When pregnancy and residency coincide

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Every morning at 5 a.m., Christa Foss, 42, a second-year anesthesia resident at Rutgers Health Robert Wood Johnson Medical School in New Brunswick, New Jersey, settles into the driver's seat of her car wearing an automatic breast pump.

"I set the timer and it just goes," she says. When she gets to the hospital, she transfers the expressed milk into a cooler.

Although it can be a scramble to find time to pump for her 6-month-old during her long shifts at work, the hospital provides the convenience of private lactation "pods."

"Having multiple places to pump scattered around the hospital really helps," Foss says. "You can use the [scheduling] app ahead of time, and it'll tell you which pods are in use, so you don't waste precious time walking all over the hospital."

As Foss has found, having a baby during residency can be a juggling act. With increasing numbers of women entering medicine - 55% of medical school students and 38% of physicians are now women - the issue of balancing pregnancy and parenthood with training is taking on new urgency for residents and residency programs alike. Governing bodies are strengthening guidelines aimed at meeting the needs of expectant and new mothers, and institutions are providing new support systems.

"We've come a long way in medicine to be more accepting of having kids during training," says Erika Rangel, MD, an acute care and general surgeon and medical director for Well-Being, Surgical, and Perioperative Services at Mass General Brigham in Boston. She has studied the issue extensively. "And there are a lot of things we can do to make the experience better - both from a health perspective and from a workforce sustainability and well-being perspective - and a tangible investment."

A fundamental dilemma

The average age of graduating female medical students is 28, while the average age of first birth in the United States is 27.5 years old. In other words, postgraduate training, or residency, directly coincides with a woman's peak childbearing years. Research shows that some 20% to 30% of trainees become pregnant during their residency or fellowship.

There are challenges.

Compared with the larger population, residents, who work an average of 80 hours a week, face higher odds for miscarriage and complications such as hypertensive disorders and preterm birth, and are at increased risk for their babies being born small for gestational age.

"I went into preterm labor after being up for 30 hours and delivered a premature child at 36 weeks," says Alessandra C. Gasior, DO, a colorectal surgeon at the Ohio State University Wexner Medical Center in Columbus.

Lead author of a 2024 survey of physician mothers on their experience during residency and fellowship, Gasior found that more than half of the survey's respondents thought the physical demands of their jobs compromised their own health and safety or that of their child. It's a particular concern for surgical residents, likely due to the physical rigors of training - i.e., long hours in the operating room on their feet. New mothers also reported high rates of burnout, postpartum depression, and relationship stress during their training years.

Waiting until training is complete to start a family has its own set of potential risks.

"We know there are biologic consequences to delaying - higher rates of infertility, higher rates of needing assisted reproduction - which is an additional burden on top of the heavy professional burden that people have now," says Linda Brubaker, MD, editor-in-chief of JAMA+ Women's Health.

However, providing accommodations for expectant or new mothers, such as time off for appointments or more favorable work schedules, can mean that other residents shoulder an unfair burden of work, which can fuel resentment.

New paradigms of support

Nevertheless, experts see signs of change on the horizon. In 2022, the Accreditation Council for Graduate Medical Education (ACGME) mandated at least six weeks of paid parental leave for residents, which applies to both genders and includes those who adopt babies. This paid time off has long been a thorny issue (though many would like to see more time off). And the American Board of Medical Specialties allows this leave without its affecting board eligibility.

In addition, "an increasing number of specialties actually are coming out with position statements around pregnancy," says Katharine Caldwell, MD, a surgery fellow at Washington University School of Medicine in St. Louis. "I'm pleased to see that, in many ways, surgical subspecialties have been leading the way."

Caldwell chaired the Council of Review Committee Residents Pregnancy in Training Task Force of the ACGME, which in 2025 issued comprehensive recommendations for residency programs. One key provision is that programs have an explicit policy that addresses the pregnancy-related needs of trainees, from preconception to the return to work, including assisted-reproduction and lactation needs. Data show that residents are often unaware of their institution's policies. In some cases, no policy exists.

"No one should be having to come up with this for the first time on the day a resident comes into their office and says, 'I'm 20 weeks pregnant,'" says Caldwell.

Among other actions, the recommendations call for individualized scheduling, including the elimination of overnight calls and shifts exceeding 24 hours during the third trimester of pregnancy. Program directors are encouraged to consider assigning residents near the end of pregnancy, or the first few weeks after their return, to rotations with minimal clinical burden, such as electives and research blocks and, to minimize the scheduling difficulties, calling on advanced-practice clinicians and faculty to fill gaps in clinical coverage.

"Programs need to be capable of handling [these recommendations] in a way that's equitable and supports the trainees who have children during training but also does not unfairly burden trainees who do not," says Caldwell.

One idea: "Programs can set aside money to cover the X number of calls from a six-week parental leave, then get volunteers to take those calls and receive X dollars per call," suggests Brubaker, who urges programs to experiment with creative approaches.

In fact, "there is not a one-size-fits-all solution, because every specialty and every program is going to have different demands and different resources," says Caldwell. "What can be done in an internal medicine residency that has 50 residents is very different from what can be done in a neurosurgery residency that has three."

Other recommendations pertain to lactation. While acknowledging that current ACGME institutional requirements ensure access to spaces for pumping, the task force recommends that the ACGME mandate protected time for trainees to express milk during clinical duties as well as policies supporting lactation in procedure areas, such as the use of wearable breast pumps if desired.

A proven intervention

A new study from Massachusetts General Hospital, published in JAMA last month, suggests that such efforts can succeed. The randomized controlled trial of 143 participants at several institutions assessed a four-pronged approach to supporting residents during pregnancy and the return to work after parental leave, with the goal of minimizing burnout and improving well-being.

"We found in our past work that burnout really goes up between pregnancy and six months postpartum," says Rangel, the study's lead author. "It's a very challenging time, where your personal and professional lives collide in a way that is unprecedented."

The intervention package consisted of a wearable breast pump that could be used during clinical hours; a "smart" bassinet equipped to soothe distressed infants, to protect mothers' sleep; an app providing 24-7 access to specialists to troubleshoot medical challenges; and a dedicated faculty mentor with childbearing experience to provide personal support during the pregnancy and postpartum period. A control group received standard support.

"We used our prior research with pregnant trainees to define the huge pain points that you can have along the way and then choosing, among them, pragmatic things we can fix with a reasonable sum of money," says Rangel.

The findings were stark. "Burnout rose significantly in the control group but stayed flat in the intervention group," Rangel adds.

Tina Moon, MD, 34, a plastic surgery resident at Mass General Brigham, participated in the trial two years ago.

"It was my first pregnancy, and especially being in a surgical residency, I was unsure of how that would be perceived," she says.

The benefits she received made her feel positive and cared for.

"Having that level of support and continuous check-ins with my mentor throughout the pregnancy and afterward was life-changing," she says.

The study also saw a large ROI. Physician burnout is estimated to cost $7,600 per employee, says Rangel, while the cost of the intervention was just $2,300.

From accommodations to assists

Experts have other ideas for how to better support both residents who become pregnant and their programs. Among the "low-hanging fruit," Rangel says: "Everyone should be able to make their [pregnancy-related] doctor's appointments, including those for fertility care and prenatal care. That should be a baseline." Women should also be allowed to take time off after miscarriages, she adds.

"There are a lot of programs that are trying in smaller ways, modifying schedules and being a little more flexible right before leave or right after you come back," says Gasior. Often residents find their call schedules are fullest at these times.

"In a perfect world we would not front-load pregnant women with additional call when they're at their most vulnerable," she says.

Work limitations in the last trimester are a worthy goal, Rangel agrees. But this is a tricky proposition when there is a limited workforce. To make things work, she has found that some residents prefer night shifts at that time in their pregnancy, specifically those in the surgical program.

"Some have told us that they're not operating all night long, but are putting out fires on the floor, which can be a lot more comfortable to do late in pregnancy because there is some opportunity to get off their feet," Rangel says. "That created the opportunity for a win-win situation where they were willing to take a few night shifts and were off-loading operative time to the nonpregnant residents, which they prefer. In that way, the pregnant trainee becomes a really valued asset on the team."

The same arrangement may work as well for postpartum trainees, who may like the chance to spend time with their children during the day.

For their part, residents are encouraged to give program directors an early heads-up when they become pregnant, thus giving them time to tweak call schedules for the best possible outcomes.

"When I was a program director, I would say, during residency orientations: 'I don't want to be the first one to know, but I want to be in the first five to know,'" says Douglas Smink, MD, MPH, chief of surgery at Brigham and Women's Faulkner Hospital in Boston. After all, he adds, "over the course of a residency program, every resident is going to need to lean on their colleagues in some way."

With the ratio of women to men in residency programs increasing, some see evidence of a culture shift when it comes to supporting residents and fellows through the transition to parenthood. In many programs, residents who are pregnant or postpartum, like Moon was, are increasingly able to rely on those who have come before them.

"Our generation of women who've gone through residency and maybe didn't have those role models now are trying to become role models for others," says Gasior. "If I have a pregnant resident or pregnant medical student, I am looking out for them. I'm not only giving them whatever hand-me-downs I have, but also making sure they're taking care of themselves - taking breaks, eating and drinking properly, and going to their doctor's visits."

Says Caldwell, "Programs have it within their power to actually make the experience so much better for these individuals, just based around a culture of support."