Residency and fellowship are unique occupational time periods for many early career physicians, generally consisting of long duty hours. Many early career physicians have or are in the process of building their families during this time period. The literature suggests many medical and psychosocial benefits of protected parental leave for both parents and children, which necessitates parental leaves of absence. The Institutional Requirements of the Accreditation Council for Graduate Medical Education require training programs to provide written policies regarding leaves of absence, including parental leave, and these policies must comply with current legislation such as the Family Medical Leave Act. The length of leave has considerable variability among residency programs. This policy statement aims to navigate and outline the challenges of parental leave policies in training programs and to put forth recommendations to protect trainees and their families. The definition of families should also be expanded to include all types of families.
Parental leave policies that address the well-being of pediatric trainees, families, and their children are under development by many residency and fellowship programs. Residency and fellowship are unique occupational time periods for many early career physicians that are characterized by long duty hours that often include 24-hour coverage. Adherence to current work hour requirements of the Accreditation Council for Graduate Medical Education (ACGME) can often disrupt and complicate the lives of trainees who are building their families as well as for their covering colleagues. The programs acknowledge the paramount importance of parent-infant attachment in the first weeks of life and that protected time at home fosters the development of healthy relationships and practices, such as breastfeeding.1
All accredited residency training programs are required by the Institutional Requirements of the ACGME to provide written policies on residents’ vacations and other leaves of absence (with or without pay), including parental and sick leave. These policies must comply with applicable laws, such as the Family Medical Leave Act (FMLA). Each program also must provide its residents with a written policy explaining the effect of leaves of absence for any reason on satisfying the criteria for completion of the residency program and information regarding eligibility for certification by the relevant board.2
The previous American Academy of Pediatrics (AAP) policy statement recommended that regardless of gender or type of parenting involved, residents who become parents should be guaranteed a minimum of 6 to 8 weeks of parental leave with pay and, in accordance with federal law, should be allowed to extend the leave time when necessary, by using paid vacation time or leave without pay.3 Nevertheless, this recommendation is not frequently followed. In a survey of surgical residents, 58% of program directors stated that residents who give birth are provided with 6 weeks of maternity leave, and the nonchildbearing parent receives 1 to 2 weeks.4
In addition, emphasis is placed on maternity leave despite the evolution of the definition of a family. Although most programs have a maternity leave policy, less than half have a paternity leave policy, and even fewer programs have an adoption leave policy. Same-sex families or other situations, such as surrogacy, in which neither individual is the child-bearer, might not be covered by such policies because traditional terminology does not apply to them.4 Foster parenting and any other family definition should also be covered by parental leave policies.
The FMLA grants families up to 12 weeks per year of unpaid, job-protected leave for a family member’s serious illness while maintaining group health benefits during this time. Parents must be allowed this same amount of leave for the birth or adoption of a child.5 In 2011, the US Supreme Court ruled that residents are employees and, therefore, protected under FMLA. However, to be eligible, residents must be employed for 12 months and have worked at least 1250 hours prior to the start of FMLA, which may not cover graduate medical education (GME) trainees in their first year.6 This legislation is pertinent, because many pediatric trainees become parents. One-half of women who enter the field of medicine give birth to their first child during their residency training.7 In addition, the percentage of women graduating from medical school has been consistently increasing, and in pediatrics, the majority of trainees are women.8–10
Training Status and Make-Up Time
According to the American Board of Pediatrics, 33 months of categorical pediatrics training is required for eligibility to take the certifying examination, with a total of 3 months allowed for vacation, sick leave, parental leave, and other time off. Any further time off must be made up, unless the program director submits a petition to the board to request an exemption allowing a well-qualified resident an additional 1 to 2 months of leave. The waived training experiences can only be electives, and the request should come toward the end of the residency to allow the program director to fully assess the resident’s competence.11
In a review of 24 primary specialties recognized by the ACGME for board certification, residents in multiple areas, including pediatrics, who take FMLA leaves of 12 weeks must extend their training by a median of 6 weeks. In some programs, including pediatrics, this can lead to a delay in their certifying examination of 6 to 12 months. In 71% of surveyed specialties, this 12-week leave delayed fellowship training by at least 1 year.12 Employment may also be delayed by several months. These delays have the potential to increase gender inequity in academic and career advancement as well as salary for women in pediatrics.
Benefits of Paid Leave
Paid leave can provide multiple benefits to both parents and infants, from mental and physical health standpoints. Paid leave may lower infant mortality by increasing initiation and duration of breastfeeding and supporting a parents’ ability to ensure their child receives essential immunizations and other postnatal care.13 In the first postpartum year, an increase in leave duration was associated with decreased maternal depressive symptoms until 6 months postpartum. A marginally significant linear positive association between leave duration and maternal physical health, especially during the first 12 weeks after childbirth, has also been noted.14
There has been more emphasis on trainee well-being over the last few years. Recent literature describes emotional intelligence as a strength of resident-parents, attributed to their unique perspective gained through their role as parents.15 In one survey, trainees indicated that parenthood made them a better doctor and that children reminded them of human fragility and vulnerability. Therefore, paid family leave is critically important as it is associated with better maternal and infant health outcomes and can close the gender presence, pay, and productivity gaps in academics and emphasize resident well-being.16
Pregnant and Postpartum Women’s Concerns
Medical school, residency, and fellowship training are highly stressful periods in a physician’s life that may lead to several adverse consequences in the perinatal period. These consequences may affect the length of parental leave required. Multiple studies confirm pregnant residents’ concerns that their job’s physical demands confer higher risks for their pregnancy or childbirth.17 Increases in pregnancy complications, such as preterm labor, preeclampsia, and fetal growth restriction, have been associated with strenuous working conditions during residency training.18 Placental abruption, hypertension, intrauterine growth restriction, and miscarriage rates were higher in medical and surgical residents than in a control group, with a complication rate of 34%. In addition, long working hours and prolonged standing have been associated with adverse pregnancy outcomes, including preterm labor.19
Pregnant residents also correctly worry that taking parental leave and then needing flexibility to care for their child and pump breast milk, will alter their fellow residents’ and attending physicians’ perceptions of them. For instance, one study showed that although faculty did not rate them lower, female internal medicine residents who had been pregnant received lower peer evaluations than their male colleagues.20 Furthermore, a significantly higher portion of male trainees report being disadvantaged by colleagues taking parental leave.21 In addition, verbal criticism from faculty and other residents can be a significant issue.21 More than 40% of women taking parental leave reported experiencing negative comments about their leave, and about 25% reported being questioned about their intentions for future pregnancies in relation to job interviews.21 A culture change is needed to better support pregnant and parenting residents.22–24 For instance, although pregnant and postpartum residents may feel guilty for putting additional work onto their colleagues, residents who can take longer maternity leaves report feeling more supported by their fellow residents and program directors.17 This may reflect a culture of acceptance and not inconvenience if a program can plan for and accommodate maternity leaves. Support of attending physicians does not vary much with length of maternity leave, as their own work may not be affected significantly by maternity leave.16
Child Care Issues
When they return to work, resident parents need child care that is stable and flexible to cover call shifts and periods of illness in the child. In a multicenter survey of residents, affordable child care was difficult to find and was an infrequent benefit in residency. Only 25% of available child care facilities at institutions reserved spaces for trainees. However, 47% of resident and fellows used a child care facility, and 37% relied on a stay-at-home spouse, 25% employed a nanny, and 10% used extended family.25 Child care issues could be improved with extended hours or on-site child care as well as sick child care.23,26,27
Written Policy Existence and Awareness
The ACGME states that programs must have a leave policy but does not specify the contents, resulting in great variability between programs.28 In one study, only 8 of 15 GME sponsoring institutions at top training programs evaluated had policies providing either paid childbearing or family leave for residents, although all 12 had policies for faculty physicians.29 In a survey of AAP member students and trainees regarding knowledge of parental leave, 30% were unaware of their training program’s policy for parental leave.30 Also noted was a significant difference in awareness between men and women and between those with and without children.30
Parental Leave Policies Vary Across Programs
Parental leave length varied between different residency programs and specialties but was found to have a median length of 5 to 8 weeks for mothers and less than 1 week for fathers.31 In pediatric programs, the average parental leave time was 8.57 weeks, with almost 30% of respondents reporting a duration of less than 6 weeks.30
Financial considerations play a large part in parental leave decisions. Residents may take FMLA for up to 12 weeks unpaid, making finances difficult for many families.5 Furthermore, if residents need to extend training time, the most significant funding sources for GME, the Centers for Medicare and Medicaid services (CMS) and Veteran’s Health Administration, do not provide additional resources to pay them.6 Arranging temporary disability insurance may provide financial assistance to residents.32,33 An employer pays, on average, $0.15 per employee per hour worked for short-term disability coverage.34 The cost of temporary or short-term disability insurance could be borne either by the trainee or by the training program to defray some of the financial burden of parental leave. Some programs may provide a “rainy day fund” to cover some time off.35
Additional Return-to-Work Concerns
Lack of time to pump breast milk and inadequate facilities create hardship for lactating residents.4,24,36,37 A half-hour break every 4 hours was provided for lactation in one program.37 Further, the physical demands of childbirth and child rearing may make the transition back to work difficult. At the time of initial return to work, only 9% of respondents in one study had less inpatient time and 9% returned to a research year; 86% had no adjustment made to their schedule.38 A graduated increase in shifts may make postnatal return to work more feasible.36
Creative Solutions to Parental Leave Issues
Pediatric residency programs are not the only ones addressing parental leave issues. General surgery and surgical specialties, internal medicine, obstetrics and gynecology, radiology, and emergency medicine programs have contributed ideas to improve the current situation. These include:
Conference attendance via remote access, PowerPoint presentations with voiceovers.40
Allowance of nondisruptive children at all conferences with content appropriate for younger children.37
Changes in training length that include more combined undergraduate/MD programs or more direct training pathways such as combined general and specialty certification.41
Other physicians hired to cover pregnant or parenting residents such as via shared residency slots, coverage by paid clinical associates, including other hired residents or locum tenens physicians.24,33,42
Adding support to residents doing additional coverage, although work hour restrictions may make it difficult to find overtime coverage.43
Competency based assessments of resident readiness for certifying board examinations versus pure time in training.4,26,33 Indeed, 8 specialty boards had explicit and clear language that allowed program directors to seek exemption of resident physicians from time-based training requirements without extending training duration.44
Parental leave is necessary for both parents and children to have time to bond, to promote healthy child development in the earliest months of life, and for postpartum mothers to physically recuperate. However, the length of the leaves, who takes them, whether they are paid or unpaid, who should cover, and how return-to-work should occur, are still hotly debated and variable. The AAP recommends the following be considered to improve parental leave for both residents and their partners and children as well as for program directors, fellow residents, and faculty. All training programs, pediatric program directors, AAP members, and pediatric trainees should advocate for the following to increase quality parental leave policies and benefits:
The ACGME should require programs to have a written parental leave policy stipulating that all residents who become parents, regardless of gender or type of parenting, can take time off after a new child enters their family. This policy must be in accordance with federal law and be presented to all interviewing residency candidates and to residents at the beginning of their training and periodically thereafter. A minimum of 12 weeks should be guaranteed, with additional time allowed as requested. This policy should explain potential ramifications to board examination times and fellowship or employment commencement. Medical training programs should update the terminology used to be more inclusive: maternity and paternity leave, gender-neutral parental leave, and return-to-work.
Pediatric societies, such as the AAP, Academic Pediatric Association, Association of Pediatric Program Directors, ACGME, and the Residency Review Committee should work with the American Board of Pediatrics to expand competency-based residency completion and add flexible examination dates for parenting residents.
Pediatric training programs should alter the culture to embrace parenting residents.
Training institutions should give serious consideration to creating 24-hour on-site child care and sick child care centers or actively facilitate access to these services in a convenient location for all residents who want them.
Programs should have lactation sites and equipment available at all resident work locations and provide residents adequate protected time to pump.
Training programs should design flexible scheduling options to allow less strenuous rotations for pregnant and returning residents. Creative training opportunities such as remote learning platforms, parenting electives, and mentored research or scholarly activities should be explored to decrease time off.
Programs should work with the Centers for Medicare and Medicaid Services, hospitals, universities, and the private sector to fund paid parental leave. Tax credits and tax-advantaged health savings accounts for new parents could offset the financial impact of paid parental leave.
Residency program directors should build a culture that supports trainees in sharing information about their pregnancies (whether their own or their partners’) or other additions to their families (adoption, foster care) as early as they are comfortable. This will allow adequate time to adjust schedules to better accommodate both the resident trainees and their colleagues.
Jennifer Takagishi, MD, FAAP
Katiana Garagozlo, MD
Council on Early Childhood Executive Committee, 2019–2020
Sherri Louise Alderman, MD, MPH, IMH-E, FAAP, Chairperson
Mariana Glusman, MD, FAAP
James P. Guevara, MD, FAAP
Andrew Nobuhide Hashikawa, MD, FAAP
Anna Miller-Fitzwater, MD, FAAP
Dipesh Navsaria, MD, MPH, MSLIS, FAAP
Bergen Ballard Nelson, MD, FAAP
Jill M. Sells, MD, FAAP
Amy E. Shriver, MD, FAAP
Douglas Lee Vanderbilt, MD, FAAP
Ami Gadhia, JD – Child Care Aware of America
Michelle Lee – Section on Pediatric Trainees
Dina Joy Lieser, MD, FAAP – Maternal & Child Health Bureau
Lucy Recio – National Association for the Education of Young Children
Florence Rivera, MPH
Section on Pediatric Trainees Executive Committee, 2019–2020
Christina M. Kratlian, MD, MA, Chairperson
Catherine Grace Coughlin, MD
Laura Chilcutt, MD
Shawnese Gilpin Clark, MD
Ashley Morgan Ebersole, MD, FAAP
Christopher Gable, DO
Hannah Glanz, DO
Amelia Mackarey, MD
Margaret Mou, DO, FAAP
Tatiana Ndjatou, MD
Lauren Elizabeth Nelson, MD
Chloe Opper, MD
Kylie Loutit Seeley
Allison Black, MD, FAAP, Immediate Past Chairperson
Julie Raymond, CAE
Drs Takagishi and Garagozlo were equally responsible for conceptualizing, writing, and revising the manuscript and considering input from all reviewers and the board of directors. Both approve of the final publication.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.
The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, considering individual circumstances, may be appropriate.
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.