Barriers to Lactation for Female Physicians
April 24, 2025
Survey
S:RM-MD.01
Abstract
INTRODUCTION: Women represent over 50% of graduating medical students in the United States and approximately 20% of current neurosurgical residents in training. An increase in female representation requires an increase in advocacy efforts related to pregnancy. Although there is extensive literature on pregnancy in neurosurgical residents, the postpartum period, sometimes referred to as the “fourth trimester”, is frequently overlooked. This study was performed in order to characterize the lactation experiences of female neurosurgeons and neurosurgical trainees and compare their experiences to their peers in other medical specialties.
METHODS: A 62-question survey examining lactation experiences was developed and electronically disseminated to members of Women In Neurosurgery, the social media group Dr. MILK, and to neurosurgical residency Program Directors throughout the United States.
RESULTS: Seventy-eight responses were received (neurosurgery: 10, other surgical specialty: 19, nonsurgical specialty: 49). When asked if respondents met their goal for lactation duration, 26 nonsurgical, 13 other surgical, and 8 neurosurgery respondents responded affirmatively (p = 0.059). A significantly greater proportion of neurosurgery respondents reported that expression of breastmilk at work caused anxiety compared to nonsurgical respondents (p = 0.02). Overall, 59% of respondents felt that they did not have adequate time to express breastmilk at work, and 69% had to stop expressing breastmilk at work prior to completely emptying. Fifty-three percent of respondents were fearful of being unable to feed their baby secondary to the inability to express breastmilk. Twenty percent reported never being able to consume sufficient liquid at work, and 17% reported never being able to consume sufficient calories at work. Additional cited barriers included limited mentorship (68%), inconvenient lactation spaces (58%), perceived discrimination (32%), and breast pump malfunction (28%).
CONCLUSION: Women residents across medical specialties face significant barriers to successful lactation experiences. With limited mentorship in lactation across medical specialties, advocacy efforts and lactation support are vitally needed for the protection of the health of physician mother and baby.
COMPETENCY: Patient Care, Medical Knowledge, Interpersonal and Communication Skills (ICS), Professionalism, Practice-Based Learning and Improvement, System-Based Practice
Introduction
Women make up over half of the graduating students from medical schools in the United States and 20% of current neurosurgical residents. Although women are still a minority of neurosurgery trainees, the number of female neurosurgery residents has nearly tripled in the last decade. While an active effort is made to recruit more women into the neurosurgery workforce, an increase in female representation requires an increase in advocacy efforts related to pregnancy.
In 2020, a survey examining perceived barriers to childbearing among women in neurosurgery reported insufficient time to care for a newborn, discrimination by coworkers, and inadequate time for completion of board requirements as the most frequent obstacles experienced or anticipated. Since then, the American Board of Medical Specialties (ABMS) has developed policies on parental, caregiver and medical leave during training stating that a minimum of 6 weeks of time away from training is allowed for this purpose.
However, a frequently overlooked period is the postpartum period, sometimes referred to as the “fourth trimester.” While best practices for the pregnant neurosurgical resident are studied, there is little to no guidance for the lactating neurosurgical resident. This study aims to characterize the lactation experiences of female neurosurgeons and neurosurgical trainees and compare their experiences to their peers in other medical specialties.
Methods
Survey Creation
In August 2023, a 62-question survey was designed to examine lactation experiences among women in neurosurgery and other medical fields. The survey was created using Google Forms and the instrument is available online (Supplemental Data 1). This study received an exemption from the institute’s Institutional Review Board.
Target Population and Survey Delivery
The survey was disseminated electronically to members of Women In Neurosurgery, the social media group Doctor Mothers interested in Lactation Knowledge (Dr. MILK), and to neurosurgical residency Program Directors nationwide.
Statistical Analysis
Descriptive statistics were calculated. For categorical and continuous variables, bivariate relationships were interrogated with Fisher’s exact test and Student’s t-test, respectively. P-values less than 0.05 were considered significant. Analyses were completed in R version 4.3.0 (R Foundation for Statistical Computing, Vienna, Austria).
Results
A total of 78 responses were received of which 10 were from neurosurgery, 19 from other surgical specialties, and 49 from nonsurgical specialties. Two neurosurgery residency program administrators responded that the survey was not applicable to anyone in their program. The demographic characteristics of the respondents are shown in Table 1. The average age of respondents was 31.9 ± 3.6 years, and most were attending physicians at the age of breast milk expression (53/78 or 67.9%).
| Table 1. Demographics of the Survey Respondents | ||||
|---|---|---|---|---|
| Overall (n = 78) |
Neurosurgery (n = 10) |
Other-surgical (n = 19) |
Nonsurgical (n = 49) |
|
| Age at expression | 31.9 ± 3.6 | 31.2 ± 0.8 | 31.8 ± 0.7 | 32.5 ± 0.8 |
| Training level at expression (%) | ||||
| Medical Student | 2 (2.6) | 0 (0.0) | 0 (0.0) | 2 (4.1) |
| Resident | 17 (21.8) | 5 (50.0) | 4 (21.1) | 8 (16.3) |
| Fellow | 6 (7.7) | 2 (20.0) | 0 (0.0) | 4 (8.2) |
| Attending | 53 (67.9) | 3 (30.0) | 15 (78.9) | 35 (71.4) |
| Race (%) | ||||
| White | 62 (79.5) | 8 (80.0) | 15 (78.9) | 39 (80.0) |
| African American | 3 (3.8) | 0 (0.0) | 0 (0.0) | 3 (6.1) |
| Latino | 2 (2.6) | 0 (0.0) | 0 (0.0) | 2 (4.1) |
| Asian | 9 (11.5) | 1 (10.0) | 3 (15.8) | 5 (10.2) |
| Native American | 0 (0.0) | 0 (0.0) | 1 (5.3) | 0 (0.0) |
| Unspecified | 1 (1.3) | 1 (10.0) | 0 (0.0) | 0 (0.0) |
| Number of infants breast fed | 1.5 ± 0.7 | 1.4 ± 0.7 | 1.6 ± 0.7 | 1.5 ± 0.8 |
Figure 1. Goal for Breastmilk Volume by Specialty
Bar graph showing the response to: “Were/are you able to meet your goal for the amount of breastmilk expressed?” by specialty (p = 0.175)
Figure 2. Anxiety Caused by Breastmilk Expression at Work
Bar graph showing responses to: “Did the expression of breastmilk at work cause you anxiety?” A significant difference was found between neurosurgical and nonsurgical respondents (p = 0.024)
Figure 3. Fear of Inability to Feed Baby
Bar graph showing responses to: “Did you fear being unable to feed your baby due to the inability to express?” No significant difference between groups (p = 0.948)
Figure 4. Workplace Support for Lactation Efforts
Bar graph showing responses to: “Did you feel supported in your lactation efforts in your workplace?” No significant difference between groups (p = 0.434)
Respondents from neurosurgery were able to express breastmilk for 10 months, while those from other surgical specialties and nonsurgical specialties continued for 18 and 49 months, respectively. However, this difference was not statistically significant (p = 0.34). When asked if respondents met their goal for lactation duration, 26 nonsurgical, 13 other surgical, and eight neurosurgery respondents responded affirmatively. This difference trended towards significance but was insignificant (p = 0.059).
Additionally, when asked if respondents were able to meet their goal for lactation volume, there was no significant difference between groups (Figure 1, p = 0.175). Of note, a significantly greater proportion of neurosurgery respondents reported that expression of breastmilk at work caused them anxiety compared to nonsurgical respondents (Figure 2, p = 0.024).
Interestingly, 60% of neurosurgery respondents continued to operate while simultaneously expressing breastmilk using a wearable breastpump, while the same was true for 47% of the other surgical respondents.
Overall, 59% of respondents felt that they did not have adequate time to express breastmilk at work, and 69% had to stop expressing breastmilk at work prior to completely emptying. Fifty-three percent of respondents feared being unable to feed their baby secondary to the inability to express breastmilk (Figure 3). Twenty percent reported never being able to consume sufficient liquid at work, and 17% reported never being able to consume sufficient calories at work.
Moreover, 50% of respondents felt that they were sometimes (less than half the time) or never supported in their lactation efforts in the workplace (Figure 4). Additional cited barriers included limited mentorship (68%), inconvenient lactation spaces (58%), perceived discrimination (32%), and breast pump malfunction (28%). Limited mentorship could include formal lactation policies, access to a lactation specialist, and/or a physician mentor within the department with lactation experience.
Discussion
Lactation Physiology
The most noteworthy event within the lactation cycle, lactogenesis, unfolds during parturition, marked by a sudden surge in the secretory activity of the mammary gland. Lactogenesis is divided into two stages; an initial phase characterized by ‘limited secretion of milk constituents in late pregnancy’ and a subsequent phase, occurring within a day or two of parturition, marked by the commencement of ‘copious milk secretion’.
Stage 1 occurs by mid-pregnancy, during which the mammary gland achieves competency for milk secretion. Elevations in lactose, total protein, and immunoglobulin concentrations occur within the secreted glandular fluid, concomitant with a reduction in sodium and chloride concentrations. This differentiation equips the gland for milk secretion, however, the inhibitory influence of elevated circulating levels of progesterone and estrogens restrain the active secretion of milk.
Stage 2 occurs around the time of delivery and signifies the onset of abundant milk secretion. This change is attributed to the rapid decline in progesterone levels following placental expulsion, coupled with increased levels of prolactin, cortisol, and insulin.
Benefits of Lactation
The current literature outlines numerous benefits of lactation to both, infant and mother. Infants who are breastfed encounter a lower frequency and shorter duration of infection, display distinct patterns of growth, and demonstrate enhanced cognitive development. Breastfeeding has also been associated with a reduced risk of sudden infant death syndrome, diarrhea, respiratory infections, malocclusion and a difference in the likelihood of chronic diseases such as obesity, type 1 and type 2 diabetes, and cardiovascular issues.
Extended breastfeeding has also shown to be beneficial towards mothers, resulting in reduced rates of ovarian cancer, premenopausal breast cancer, obesity, type 2 diabetes, and heart disease. Furthermore, mothers who breastfeed their infants are on average 8 kg lighter than those who do not, 6 years after giving birth.
Recommendations for Best Practices
Parental Leave
As of July 2021, the American Board of Medical Specialties (ABMS) mandated a minimum of six weeks of time away from training, while maintaining at least two weeks of vacation time, for parental leave. This policy has been further adopted by the Accreditation Council for Graduate Medical Education (ACGME), as of July 2023. In the same vein, the official parental leave policy of the American College of Obstetrics and Gynecology recommended paid parental leave lasting a minimum of six weeks, separate from vacation and sick time.
Lactation Spaces
As demonstrated by the current study, the availability of convenient lactation facilities poses a significant challenge to women in neurosurgery. In 2018, the Accreditation Council of Graduate Medical Education (ACGME) instructed that residency and fellowship training programs must offer lactating trainees designated private and hygienic locations to express and store breastmilk. Furthermore, these areas should be conveniently located near their clinical duties.
Protected Time to Lactate
A recurring barrier to expressing breastmilk as a trainee is the lack of time to express breastmilk with 69% of respondents in this study echoing the same sentiment. Under the Fair Labor Standards Act in the Unites States, employers are to provide ‘reasonable break time’ to allow employees to express breastmilk for up to one year following the birth of their child. On average, women need 20 to 30 minutes for milk expression every two to three hours to avoid complications.