Motherhood and medicine: systematic review of the experiences of mothers who are doctors

Increasing numbers of women are graduating in medicine in Australia1 and overseas.2,3 This has led to a “feminisation of medicine”,4 and concerns have been expressed that women work fewer hours than men, primarily because of family commitments.5 Such criticism focuses on the competing demands of being mothers and doctors, and the career breaks taken by women to care for children.4

Balancing the two roles can be challenging. Doctors must prioritise patient care, often to the detriment of their own needs and those of their families.6,7 Motherhood can be as personally rewarding as medicine, and similarly requires placing another person's needs before one's own.8 In this systematic review, we identify what is known about women balancing motherhood and medicine by examining the published research into their experiences and perspectives.

Methods

Search strategy

Our systematic review was prospectively registered with PROSPERO on 30 April 2019 (CRD42019116228). We searched the CINAHL (Cumulative Index to Nursing and Allied Health Literature), MEDLINE, PsycINFO, Web of Science, and Scopus databases in November 2019 for relevant published studies with the same search string: female/women AND doctor*/physician*/clinician* AND family OR child* OR mother* OR parent AND “family work relationships” OR “work life balance” OR “work home culture” (Supporting Information, table 1).

Study selection and data extraction

The titles and abstracts of articles identified by our search were screened by two authors (RH, MN), and the full text of relevant articles were then assessed according to our inclusion criteria:

• published during 2008–2019;
• full text was available in English;
• the publication described original research;
• the publication had been peer‐reviewed;
• the study population included medical doctors;
• the study examined women's experiences, or women/female sex was a variable in the study;
• the study examined a component of parenthood.

Articles were excluded if doctors were not explicitly objects of the study, sex was not a variable in the study, or motherhood or parental experiences were not reviewed. Disagreements about inclusion were resolved by consensus between the two authors.

Screening identified 101 potentially relevant articles. After excluding nine because no English language versions were available, 43 not specifically related to motherhood or medicine, one undergraduate study not about doctors, and twelve non‐research articles, 35 original research studies were included in our systematic review (Box 1).

Thematic analysis

We undertook an integrative review synthesis of the included research studies. Information was categorised according to emergent themes and synthesised. A quantitative meta‐analysis was not attempted because of marked differences between studies in the outcomes and variables assessed.

Results

Nineteen of the 35 research studies (32 quantitative, three qualitative studies) were from the United States, and three each from Japan and Germany. The quantitative studies were either cross‐sectional surveys or longitudinal in design (32 to 10 866 participants each) from specific specialities to large multi‐centre studies. The qualitative studies included focus groups and semi‐structured interviews (eight to twenty participants each) (Box 2; Supporting Information, tables 2–4).

All 35 included studies were appraised by one author (RH) with the Joanna Briggs Institute Critical Appraisal tools9 and deemed to be of moderate quality. No study included a matched comparison group, and only one10 included longitudinal follow‐up of a cohort of women.

Three core themes were identified by thematic analysis:

• Motherhood: the impact of being a doctor on raising children;
• Medicine: the impact of being a mother on a medical career; and
• Combining motherhood and medicine: strategies and policies.

1. Motherhood: the impact of being a doctor on raising children

The first theme, derived from one qualitative study (20 participants)10 and ten quantitative cross‐sectional surveys (183 to 6880 participants),8,11,12,13,14,15,16,17,18,19 was the influence of a medical career on decisions and priorities related to motherhood, including decisions about whether to have children, and when and how many, as well as the ongoing effect of a medical career on a woman's family (Supporting Information, table 2).

Five studies reported that women who were doctors described decisions about having children or pursuing career progression as difficult.10,12,13,16,18 Most participating women reported prioritising their careers, including completion of specialty training, by choosing to delay having children.10,13,16,18 In one study,12 513 of 801 respondents (64%) deferred having children for career reasons. Other studies similarly found that women delayed having families to attain specific career goals.11,12,14,19 Female surgeons in the US were twice as likely as male surgeons to delay having children until after postgraduate residency training; women who had children early in their career felt less financially secure and more anxious than women who commenced families later in their career.16 In another study, women who had children during training reported greater family strain than women who did not have children.17

Decisions about career progression influence family size; for instance, an Egyptian study found that 247 of 300 women (82%) had smaller families because they had decided to prioritise their advancement as physicians.19 Two other studies found that a smaller family was a possible consequence of deferring pregnancy for career reasons,11,12 highlighted by the remark: “I [deferred] having a second child. Never got to it. Big regret in my life.”12 Shift work and certain specialisation choices (such as dermatology)14 were also found to influence family size.

Several studies found that a medical career could have a negative impact on family life and relationships.8,14,15,16,17,19 For example, two US studies identified that the working hours of women surgeons caused family strain;16,17 another found that 2071 of 5582 female doctors (37%) believed that their career negatively affected relationships with their children.15 Similarly, 36 of 91 female dermatologists with children (40%) felt that they had missed their children's milestones because of their careers.14

2. Medicine: the impact of being a mother on a medical career

The second theme, derived from 17 quantitative studies (32 to 10 866 participants)8,13,19,20,21,22,23,24,25,26,27,28,29,30,32,33,34 and one qualitative study (eight participants),31 was the impact of being a mother on working as a doctor (Supporting Information, table 3).

There were two subthemes. The first was the effect of the responsibilities and preferences associated with pregnancy and parenthood on career motivation. Four studies found that motherhood did not reduce the motivation and ability of female doctors to return to work.13,20,32,33 A Dutch study found that female doctors who wanted or already had children remained motivated to work;33 a Swiss study found that 78 of 109 female doctors (72%) continued working more than half‐time after having children.32 Similar findings were reported by British13 and Latin American studies20 in which respectively 47% and 54% of female doctors sought work in family‐friendly environments (generalist or primary care settings).

The number of hours worked after maternity leave was influenced by childcare availability, personal and family preferences, and working arrangements.8,19,27,28,34 A Japanese survey (224 respondents) found that 38% of female surgeons changed their work plans to accommodate childcare; further, acute childhood illnesses, educational activities, and parenting responsibilities affected decisions about work, and 11% had resigned their jobs.27 Time required for parenting also affected working hours.19,21,23,25,29 Two US studies reported that female surgeons undertook a greater share of childcare planning and domestic activities than male surgeons.21,25 A multinational study similarly found that women bore greater responsibility for parenting and domestic roles than men in the same surgical specialty.29

The second subtheme concerned perceptions of pregnancy and motherhood, discussed in four studies from the viewpoint of the colleagues of female doctors and program directors.23,24,26,30 In three studies, conducted in the Lebanon,23 South Africa,24 and the US,26 doctors reported that their workloads were greater when working alongside pregnant doctors, and they rated pregnant colleagues as less productive.23 The US study also found that ten of 22 program directors (45%) reported that their hiring decisions were influenced by disclosures by potential employees regarding pregnancy or pregnancy plans;23 it was unclear whether this reflected policies on pregnancy in training positions, or personal beliefs about pregnant doctors. According to a longitudinal cohort study, negative perceptions of pregnant colleagues have improved in the US; the authors found that support from program directors and faculty staff for hiring and retaining female doctors had increased during 2008–2015.26

Female doctors reported perceptions of gender bias; for example, a surgical training registrar commented that “women are not taken seriously, as they may soon get pregnant.”24 A qualitative study in the US found that female doctors were often presumed to be disinterested, unavailable, or unwilling to complete tasks, work extra hours, or be promoted if they had children; one participant stated that colleagues thought that “you don't want to deal with that: you have small kids.”22

3. Combining motherhood and medicine: strategies and policies

The final theme, derived from two qualitative studies31,40 (eight participants each), and ten quantitative studies (45 to 546 participants),14,30,35,36,37,38,39,41,42,43 concerned the strategies and policies for assisting women balance motherhood and a medical career (Supporting Information, table 4).

Maternity leave and policies on leave and career progression directly influenced the ability of women to balance motherhood and medical careers.14,30,35,37 A US study found that 89 of 96 female dermatologists (93%) took less than three months’ maternity leave after giving birth; 24 (25%) had returned to work within a month.14 In another US survey, 251 of 320 female surgeons (78%) took less than six weeks’ maternity leave, and 250 of 347 (72%) thought the duration of leave inadequate.37 That the American Board of Surgery allows a total of only six weeks’ leave, including annual and maternity leave, was cited in one study as one reason for this situation; a participant commented that surgery “is hard, being a mum is hard … I gave up all of my vacation for maternity leave … [that] hurt my morale and spirit the most.”35 A German article discussed how hospital policies discouraged women from working in surgery when pregnant, causing them to disclose pregnancies late or to retire from theatre surgery.30

Several studies described strategies for assisting women balance motherhood and medicine.31,36,39,40,42,43 Strategies included workplaces with policies for expanded childcare and breastfeeding facilities or otherwise promoted flexibility in the workplace.39,42 In a survey of paediatricians (546 respondents), 88% reported their residency programs included maternity leave policies; 63% reported flexible rostering, 24% on‐site childcare, and 51% lactation rooms.43 This study also found that child‐friendly workplaces and those with flexible policies were deemed to be more attractive as training locations.43

The few studies that have evaluated pregnancy and maternity leave policies have been conducted in the US.36,38,41 Thirty‐three of 52 plastic surgery residency programs did not have formal maternity leave policies (63%);38 there was no identified national maternity or paternity policy for orthopaedic surgeons, and hospital and training programs had policies that were often not implemented.41 Further, program directors from a range of specialties commented that 137 of 298 programs (46%) did not adequately support women during pregnancy and parenting.36 Similarly, surgical residents reported that maternity support and policies were inadequate.35

Discussion

Our systematic review provides insights into possible barriers and facilitators for women striving to balance their aspirations for both a medical career and family. The key themes identified indicate the diversity of factors that affect pursuing the dual careers of mother and doctor. It was often reported that women prioritise career advancement by delaying starting a family.10,12,13 Women who have completed higher education in areas other than medicine are similarly likely to delay pregnancy and motherhood until their thirties; in an American survey, more than 50% of women with tertiary educations had their first children after the age of 30, while 64% of women with first pregnancies before age 25 had not completed high school.44 Delaying having children may affect a woman's ability to conceive, increases the risks of complications during pregnancies, and increases the risks of mother and child requiring medical interventions.45 These implications may not be considered by women when giving priority to career opportunities.

Some studies reported that female doctors believed that career progression would be slowed by motherhood,28,29 similar to findings in other professions. In business careers, for example, leaves of absence have been associated with fewer promotions and poorer annual review outcomes,46 especially for women who take leave of absence to have children;47 in managerial positions, each year of delayed motherhood was found to increase earnings by 9%.48 The perception that women should be at home providing childcare is a barrier to career progression in many professions.49 Strategies for overcoming this problem include education and targeted leadership development programs,50 but research specific to medical practice is needed. Few evaluations of policies for supporting pregnant doctors, providing maternity leave, and assisting their return to work after giving birth have been published. There is, however, some evidence that trainees prefer programs that provide maternity leave and offer flexible return‐to‐work strategies.39,42

Limitations

The methodological quality of the included articles was moderate. Most described single cohort studies, only one of which was a longitudinal study. Most investigations focused on hospital‐based specialties and were restricted to single hospitals or specialty training programs, with only limited consideration of community‐based specialties such as general practice. Specific cultural and religious factors that can influence choices related to motherhood and career were not investigated. We found no relevant studies conducted in Australia or New Zealand. A final limitation was that we excluded studies for which English language versions were not available.

Conclusion

Notable barriers to women pursuing both a medical career and motherhood have been identified. Prospective studies and rigorous evaluations of policies and support mechanisms in different medical specialties should be undertaken. As more than one‐half of medical trainees are women, the dual roles of mother and medical practitioner need to be considered in greater depth, with a view to establishing sustainable strategies that enable women to excel in both roles.

Box 1 – Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) flow diagram of article selection for our review

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