Women Cardiologists Pay a Steep Price for Childbearing

Female cardiologists who become pregnant are often required to work extra hard in the months before going on maternity leave—and when that leave does arrive, it’s frequently unpaid and fleeting, according to results of a new survey. Upon their return, they may face penalties, as well.

The paper, published today in the Journal of the American College of Cardiology, makes clear that these experiences aren’t uncommon. Nearly one in four of the more than 300 women who replied to the survey reported troubling information that suggests federal laws are being broken at their workplaces. That includes the Family and Medical Leave Act (FMLA) and Title VII of the Civil Rights Act of 1964 as well as, at academic institutions, Title IX of the Education Amendments of 1972.

Yet the specifics of what’s legally required varies from state to state, and among practice settings, creating uncertainty even among cardiology leaders who want to do better, said Martha Gulati, MD, the paper’s lead author and president-elect of the American Society for Preventive Cardiology. She recalled her own experience as chief of cardiology, realizing how hard it was to be consistent and fair when the policies at a single workplace differed based on whether the parent-to-be had been hired by the hospital or the university.

There’s a finite window of time that you can have a child, and you make choices. Martha Gulati

Taken together, the difficulties related to childbearing could be a deterrent to women seeking to enter the field, she told TCTMD, noting that the survey focused on practicing cardiologists, since trainees often look to them as a preview of what’s to come in their own careers.

“We want everyone to be happy in their career. It’s a long road—we’re all thirtysomething by the time we start practicing. After all that work, we should enjoy what we’re doing,” Gulati said. “There’s a finite window of time that you can have a child, and you make choices.” For instance, she’s often asked by trainees whether they should have a child during fellowship or when they’re an attending, she said. “There’s pros and cons about both.”

Their paper, said Gulati, aims to provide guidance “for women in cardiology when they’re preparing for pregnancy and thinking, ‘What are my rights?’”

But it’s “also for chiefs of cardiology and chairs of medicine, as a reference document to advocate for their faculty or for their cardiologists,” she added. With this knowledge, “they can use the legal argument [to say], ‘Maybe our practices are not the right practices.’”

Mary Norine Walsh, MD (Ascension St. Vincent Heart Center, Indianapolis, IN), past president of the American College of Cardiology (ACC), said sadly the survey’s results don’t come as a surprise. Even so, seeing the problems documented “makes it all the more real that people are having their work lives constricted over this issue,” said Walsh.

“Some of the quotes and comments are shocking,” she commented to TCTMD, such as the woman who said she’d been admonished for being pregnant. “I was told not to have more children,” the respondent wrote. Perhaps most disturbing, said Walsh, is the upfront cost of pregnancy that many women face: the notion that female cardiologists must “pay in advance or pay back” hours they won’t work while on maternity leave when “a medical leave of any other sort requires none of that.”

Another powerful thing about this report is that several of its co-authors were from the Center for WorkLife Law, and contributed their expertise from this vantage point, Walsh observed. “They were well within the ‘right lane’ for stating what was literally against the law.”

Walsh pointed out that prior research has shown trainees considering a career in cardiology don’t think of the field as family friendly, suggesting that this paper may further dissuade them. “This may be a shock to the system for internal medicine residents,” she predicted.

Women in Cardiology

The anonymous survey was announced via email to the 1,351 members of the ACC’s Women in Cardiology Section as well as to Women as One members. In all, 323 women who had been pregnant as a practicing cardiologist replied between May 11 and June 11, 2021. Nearly half (48.3%) had been working in academic settings when pregnant. Most were pregnant within the past 5 years (50.2%), while 21.1%, 18.3%, and 10.5% had been 5 to 10 years, 10 to 20 years, and more than 20 years prior, respectively.

Almost three-quarters (73.4%) responded with details that raised concerns about at least one behavior that was illegal or potentially illegal.

Women typically chose to tell their chair, chief, or practice of their pregnancy in the late first trimester (37.2%) or early second trimester (43.0%). The timing related to concerns about adverse treatment or perception (37.5%), high-risk pregnancy/other medical factors (26.3%), the business itself (12.7%), radiation exposure (8.9%), or being perceived as less competent or committed (5%).

After announcing their pregnancy, women tended to work harder than ever. More than one-third (37.2%) reported doing extra service or call before their maternity leave. Yet 41.2% said they had a decrease in salary during the year of pregnancy and 57.9% saw no change in their earnings. For those whose salary was based on relative value units (RVUs), 51.8% maintained their output despite pregnancy. Just 7.4% saw their RVUs prorated to account for maternity leave.

Complications were common—most often bed rest (29.3%), followed by preterm delivery (24.4%), miscarriage (18.7%), preeclampsia (15.5%), preterm-preeclampsia (4.1%), and stillbirth (4.1%). Women who performed extra call or service while pregnant were no more likely to experience these problems, but they were more likely to be put on bed rest (17.5% vs 7.4%; P = 0.005). They also were more likely to say their pregnancy had adversely impacted their career as a cardiologist than those who didn’t do this extra work (59.3% vs 46.0%; P = 0.020).

The burdens posed by extra work are not without consequence, Gulati stressed. “[The] middle of the night emergencies at the most vulnerable time of your pregnancy, I think we need to reconsider this, because you can see . . . that we have a very high rate of pregnancy complications.”

Altogether, 38.1% of the female cardiologists experienced some form of complication. This, the paper notes, is in stark contrast not only to the general population—for whom the complication rate is 16.4% of all deliveries—but to other medical specialists like urology, where the rate is around 25%. Women also said they were treated differently while pregnant than men who had medical needs. And tellingly, those whose replies included behavior that was potentially illegal or discriminatory were more likely to also report having a pregnancy complication than those who didn’t cite such behavior (53.5% vs 32.4%; P < 0.01).

Then, after having birth, whether women would be paid during maternity leave varied substantially, though it was more likely for those working at an academic/hospital-based practice than in private/self-employed practices. Just 0.1% had 1 year of paid leave, 0.9% had 6 months, 19.2% had 3 months, and 22.9% had 6 weeks. Nearly three-quarters (23.2%) had no paid leave at all. Even so, approximately half of the respondents took 3 months of leave—paid or not.

Even on leave, many women were still available via email. While 40% had an out-of-office alert and didn’t check their work-related emails, 20.4% still checked email and did patient-related work despite having that alert in place. One-quarter continued to check emails. Fully 15% had no out-of-office message and still continued to manage patient issues from home during leave.

Gulati and colleagues offer several potential solutions to the wide-ranging problems. Beyond “transparent and consistent” policies, there should be “no paybacks for maternity leave,” they say. During leave, contact by e-mail for work-related issues should be prohibited. Employers should “provide a private and comfortable place for lactation/pumping,” as well as the time to do so. And to alleviate pressure on women in cardiology to work harder ahead of maternity leave—and the pressure on their colleagues during leave—it makes sense to “consider locum as temporary replacement,” they suggest.

The latter is important, said Gulati, so that already burnt-out clinicians aren’t further burdened and patient care doesn’t suffer. With locums as backup, “there will be no resentment from faculty who are not pregnant or are saying, ‘Why do I have to do extra call?’ We’re all working a lot, and hard,” she added.

Walsh, who is not a co-author but filled out the survey when it was released last year, said she does see hopeful signs. “I see a difference around me, both in my institution and for younger pregnant cardiologists compared to my experience as a fellow and as a junior attending,” she noted. For example, “breastfeeding is a normal experience in the office, the clinic, and the lab now. That was not the case in years past. It was done on an ad hoc basis, where one could.”

She emphasized that individual chiefs, chairs, and program directors should realize they can initiate change. It’s possible to even go above and beyond what’s required by policies, Walsh said. “We want people to come back strong and feel good about coming back when they want to.”

COVID-19 Creates a Chance to Reboot

In an accompanying editorial, Laxmi S. Mehta, MD (The Ohio State University, Columbus), and colleagues agree that it’s time for a serious exploration of what could be holding women back from the field, particularly since “the moral injury and exhaustion of the COVID-19 pandemic has disproportionally impacted the careers of women in medicine with increasing demands at home, less time for research, and negative implications on career advancement,” they write.

Professional societies can play a role by endorsing best practices, and leadership that condones poor behavior, either by promoting or ignoring it, must be held accountable, they say. Moreover, efforts to promote diversity, equity, and inclusion should be recognized by those in charge as a “core leadership competency.”

To create change, “we need to normalize pregnancy and parenthood during training and practice and provide postpartum and lactation resources, such as safe and secure lactation rooms and career flexibility. In terms of parental leave, employers need to allow their workforce to spend time with their newborns without interruption, the fear of retaliation, discrimination, loss of employment, or financial implications,” Mehta and colleagues note.

Men cardiologists, too, should take parental leave and be allies to their female colleagues, they stress. Both women and men “should obtain legal counsel while undergoing contractual negotiations, understand the cascading implications if policies are not clear, and pay specific attention to the FMLA laws in the contract.”

As Gulati emphasized, how female cardiologists are treated during pregnancy carries wide implications for the field going forward. “This isn’t the only problem, but this is one of the problems,” she said, noting that the prevalence of women among cardiologists has been “relatively stagnant” over the years: rising from 8.9% in 2006 to just 14.9% in 2020.

Gulati pointed out that she does not have children. Yet even for those without this personal experience, she said, the main takeaway still applies: “As women, I think we want our lives to not be adversely affected by natural things that happen in life.”