CT Surgery Needs Universal Policies for Pregnancy and Family Leave, Survey Shows

SAN ANTONIO, TX—Female cardiothoracic surgeons have fewer children and are more likely to face infertility when compared with their male counterparts, according to new survey data. Additionally, when female surgeons are pregnant, they experience a higher than typical rate of pregnancy complications.

Family planning and medical training are established mutual obstacles because they typically occur at the same time in a trainee’s life. Achieving balance often comes at an understood cost, especially for women, but at the 2024 Society of Thoracic Surgeons (STS) meeting, leaders in the field argued that systemic changes need to be made to attract the best future surgeons.

“The proportion of women is increasing [in cardiothoracic surgery], but I think an inclusive environment that allows surgeons of both genders to have the work and family life that they want is important for recruitment, retention, [and] overall wellbeing of the workforce,” Anna Olds, MD (University of Southern California, Los Angeles), who shared the data in two presentations at STS 2024, told TCTMD. “And we want surgeons to be happy—we want people to be happy and come to work because we're helping other people.”

STS President Jennifer Romano, MD (University of Michigan Congenital Heart Center, Ann Arbor), who co-chaired the session, highlighted the importance of bringing greater awareness to these issues.

“So many of us went into this specialty without necessarily even thinking about the fact that it could potentially impact our ability to have a family,” she told TCTMD. “I've learned that if you ask, if you speak up, quite often it's not a matter of ‘people don't want [to help],’ it's that they don't know [how]. So the more that we inform people and educate those around us, really can impart change. It's pretty simple.”

Survey Results

For the first survey, Olds and colleagues polled STS and Women in Thoracic Surgery trainee and surgeon members between January and June 2023, with males instructed to answer pregnancy questions regarding their nonsurgeon childbearing partners. In all, 378 people sent in complete responses, of whom 45.8% were female, 75.1% were academic/academic-affiliated, and 20.1% were trainees.

Compared with men, more female cardiothoracic surgeons were single or never married (19.1% vs 5.9%) and fewer had spouses who did not work outside the home (9.6% vs 21.8%). Additionally, women were less likely to have children (56.7% vs 85.4%) and to have fewer children on average than male surgeons (1.9 vs 2.5; P < 0.001 for all).

Fewer female surgeons said they had the number of children they wanted naturally without assisted reproductive technologies, fertility, and surrogacy (37.8% vs 63.4%; P = 0.001). About one-third of women reported using infertility testing or assisted reproductive technologies, with fewer than one in five men saying they’d turned to these tools.

Strikingly, 41.6% of female respondents said their desire to have children deterred them from pursuing cardiothoracic surgery, compared with only 22.9% of males (P = 0.004).

Pregnancy loss was reported by 42% of all female respondents, which is substantially higher than the estimated rate of 20-25% in the general population, Olds stated. Notably, 70.5% of these women took no time off after their miscarriage. “It is unclear if this is due to fear of judgement and stigma from colleagues, or part of the traditional surgical culture where personal needs often come second to patient care,” she said. “These challenges with starting a family may limit recruitment of talented female candidates into the field of cardiothoracic surgery.”

These challenges with starting a family may limit recruitment of talented female candidates into the field of cardiothoracic surgery. Anna Olds

In her second presentation, Olds showed more data from 255 respondents (63% male) who had had at least one live birth. Female cardiothoracic surgeons were on average 3 years older than female nonsurgeons at first live birth (34.5 vs 31.5 years; P < 0.001). Additionally, more surgeons used assisted reproductive technologies than nonsurgeons (31.2% vs 15.4%; P = 0.003) and they were also more likely to work more than 60 hours per week during pregnancy (70.3% vs 14.1%; P < 0.001).

Almost half of all female surgeons (45.2%) reported a major pregnancy complication compared to only 27.2% of nonsurgeons (27.2%; P = 0.003), including higher rates of preeclampsia and preterm labor or preterm premature rupture of membranes.

Among the 93 female surgeons surveyed, only 18.3% said they had a reduced work schedule during pregnancy. Slightly more than half (51.3%) of those who chose a regular workload said they would have liked to cut back their hours but didn’t because of a fear of stigma or judgement of weakness (52.7%), concern about burdening colleagues (44.6%), or employer disapproval (31.1%). Additionally, 78.5% worked more than four overnight call shifts per month and 72.0% worked at least 12 hours in the operating room per week during their last trimester.

Among all respondents, being age 35 years or older and being a female surgeon were associated with major pregnancy complications in a multivariate analysis. When the model was limited to female surgeons alone, working at least 12 hours per week in the OR during the last trimester was an additional risk factor.

“This study highlighted a need to develop formal policies to protect the maternal-fetal health of female cardiothoracic surgeons, protect autonomy in family planning timeline decisions for surgeons and trainees, and provide education about pregnancy in surgeons,” Olds said. “This is particularly applicable to women surgeons as older age is a risk factor for worse pregnancy outcomes.”

Need for a National Policy

Until recently, parental leave policies in cardiothoracic surgery training—and most other fields of medical education—had been largely institution-based. In 2020, the American Board of Thoracic Surgery instituted a specialty-wide policy that guarantees one 6-week leave for all trainees (two for those in an integrated program). However, many feel that this still is not enough.

Leading the charge at her institution, Romano created the “most lenient” policy for pregnant and lactating trainees in the field, she said during the discussion. “It allows for 12 weeks regardless of gender for any type of parental leave or major medical illness, and it does not extend your duration of training,” Romano explained. “It was amazing, when I presented it . . . unanimously everybody applauded. All the directors were like ‘We should have thought of this years ago.’” The fact that this idea had not occurred to administrators is why the policy was needed, she added.

“My dream would be that one day this is an ACGME policy for everybody, for all female residents, and in other specialties too,” Olds said. “Having that level of support and having written policies—formal written policies—is crucial because then everyone knows what to expect.”

Commenting during the session, Douglas Wood, MD (University of Washington, Seattle), a former STS president, agreed that having a “gender neutral” formalized policy will reduce stigma and benefit all. “If you’re in a power situation in this room, go home and develop a policy,” he urged. “If you’re . . . a trainee, go home and get an ally and ask: ‘Can you develop policies and can I help with them?’ If it’s written down and makes clear the expectations and what the rules are, it makes it easier for everyone to understand and [is] much more equitable.”

Romano’s advice for anyone looking to follow in her footsteps would be to bring in a visiting professor like herself to help educate both trainees and higher-level executives at an institution.

“Everywhere I go and give this talk, it gets that message out there,” she said. “It somewhat drives my husband crazy because I share a lot of information. I went through 12 cycles of IVF and had my children at 42 and 44 and feel so very blessed to have them, but it was not an easy journey, and I did it when it wasn't okay to talk about it.”

Working to enact national level policies regarding pregnancy and parental leave is a priority for the STS, Romano said. “It's not fair that trainees and junior faculty members need to be fighting this over and over again at an institutional or a state level,” she said. “There are a lot of other things that also impact our female trainees as well as faculty, but the more that we can help them take this battle to the right place, the better.”