Background Internationally, supporting surgical trainees during pregnancy, maternity and paternity leave is essential for trainee well-being and for retention of high-calibre surgeons, regardless of their parental status. This study sought to determine the current experience of surgical trainees regarding pregnancy, maternity and paternity leave.
Methods A cross-sectional anonymised electronic voluntary survey of all surgical trainees working in the UK and Ireland was distributed via the Association of Surgeons in Training and the British Orthopaedic Trainees’ Association.
Results There were 876 complete responses, of whom 61.4% (n=555) were female. 46.5% (258/555) had been pregnant during surgical training. The majority (51.9%, n=134/258) stopped night on-call shifts by 30 weeks’ gestation. The most common reason for this was concerns related to tiredness and maternal health. 41% did not have rest facilities available on night shifts. 27.1% (n=70/258) of trainees did not feel supported by their department during pregnancy, and 17.1% (n=50/258) found the process of arranging maternity leave difficult or very difficult. 61% (n=118/193) of trainees felt they had returned to their normal level of working within 6 months of returning to work after maternity leave, while a significant minority took longer. 25% (n=33/135) of trainees found arranging paternity leave difficult or very difficult, and the most common source of information regarding paternity leave was other trainees.
Conclusion Over a quarter of surgical trainees felt unsupported by their department during pregnancy, while a quarter of male trainees experience difficulty in arranging paternity leave. Efforts must be made to ensure support is available in pregnancy and maternity/paternity leave.
- maternity leave
- paternity leave
- surgical training
- surgical education
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Feminisation of the workforce has occurred in the past two decades in medicine, with women now representing 57% of all doctors in training in the UK.1 However, surgery has lagged behind other disciplines in achieving true gender equality at more senior levels, including consultant and academic surgical posts,2 3 with female trainees experiencing pervasive discriminatory attitudes.4 Healthcare structures can promote or impede female leadership in surgery, with countries like Finland providing positive models.5 Good support structures to facilitate trainees’ plans to have children while training is essential to attract and retain graduates to surgical specialties.
For both male and female trainees, combining surgical training with having a family brings great reward and significant challenges. Sullivan et al 6 reported that general surgery trainees in the USA who were either married or parents reported greater satisfaction, but also greater work–life conflicts. The increasing number of women entering surgical training means that a greater proportion of surgical trainees will be pregnant during their surgical training.7 Pregnant trainees require sufficient support to level the playing field of surgical training.8 Unfortunately, many trainees do not feel supported in pregnancy, even by female colleagues.7 Chen et al 9 reported findings from the USA that male trainees who had children during residency felt supported, while women who had children during residency were more likely to report feeling overwhelmed.
As well as the physical and emotional aspects of childbirth, having children in surgical training may impose a significant financial burden on trainees, including the high costs of childcare to cover on-call commitments.10 This is particularly relevant given the high costs of surgical training.11 Regardless of gender, the ability to take time off work for major life events and contribute to childcare is important. Improving paternity leave uptake and entitlements can contribute to gender equality.12
The aim of this study was to establish current experiences of surgical trainees of pregnancy, maternity and paternity leave during surgical training.
Participants and setting
The Association of Surgeons in Training (ASiT) is a pan-surgical specialty professional body and registered charity working to promote excellence in surgical training for the benefit of junior doctors and patients alike. Originally founded in 1976, ASiT is independent of the National Health Service, surgical royal colleges and specialty associations. The British Orthopaedic Trainees’ Association (BOTA) is affiliated with the British Orthopaedic Association and was established in 1987 to represent the views of orthopaedic trainees.
The survey was distributed to surgical trainees in the UK and Ireland through the mailing lists of ASiT and BOTA. Postgraduate surgical trainees surveyed included the 10 recognised surgical specialties: cardiothoracic surgery, general surgery, otolaryngology, oral and maxillofacial surgery, neurosurgery, paediatric surgery, plastic surgery, trauma and orthopaedics, urology, and vascular surgery. The training pathway in the UK and Ireland has been detailed previously.11 In brief, a typical training pathway comprises foundation years 1 and 2 (or one intern year in Ireland), then core surgical training years 1 and 2, followed by higher surgical training years 3 to 7 or 8 (dependent on the specialty). There are also academic and military surgical training pathways which differ somewhat in their duration. In 2015 when the survey was distributed, there were 5323 surgical trainees in the UK and 438 surgical trainees in Ireland. Maternity and paternity leave entitlements for the UK and Ireland are detailed in online supplementary appendices 1 and 2.
The survey design and distribution used a similar approach previously validated and described for undertaking national surgical trainee surveys.11 13–16 The questionnaire was designed with reference to previously published guidelines on conducting questionnaire research.17 18 A link to the online survey (SurveyMonkey.com, Palo Alto, California, USA) was distributed to members of ASiT and BOTA and through surgical specialty associations and surgical royal colleges mailing lists, and publicised on social media platforms. Data collection took place from 12 January 2015 to 9 March 2015. Completion of the questionnaire was taken as implied consent to participate in this study. No incentive was offered for participation. Individual trainees were not identifiable from the survey. It was not possible for multiple survey completions to be performed on the same device.
The same survey also investigated trainee experiences of less than full-time training, and these results have been reported previously.15
Only fully completed questionnaires were included in the analysis. Microsoft Excel (Microsoft, 2010, Redmond, Washington, USA) was used to calculate descriptive statistics. Statistical analysis was performed using SigmaPlot V.11 (Systat Software, UK), and statistical significance was accepted at p<0.05. Significance testing was performed using χ2 test for non-parametric binary data. Survey sample size calculations were based on standard published formulae.19
There were a total of 876 complete responses, with a range of grades from first-year core surgical trainees to post-CCT (certification of completion of training) fellows represented, giving an overall response rate of 15.2% (table 1). The median age of respondents was 33 years old. Of the respondents, 63.4% (n=555) were female, 6.1% (n=53/876) were in an academic post, and 2.2% (n=19/876) were military trainees.
Pregnancy and surgical training
Out of the female respondents, 46.5% had been pregnant during surgical training (n=258/555). Of these, 47.3% (n=122/258) had been pregnant once, while 41.1% (n=106/258) had been pregnant twice, and 11.6% (n=30/258) had been pregnant three or more times. The majority (52.7%, n=136/258) had their first pregnancy between higher surgical training years 3 and 5. This was followed by higher surgical training years 6–8 (20%, n=52/258), core training years 1 and 2 (18%, n=46/258), and other grades (11%, n=28/258).
On-call shifts in pregnancy
A total of 24% (59/246) of those trainees who had stopped night-time working chose to stop at 25 weeks or earlier, with a majority of trainees stopping night on-call shifts by 30 weeks (51.9%, n=187/246) (table 2). For daytime on-call, 50.4% (n=129/243) stopped on-call shifts by 34 weeks, with a total of 82.1% stopping by 37 weeks. The reasons for stopping on-call shifts are given in table 3. Night on-calls were most commonly stopped early due to concerns related to tiredness (35.3%) or personal health concerns (27.9%), whereas daytime on-calls were most commonly stopped due to starting maternity leave (54.7%). During night on-call shifts, 58.9% (n=151/258) had rest facilities made available to use, and 27.1% (n=70/258) and 19.4% (n=50/258) did not feel supported by their hospital department (includes other consultants not counted as educational or clinical supervisors, managerial and non-clinical staff) and educational/clinical supervisors, respectively, during their pregnancy. There was no difference in the proportion who felt supported based on their specialty.
Sixty-five (25.2%) of the 258 female respondents were pregnant at the time of the survey, but not yet on maternity leave. Of the respondents, 17.1% (n=33/193) found the process of arranging maternity leave difficult or very difficult. Twenty-seven per cent (n=68/258) had a neutral response to the process of arranging maternity leave. Of the trainees, 56.5% (n=109/193) commenced their maternity leave at 36 weeks’ gestation or earlier, 16.6% (n=32/193) commenced maternity leave at 37 weeks, and 26.9% (n=52/193) commenced maternity leave at 38 weeks’ gestation or more. Twenty-five per cent (n=49/193) intended to take 26 weeks or less of maternity leave, while 35.8% (n=69/193) intended to take up to 32 weeks and 38.9% (n=75/193) intended to take a year.
Returning to work after maternity leave
Out of those who had taken maternity leave, 83.9% (n=162/193) had already returned to work after their maternity leave period. Only 26.4% (n=51/193) took or were intending to take ‘keeping in touch’ days during their maternity leave. While 28% (n=54/193) felt they had returned to their level of working prior to maternity leave within a month and 61% by 6 months (n=118/193), a significant minority took over 6 months to feel they had returned to their level of working prior to maternity leave (figure 1).
Out of the male respondents, 42.1% (n=135/321) had taken paternity leave during surgical training. Fifty-one per cent (n=70/135) found the process of arranging paternity leave easy or very easy, while 25% (n=33/135) found it difficult or very difficult. Only 14.1% (n=19/135) felt their hospital department supported them during their paternity leave. The most common source of information used by trainees regarding paternity leave was other trainees (figure 2).
This study describes the experiences of surgical trainees during pregnancy and the process of obtaining maternity or paternity leave. Over a quarter of female trainees felt unsupported during pregnancy, with a considerable proportion of male trainees finding it challenging to arrange paternity leave.
The majority of trainees in this study became pregnant for the first time during higher surgical training. This pattern is also seen among a similar study of anaesthetists in the UK.19 This is a critical time in surgical training, and therefore it is important to support pregnant trainees to find ways to overcome the challenges to surgical training that pregnancy can present during this time period.
Evidence is emerging that long hours and prolonged standing can be detrimental in pregnancy. This makes supporting surgical trainees particularly important, as an increased rate of fertility issues, intrauterine growth retardation and preterm labour has been reported.20–28 In the USA, Davids et al 20 examined pregnancy outcomes in procedural versus non-procedural trainees and reported higher rates of assisted reproduction among procedural trainees after controlling for maternal age and a trend towards longer duration to conceive. They also reported higher levels of career dissatisfaction.20 Data on surgical trainees in the USA have also shown an increased risk of placental abruption, low birth weight, preterm labour and intrauterine growth restriction among female residents.23 24 Increased rates of infertility have also been reported among US surgical residents.25 Behbehani and Tulandi26 showed an increased risk of obstetric complications among obstetric residents compared with matched healthy control women- there was a relationship between work intensity and complications, with those working greater than 6 on call shifts per month and longer operating at higher risk. These findings are not unique to the USA, and similar data are emerging internationally. Among Japanese physicians, there was a 4.1-fold increased risk of preterm birth in those who worked over 70 hours per week during the first trimester, as well as an increased risk of threatened abortion.21 Higher rates of pregnancy-related complications have also been reported in Ireland.22 There is also a recently published study showing a higher miscarriage rate in women who work excessive night shifts.28
In the present study, a significant proportion of trainees continued with on-call shifts late into the second and third trimester. The reasons for continuing with on-call shifts were not specifically examined in this paper, and it is not clear if this was due to personal or managerial reasons. However, it is concerning that a significant number of trainees did not feel supported during their pregnancy by their department or their clinical or educational supervisor especially with the growing evidence of the risks of on-call shifts becoming apparent. This may also represent a perceived lack of managerial support structure. There is a need for high-quality evidence to qualify the risk in the pregnant surgeon to allow informed decision making in work and policy planning.29
This study identified key areas for improvement. First, there is a lack of clear guidance currently on when to come off the on-call rota, and it may be useful to determine trainee and trainer perceptions of what this should be. UK guidance states that if a pregnant employee or their child would be at risk by continuing on-call shifts and they can continue to do the rest of their normal job, they should not be expected to continue with on-call duties.30 31 In Ireland, if a doctor has certified that night duty poses a risk to an employee, they must be reassigned or given leave.32–35 It is also imperative to ensure an active supportive discussion between the trainee and their trainer occurs about how to best facilitate and support their ongoing surgical education and training while ensuring the pregnant trainees health and wellbeing.
Returning to work can be a challenge to surgical trainees who have taken maternity leave, and presumably to any trainee returning from any form of extended leave. While the majority of trainees regained a feeling of being back to normal function relatively quickly, a significant minority did not. The reasons that trainees did and did not feel back to their normal working level were not explored in this study, but may include issues with confidence. It is well described that some female surgical trainees struggle disproportionately with confidence, and a period of maternity leave may exacerbate this.36 The uptake of ‘keeping in touch’ days was relatively low in the study respondents, which may relate to a lack of awareness of this option. A mentoring system for trainees returning to the workforce from extended leave, including maternity leave, may help ameliorate issues that may arise. Trainers should be supportive and approachable, taking into consideration that trainees may need some time and additional support to regain confidence after extended leave. For some trainees, a staggered approach to returning may be helpful, while other trainees may prefer to return directly to full clinical activity. The need for mentoring has been highlighted previously by ASiT and other professional groups in promoting women in surgery.14 37 Mentoring may play a key especially those returning from maternity leave—ideally with a formal mentoring programme, and perhaps a duo of mentors from both within the work environment and external to it to assist the surgeon in rebuilding confidence. Some trainees may wish to return to training ‘less than full-time’, while others prefer to resume full-time surgical training. ASiT has previously highlighted the need for information and availability of less than full-time training posts in surgery, particularly for those looking to return from maternity leave.15 38
One aspect that is important to highlight is the provision of adequate staffing to comfortably accommodate the pregnant trainee or trainees taking maternity or paternity leave. A Canadian study highlighted the need for adequate contingency plans to avoid overburdening other residents when pregnant trainees cannot perform clinical tasks.39 Failure to address staffing issues can promote pervasive discriminatory attitudes towards pregnant trainees, by peers and seniors of both genders.7
Although not specifically the focus of this study, it is worth noting the potential financial impact of taking maternity leave on surgical trainees. Prolonged maternity leave has considerable implications for pay. In addition, the cost of childcare for those in surgical jobs who work unpredictable and antisocial hours can be significant. Efforts to reduce the cost of surgical training are essential to ensure that financial pressures do not discourage trainees wishing to pursue a career in surgery.11
To achieve true gender equality, options for shared parental leave are needed. In this study, a quarter of men reported that they found it difficult or very difficult to take paternity leave. Also, the main source of information was from other trainees, rather than from an official source. The Swedish model of shared paid parental leave is helpful in achieving true gender equality, as it promotes a shared approach to childcare and reduces discrimination against women of childbearing age in the workplace as men are equally likely to go on extended leave during their employment.40 Efforts should be made to improve the duration of adequately paid paternity leave in training systems internationally.
This survey provides an insight into surgical trainees’ experiences in dealing with pregnancy and parental leave. The survey methodology was unable to determine the proportion of the total surgical trainees in the UK and Ireland who received the survey through distribution mailing lists. However, the response rate of 15.2% was deemed an adequate sample size based on standard published formulae,41 and the results obtained represented a wide response from all training levels and specialties. It should be acknowledged that all survey-based research is susceptible to responder bias, with those who have had an overly negative or positive experience potentially being more likely to complete the survey and those who are aware of leave arrangements being more likely to respond. In this survey, there may have been a bias towards trainees who had experienced the issues involved taking the survey. We also acknowledge that the results presented in this survey are limited to the UK and Ireland, and therefore caution should be exercised when applying these results to other training systems. Despite the limitations, this paper highlights important and relevant issues in surgical training internationally.
Despite increasing numbers of women entering surgical training, there is still a “leaky pipeline” with lower numbers at senior levels. Issues surrounding attitudes to and support of trainees regarding childbearing may contribute to this gender imbalance.
This study found that there is a lack of support for trainees in pregnancy, with over one in four not feeling supported by their department during pregnancy.
Trainees require extra support on return from leave, as a significant proportion took several months to feel back to normal.
The process of arranging paternity leave is difficult for a quarter of trainees.
Current research questions
What measures can effectively support trainees, build confidence and accelerate the reintegration process after return from parental leave?
How should pregnant trainees be supported?
What is the impact of issues surrounding pregnancy, maternity and paternity leave on recruitment and retention of surgeons?
In summary, pregnancy, maternity and paternity leave is a challenging area in surgical training but one which is essential to address in order to attract and retain the next generation of surgeons. Surgical rotas must be adequately staffed to minimise disruption when trainees go on maternity or paternity leave. There is huge variation in surgical trainees’ experiences of pregnancy, and a tailored approach with open dialogue between the trainer and the pregnant trainee should be encouraged to maximise training opportunities while minimising risk and discomfort during pregnancy. There is significant room for improvement in supporting trainees in pregnancy, maternity and paternity leave. In particular, trainees must receive adequate support on returning from a period of extended leave. Encouraging uptake of extended paternity leave may help address issues regarding gender balance in surgery.
We gratefully acknowledge the Royal College of Physicians and Surgeons of Glasgow (RCPSG), the Royal College of Surgeons of Edinburgh (RCSEd), the Royal College of Surgeons in Ireland (RCSI), and the Royal College of Surgeons of England (RCSEng) Women in Surgery group for distributing the survey to their trainee members. We additionally thank all those trainees who took the time to complete the survey. We also acknowledge the contribution of the British Medical Association (BMA), including Shahenda Suliman and Jeeves Wijesuriya, to online supplementary appendix 1, and the Irish Medical Organisation (IMO), including Paul Maier, to online supplementary appendix 2.
Contributors RH and JEFF conceived and designed the study. RH, OA, HM, CM, PS and JEFF designed the questionnaire. RH collected the data. RH and HM analysed the data. RH, OA, HM, CM, PS and JEFF were responsible for compiling the manuscript and approving the final article.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests The authors are either current or previous surgical trainees and elected members of the Council of the Association of Surgeons in Training (Registered Charity No 274841) or the British Orthopaedic Trainees' Association. JEFF is now an employee of KPMG Global Health Practice, Honorary Clinical Advisor to the Lifebox Foundation, and Trustee of the SURG Foundation research charity. The authors have no other relevant financial or personal conflicts of interest to declare in relation to this paper.
Patient consent for publication Not required.
Ethics approval Ethical approval was not required for this voluntary opt-in survey. The ethical dimensions of this non-mandatory, anonymous evaluation survey were considered and no concerns were identified.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No data are available.
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