The Difficult Road to Motherhood
Several months ago, I suffered a miscarriage during my first pregnancy. The experience was emotionally taxing; I experienced sadness like never before. Perhaps worse, the experience was isolating. Miscarriage is an uncomfortable topic in most environments, and this is only elevated in a field like cardiology that has historically lacked female mentorship.
I also came to learn miscarriage can be a drawn-out process. Weeks passed with emergency department visits for various magnitudes of pain and bleeding, ultrasounds to determine viability, and medical and surgical interventions for retained products of conception. I strategically maneuvered around my clinical rotations, clinics and conferences in order to draw minimal attention to my absence during this harrowing experience.
Slowly, I began to reach out to my support network. I am uniquely situated in a fellowship program with a program director who is a staunch advocate for women's rights, and a fellow class where half of us are women. Through conversations, I learned my experience was far from unusual. I spoke to fellows who made countless visits to fertility specialists trying for a successful pregnancy. I heard stories of physicians who miscarried while trapped at work in the middle of rounds or on a busy night of on-call duty. I listened to physicians recount painful memories of late pregnancy fetal demise and enduring the grief of burying their deceased children.
The silver lining in my experience illuminated a pervasive, but often guarded, condition among many physicians trying to navigate the difficult road to motherhood. A recent Journal of the American Medical Association (JAMA) article reported 42% of female surgeons experienced pregnancy loss – a rate nearly double that of their non-surgeons counterpart. In addition, they also experience significantly more pregnancy complications.
If these statistics surprise you, it's likely because topics like infertility and miscarriage are deeply stigmatized, even among the most informed practitioners. But as medical providers, we are uniquely positioned and should be deeply motivated to stay informed about these experiences as they will impact not only our patients, but also our friends and colleagues. Our training programs and employers must adopt durable systems to help support physicians. Three aspects of support are vital to consider: financial, paid bereavement and counseling.
The road to motherhood can start with difficulty getting pregnant. The prior JAMA article found female physicians often delay trying to conceive until completion of their training, resulting in higher risk, advanced maternal age. They often experience greater overall stress and more inconsistent sleep hours as compared to their non-physician female counterparts, much of which compounds into difficulty conceiving.
For many women, investigations and treatment for infertility do not start until following one year of an inability to conceive. Following this, women will endure various fertility specialist visits, lab work, invasive and non-invasive imaging, followed by pharmacologic and invasive therapeutic interventions toward successful pregnancy. This amounts to a timely and expensive process. An article in Fertility and Sterility, the American Society for Reproductive Medicine's journal, found that over an average of 18 months of evaluation and treatment, women spent from $1,100 on medications alone, to $61,000 for successful in vitro fertilization (IVF) treatments.
These costs are prohibitive under trainee salaries and are steep even for young practitioners. Yet, this is often the time frame when many physicians are trying to conceive. Progressive companies like Bank of America, Johnson & Johnson and Starbucks offer IVF benefits to attract and retain their hardworking, career-driven female workforce. It is time the health care industry follows suit and provides some of this financial support for clinicians who want to conceive.
Paid Bereavement Support
Bereavement policies are often put in place among training programs and by employers to offer time and support for clinicians and their families following the loss of a partner or close family member. Yet, miscarriage and fetal loss can be equally devastating. A societal tradition of not revealing pregnancy until the second trimester, when miscarriage becomes less likely, underscores deeply rooted negative perceptions about pregnancy loss and can contribute to difficulty with coping.
The U.S. makes up one of the few industrialized countries in the world that does not have legislation guaranteeing paid maternal leave. The Family and Medical Leave Act offers unpaid, but job-protected time off for up to 12 weeks following the birth of a child, adoption, or for the care of a sick loved one and one's own medical condition. Miscarriage and fetal demise are appropriately considered serious health conditions and assumed under this recovery period. Besides the financial difficulties that can results from this policy, time off can also create additional hardships, including extension of fellowship.
Destigmatizing pregnancy loss starts with expanding policies to include initiatives like flexible work hours to allow time for counseling and therapy. While some physicians feel being at work with their colleagues may be helpful, they should be afforded flexibility and protected time to cope. The inflexibility at most fellowships and health care institutions creates more stress for women when trying to make plans and decisions, and their emotional responses can vary from day to day.
Difficulty conceiving and pregnancy loss are experienced differently. Some women can move forward with knowing, for example, a chromosomal abnormality most commonly leads to miscarriage in the first trimester. Some become fraught with guilt whether they could have taken preventable actions. Some feel deep remorse. Training programs and hospital systems have established confidential referral services to therapists and psychiatrists as well as peer-to-peer support lines.
Fellowships and health care employers should ensure their resources are adequate to support women through this time. There are several fellowship directors who are well-versed in navigating pregnancy related issues encountered during training. All programs should familiarize themselves with support networks available to their trainees.
The desire for motherhood is certainly not universal among women. For those who choose to pursue pregnancy, the road can be long, emotionally difficult and financially burdensome. We cannot allow women to continue burying their experiences with guilt and shame. We must create more progressive policies and build more robust support structures so that trainees who encounter infertility, miscarriage or fetal demise have the tools and community to overcome these hardships.
This article was submitted by Agnes Koczo, MD an FIT at University of Pittsburgh Medical Center. Twitter: @AkoczoAgnes