Pregnancy and parental leave (executive summary)

Erin Brennan, Kyla Caners, Christopher Bennett Heyd, Aimee Kernick, Emma McIlveen-Brown, Alim Pardhan, Chau Pham, Éliane Raymond-Dufresne, Gillian Sheppard, Hannah Shoichet & Kelly Van Diepen

Introduction

A career in Emergency Medicine can be very rewarding but comes with a unique set of challenges related to shift work and the need to function in an unpredictable, high-stress environment. These environmental considerations can be particularly impactful around the time of pregnancy and infant care, and it is imperative that departments have policies in place to protect and support physicians who become pregnant or take parental leave.

The following policy statement is intended to provide a template for individual emergency departments in Canada to develop, adopt, update, or modify pregnancy and parental leave policies. The goal of these policies is to support physicians by optimizing physical and mental health throughout their pre-pregnancy, pregnancy, parental leave, and return-to-work journeys. An additional benefit is that policies with clear expectations can help departments and leadership navigate their human resource management, including recruitment and retention, recognizing that there will be differences based on geographic location and size of department.

A previous position statement from the Canadian Association of Emergency Physicians (CAEP) has identified a need to have parental leave and chestfeeding policies in place that are reviewed and updated by a gender-balanced committee at regular intervals.¹ This policy statement will help provide guidance and evidence for departments to achieve that goal.

List of Recommendations

Pregnancy

1. The pregnant physician should be provided with the option to stop night work as early in the pregnancy as possible, and no later than 28 weeks gestational age.

Several consensus statements,² ³ emergency departments,⁴ and residency associations⁵ specifically recommend no call or night shifts after a gestational age ranging from 24–28 weeks. Some of these also support stopping shifts that end after midnight over this time period.⁴ Numerous studies across the global landscape⁶ ⁷ ⁸ ⁹ and several systematic reviews and meta-analyses,¹⁰ ¹¹ ¹² reflect moderate evidence of increased risk of preterm birth in association with night shifts or irregular shift hours.

2. It is expected that a physician in the third trimester may require accommodations in shift type, timing, and structure to reduce the physical demands.

The literature reflects a modest increased risk of preterm birth in association with higher work hours.⁷ ⁸ ¹⁰ ¹¹ Many factors associated with working in an Emergency Department (long periods of standing, heavy lifting, a high physical workload) may be associated with increased risks of preterm birth,⁹ ¹⁰ small for gestational age infants,⁹ ¹³ ¹⁴ ¹⁵ and gestational hypertension⁹. To mitigate this risk and allow pregnant physicians to keep working safely, departments should consider a variety of options where possible, such as ensuring the pregnant physician has double coverage, the option to stop resuscitation or acute care shifts, and the ability to reduce the number of shifts worked.

To avoid last-minute shift coverage concerns, some physicians may choose to stop working several weeks prior to delivery.⁴ Should the physician choose to do so, the department should support this option as well as the option to pick up last-minute shifts in lieu of pre-scheduled shifts. In addition to the specific suggestions above, physicians may require further accommodations on the advice of their treating health care provider, regardless of stage of pregnancy.

3. Physicians should not be required to make up missed shifts before and/or after a pregnancy or parental leave in order to accommodate the leave.

Requiring increased shift loads to compensate for shifts not worked during pregnancy and parental leave counteracts the support provided by the leave. Further, several studies reflect a correlation between shift work or long work hours in the first trimester and increased risk of preterm birth.⁷ ⁸

4. Where possible, it is ideal to have another, non-pregnant physician see the very sick febrile patient, patients with undifferentiated rashes, chemical or radioactive exposures, and patients who are agitated or violent. If this is not possible, adequate PPE and security support should be provided.

There are inherent risks to personnel working in an Emergency Department. Minimizing risk of harm to the growing fetus from specific infectious scenarios, chemical and radioactive exposures, and trauma is a reasonable expectation. If double coverage is available for pregnant physicians, then this should be feasible. Emergency departments should engage in proper screening and isolation of patients in addition to provision of PPE.¹⁶

A pregnant physician may ask a colleague to assist with procedures that may become more challenging in the third trimester due to physical constraints (such as intubation and central line insertion).⁴ Violence in the ED is a recognized issue in Canada, with woman physicians being more likely to experience physical assault than their colleagues.¹⁷ ¹⁸ Measures should be taken to ensure security protection is available.¹⁷ ¹⁸

Parental Leave and Alternative Pathways to Parenthood

1. Both birthing parents (including surrogate parents) and non-birthing parents (including adoptive and foster parents) are entitled to and should be fully supported to take both pregnancy and/or parental leave in conjunction with provincial and federal laws.

There is limited research on this topic in the Canadian medical setting; a single publication in the Canadian Medical Association Journal in 2000 emphasized that parental leave planning should be part of all physician human resource planning for the future.¹⁹ A review of parental leave policies in Canadian residency education identified that all provincial residency organizations offer at least 35 weeks of total leave, with most offering some degree of supplemental income.⁵

In Canada, provincial and federal labour laws guarantee an employee's right to take time off work to care for a new baby or adopted child.²⁰ The same should be offered to physicians. There are many reasons individuals may choose to pursue adoption, surrogacy, foster parenting or other alternative pathways to parenthood and these individuals have a right to the same accommodations.

Return to Work

1. The returning Physician should be offered flexibility in shift structure, type, and duration on return-to-work.

   
   

Many physicians may return to work after a parental leave shorter than the Canadian average or allowable duration.¹⁹˒²¹ At this stage many infants may not be sleeping through the night and childcare may be precarious. Accommodations for the returning Emergency Physician after parental leave proposed by Wilson et al.⁴ suggest no resuscitation or night shifts for a set period of time, a shift reduction or gradual return to work over several months or a set schedule to accommodate childcare transitions. Additional accommodations may include part time return to work, no solo coverage shifts, job sharing, buddy shifts (whereby the returning MD works in parallel to a colleague), shorter/split shifts, or no supervision of learners.⁴˒²²˒²³˒²⁴˒²⁵

2. The returning physician should have the opportunity to engage in continuing professional development and education prior to and/or during return-to-work.

Clinicians taking leaves, particularly longer leaves, may express concerns over loss of skill and lack of confidence on return to work.²²˒²⁶ Multiple sources support the use of continuing education in conjunction with return to work.⁴˒²¹˒²² These sessions may include simulation sessions, mentorship or procedural sessions.⁴˒²¹˒²²˒²⁷

3. The pregnant and/or returning parent should be considered equally for promotion, tenure and career advancement.

Several studies cite the process of pregnancy/parental leave and return-to-work as having a negative impact on career opportunities and advancement.²²˒²⁴˒²⁸ Suggested inclusive support for professional involvement and advancement are family-supportive meeting schedules, virtual attendance options for meetings, mentorship, and stop-the-clock policies for promotion.²²˒²³˒²⁸˒²⁹

4. The returning physician should be provided with chestfeeding accommodations.

Barriers to chestfeeding in the work environment contribute to parents not reaching their chestfeeding goals.³⁰˒³¹˒³²˒³³˒³⁴ Departments should have clear chestfeeding policies.¹ The lactating parent should be provided with adequate breaks/time and space in close proximity to the ER to chestfeed or pump milk, including access to a private, locked room with a sink, sterilization capabilities (i.e. microwave), a fridge to store human milk, as well as a computer and phone access to continue administrative duties.⁴˒²¹˒²³˒²⁵˒³¹˒³²˒³⁵ Furthermore, the lactating parent should be excluded from evaluation using departmental productivity metrics given the additional time required to feed/pump.⁴˒²⁹

Fertility and Pregnancy Loss

1. Where possible, departments should offer accommodations if and when physicians with a history of pregnancy loss or infertility are attempting to conceive.

Many women in medicine have delayed childbearing because of perceived threats to their careers.³⁶ These women often face resultant challenges with fertility and pregnancy loss, requiring fertility treatments and/or alternative pathways to parenthood at a higher rate than the average population. The infertility rate among female physicians is reported between 24–32%.³⁷ It has been demonstrated that in women undergoing fertility treatments for female infertility there is an inverse association between likelihood to conceive and perceived excessive workload, as well as an inverse association between likelihood to deliver and objective measures of workload (e.g. part vs full time).³⁸ There is a paucity of literature on how best to support physicians undergoing fertility treatment, however it is appropriate to provide accommodations to enable attendance at necessary medical appointments and abide by any recommendations from the treating reproductive specialist. These accommodations may vary based on geographic location and availability of treatment facilities.

2. A physician experiencing pregnancy loss should be offered time off work as needed or requested to grieve and recover.

There is very little research on pregnancy loss and the workplace. Experiencing a loss at any point in a pregnancy can be emotionally and physically stressful and may require varying degrees of medical intervention and recovery. Having a supportive work environment with flexibility for short-term leave to accommodate necessary medical procedures and grief were identified as important.³⁹

Summary Table of Recommendations

Next Steps

There have been advances in research and policies related to pregnancy and maternity leave in emergency medicine, but there remains work to be done in the areas of parental leave and in the experiences of physicians who are undergoing fertility treatment or experiencing pregnancy loss. Despite this lack of fulsome evidence, departments are encouraged to adopt flexible policies that address the recommendations in this statement while respecting everyone’s unique needs. These policies should be reviewed regularly by gender balanced committees and incorporate new evidence as it arises.

Conclusion

There is increasing recognition and commitment to the importance of enabling physicians to fulfill important roles in both their professional and family lives. Meaningful work-life integration can help mitigate burnout and it is imperative that departments are able to recognize the unique challenges of physicians who are often balancing early career with starting a family. Recognizing that any leave from practice has the potential to impact human resources, departments should be proactive about operationalizing policies and procedures that enable staff to take the necessary leave and support re-integration, while being mindful of the fact that the requirements for each physician and leave will be unique.