Combining pregnancy with surgical training

Authors: Julie Cornish, Anne Gaunt, Diane Adamson, Sarah Mills, Pirko Schuppan, Deborah Markham 

Publication date:  02 Nov 2012

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Julie Cornish, Anne Gaunt, and colleagues report on the varied clinical experiences of surgical trainees during pregnancy

Over the past decade more than 50% of UK medical graduates have been women,[1] and 54.1% of current trainees (foundation year 1 to specialist registrar) are women.[2] Women made up 8.4% of consultant surgeons in 2008, but 27% of the core surgical trainees appointed in 2007 were women.[3] If all these female core surgical trainees progress with their surgical training, just over a quarter of all surgical registrars could opt to take maternity leave at some point during training, and many of them will potentially work part time afterwards.

Combining starting a family with a career means that pregnancy creates special challenges for doctors in training (box 1).[4] Our own experiences as pregnant surgical trainees were that it was difficult to find and get access to reliable advice about working during pregnancy, and our individual experiences of working during pregnancy differed widely. We conducted a survey of surgical trainees to establish their concerns about training during pregnancy.

Survey of pregnant surgical trainees

In October 2010 members of Women in Surgery (a branch of the Royal College of Surgeons of England) were invited to complete an online questionnaire about their experiences of training during pregnancy. The questionnaire was sent to over 2000 members, and only those who had been pregnant during surgical training were eligible to complete the questionnaire. A total of 187 responses were valid for analysis. Over half the respondents were still trainees (58% of the total), mostly specialty registrars (47%), and the remainder have now become consultants (42%).

First pregnancy was at 31 years (mean), with respondents having a median of two pregnancies (range 1-8). Of the women who were now consultants, 97% were pregnant as trainees, with 28% of this group also going on to experience pregnancy as consultants. The median time for starting maternity leave was at 36 weeks’ gestation, with a third of women working beyond this.

The respondents who were currently trainees were more likely than their consultant colleagues to have become pregnant during their core surgical training posts. There may be several explanations for this. For example, an increase in the number of graduate entry medical students could mean that women were older in core training than previously and more likely to start a family earlier in their career, or the reduction in working hours could have meant that trainees felt more able to work during pregnancy and as mothers. Finally, it is possible that pregnancy has become more acceptable during surgical training.

Physical demands

Only a small proportion of trainees (12%) found that no aspect of clinical work was more demanding during pregnancy than when they were not pregnant, but despite this nearly all trainees (94%) took little or no time off sick during their pregnancy. Many women believed that on-call night shifts were demanding during pregnancy, and daytime on-call shifts were generally perceived as less demanding. Nearly a fifth of all respondents (19%) reported having difficulties with their trainer while pregnant, and 18% had difficulty with other trainees.

Most respondents (over 90%) were physically able to operate as normal during pregnancy. Nearly one in six trainees was not allowed to operate as normal during pregnancy because of restrictions imposed on them by their trainer, local protocols, or managers.

Only one in three trainees found information from their trainers and occupational health to be useful. Most respondents did not seek information from all available sources (table). Respondents said that information about on-call commitments (70% of current trainees and 39% of consultants) and theatre safety (53% of current trainees and 37% of consultants) would be most useful.

Source	Useful	Not useful	Didn’t ask
Occupational health	22	34	44
Trainer	30	35	35
Female surgeon	46	14	40
BMA	36	13	51
Association of Surgeons in Training	0	4	96
Royal College of Surgeons of England	2	12	86
Other hospital staff	49	18	33

Respondents’ concerns

Qualitative data identified some of the concerns that current trainees and new consultants had about working when pregnant. Some were anxious about working during pregnancy (figs 1 and 2 ). This was related to a perceived change in role, concerns about what other people thought, not wanting to let other people down, and concerns about future career planning. Other respondents were more confident about working during pregnancy and suggested that trainees should put themselves first and not be afraid to ask for help.

External factors affecting respondents’ experiences of working during pregnancy included dealing with colleagues’ perceptions of pregnancy in training and trainees’ experiences with their trainers. Also, trainees wanted consistent advice to be available, particularly about on-call issues, accepting that “all experiences of pregnancy are different.”

Our results show that generally pregnancy is well tolerated among surgical trainees and most were able to continue with training with no or some modification to their current role. However, trainees lacked clear guidance on their rights and responsibilities during pregnancy. Better sources of information are needed to allow people to make the appropriate choices for themselves and their families during pregnancy.

Working successfully during pregnancy

Telling your employer

NHS Employers details the requirements for informing your NHS employer about taking maternity leave.[5] You must inform your employer that you are pregnant by the 15th week before your expected week of childbirth—that is, 25/40 pregnant. You are expected to tell your employer your estimated week of childbirth and the date that you wish to begin maternity leave. You can start maternity leave from any point after you are 29 weeks pregnant. Many employers want to see a copy of your maternity certificate (MATB1 form), which you get from your midwife after 20 weeks of pregnancy.

Safety

The evidence about working during pregnancy in acute hospital specialties is limited (box 2). A cohort study from the Netherlands reported that there were no significant associations between physically demanding work or working hours in relation to babies born small for gestational age or with low birthweight, or preterm delivery, although women in physically demanding jobs who worked more than 40 hours a week had slower rates of fetal growth, which resulted in slightly smaller babies.[6] One review of shift working during residency training in America concluded that there was an increased risk of preterm labour, premature delivery, pre-eclampsia, stillbirth, low birth weight, and placental abruption among pregnant residents.[7] It should be noted, however, that a number of the studies used in this review pre-date current junior doctor working patterns and are unlikely to be relevant to the UK.

According to the Royal College of Physicians’ national guideline, physical and shift work in pregnancy are associated with a small level of risk for some adverse pregnancy outcomes in relation to lifting and heavy work, prolonged standing, and long working hours.[8] The college adds, however, that studies to date have been inconclusive and that further evidence is needed. It recommends that, where possible, pregnant women should reduce very heavy physical activities and lifting; avoid standing for longer than three hours; and limit working hours to about 40 a week.

When it comes to working with imaging, current advice states that if you wear a lead gown, the effective radiation dose to the fetus is very low. It is your right to decide how much radiology you do, but in certain specialties, such as orthopaedics, your training may require that you complete a certain number of cases.

On-call shifts

No guidance is currently available to trainees on whether or when to stop being on call before taking maternity leave. This may be because every trainee’s pregnancy and pattern of working are unique to them. The BMA guidance for on-call shifts states that, if the employee or her child would be at risk by continuing and she can do the rest of her normal job, she would not be expected to continue with on-call shifts.[9]

Your NHS employer is obliged to arrange for you to have a risk assessment of your working conditions during pregnancy. This documentation is usually available through human resources departments.

Conclusions

Without giving support and guidance it is possible that the NHS may lose current or future consultants as a result of bad experiences during pregnancy, despite its having invested time and resources in their training. Prospective data need to be gathered on the number of women becoming pregnant during medical training and the effects on their future careers. With there being increasing numbers of women medical graduates, these issues will grow in significance in the future. We also suggest that a peer mentoring programme may be helpful, so that trainees can access informal sources of information and advice. Our advice for pregnant trainees, along with that offered by our survey respondents, would be to do what is best for you and your baby.

Competing interests: None declared.

Julie Cornish specialist registrar, general surgery  University Hospital of Wales, Cardiff, UK
Anne Gaunt specialist registrar, general surgery  Warwick Medical School, Coventry, UK
Diane Adamson specialist registrar, general surgery  Wrexham Maelor Hospital, Wrexham, UK
Sarah Mills specialist registrar, general surgery  St Mary’s Hospital, London, UK
Pirko Schuppan registrar, plastic surgery  Staedtisches Klinikum Braunschweig, Braunschweig, Germany
Deborah Markham associate clinical professor in medical educationhonorary consultant surgeon  Warwick Medical School, Coventry, UK

Correspondence to: Anne Gaunt  annegaunt@doctors.org.uk