By Rebecca H. Allen, MD, MPH, Editor
SYNOPSIS: In this cross-sectional national survey of 850 surgeons, compared to the partners of male surgeons, female surgeons were more likely to have fewer children (1.8 vs. 2.3) and to delay having children because of surgical training (65% vs. 44%). Female surgeons also were more likely to use assisted reproductive technology (25% vs. 17%).
SOURCE: Rangel EL, Castillo-Angeles M, Easter SR, et al. Incidence of infertility and pregnancy complications in US female surgeons. JAMA Surg 2021;156:905-915.
Female surgeons undergo long training periods and often delay childbearing.1 This study was conducted to determine whether working as a surgeon influenced rates of infertility and pregnancy complications. This was a cross-sectional electronic survey that was created after conducting focus groups of male and female faculty and resident surgeons in two academic teaching hospitals regarding infertility, barriers to childbearing, and pregnancy complications. After testing, the final survey collected data on demographic characteristics, practice information, work hours, family goals, use of assisted reproductive technology, and multiple gestations. Antepartum, intrapartum, postpartum, and neonatal complications also were queried. The survey was distributed via emails and newsletters to multiple surgical societies between November 2020 and February 2021, as well as through targeted social media platforms. The target participants were male and female surgeons and surgical trainees in the United States, with nonchildbearing surgeons being asked to answer questions about their partner’s pregnancies. Surgeons who had never attempted a pregnancy, male surgeons whose partners also were surgeons, and female surgeons in same-sex relationships in which the gestational carrier could not be confirmed were excluded.
After applying exclusion criteria, 850 respondents were included in the analysis, with 692 (81.4%) being female. The control group (n = 158) ended up including only the childbearing partners of male surgeons. Because of the manner in which the survey was distributed, a response rate could not be calculated. Compared with male surgeons’ partners, female surgeons had fewer children (1.8 vs. 2.3, P < 0.001), were more likely to delay having children because of surgical training (65% vs. 44%, P < 0.001), and were more likely to use assisted reproductive technology (25% vs. 17%, P < 0.04). Female surgeons also were more likely to be older at first birth (median age 33 years vs. 31 years, P < 0.001) and were more likely to work more than 60 hours per week during pregnancy (57% vs. 10%, P < 0.001). Among female surgeons, 290 (42%) experienced a pregnancy loss, with 85% having a loss at < 10 weeks’ gestation, 32% between 10 weeks’ and 20 weeks’ gestation, and 3.8% at 20 or more weeks’ gestation. Major pregnancy complications (preeclampsia, placental abruption, malplacentation, intrauterine growth restriction, preterm labor/preterm premature rupture of the membranes, and placental insufficiency/oligohydramnios) were more common for female surgeons after controlling for age, hours worked per week, race and ethnicity, in vitro fertilization usage, and multiple gestations (odds ratio, 1.72; 95% confidence interval, 1.11-2.66). Preterm delivery rates and neonatal complications were similar between the two groups.
COMMENTARY
This study sought to describe the experiences of female surgeons in the United States and how training affected their pregnancy outcomes. The study used the partners of male surgeons as the control group, given that the socioeconomic circumstances of both groups likely would be similar. The study did not include obstetrician-gynecologist surgeons but only general surgeons and subspecialties. According to the article, women now make up 38% of surgical residents and 21% of practicing surgeons in the United States. Yet, surgical training, lasting between five and seven years after medical school, is demanding in terms of work hours and physical exertion. Most residencies offer little support for pregnancy and lactation; therefore, many individuals choose to delay childbearing until the completion of training, which was confirmed in this study.1 Delaying childbearing can place the patient in an age bracket (35 years of age and older, advanced maternal age) where complications, such as infertility, pregnancy loss, and preeclampsia, are higher.
This survey report received a lot of attention in the lay press because of its dramatic findings.1 The results demonstrated struggles with infertility, which likely are age-related, and pregnancy loss rates higher than average, which the authors theorized were related to work hours and physical exertion. There are some data suggesting that adverse pregnancy outcomes may be related to working more than 40 hours per week, prolonged standing, and shift and night work.2 Looking at the data, the difference between the two groups in major pregnancy complications was driven by a difference in preeclampsia rates only. There was no difference in placental disorders or preterm labor or delivery, interestingly. The methodology of this analysis had several limitations, however. Since there was no way to determine a response rate, there could be sampling bias, since those surgeons who were more interested in the topic because of personal pregnancy complications chose to answer the survey compared to those who did not have that history. Furthermore, there could be recall bias and inaccuracies in the recollection of certain pregnancy complication details. Finally, the control group was much smaller and, again, there could be sampling bias in terms of which male surgeons responded to the survey. Certainly, the approach was not a random representative sample of surgeons in the United States.
Nevertheless, the authors made several recommendations for surgical training programs and surgical departments to better facilitate pregnancy earlier in a surgeon’s career if desired. These included having policies that support schedule flexibility for pregnant surgeons, at least six weeks (and ideally 12 weeks) of paid parental leave exclusive of vacation time, even if this required an extension of residency or fellowship training, and lactation support. An interesting idea was to have the service coverage during leave performed by moonlighting physicians or advance practice clinicians to avoid resentment from colleagues. There is documented stigma associated with childbearing during surgical training.1 An accompanying editorial called out the American Board of Surgery policies that only allow trainees two weeks of parental leave.3 Certainly, the field of medicine, and the country as a whole, can do better with parental leave policies, since the United States is one of the few countries without a federally supported paid parental leave program. We need to do a better job supporting physicians at all stages in their career, from medical school to residency to faculty, with family building.
REFERENCES
- Rangel EL, Smink DS, Castillo-Angeles M, et al. Pregnancy and motherhood during surgical training. JAMA Surg 2018;153:644-652.
- Goldberg E. Surgeons at greater risk of pregnancy loss, study finds. The New York Times. Published July 28, 2021. https://www.nytimes.com/2021/07/28/health/women-surgeons-pregnancy.html
- Mozurkewich EL, Luke B, Avni M, Wolf FM. Working conditions and adverse pregnancy outcome: A meta-analysis. Obstet Gynecol 2000;95:623-635.
- Diego EJ, Carty SE. When leaning in becomes unhealthy, can we fix it? JAMA Surg 2021;156:915-916.
