A Practical Approach to Childbearing in Fellowship Training

Case: You are a G0P0 fellow in hematology-oncology and find out that you are pregnant. You have started to experience some pregnancy-associated symptoms and are feeling somewhat overwhelmed by the realities of pregnancy. What can you do to integrate your pregnancy and future child into your medical training?

Family building is an intensely personal journey, and studies indicate that many physicians of reproductive age desire children.¹ Compared to the general population, female physicians have a higher rate of delayed childbearing and infertility.^2,3 Further, pregnancy in medical trainees can be associated with increased psychosocial burdens.⁴ While there is no panacea for the challenges of childbearing, we aim to provide some practical strategies for navigating cultural and organizational barriers presented by hematology and oncology fellowship. This article will focus predominantly on pregnant trainees, though it may also present useful information for other means of family building (e.g., adoption, surrogacy). If you are currently trying to get pregnant while in medical training and having a difficult time, it may prove helpful to use an ovulation tracking kit/app and/or discuss things early on with your obstetrician (OB).

Who needs to know?
First, congratulations! While many women wait until the early second trimester to share news of their pregnancy, you should consider letting your program director (PD), chief fellow, and program administrator know as soon as you feel comfortable sharing, as this will provide the maximum time for planning. Email communication is sufficient and can make for a less intimidating conversation. It may also be beneficial to let your other mentors know, as they may be able to help structure your experiences in ways that allow you to maximize training and protect your leave. Finally, if your duties require you to do something dangerous or that you do not feel comfortable with while pregnant (e.g., administering intravenous chemotherapy or seeing a patient with a zoster infection), it is appropriate to ask program leadership to help you arrange coverage with (or without) disclosing the pregnancy to other colleagues.

Physical challenges associated with pregnancy
A hematology fellowship can present multiple challenges when dealing with pregnancy symptoms. Take care of yourself first. Suggestions include minimizing discomfort by staying hydrated, eating regularly, and wearing compression stockings and breathable clothing. Try to get as much rest as possible, delegate tasks, accept help, and be unafraid to ask for what you need, such as sitting instead of standing or taking a break. Discuss symptoms with your OB early, as supportive medications such as antiemetics may help get you through the day. If you are taking board exams while pregnant (or nursing), apply for accommodations to help you be successful. Pregnancy can also complicate planning for the future, including advanced fellowships or jobs after fellowship. If possible, start the application process early, which will give you more time and flexibility for interviews and negotiations. Keep in mind that travel during the third trimester will be limited, and being visibly pregnant during an interview can be daunting. Consider using such challenges as an opportunity to ask a potential employer about leave and family support policies.

Navigating leave
You will need time for appointments and maternity leave. See Table 1 for some possible solutions to common scheduling problems. Maternal discrimination has been reported in medicine,⁵ but gathering support from those you trust may allow you to focus maximally on your family during this phase.

Institutions vary widely in their approach to parental leave, and the sooner you know your institution’s policies, the more input you may have. The American Board of Internal Medicine (ABIM) allows five weeks for leave of absence and vacation (35 days) and five additional weeks for “deficits in required training,” meaning that the maximum ABIM allows is 10 weeks total leave (including vacation time) without extending training.

Financial considerations
Having a baby on a trainee salary can also be a challenge, so planning while pregnant can ease stress. Check your insurance policy to understand what medical bills to anticipate, as well to find information on insurance-covered breast pumps. Aim to budget baby-associated costs including, if needed, child care. (Per the U.S. Census Bureau, child care generally ranges from $5,000 to $17,000 annually, and in some locations costs even more).⁶ While you may still be paying back your own loans, starting to save for your baby’s future education costs early is recommended and can be done through 529c savings accounts. Also make sure that any life or disability insurance policies and wills match the needs of your growing family.

Conclusions
There is no perfect template for successfully completing hematology training after having a baby. Anticipate that it will take time to rebalance your personal and professional life. Your family’s needs and preferences will likely continue to change as your baby grows, so it’s helpful to have flexibility to reevaluate your plans over time. Some important postpartum considerations are summarized in Table 2.

Having a baby while in medical training is a source of tremendous joy, but it also comes with significant challenges. Planning in advance and communicating with a trusted support network within (and outside of) the hematology-oncology section can help you engage more fully in both your personal and professional life.

Table 1. Scheduling considerations

Problem	Possible Solutions
Numerous doctor appointments during (and after) pregnancy	Schedule appointments as early as possible so that you can have maximum flexibility. Disclose the pregnancy to your PD/chief fellow/administrator so they can help ensure you have time for appointments. Choose an OB close to home or work to minimize travel time.
Debilitating pregnancy symptoms	Consider altering your schedule so you have less-intensive rotations during pregnancy. (Symptoms are often worse during the first and third trimesters.) See the section on “Physical challenges associated with pregnancy” for additional suggestions.
Patient care duties during your leave	Work with your PD, chief fellow, and covering colleagues for a smooth transition during leave. Have a clear coverage plan for emergencies, inbox messages, and any other duties for which you would normally be responsible.
Deadlines will not pause while you are pregnant or on leave	Consider communicating early with your mentors to determine the best way to advance projects during your pregnancy/leave. Use resources available to you or your mentors to advance projects such as mobilizing additional help. Aim for local conferences or other opportunities that can be attended virtually. Some funding mechanisms/grants (such as the ASH Research Training Award for Fellows) allow for no-cost extensions for maternity leave. If you have grant funding, ask early about maternity leave policies and secure an extension if possible.
Limited amount of leave may feel like a short time to recover physically and bond with your new baby	If your allotted leave time is insufficient, have a discussion with your PD and human resources about your unique circumstance to see if you can get an extension or schedule changes to make the transition easier. Schedule lighter rotations upon your return to work. Heavier clinical rotations can be strategically scheduled, such as prior to or during pregnancy and later in the current or subsequent academic year(s). If applicable, learn about your partner’s leave policy to plan strategically, such as employing tandem maternal and paternal leave. If possible, enlist help from extended family members or close friends to ease the transition for you and your newborn.

Table 2. Postpartum considerations

	Background	Considerations
Mental Health	Mood disorders are common both during pregnancy and post-partum. Risk factors for postpartum depression include a previous episode of major depressive disorder, life stress, and lack of social support (all of which may be true of medical trainees.)⁷ Screening is not universally recommended.	Discuss mental health with your OB before delivery to assess your risk. Communicate with your provider early if symptoms arise. Treatment options are available. Familiarize yourself with your institution’s mental health support resources and use them if needed. Formal or informal support groups with other moms at work or in other areas of your life can ease the stresses of transitioning to motherhood.
Child Care	High-quality child care can impact development.⁸ There are many possible caregiving scenarios (nannies, nanny shares, and daycare are common), and quality of care, hours of care, convenience, and price are major considerations for fellows.	Consider multiple child care scenarios and interview candidates or facilities to understand the pros and cons. Start early. Daycares often have long wait lists, and you may want to explore the most cost-effective option, so consider getting on these lists early on in your pregnancy to give you options. If your child is placed in group care, he or she will get sick more often. Know your jeopardy coverage system and work out a plan with your partner (and any backup care) for who will be available if illnesses arise.
Lactation / Breastfeeding	Nearly half of physician mothers would breastfeed longer if their jobs were more accommodating, and only 24.8% of trainees breastfed to their personal goal.⁹ Barriers to breastfeeding for physician mothers include inadequate time to pump, schedule inflexibility, and inadequate space.⁹	Choose the feeding strategy that makes sense for your family, which may change over time. If lactation is important to you, there are ways to make it work during fellowship training. Communicating with clinic and inpatient colleagues about pumping schedules and how you will complete your work can facilitate clear expectations for moms to express milk with appropriate frequency. A wearable pump during clinic/inpatient duties can help reduce the need for dedicated space. Hospitals usually publish information on their lactation spaces, though empty clinic and call rooms work well for pumping too. Plan ahead to use pumping time for charting or clinical duties as able, and to store milk and pumping supplies nearby.
Sleep	Tailored sleep interventions are associated with a reduction in infant sleep problems and reduced long-term maternal depression symptoms, without differences in child behavior or relationships.^10,11	Sleep training is not for everyone, but there are many different methods that may be considered (and discussed with your pediatrician) if you are not getting enough sleep to function at work.
Outsourcing	Female physicians name conflicts between work and family as a limit to academic productivity.¹² Time is a precious resource during fellowship.	Outsource things that do not increase your quality of life. Cleaning services, grocery delivery services, and laundry services are available for a variety of budgets and can help decrease domestic burdens for physician parents.

Levy MS, Kelly AG, Mueller C, et al. Psychosocial burdens associated with family building among physicians and medical students. JAMA Intern Med. 2023;183(9):1018-1021.
Stentz NC, Griffith KA, Perkins E, et al. Fertility and childbearing among American female physicians. J Womens Health (Larchmt). 2016;25(10):1059-1065.
Cusimano MC, Baxter NN, Sutradhar R, et al. Delay of pregnancy among physicians vs nonphysicians. JAMA Intern Med. 2021;181(7):905-912.
King Z, Zhang Q, Liang JW, et al. Barriers to family building among physicians and medical students. JAMA Netw Open. 2023;6(12):e2349937.
Adesoye T, Mangurian C, Choo EK, et al. Perceived discrimination experienced by physician mothers and desired workplace changes: a cross-sectional survey. JAMA Intern Med. 2017;177(7):1033-1036.
Yonkers KA, Vigod S, Ross LE. Diagnosis, pathophysiology, and management of mood disorders in pregnant and postpartum women. Obstet Gynecol. 2011;117(4):961-977.
Grundy, A. Estimated revenue for child day care services climbed as child care options declined in 2021. United States Census Bureau. Accessed July 12, 2024
National Institute of Child Health and Human Development Early Child Care Research Network. The relation of child care to cognitive and language development. Child Dev. 2000;71(4):960-980.
Melnitchouk N, Scully RE, Davids JS. Barriers to breastfeeding for US physicians who are mothers. JAMA Intern Med. 2018;178(8):1130-1132.
Hiscock H, Bayer J, Gold L, et al. Improving infant sleep and maternal mental health: a cluster randomised trial. Arch Dis Child. 2007;92(11):952-958.
Hiscock H, Bayer JK, Hampton A, et al. Long-term mother and child mental health effects of a population-based infant sleep intervention: cluster-randomized, controlled trial. Pediatrics. 2008;122(3):e621-e627.
Reed DA, Enders F, Lindor R, et al. Gender differences in academic productivity and leadership appointments of physicians throughout academic careers. Acad Med. 2011;86(1):43-47.

Dr. Cooperrider's husband is employed by Abbvie, Inc. Drs. Dykes and Williams indicated no relevant conflicts of interest.

Acknowledgment: This article was edited by Drs. Emily Liang and Robert Stern.