The unhealthy state of parental leave policies in gastroenterology: A call to action
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Despite strong evidence of the mental and physical health benefits of paid parental leave on parents, children and the community, the Unites States is one of only six countries that does not offer it.
This support for new parents is widely available outside the U.S, with Canada providing up to 40 weeks, many European countries offering 14 to 44 weeks and Mexico providing 12 weeks. The American Academy of Pediatrics (AAP) recommends a minimum of 12 weeks of leave for new parents — a length of time that is associated with lower rates of postpartum depression, higher rates of sustained breastfeeding and improved child and maternal outcomes.
With national policies lacking, parental leave practices in the U.S. remain inconsistent and largely unsatisfactory in various training institutions and clinical settings. And because fellowship training and the start of one’s career typically occur during peak childbearing age, the lack of transparent and robust parental leave policies can have tremendous impact on women choosing a procedural career like gastroenterology.
Disparity by Numbers
A survey of internal medicine residents’ attitudes toward the field of gastroenterology (Advani R, et al) showed that although women were as interested as men in pursuing a GI fellowship, women had greater concerns about fertility, maternity leave, radiation exposure and work-life balance. These concerns are not unfounded: In a survey of GI trainees (Feld LD), 87% reported receiving 6 weeks or less of parental leave and more than 80% reported inadequate space and time for pumping breastmilk.
In addition, trainees often feel pressure to quickly resume fellowship after childbirth because of financial constraints (unpaid or low paid leave), fear of a delayed off-cycle graduation and board exam eligibility, and the stigma against parental leave in the field of medicine. In the same survey, more than half of pregnant women trainees had increased call days to “make up” for time off and perceived bias against them as expecting or new parents from program faculty and peers. While there is no study to date on how to reduce endoscopic injuries in pregnant endoscopists, most women report that their procedural volumes were not adjusted during pregnancy.
Although women are more likely to choose programs based on parental leave policies, many do not ask about these policies during their fellowship or job interview out of fear of not being considered for the desired position. Conversely, these policies often are not readily disclosed by the employer, leaving pregnant physicians juggling vacation time and short-term disability ad hoc to get a minimally adequate leave.
These systemic barriers to a healthy pregnancy and postpartum experience largely explain why women in gastroenterology often must choose between starting a family or advancing their career. Female GI fellows are more likely to be single or have fewer children than their male counterparts (Arlow FL, et al). Most women in gastroenterology delay having children until completion of their training or career advancement out of concern that their pregnancy will have a negative impact on their professional reputation and success (David YN, et al).
The reality is that women often get penalized for taking parental leave in terms of salary, RVU target, grant funding, academic promotion and partnership in private practice. And as we know, a maternal age of older than 35 years is associated with an increased risk for infertility and pregnancy complications. Plus, assisted reproductive technologies can be financially, emotionally — and sometimes ethically — taxing.
The results of a survey presented at the 2022 American College of Obstetricians and Gynecologists Annual Meeting show that one in four new mothers who are physicians experience postpartum depression — twice the rate seen in the general population (Eischen EBS, et al). Postpartum depression was more common among those who did not meet their breastfeeding goals and was attributed to inadequate maternity leave (41%) and lack of support at work (33%).
Let’s pause here for a moment and absorb all this: Women are underrepresented in the field of gastroenterology (only 18% of practicing gastroenterologists are women) and in leadership positions in academia and in private practice. To ensure our field is inclusive and diverse and that its workforce represents the population we serve, we want to encourage more women to choose a career in gastroenterology, and, even more important, we want to retain them and give them a fair and equitable chance to thrive.
And yet, women are often asked to choose between a career and not having a family or delaying family planning. They are reluctantly allowed bare-minimum maternity leave, they receive minimal accommodations for the physical restrictions of pregnancy and for breastfeeding, and their career trajectory is penalized for pausing or slowing down for family duties. The lack of organizational support for expecting or new parents not only affects their career experience but also their physical and emotional health and potentially the health of their infant and their entire family.
Basically, our health system is depriving female physicians of the time and energy to care for themselves and their newborns during this critical phase of life. It is no surprise then that this lack of clear and fair parental leave and organizational support for new parents contributes to perpetuating gender bias and inequity in the field, not to mention the burnout and attrition of female physicians early in their careers.
Systemic Solutions
For the sake and health of our field, physicians, patients and communities, it is imperative that we implement systemic policies to support pregnancy and parents in the pre- and postpartum periods. Ideally, all GI fellowships, divisions and practices should support paid parental leave of at least 12 weeks, as recommended by the AAP, separate from vacation and sick time. Of note, up to 40% of female physicians report that 4 to 6 months family leave would be ideal (Juengst SB, et al).
In line with promoting gender equity, paid parental leave should be granted regardless of gender and who is the childbearing parent, which would allow every parent to bond with the child, be part of child development and share childcare responsibilities. In addition, GI fellowship programs and institutions should intentionally implement practical measures that support pregnancy: Organizations should be transparent about their parental leave policies, and candidates should proactively be informed of their parental rights. Microaggressions and bias against expecting or new mothers should not be tolerated, and a culture of team collaboration to patient care should be nurtured.
Women should not be pressured to perform procedures they deem uncomfortable or potentially harmful to their health during pregnancy and in the postpartum recovery period (eg, pushing the cart, fluoroscopy, long procedures such as single balloon). Adequate time for pumping breastmilk in a private space must be built in the schedule of lactating mothers, and ideally affordable childcare should be provided on site.
In addition, a flexible, nonpunitive schedule should be offered: During the third trimester and in the following postpartum months, night call should be decreased and procedure volumes adjusted, with an option to increase teaching or research time. Monthly RVU targets should be adjusted to account for protected time for lactating physicians, and the annual target modified to account for parental leave.
Finally, trainees who take parental leave should undergo a competency-based assessment, and if clinical and procedural competencies are met, then extending the fellowship (to simply reach a set length of training time) might not be necessary (Uchida AM, et al). Similarly, women who take a longer pause for family reasons should have the option to enroll in a professional retraining program for re-entry in the field, and promotion or grants rewards should not be withheld for a parental leave gap in the resume.
Our GI societies and the Accreditation Council for Graduate Medical Education should partner to develop and implement transparent, comprehensive and robust parental leave policies across training systems and institutions, which is key to achieving gender equity and transforming the field into the inclusive space it needs to be.
As a medical profession, we advocate for the physical and mental health of our patients: We strive to do no harm and always deliver compassionate and comprehensive care to our patients. We have the utmost respect for human lives. Let us show the same respect and values to the women who choose to have children while serving the GI community.
- References:
- Advani R, et al. Dig Dis Sci. 2022;doi:10.1007/s10620-022-07541-5.
- Arlow FL, et al. Am J Gastroenterol. 2002;doi:10.1111/j.1572-0241.2002.05485.x
- David YN, et al. Gastroenterology. 2021;doi:10.1053/j.gastro.2021.05.053.
- Eischen EBS, et al. Obstetrics & Gynecology. 2022;doi:10.1097/01.AOG.0000825680.32694.d4.
- Feld LD. Am J Gastroenterol. 2021;doi:10.14309/ajg.0000000000001145.
- Juengst SB, et al. JAMA Netw Open. 2019;doi:10.1001/jamanetworkopen.2019.13054.
- Marshall AL, et al. Acad Med. 2020;doi:10.1097/ACM.0000000000003079.
- Uchida AM, et al. Am J Gastroenterol. 2021;doi:10.14309/ajg.0000000000001331.
- For more information:
- Aline Charabaty, MD, AGAF, FACG, is director of the IBD Center at Johns Hopkins Sibley Memorial Hospital, founder of MondayNightIBD and co-founder of Scrubs and Heels.
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