Working conditions during pregnancy: European perspective
Myron Yaster MD and Natalie Barnett MD
For the first decade or 2 of my career in Baltimore, women made up only a small percentage of faculty and trainees. Interestingly, upon graduation from residency and fellowships at Hopkins, women, even our very best, were often denied employment in the many private practices in the Baltimore metro area precisely because they were women and by the fears of the private practice groups that women would not be reliable because of pregnancy and motherhood responsibilities. I assume this is no longer the case, but despite the significant transformation of the medical and anesthesia workforce, gender disparities in leadership, research, clinical work, and overall career progression persist. In today’s PAAD, Zdravkovic et al.1 surveyed European anesthesiologists to determine “How do gender, personal experiences of pregnancy and parenting, and awareness of national or institutional policies impact attitudes towards pregnant colleagues, childrearing decisions, and career progression in anesthesiology and intensive care medicine?” Although focused on Europe, the results have important implications for all of us regardless of where we practice. Myron Yaster MD
Original article
Zdravkovic M, Kabon B, Dow O, Klincová M, Bilotta F, Berger-Estilita J; Collaborators. Working conditions during pregnancy: a survey of 3590 European anaesthesiologists and intensivists. Br J Anaesth. 2024 Nov;133(5):1062-1072. doi: 10.1016/j.bja.2024.08.002. Epub 2024 Sep 10. PMID: 39256092.
This survey-based study sought to describe the working conditions and experiences associated with pregnancy for both women and men working as anaesthesiologists and intensivists in European countries. Respondents’ perception of safety and working conditions during pregnancy was the primary study outcome while secondary outcomes included impact of pregnancy on clinical practice, work and training demands on family planning, and awareness of national and institutional policies and regulations.
“The survey was available for completion for 12 weeks, from October 8 to December 29, 2023. It was an open survey conducted with a convenience sample. The primary survey distribution method involved email contacts of active European anaesthesiologists/intensivists distributed through the European Society of Anaesthesiology and Intensive Care (ESAIC) mailing list. In addition, we used social media platforms, such as LinkedIn, Facebook, and X (Twitter), and email invitations, with support from several European national societies who forwarded the link through their mailing lists.”1
“Of the 4406 respondents who started the survey, 816 (18.5%) were not included in the main analysis. The survey completion rate was 91.5%. The 3590 respondents included in the primary analysis were from 47 self-identified European countries. Thirty-one countries (70%) reached the calculated minimum target of respondents.”1 The authors are unable to precisely identify the number of potential survey recipients due to the complexity of the available information on memberships of national societies and the ESAIC. However, the authors’ best estimate is that approximately 12,000 recipients were eligible to participate which would yield at least a 29.9% response rate estimation. For many reasons, survey response rates are often very low; however, a total of 3590 respondents as reported in this study is about as good as it gets.
Ok, what did they find? “Only a minority of women (four out of 10) were satisfied with their experience of work while pregnant or felt safe at work while pregnant, and an increasing proportion took sick leave to avoid problematic work conditions (e.g., radiation, infection, vapor anesthetic exposure) over time. Awareness of national regulations was limited.”1
Based upon survey responses, there was an increased proportion over time of those who changed their clinical practice while pregnant. The most common reported changes to clinical practice while pregnant included a preference for TIVA, avoidance of inhaled anesthetic exposure, avoidance of X-ray exposure, and reduced or quit night shifts. However, only 41.7% of respondents reported that pregnant colleagues could choose their preferred clinical area at work and approximately 10% of pregnant women were not allowed to change practice to avoid x-ray exposure. Respondents who reported at least one pregnancy experience, including men with a pregnant partner, were more likely to change their practice in the OR/ICU when working with pregnant colleagues. And, women were more likely than men to change their practice. Perhaps uncovering a greater awareness and understanding of challenges faced during pregnancy with a prior experience to reflect upon.
When asked about family planning and the effects of training demands, “Some men and women felt discouraged from having children during training and considered abandoning training during their or their partner’s pregnancy (women significantly more than men).”1 Further, the authors “observed significant differences among men and women regarding family planning. Men become parents more frequently during residency than women. Unfortunately, pregnancy during medical training is often seen as a burden and has been linked to discrimination and stigma for anaesthesiologists.”1 Women respondents were more likely than men to have felt discouraged from having children during training (43.1% vs 17.5% respectively). Moreover, “In a US survey,2 half of the female anaesthesiology trainees who responded felt deterred from having children because of their careers, with many citing inadequate maternity leave and missed obstetric appointments as a result of work.”1 This discouragement stretches into all phases of training and career development. The authors conclude, “Finally, the top three non-safety concerns reported in our study included delay in professional development, significant interruption and extension of the training period, and general career setbacks for pregnant colleagues.”1
One-third of respondents reported obstetric complications, which is a higher rate than previously reported.2-5 Several studies point to an increased risk of maternal and foetal morbidity in physicians vs non-physicians, ranging from 19% to 57%.5,6
There appears to be an educational gap when considering occupational risks to pregnancy. “Almost half of the respondents were unaware of any national regulations regarding work during pregnancy.”1 Not unsurprising, 82.5% of respondents rate a revision of regulations and working conditions during pregnancy as very important or important. The authors call for “attention to the need for stricter guidelines and policies to protect pregnant healthcare workers in high-risk environments.”1 Sadly, even if formal policies exist, there is often inconsistent implementation. “It is fundamental to recognize that pregnant physicians may face significant barriers to advocating for their own protections in the workplace, such as the negative perception of requesting work schedule modifications or avoiding radiation exposure.”1 The authors highlight the role of leadership in creating a more safe and supportive workplace. “This underscores the need for departmental leadership to proactively create and enforce policies that support pregnant physicians, ensuring their safety and well-being while minimising the impact on their professional responsibilities.”1
Are you surprised by these findings? We aren’t and because of the nature of our practice, pediatric anesthesiologists may face the highest risks of work exposure to harmful conditions and the fewest workplace accommodations. During my first pregnancy (NB), I was in my final year of residency training and a pediatric attending scolded me for using nitrous oxide during a mask induction. She said that as pediatric anesthesiologists, we are exposed to so many potential pregnancy risks and educated me on those that can be avoided. Do you change your practice and/or change your clinical instruction when someone is pregnant in the OR?
Although pregnancy is not a disease, particularly in surgery and anesthesia, we often treat it as if it were despite the known physical changes and limitations that exist in the pregnant state. We think an updated survey of pediatric anesthesiologists is long overdue. Hopefully a future survey will also include questions about adoption, reproductive assistance, surrogacy, the experiences of single-parents, and those in non-heterosexual relationships as well.
What do you think? Send your responses to Myron who will post in a Friday reader response.
References
1. Zdravkovic M, Kabon B, Dow O, Klincová M, Bilotta F, Berger-Estilita J. Working conditions during pregnancy: a survey of 3590 European anaesthesiologists and intensivists. British journal of anaesthesia 2024;133(5):1062-1072. (In eng). DOI: 10.1016/j.bja.2024.08.002.
2. Kraus MB, Thomson HM, Dexter F, et al. Pregnancy and Motherhood for Trainees in Anesthesiology: A Survey of the American Society of Anesthesiologists. J Educ Perioper Med 2021;23(1):E656. (In eng). DOI: 10.46374/volxxiii_issue1_kraus.
3. Sharpe EE, Ku C, Malinzak EB, et al. A cross-sectional survey study of United States residency program directors' perceptions of parental leave and pregnancy among anesthesiology trainees. Canadian journal of anaesthesia = Journal canadien d'anesthesie 2021;68(10):1485-1496. (In eng). DOI: 10.1007/s12630-021-02044-9.
4. Kraus MB, Dexter F, Patel PV, et al. Motherhood and Anesthesiology: A Survey of the American Society of Anesthesiologists. Anesthesia and analgesia 2020;130(5):1296-1302. (In eng). DOI: 10.1213/ane.0000000000004615.
5. Barnett NR, George RM, Hatter KH, et al. Pregnancy complications and loss: an observational survey comparing anesthesiologists and obstetrician-gynecologists. J Matern Fetal Neonatal Med 2024;37(1):2311072. (In eng). DOI: 10.1080/14767058.2024.2311072.
6. Rangel EL, Castillo-Angeles M, Easter SR, et al. Incidence of Infertility and Pregnancy Complications in US Female Surgeons. JAMA surgery 2021;156(10):905-915. (In eng). DOI: 10.1001/jamasurg.2021.3301.