Successful return to work in anesthesia after maternity leave: a qualitative study
Jessica Yeh, MD, Katherine Keech, MD, Samantha Vizzini, MD, Renee Nierman Kreeger, MD
During the holiday season, I will be reposting some of our most highly read and commented upon PAADs. This first appeared on June 10, 2024 Myron Yaster MD
Original article
Allen KJ, Chiavaroli N, Reid KJ. Successful return to work in anaesthesia after maternity leave: a qualitative study. Anaesthesia. 2024 Jan 4. doi: 10.1111/anae.16231. Epub ahead of print. PMID: 38177064.
Maternity leave is the most common reason for extended leave longer than 3 months, with leave duration varying significantly from country to country and among institutions.1,2 In the US, most women return to work between 5 and 12 weeks after giving birth while longer leave periods are more common in countries such as the UK, Australia, and New Zealand.3,4
Some earlier studies emphasize the resultant disadvantages women face after pregnancy and maternity leave such as decreased earnings, workplace discrimination, and barriers to career progression, yet few studies qualitatively examine the experience of physicians returning from leave. A lack of support for female physicians returning after maternity leave has been linked to adverse outcomes for both patients and physicians. 5, 6,7, 8
The authors of this study sought to qualitatively interview anaesthetists/anesthesiologists who had at least 3 months of maternity leave and had successfully re-entered the workforce at least 6 months ago at a minimum of 0.1 FTE to do public hospital work in Australia or Aotearoa, New Zealand. Interviews were conducted by an anaesthetist outside of the workplace either in person or virtually. The authors employed an interviewer who had undergone formal interview training and experienced re-entry to the workplace after maternity leave to maximize genuine responses. To minimize the risk of bias they utilized two other non-medical researchers to perform the literature review and develop research questions. All three worked together to review the data to balance the perspective of experience and observation.
Ninety-five women who had previously attended a workplace re-entry course and two participants included via snowball recruitment were invited to participate, with fifteen women completing the study. The final participants ranged in age from 36-42 and all had at least one re-entry after maternity leave in Australia or Aotearoa, New Zealand in the past four years. Thirty-seven re-entries were discussed, 24 of which were during training and 13 of which were as established “consultants.” Most participants had formal childcare including daycare or nannies, some had family or partners caring for children primarily or to supplement formal childcare.
The study identified 5 dominant themes from their interviews. The first theme was leave duration. There was a strong link between participants’ leave duration and their expectations regarding re-entry back into the workplace. Concern for deskilling drove some to return to work earlier, but those who did encountered additional challenges such as maintaining breastfeeding and experiencing significant fatigue. Other factors leading to a shortened leave duration were related to training requirements, job availability, and work satisfaction (even though lower job satisfaction was reported initially by those who did return to work early).
Theme 2 was planning for re-entry. This theme was identified as being ubiquitously beneficial, however, formalized processes were rare and most participants planned for their return independent of their workplace, via a course or other means. The most valuable aspects of planning for re-entry included a graded return to work schedule, departmental support, and breastfeeding support. Participants who experienced a graded return had the flexibility to gradually increase their work hours and the acuity of their cases, as well as to delay the resumption of taking after-hours call shifts. They felt that this reduced the duration of their leave, helped relieve the fear and anxiety around deskilling, and ultimately assisted in diminishing the challenges surrounding re-entry. This emphasizes that planning for re-entry needs to be individualized, collaborative, and endorsed by the institution.
Theme 3 was workplace culture. It is not surprising that all participants stated that workplace culture had a significant influence on their workplace re-entry experience. In a place with a positive culture, navigation of difficult things is much less onerous, while the opposite is true in a place with a negative or toxic culture. In the study, the better re-entry experiences were ones where there were role models present within their groups who had recently navigated this well (or as well as could be expected) and shared their knowledge freely.
Theme 4 was career impact. The participants described negative attitudes toward pregnancy and subsequent maternity leave. Some examples include: a lack of offers for work when interviewing while pregnant, being discouraged from even applying for work or sitting for exams while pregnant and women of childbearing age being hired only on locum contracts until “explicit disclosure that childbearing was complete.”
Theme 5 was the emotional impact of returning to work. Participants endorsed feeling anxiety upon returning, with many finding it extremely challenging, especially those who were making the transition from trainee to supervisory roles upon return.
The authors found planning a graded re-entry, rostering considerations, and breastfeeding arrangements to be among the most supportive interventions, with negative attitudes toward re-entry to be among the most challenging. This article excluded anyone who took < 3 months of maternity leave, so we don’t have data on those shorter leaves. However, we can extrapolate that the difficulties identified by participants would only be magnified by a shorter leave duration since, anecdotally, most women feel that returning to work even 12 weeks after the birth of a new baby is difficult at best. The burden of sleeplessness, being away from their baby, being tasked with potentially teaching anywhere from very junior to senior trainees, and lactation challenges can be quite overwhelming and can contribute to medical error, job dissatisfaction and, potentially, leaving medicine altogether.
Although this article highlights some very important themes and issues with returning to work after maternity leave, it is hard to extrapolate the authors’ findings into the system that is in place in the United States. The themes that the authors have highlighted are certainly transferable, however, and one could reasonably argue that their negative findings are most likely amplified in the US due to less generous leaves. The current perception is that most faculty physicians will take the “allowed” 12 weeks of maternity leave, however, that duration certainly seems to be decreased for trainees, with many being given 8 weeks of leave or less.
We have a long way to go, particularly in the US, to improve the experience of returning to work following maternity leave. It seems that despite improvement efforts, many things remain the same.
PAAD Reviewers Personal Stories
I (JY) completed medical school and a couple of years of surgical training in Australia before moving to the USA for anesthesia residency. The difference in work-life balance between the two countries is stark - with Australia offering greater leave entitlements and flexibility in part-time work, even as a trainee. I can’t help but read this article and ruminate on how far behind we are in this aspect. But I am glad that we are shedding light on such an important topic so that we can continue to make strides toward maintaining a sustainable and satisfactory working environment.
I (KK) will comment that in this current work-force environment, it is probably extra difficult for many groups to have women out on maternity leave (or men or women out on other medical leaves, although that is not the scope of this article). However, it is more important than ever to support our colleagues and try and ease transitions such as these. It may make a world of difference for someone and ultimately keep a colleague in your practice long term.
Many of us have had the experience of returning to work after maternity/paternity leave. Personally (SV) this was one of the hardest times of my life and there was no “re-entry” experience as the authors detailed here. I was on call with a very difficult case on my first day back which was in the OR until 7pm with add-ons going until close to midnight. My child was home with family because we didn’t have a spot in daycare for another week, so I was stressed with work, worrying about my child whom I had never been away from for more than a few hours, and riddled with guilt. I wasn’t even worried about what my colleagues thought, but now, four months later, I worry that they think I am “that mom” who calls out all the time or asks for favors to make our two-physician household work. For me, my family will always come first, but at what cost?
I (RK) also had a challenging return to work and vividly remember it all these years later. My colleagues were supportive, but it was incredibly difficult. My vision for the future is one where women are given opportunity, support, and, dare I say, encouragement as they build their families and take care of our most fragile patients. We can set an example and advocate for ourselves and those who will follow us on this path, creating a better environment where we can thrive at work and at home. Until then, we will continue to carry the torch…
References:
1) Campell P, Duncan-Millar J, Torrens C, Pollock A, Maxwell M. Health and social care professionals return to practice: Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling. 2019. https://www.hcpc-uk.org/globalassets/resources/reports/research/health-and-social-care-professionals-return-to-practice---full-report.pdf.
2) General Medical Council. Skills fade literature review: full report. 2014. https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/research-and-insight-archive/skills-fade-literature-review.
3) Ray R, Gornick JC, Schmitt J. Who cares? Assessing generosity and gender equality in parental leave policy designs in 21 countries. Journal of European Social Policy 2010; 20: 196–216.
4) Juengst SB, Royston A, Huang I, Wright B. Family leave and return-to-work experiences of physician mothers. Journal of the American Medical Association Network Open 2019; 2: e1913054.
5) Freed GL, Dunham KM, Switalski KE. Clinical inactivity among pediatricians: prevalence and perspectives. Pediatrics 2009; 123: 605–610.
6) Halley MC, Rustagi AS, Torres JS, et al. Physician mothers' experience of workplace discrimination: a qualitative analysis. British Medical Journal 2018; 363: k4926.
7) Asgari MM, Carr PL, Bates CK. Closing the gender wage gap and achieving professional equity in medicine. Journal of the American Medical Association 2019; 321: 1665–1666.
8) Critchley J, Schwarz M, Baruah R. The female medical workforce. Anaesthesia 2021; 76(Suppl 4): 14–23.