Experience of pregnancy during family medicine residency

Pregnancy

Perceived increased adverse symptoms due to workload. Many participants reported increased adverse symptoms during pregnancy, including excessive fatigue, frequent and severe contractions, bleeding, threatened preterm labour, poor weight gain, musculoskeletal pain, and poor sleep quality (Table 2). Three participants also experienced miscarriage during residency before successfully delivering term infants in a subsequent pregnancy. The residents attributed these increased adverse symptoms to the heavy workload of clinical duties because these symptoms improved after they took a leave or a rest.

I had to stop working at 33 or 34 weeks mainly because of the very bad contractions at work; although, I didn’t have contractions when I was able to be at home.

General pregnancy symptoms such as nausea, emesis, and fatigue were also reported as challenges.

Prioritizing work over well-being. Residents who worked busy rotations during pregnancy reported external and internal pressures to prioritize work over their well-being. Busy rotations included obstetrics, surgery, and clinical teaching units, while office-based rotations, such as family medicine, were generally perceived as pregnancy-friendly, with less standing time and more predictable working hours. External pressure was created by high workloads, including frequent calls from wards and emergency departments, insufficient support from the preceptors to manage the workload, and requests to take extra night-call shifts.

I felt so much external pressure from nursing staffs and my preceptors. That’s why I didn’t even tell anybody I was pregnant because I couldn’t have them thinking that I needed anything special …. I needed to just be a workhorse then.

Internal pressure was attributed to the strong motivation to be keen and competitive as residents, which disinclined residents to ask for help and rest.

I was anxious. I knew that I wasn’t taking care of myself properly. My co-residents had to remind me to take time off because I wasn’t taking care of myself. Because we are residents, you feel like you always have to prove something. So I didn’t want to take time off. I was saying that I was fine even if I wasn’t so.

Program requirements to achieve passing grades on short rotations were reported as barriers to requesting sick leave.

Support from the residency program. Participants noted several supports from the residency program: offering emotional support; arranging requested time off; providing an exemption from night calls, especially after 28 weeks’ gestation; rearranging rotation schedules; and offering part-time options. In 2017, the UBC Resident Policy was revised to state that pregnant residents would not be required to work shifts longer than 12 hours after 24 weeks’ gestation, amended from the previous guideline of 28 weeks.¹⁵ Some sites also offered to use vacation days to accommodate half-day work, without income reduction. Residents regarded these supports as very helpful in both reducing stress from pregnancy-related challenges and maintaining their clinical function.

During maternity leave

Postpartum depression and anxiety. Three residents reported increased anxiety and depression after childbirth, especially before returning to work.

I was dealing with a lot of anxiety. I connected with my family physician and eventually a reproductive psychiatrist and ended up on antidepressant medication. But over the entire time, my anxiety was definitely the highest when I got back to work.

Identity crisis. One resident reported feeling helpless by the sudden transition from being a trained provider of evidence-based medicine to being a new, inexperienced parent, which she called having an “identity crisis.”

Support from the residency program. Programs supported postpartum residents by offering a requested length of unpaid maternity and parental leave. In December 2017 that became extendable up to 78 weeks.¹⁶ Most participants took maternity leave for 8 to 12 months, and they reported it as being optimal for themselves, except for 1 resident who wished to have longer leave because of their child’s health. Residents found the long maternity leave with employment insurance income helpful as it allowed them to spend more time with family and bond with their new children.

Return to work

Perceived decreased clinical function. All participants who had already returned to work and most of those currently on maternity leave reported challenges and anxiety when transitioning back to work. These challenges included performance anxiety after a long maternity leave, impaired memory due to sleep deprivation, fatigue from dual duties at work and home, limited time to study after work, and increased workload with the addition of breast pumping at work.

I had a lot of anxiety [about coming] from mat leave. Just anxiety about performance, about lack of knowledge. Also, I felt like my brain was not well cleared with sleep deprivation. That was hard. I felt like I didn’t remember things at all.

Residents suffered from feelings of being “rusty” or “inferior” to other colleagues because of their limited time availability, fatigue, and impaired memory. Attending academic curriculum classes before returning to work was reported as helpful in easing the mental transition; networking with new classmates provided another source of support.

Burden of breastfeeding. Breastfeeding was reported as challenging because breaks for pumping, private rooms, and fridges were not available in some rotations. Also, pumping breast milk added time and another task to the residents’ workloads. All participants who returned to work breastfed their babies at the time of return, and half of them gave up breastfeeding earlier than they had planned because of the burden of breast pumping at work.

There’s no pumping room in the hospital. When I was in emerge rotation, I pumped in the washroom, which is gross, or in my car. So there’s no nursing rooms or any pumping stations. Also, it’s hard to get time. People are not understanding when you take a few more breaks for pumping. So basically I had to stop pumping 2 months into residency because I just couldn’t physically do it.

Support from the residency program. Some, but not all, sites were supportive of breastfeeding by offering information about resources such as private spaces, fridges, and pumping equipment, and were understanding of the need for breast-pumping breaks.

Shared burden of residency with family. Residents reported sharing the burden of residency with their families. They reported that although they had hoped to spend more time with their babies and partners, they felt the pressure to prioritize work over family because of the unpredictable and lengthy hours of work. Residents were also too exhausted to spend time with their families or felt a need to compromise family time to study for examinations, which brought a sense of guilt about family neglect.

I felt like I was neglecting my family because of my job and the practice [because of the] unpredictability of the time to work. People [at work] would lose faith with me if they felt I wanted to prioritize my family, but I wanted to be reliable. I just felt helpless because I really couldn’t control my schedule.

Limited availability of child care was considered a serious issue, especially for residents at urban sites. Because wait times for day-care spots in urban areas could be as long as 3 years, working residents had to rely on their partners and extended families to take care of their children during work. Unpredictable and long work hours made child care coverage more challenging. If sufficient family support was not available, residents could only work when child care was available. Respondents reported that private nanny services were expensive, which put additional financial pressure on residents if hiring a nanny was their only child care option.

Support from the residency program. Residents reported varying levels of support among the programs after their return to work. Some, but not all, sites were supportive. One resident reported a strong sense of isolation and helplessness.

I felt I was not part of the program anymore. I literally had to do everything by myself, like consulting my preceptors directly by myself one-to-one to arrange and schedule rotations. A lot of information did not reach me, like [the] licence package. They just said contact them directly. I felt rejected. I felt they told me you should not be here anymore, nothing to continue anymore at all.

A schedule for a gradual return or a part-time option was reported helpful for some residents (ie, in cases of difficulty in securing child care or a child having an unexpected physical condition). Because unpredictable, long working hours were reported as a challenge for returning residents and their families, residents found it helpful to arrange the initial schedule after their leave to begin with shift-based or office-based rotations to have more predictable working hours.