0) | 45 (13.8) | 21 (6.4) |
| Would not be taken seriously at work | 66 (20.1) | 59 (18.0) | 66 (20.1) | 35 (10.7) | 46 (14.0) |
| Lack of resources (i.e., lactation rooms) | 22 (6.7) | 34 (10.4) | 56 (17.2) | 75 (23.0) | 78 (23.9) |
| Stepping out of cases to pump | 47 (14.3) | 62 (18.9) | 56 (17.1) | 51 (15.5) | 51 (15.5) |
| Stepping out of cases during cementing | 34 (10.4) | 50 (15.2) | 52 (15.9) | 50 (15.2) | 82 (25.0) |
| Being able to perform clinical duties while pregnant | 63 (19.3) | 60 (18.3) | 64 (19.6) | 47 (14.4) | 36 (11.0) |
| Pregnancy complications due to hours worked* | 65 (19.8) | 69 (21.0) | 63 (19.2) | 42 (12.8) | 32 (9.8) |
| High radiation exposure | 49 (15.0) | 46 (14.1) | 67 (20.5) | 70 (21.4) | 41 (12.5) |
| Coresident support | 66 (20.2) | 59 (18.0) | 55 (16.8) | 61 (18.7) | 31 (9.5) |
| Faculty support* | 76 (23.2) | 58 (17.7) | 66 (20.1) | 52 (15.9) | 20 (6.1) |
| Adequate maternity leave policies* | 70 (21.3) | 72 (22.0) | 56 (17.1) | 35 (10.7) | 35 (10.7) |
| Falling behind peers* | 82 (25.0) | 60 (18.3) | 55 (16.8) | 38 (11.6) | 36 (11.0) |
| Delaying graduation* | 86 (26.2) | 46 (14.0) | 47 (14.3) | 44 (13.4) | 48 (14.6) |
| Size of residency program | 49 (14.9) | 37 (11.3) | 47 (14.3) | 57 (17.4) | 82 (25.0) |
| Finding childcare postpartum | 90 (27.4) | 42 (12.8) | 52 (15.9) | 44 (13.4) | 42 (12.8) |
| Associated costs | 76 (23.2) | 47 (14.3) | 40 (12.2) | 51 (15.5) | 56 (17.1) |
| Long hours/unpredictable schedule*† | 146 (44.5) | 61 (18.6) | 27 (8.2) | 24 (7.3) | 15 (4.6) |
| Accessible family support | 86 (26.2) | 39 (11.9) | 48 (14.6) | 54 (16.5) | 43 (13.1) |
| Ability to schedule peripartum appointments | 56 (17.1) | 60 (18.3) | 66 (20.1) | 46 (14.0) | 42 (12.8) |
| Morning sickness | 50 (15.2) | 49 (14.9) | 65 (19.8) | 65 (19.8) | 44 (13.4) |
≥40% “very impactful” or “extremely impactful.”
Most impactful response.
Eighty percent (264/328 and 260/328 respectively) agreed with the following statements: “There should be a standardized policy across all orthopaedic surgery residency programs regarding maternity leave” and “difficulties with work-life balance deter qualified female applicants from entering the field.” Seventy percent (230/328) agreed with the following statement: “If policies were in place to support women who desire to have children during residency, more women would choose orthopaedic surgery as a career.”
All respondents were asked, “In your opinion, what are the most prominent barriers to pursuing pregnancy and motherhood during orthopaedic residency,” and were instructed to select 3 answers. The 3 most selected barriers were concerns about the ability to balance clinical and maternal duties (219/328, 67%), fear of how the resident would be viewed by those in the program (197/328, 60%), and being unable to ensure optimal prenatal and postpartum care for the mother and child given an unpredictable schedule (126/328, 38%)
Among 71 respondents who reported ≥1 pregnancy during residency, the average length of maternity leave was 6.5 ± 3.9 weeks (2-24 weeks); 50% (35/71) took additional call before delivery; 32% (23/71) took additional call after delivery; 8.5% (6/71) reported a portion of leave that was unpaid; and 21% (15/71) missed at least 1 prenatal appointment because of residency obligations. Within this cohort, 31% (22/71) were the first in their program to have a child, and 59% (42/71) felt that they did not have adequate female faculty to turn to for support/guidance during their pregnancy. Sixty-five percent (46/71) did not have official maternity leave policies in place, and 22.5% (16/71) noted that they would consider choosing a nonsurgical career more accommodating of motherhood.
On univariate analysis of those who reported ≥1 pregnancy during residency (n = 71), professional dissatisfaction was associated with length of maternity leave, lack of formal maternity leave policies, and lack of access to lactation facilities. Independent risk factors contributing to each of the 3 measures of professional dissatisfaction are listed in Table III. Maternity leave ≤6 weeks was associated with “revisit career choice” and “lack of resources/support.” Lack of official maternity leave policies and lack of access to lactation facilities were each associated with “considered quitting.”
TABLE III.
Univariate Analysis (Surrogate Markers of Professional Dissatisfaction)*
| Participant's Experience During Pregnancy | “Given an opportunity, you would consider choosing a nonsurgical career more accommodating of motherhood” (revisit career choice)† | “I do not feel that I had the resources/support available to have a child during residency” (lack of resources/support)‡ | “I considered quitting due to difficulties associated with having children as a resident” (considered quitting)§ | |||
|---|---|---|---|---|---|---|
| OR (95% CI) | p Value | OR (95% CI) | p Value | OR (95% CI) | p Value | |
| Maternity leave ≤6 wk | 0.2 (0.1-0.7) | 0.02# | 39.9 (2.1-72.9) | 0.01# | 0.7 (0.21-2.4) | 0.57 |
| First woman in program to have children | 0.7 (0.2-2.7) | 0.8 | 1.5 (0.4-6.1) | 0.56 | 0.87 (0.24-3.2) | 0.84 |
| Additional call before delivery | 0.4 (0.1-1.5) | 0.3 | 1.05 (0.3-3.8) | 0.94 | 1.04 (0.34-3.12) | 0.94 |
| Unpaid leave during pregnancy | 2.7 (0.6-12.2) | 0.3 | 0.71 (0.08-6.7) | 0.76 | 0.56 (0.06-5.2) | 0.62 |
| Official maternity leave policies | 0.6 (0.3-2.3) | 0.6 | 1.38 (0.36-5.3) | 0.63 | 0.13 (0.03-0.54) | 0.0044# |
| Female faculty for guidance/mentorship | 1.4 (0.5-2.1) | 0.5 | 0.21 (0.04-1.12) | 0.06 | 2.48 (0.71-8.7) | 0.15 |
| Access to lactation facilities | 1.4 (0.2-9.7) | 0.7 | 0.48 (0.12-2.0) | 0.32 | 0.19 (0.055-0.66) | 0.009# |
| Other residents with children | 0.7 (0.2-2.4) | 0.6 | 2.8 (0.75-11.05) | 0.12 | 1.48 (0.49-4.48) | 0.48 |
CI = confidence interval, and OR = odds ratio.
Of all participants, 23% responded yes.
Of all participants, 17% responded yes.
Of all participants, 24% responded yes.
Statistically significant.
Discussion
It has been previously shown that across surgical subspecialities, women have their first pregnancy later in life, have fewer children, and have a higher incidence of infertility and pregnancy-related complications than the general population6-8. In a 2012 study by Hamilton et al., 48% of female orthopaedic surgeons deferred having children until after residency6. This substantially delays childbearing compared with the national average of 27 years for first-time mothers7. In addition, the authors found that pregnancy complication rates were significantly higher in orthopaedic surgeons at 31% compared with 15% in the general population6. In 2020, Dwyer et al. posed the statement, “Consider presenting patients with a potential 31% complication rate of surgery: Would they still want surgery, or would it even be recommended as a valid option?”9
In this cohort of female orthopaedic surgeons and trainees, 68.6% intentionally delayed childbearing because of the demands of residency training, and the average age of first pregnancy was 32.9 years. This delay places these women at an increased risk of infertility, miscarriage, gestational diabetes, low birth weight, and overall pregnancy complications6. For comparison, a 2011 study noted that the average age of “birthing residents” in family medicine was 29.3 years; however, this study did not specify whether this was the average age of first pregnancy10. A 2009 study by Lerner et al. found that the average age of first pregnancy in urology residents was 32.6 years11. In our cohort, 24.3% who had children during residency did not carry to term. This is significantly higher than the national preterm birth rate of 10.1% reported by the Centers for Disease Control and Prevention in 202012.
In this study, 42% reported a desire to have a child during residency, but only 21% felt that they had the resources to do so, and 12% considered quitting because of associated with having children as a resident. In addition, respondents were statistically more likely to consider quitting when official maternity leave policies were not in place. Those with maternity leave of ≤6 weeks were more likely to report that they did not have the support/resources available to have a child during residency. Similarly, in a study of 347 female general surgeons who had at least 1 pregnancy during residency, only 35% reported having a maternity leave policy, and the duration of leave was less than 6 weeks for the majority, which was perceived to be inadequate by 72% of women13. Nearly 40% reported that they considered leaving residency and 33% would discourage female medical students from pursuing a surgical career13. Of the women in this study who had children as a resident, 22.5% said that given an opportunity to revisit career choice, they would consider choosing a nonsurgical career more accommodating to motherhood. Again, we found that respondents were significantly more likely to consider an alternate career if their maternity leave was ≤6 weeks.
In this study, 71 women (22%) had a child/children as a resident. The average length of maternity leave was 6.5 weeks, and 65% reported that there were no official policies in place regarding maternity leave. According to the Family and Medical Leave Act and the American Academy of Pediatrics, the recommended length of maternity leave is 12 weeks, given the evidence of benefits for both the parent and the child. When looking at high-income countries, the United States is an outlier in parental leave policies. In many European countries, women are allotted 6 to 12 months of paid maternity leave, which has significant implications regarding length of breastfeeding, parental bonding, and postpartum depression. However, a 2020 study written by Nguyen et al. reported that the average amount of paid leave offered to orthopaedic surgeons is only 4.6 weeks14. Not only is this far less than the recommendation but also places women at risk to disregard postpartum restrictions given the physical demands required while at work. The authors also found a significant difference between the length of leave taken between residents (6.3 ± 5 weeks), fellows (8.3 ± 7.2 weeks), and practicing surgeons (9.6 ± 8.5 weeks), with residents taking the shortest amount of leave14.
Interestingly, of the women who had children as a resident, 50% were required to take additional call before delivery and 32% had to take additional call after delivery; however, there are no current guidelines reported by the American Board of Orthopaedic Surgeons (ABOS) that indicate a designated number of weeks on call required for graduation. Per the ABOS, residents must complete 46 weeks of full-time orthopaedic education per year, averaged over 5 years, to be eligible for graduation. For an orthopaedic residency program that allows 3 to 4 weeks of vacation per year, this leaves an additional 2 to 3 weeks each year (or a total of 10-15 weeks combined) that can be used toward parental leave without extending training (if specialty-specific requirements are also met).
Of the entire cohort, 80% reported that there should be a standardized policy across all orthopaedic residency programs regarding maternity leave, and 70% noted that if polices were in place to support women who desire to have children during residency, more women would choose orthopaedics as a career. Similarly, 80% believed that difficulties with work-life balance deter qualified applicants from the field. This is especially important given the significant underrepresentation of women in orthopaedics.
The limitations of this study are related to its survey design. This is not a validated survey tool, and the survey is subject to voluntary response bias. Given the method of distribution, we were unable to calculate a response rate. According to the Association of American Medical Colleges, in 2019, there were 1,099 practicing female orthopaedic surgeons and 673 residents/fellows in the United States15,16. Although the data for 2022 is unknown, we infer that 328 responses represent a notable portion of the study population. In addition, this survey was focused on pregnancy during orthopaedic residency specifically. We do not know how many in this cohort had a pregnancy or considered pregnancy later in their career. The experience of surgeons who trained before the implementation of the 80-hour work per week (n = 39 or 11.9%) also reflects a time when residency training and expectations were quite different, which may affect the results. Furthermore, this survey does not capture the women who have left the field of orthopaedics, possibly because of difficulties related to childbearing during their career. There may be women who are not interested in or not capable of pregnancy, and therefore, the concerns related to this topic do not necessarily apply to every woman in orthopaedics. Our results are only generalizable to the cohort in which pregnancy during orthopaedic residency is relevant.
Conclusion and Recommendations for Improvement
While there are multiple barriers that may discourage women from pursuing pregnancy during orthopaedic residency, our study suggests that the 3 most prominent barriers include concerns about the ability to balance clinical and maternal duties, fear of how the resident would be viewed by those in the program, and inability to ensure optimal prenatal and postpartum care for the mother and child. Maternity leave ≤6 weeks and lack of official maternity leave policies were causes for questioning the decision to pursue orthopaedic surgery as a profession. The results raise concern that qualified women may be deterred from the field of orthopaedics given perceived difficulties that come with pregnancy as a resident. Based on the results of this study, the authors propose the following measures to be considered for residency programs on a nationwide scale:
•Establish a standardized policy supported by the ABOS and ACGME that (1) allows for 12 weeks of paid maternity leave without need to extend residency training, (2) prohibits a requirement for extra on-call shifts, (3) sets limits on 24-hour call shifts during the third trimester, (4) affords protected time for clinical absence to attend prenatal and postpartum medical appointments, and (5) sets minimum requirements on the accessibility and resources of lactation areas.
•Facilitate the connection of residents who desire to pursue pregnancy with others in the field willing to offer support/guidance, perhaps through a national society such as the American Academy of Orthopedic Surgeons or Council of Residency Directors.
•Create a culture, led by department and residency leadership, that shows overt support for pregnant residents
•Subsidize childcare services for resident physicians or provide standard monthly financial allotment to be used for childcare.
If policies are created to address barriers for women who desire to have children during orthopaedic surgery residency, more women may be encouraged to pursue a career in orthopaedic surgery.
Appendix
Supporting material provided by the authors is posted with the online version of this article as a data supplement at jbjs.org (http://links.lww.com/JBJSOA/A448). This content was not copyedited or verified by JBJS.
Footnotes
Investigation performed at Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, Michigan
Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A447).
Contributor Information
Stacia Ruse, Email: rusesm@med.umich.edu.
Rachel Bergman, Email: rachel.bergman1@northwestern.edu.
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