INTRODUCTION

Pregnancy and parenthood are life-changing events that often alter a physician’s career structure and trajectory. While some changes may be welcome, there is evidence that physicians encounter interpersonal and structural barriers related to pregnancy and parenthood that negatively impact their careers or personal lives.1 For example, frank maternal discrimination may influence specialty selection2,3 and a lack of lactation spaces at work may contribute to early discontinuing of breastfeeding.4 Importantly, the impacts of pregnancy and parenthood on work have been shown to be greater for women physicians compared to men physicians and may contribute to observed differences in career progression, leadership attainment, and research success.1,5,6,7 While there have been multiple calls to action for systems-level supports to address these challenges,8 the development and implementation of policies and programs to support physician parents has been variable.9

Our previous mixed methods study of gender equity in an academic department identified parenthood as a significant theme associated with gender inequity.10 In this secondary analysis of the qualitative data collected in that study, we further explore the challenges and nuances associated with pregnancy and parenthood experienced by women and men physicians in our department.

METHODS

Setting

These results report findings generated from a sub-analysis of the qualitative strand of a larger sequential, explanatory mixed methods study examining the experiences and perceptions of gender equity in an academic Department of Medicine (DOM) at the Cumming School of Medicine in Canada.10 There are 389 physicians in the DOM (n=171 women, 44%) in 10 sections. DOM physicians may be remunerated in fee-for-service, academic salaried, or non-academic salary positions. At the time of data collection, the DOM did not have a formal parental or pregnancy policy.

Study Design

We conducted individual semi-structured interviews with physicians of any gender between May and October 2018.10 The interviewer (G.F.) is a woman feminist with experience in interviewing and qualitative methods. She is external to the DOM and did not work with any of the study participants. Participants were recruited through purposive criterion sampling by e-mail invitation to all physician faculty members of the DOM with no exclusions. Participation was voluntary and not reimbursed. Interviews were conducted until no additional volunteers requested to participate, rather than based on data saturation.

A standardized interview guide was used (Appendix 1). Questions were based on a survey instrument designed to understand the culture of an academic department for women,11 open-ended questions about experiences or perceptions of gender equity in the DOM, and views on proposed interventions that could potentially reduce inequities. These interventions were based on literature review and consultation with other institutions and included onsite childcare,12 funding for parental leaves, formal mentorship programs,12 implicit bias training,13 application blinding,14 and a second-shift sharing application.

Interviews were conducted in-person or by telephone, audio-recorded, transcribed verbatim, and manually cleaned for accuracy and to remove identifying details before analysis (G.F.). Transcripts were not reviewed by participants. Interviews were originally analyzed using inductive thematic analysis methods15 by G.F. and S.M.R. (a feminist, physician mother in the DOM). The philosophical framework of the analysis was constructivism, acknowledging that knowledge is socially constructed based on individual experiences.16 Initial codes were developed independently by each analyst after a close reading of all transcripts and were iteratively refined and grouped based on similarity through discussion of both analysts to form a coding framework.10 The coding framework was then deductively reapplied to the data during a second round of coding of all transcripts performed independently in parallel with both coders (G.F. and S.M.R.). Disagreements in coding were reconciled between investigators.

In the original analysis,10 five codes were related to parenting (Parenthood, Onsite Childcare Intervention, Second-Shift Sharing Application Intervention, Parental Leave Funding Proposal, and Mentorship/Sponsorship Intervention) (Appendix 2). In this secondary framework analysis,16 all data coded as one of these parenting-related codes was ordered chronologically to identify themes relevant to each stage (planning a pregnancy, pregnancy, planning a parental leave, during parental leave, returning from parental leave, and parenting). Framework analysis uses visual strategies to organize and examine relationships between codes and themes, in this case chronologically throughout pregnancy and parenthood, often with the intention of developing policy recommendations.16 Participant experiences at each time point were then mapped to interventions to address challenges or amplify positive experiences (Appendix 3). Interventions were based on the pre-study literature review, suggestions by study participants and study team members, and a post-study literature review. Data were managed and analyzed using Excel (Microsoft Corp).

This study was approved by the University of Calgary’s institutional ethics review board. Informed consent was obtained from participants. Reporting of this study was informed by the Consolidated Criteria for Reporting Qualitative Research reporting guidelines17.

RESULTS

There were 28 participating physicians, representing 7.2% of the DOM (n=389) (Table 1). There were 22 women participants and 6 men participants (12.9% of 171 women and 2.8% of 218 men DOM members). Eighteen participants were parents (81.8%, n=15 mother, 68.2%).

Table 1 Characteristics of Interview Participants (n=28)
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Systems-level challenges were reported throughout pregnancy and parenthood, including workplace accommodations for pregnancy, planning for a parental leave, parental leave, returning to work after parental leave, and parenthood as a physician (Appendix 3). Overall, a lack of uniform guidance in navigating pregnancy and parenthood left individual physicians to expend time and effort to repeatedly solve similar problems also faced by other physician parents. This also meant that decision-making about pregnancy and parenthood was dependent on divisional leaders, resulting in variation in the experiences of DOM physicians. In addition, participants reported instances of parental discrimination that are counter to the stated values of the DOM. Participants and study team members suggested several new, systems-level interventions to address these challenges (Table 2).

Table 2 Identified Challenges for Pregnant Physicians and Physician Parents with Proposed Systems-Level Interventions Based on Study Participant Suggestions and Literature Review
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Workplace Accommodations for Pregnancy

Participants described variability in the advice, mentorship, and support that they received during their pregnancies due to a lack of uniform guidelines. Being on call, referring to caring for patients outside of standard work hours either by telephone or in-person, was a challenge for pregnant physicians. Due to the lack of guidelines, participants relied on individual judgements of their leaders and coworkers on when it was reasonable to stop overnight call. One respondent shared that she “was told [her division would] follow the resident guidelines [for when she would stop doing overnight call] and when I came back and told them what the resident guidelines were, my male leader said, ‘In my experience, working up to 32 weeks on-call is much more reasonable’” (participant 19). Another respondent “asked to come off the call schedule at 36 weeks... all of the men... said no, if you're not able to do call, then you're not able to [do procedures during the day] and [procedure] is my entire income, my entire career” (participant 22, woman).

Planning for Parental Leave

Participants navigated preparing for parental leave individually, without guidance or leadership support. One participant felt frustrated that “the process… was not clear, there could easily be a document or a checklist... I can’t be the first person that has done this” (participant 27, woman). Similarly, another participant found that “the first barrier that I ran into was that there wasn’t a lot of knowledge from a divisional level as to what was actually available [to support my maternity leave]... I had to reach out to multiple people and got conflicting information” (participant 11, woman).

Participants were expected to arrange clinical coverage independently, without consistent support or guidance from their divisions or colleagues. One participant reported, “Initially I was told we were going to get a locum and [then] there was no locum, so that was extremely stressful, right before I went on mat leave I had to split all my patients” (participant 07, woman). This experience was common; another participant shared “I couldn’t find anyone [to cover my patients], but I also didn't know how to [find a locum]... and half [of my division] was like ‘Whatever, she’s going on mat leave, it’s not my problem’” (participant 10, woman). A man participant reported a similar experience: “My son ended up coming a little bit late... I was reaching out to my colleagues... could I switch shifts, get people to cover a couple of weeks for me so that I could spend more time at home... people said ‘Don’t worry about it, when it comes we’ll take your time’... and when it actually came time for that, there was actually very little support from my division” (participant 12).

Women participants in academic career tracks (i.e., clinician scientists) were concerned about how the duration of their parental leaves would impact their careers. One participant was told that “women who tend to be more focused tend to take shorter mat leaves... I left feeling like I better take a short mat leave because I didn’t want to be perceived as someone who’s just not focused” (participant 03, woman). Another participant shared that “I would love to take a year off, but I don’t feel I can” because of the potential dip in academic productivity (participant 09, woman). These experiences were not universal; one participant’s division head encouraged her to take a longer maternity leave (participant 07, woman).

For women in non-academic, clinical career tracks, loss of income, inability to find coverage for patients, and concern about the potential loss of clinical skills were important factors in determining the length of their parental leave. One participant reported that her “fee-for-service colleagues are taking a shortened mat leave so as not to impose too much on their clinical colleagues... and they have to cover all of their overhead” (participant 17, woman). Similarly, another participant shared that a longer maternity leave “is too expensive... how are you able to support yourself for a year, especially if you’re the one who’s the primary earner in the family?” (participant 10, woman).

These experiences were in contrast to the perceptions of some participants; “I think they do a good job of finding coverage for people on maternity leave” (participant 04, man); “[maternity leave should be] addressed the same way as somebody who was going on sabbatical... who was ill, or had a tragedy in the family and had to take time off” (participant 12, man); and “there were three maternity leaves [in my division] last year, and we all pitched in, everything was ok” (participant 11, woman). This reflects that supports for participants planning a parental leave may have varied depending on the participant’s division; as explained by one participant, “the person you negotiate with is your division lead, and... it depends on how well you get along with them or how comfortable you feel negotiating. But the senior-junior power struggle thing can sometimes be intimidating, especially if that person is a male who is in his 60’s and you’re a female who just started your career... asking for these things” (participants 10, woman).

Participants were concerned that their men colleagues faced additional struggles in taking parental leave compared to women colleagues based on traditional gender roles. One participant felt that “for some of my male colleagues... [there’s] this expectation that they’re just going to work the way their older male colleagues have worked... they have to fight against this very dominant, patriarchal culture” (participant 08, woman). Another wondered if men in the department were offered the same things that women were: “How many times are the men asked if they want to step back for parental reasons? I feel bad for the men in my division who aren’t given that opportunity” (participant 17, woman). One participant shared that a man colleague who had tried to take a parental leave was not taken seriously by division leadership: “He had to actually pull up his contract and get the fine print out for our boss, to say I am entitled to this time and gave you plenty of warning... [because] nobody made any.... arrangements for him [to take parental leave]” (participant 08, woman).

Parental Leave

Multiple participants reported that they continued clinical or academic work during parental leave—all of which was uncompensated due to structural barriers. In our setting, physicians on parental leave cannot submit billings for clinical work without forfeiting their parental leave stipend or renewing their yearly medicolegal coverage, which is often paused on parental leaves due to cost. The minimum full-time equivalent allowed for administrative, education, and research roles is 20 hour per week, which was too great for any participant to meet during parental leave. Most participants reported that they performed this work out of obligation and that it was stressful. For example, one participant described “going to a research meeting, which was mandatory... for me to maintain my funding, early on in mat leave with my third child. [I brought] this baby to the meeting, she was quiet, I just nursed her in the back... but was told afterwards that if I was going to bring a baby and particularly if I was going to be breastfeeding, I was not welcome at those meetings. That had implications on my funding” (participant 01, woman). Similarly, another participant shared:

I’ve been on maternity leave... this has been a hard, hard year... I had a [prestigious national research] grant, I asked if I could defer it and they said you can’t... I ended up deciding to start my research program three months into my maternity leave, hiring somebody to help move things forward… my department really wanted the research done... I felt pressured to continue doing this... my baby, she hasn’t slept well... so every time she’s down, which isn’t for long, I'm constantly trying to keep things moving... all the while I’m not getting paid at all and in fact, I’m negative money every month because I’m still paying in the benefits plan. (participant 27, woman).

Returning to Work after Parental Leave

Women returning to work after a parental leave found that finding childcare and spaces to express breastmilk at work were challenges. One participant reported that “in my life, [childcare] has been the most stressful decision I’ve had to make” (participant 22, woman). Another shared “I don’t even know that there’s somewhere I can breastfeed these days... I’m going to be back at work [soon]” (participant 27, woman).

Participants described concerns about losing their clinical privileges or leadership roles due to parental leaves. For example, one participant shared “I wanted to come back at two-thirds [full time equivalents] with the goal to get up to fulltime at some sort of graduated rate, I was told ‘You can come back at two-thirds time but we’re giving away your [procedural] time, and if you want to get it back later then you’re at the bottom of the list’... so you may never get [your procedural time] back, so I had to come back [full time]” (participant 19, woman). Another reported “If you have a certain teaching role, will you get that teaching role back when you come back? There’s nothing to say that’s guaranteed… if somebody [does it] while you’re gone, and they like that person better” (participant 10, woman).

Parenthood

Participants reported several instances of discrimination or exclusion related to parenthood. One participant reported that she was not hired for the job that she applied for “and the reasons they gave me when they offered me a modified job was ‘We don’t want you to be burnt out, given that you are a single mom’ and I thought that was a very offensive statement” (participant 16, woman). One participant reported, “at a meeting to discuss hiring another specialist into our group, [a man said] ‘I don’t think we should hire any more women, they have two jobs: [specialist] and mom’” (participant 19, woman). The bias against parenthood and pregnancy was often subtle. One participant reported that her division head “on several occasions has made backhanded comments, to the entire group at division meetings, ‘We’ll be fine with scheduling as long as nobody goes on a mat leave’ and I’m the only person who has gone on a mat leave” (participant 22, woman). One participant relayed that “certain people have said to me ‘I know I’m not allowed to ask you about having more children’… and I’m like I will tell you [that I am not having more children] because if I were to choose to have more children, that might impact the department’s decision to hire me” (participant 23, woman).

DISCUSSION

This secondary analysis of qualitative data from interviews with 28 physicians found that systemic barriers associated with pregnancy and parenthood for physicians in an academic internal medicine department spanned the entire process of parenthood, from planning a pregnancy to returning to work after a parental leave. Due to a lack of uniform, systems-level guidance, individual physicians had very different experiences within the same department depending on their relationship with their division leader or colleagues, raising issues of fairness. Notably, these findings suggest that addressing these barriers is important to both men and women physicians. Overall, these findings support the importance of systems-level interventions to reduce barriers for pregnancy and parenthood.

In this study, multiple men and women participants experienced discouragement, lack of support, and outright discrimination related to pregnancy and parenthood. Some examples may violate Canadian employment or human rights legislation. Consistent with this result, discouragement, and discrimination related to pregnancy and parenting are commonly reported in the literature.1 Many respondents in a qualitative study of pregnant residents reported comments from preceptors about how inconvenient their pregnancies were for clinical or residency responsibilities.18 Another study reported that more than 50% of women orthopedic surgery residents had been explicitly discouraged from pregnancy by their attending physicians and co-residents.19 Similarly, a study of emergency physicians found that half felt supported by colleagues during pregnancy and 40% felt supported during their parental leave.20 In contrast, a survey of general surgery resident parents found that only 13% did not feel supported during pregnancy.21 Overall, our results add to these data reflecting a pervasive cultural issue in medicine that should be explicitly addressed by medical leadership.1

Our study identified a lack of uniform safety guidelines for working while pregnant. The lack of policies to guide workplace accommodations for working while pregnant observed in our results is common, though not universal. For example, one study found that 90% of residents and 85% of staff physicians do not receive workplace modifications during pregnancy22 while more than 70% of Canadian general surgery residents reported having modified duties.21 Lack of accommodation may lead to worse outcomes for pregnant physicians; one qualitative study found that pregnant residents felt that duty hours and call shifts had adversely impacted their own or their child’s health.18 However, literature on workplace safety for pregnant physicians is conflicting, which may contribute to this variability.23,24 High-quality evidence is urgently needed to guide decision-making. In the interim, institutions must implement guidance on workplace safety for pregnant physicians that is uniform and evidence-informed.

The lack of consistent and clear guidelines for parental leave among physicians reported in our study has previously been described,1,25 with between 40 and 90% of physician mothers having no formal parental leave policy in their contracts.20,26,27 Similar to our respondents, physicians in a qualitative study of academic hospitalists reported “haggling” with their leadership to arrange their parental leaves.27 In our study, the lack of comprehensive systems to support physicians meant that individual experiences depended on each division’s leadership and culture or the participant’s ability to self-advocate or negotiate. This is especially important as we have previously reported that senior men, who occupy the majority of leadership roles in our department, may not understand the unique challenges faced by junior women physicians.10 In this current study, we report additional evidence that men department members may not be aware of the burden that planning for a parental leave places on their women colleagues.

It was common among women participants in our study to perform uncompensated work on their parental leaves due to external pressures. This highlights a need for innovation in research funding and programs, clinical work, and parental leave compensation to address this inequity. Solutions should consider the needs of both academic and clinical physicians. For example, the experience of losing money to continue working during a parental leave was reported in our study and is previously reported,28 and concerns about the impact of parental leave on academic career tracks were common in our study and in other settings.7

Parents in our study reported competing tensions after return from leave between childcare and work. This result suggests that medicine may be unintentionally excluding parents from career opportunities. The theme of exclusion of women physicians from leadership due to parenthood has been reported previously in this study population10 and in other settings.1 Formal programs that support part-time, non-clinical work during parental leaves or graduated return-to-work after parental leave are viewed favorably by physicians.18

Notably, this study was conducted in Canada, where most people qualify for government-sponsored parental leave for up to 18 months and discrimination based on pregnancy is against the law.29 Though physicians do not receive government parental leave benefits, these legislative supports suggest a broader cultural acceptance of parental leave and pregnancy. Despite this, the lack of systems-level supports reported in the literature and in findings from this study demonstrate that Canadian medical culture remains less accepting and accommodating of pregnancy and parenthood. The barriers and experiences of physicians in other countries with differing support toward pregnancy and parenting may differ in important ways. The relationship between national culture and medical culture toward pregnancy and parenting is an area of future potential study.

These findings should inform the development of systems-level interventions, including comprehensive policies and programs, to support physician parenthood (Table 2). For example, our results emphasize findings from previous literature that requiring individual physicians to arrange their own clinical coverage for parental leave is stressful and leads to disparities based on a physician’s relationship with their colleagues. Leaders can reduce inequity by creating a defined procedure for clinical parental leave coverage. In addition, universal parental policies are needed to reduce the observed variability of individual leader judgement from decisions around pregnancy and parenthood for physicians. These policies should consider the different roles and remuneration of physicians within their scope.

There are several limitations of this study. This qualitative study was conducted at a single academic department and may not be transferrable to other settings with differing cultures or parental leave policies. The original objective of the primary study was to understand experiences and perceptions of gender equity in our department, and so we did not actively sample parents or specifically ask about parenthood and caregiving in the interview guide. Rather, it was a prominent theme that emerged in the original analysis of the data that warranted further attention; however, our results may not comprehensively describe parenthood for physicians in our department. Importantly, parental status was not a sampling criterion or an explicit focus in the interview guide and was inferred based on participant responses. In addition, all participants self-identified as a man or a woman, so these results cannot be generalized to the experiences of gender-diverse and transgender physicians. Women physicians were overrepresented as participants, and further research may be needed to understand the experiences of parenthood for men physicians. We also acknowledge that our decision to not collect data surrounding race and sexuality limited our ability to conduct intersectional analysis; parents who are racialized or in same-sex relationships may have different experiences that are impacted by these factors.

Overall, the results of this study provide additional insight into the challenges associated with different stages of pregnancy and parenthood for physicians in an academic center. Ongoing failure to address these barriers perpetuates systemic inequities for physician parents. This is an issue of justice; while our data demonstrate these barriers are important for men and women physicians, women physicians endure disproportionate inequity related to pregnancy and parenting. In particular, maternal discrimination and lack of lactation spaces at work violate human rights and workplace legislation enacted to support women. Furthermore, the lack of workplace adaptations for pregnancy and compensation for maternity leave uniquely affect women physicians. Lastly, exclusion of parents from workplace events is likely more of an issue for women physicians, who perform the majority of childcare responsibilities even in physician-physician relationships.6,30 Medical leaders and organizations have a moral and legal responsibility to take an evidence-informed, systems-based approach to address gender-based inequities.