Differing Experiences with Breastfeeding in Residency Between Mothers and Coresidents

Introduction

Physicians are often expected to be champions of breastfeeding given the well-documented health benefits for both infant and mother and current professional organization recommendations for breastfeeding until at least 12 months of age. ¹ However, the rates of breastfeeding among physician mothers are less than the national average^2–7 and reflect that there are additional barriers for this group that are only recently being examined.^8–11 Aside from the inherent challenges of breastfeeding that many mothers experience such as supply concerns, extrinsic factors such as a navigating breastfeeding in the workplace can pose additional impediments that affect a mother's ability to continue breastfeeding after returning to work. This is particularly true for physician mothers who frequently list lack of appropriate time and location for pumping. ¹⁰

As more residents are choosing to start families during residency,^10,12–14 there is increasing attention to the difficulties of breastfeeding during residency. ¹⁵ Many of the challenges previously discussed have focused on the need for time and space to facilitate pumping while at work; however, our work illustrates that as the practice of medicine becomes more team-based, the attitudes about breastfeeding from both resident mothers and their coresidents are important considerations for successfully implementing policies and systems to facilitate breastfeeding and team-based medicine. We hypothesized that resident mothers would have varied perceptions of the challenges they experienced while pumping and of the effects that their pumping had on their teams. Furthermore, we hypothesized that resident mothers would view pumping at work as a more significant burden on their team than actually experienced by their coresidents.

Materials and Methods

An online survey (Qualtrics, Provo, UT) was sent to all residents in Pediatrics, Internal Medicine, Anesthesia, and Family Medicine at the University of Michigan. The survey was voluntary, anonymous, and was deemed exempt by the institution's institutional review board committee (HUM00134687). The survey was distributed by individual residency program leadership, and survey responses were collected over a 7-day period. The survey contained 24 multiple choice and free-text questions that identified gender, individuals who had breastfed during residency, and residents who had worked with breastfeeding residents. Additional questions for resident mothers who breastfed during residency focused on duration of breastfeeding, challenges encountered while breastfeeding, and ability to pump while at work. Residents who worked with breastfeeding residents were identified and asked questions about the impact of resident mothers pumping at work and its effect on team dynamics and patient care. All questions were optional and respondents were allowed to skip questions if they preferred not to answer them. Previous surveys have focused on barriers encountered while breastfeeding in residency. Our survey of both breastfeeding residents and their coresidents examining perceptions on team efficiency is a novel contribution of our study. Statistical significance of respondent demographics was calculated by chi-squared testing in Excel (Microsoft, Redmond, WA).

Results

Surveys were sent to 413 residents from Pediatrics, Family Medicine, Internal Medicine, and Anesthesia residency programs at the University of Michigan in the fall of 2017. There were 161 internal medicine residents surveyed (96 men and 65 women). There were 106 pediatrics residents surveyed (24 men and 82 women). There were 34 family medicine residents surveyed (12 men and 22 women). There were 112 anesthesia residents surveyed (66 men and 46 women). A total of 82 responses were collected (20% response rate). Twelve respondents (15% of respondents) reported having a child during residency or within 12 months of starting residency. Response rate surveyed varied significantly based on gender (n = 58 female respondents, 27% response rate among women, whereas n = 24 male respondents, 12% response rate among men, p < 0.05).

Breastfeeding residents' experiences suggest that resident mothers encounter common challenges

Resident mothers had similar experiences during their first months of motherhood. All resident mothers who responded to the survey breastfed their infants. The majority (n = 9 of 12 responses, 75%) of resident mothers felt pressured to breastfeed, almost unanimously self-induced (n = 8 of 9 responses, 89%). Most (n = 8 of 12 responses, 66%) experienced some or significant difficulties during the first 4 weeks (Fig. 1A). The difficulties with breastfeeding in the first 4 weeks frequently affected the mother's mood (n = 7 of 10 responses, 70% as shown in Fig. 1B). The length of maternity leave varied from 6 weeks to more than 3 months in an evenly distributed manner. Almost all mothers (n = 11 of 12 responses, 92%) encountered difficulty in breastfeeding after returning to work (Fig. 1A), and the majority of mothers reported that their mood was affected by these difficulties (n = 10 of 12 responses, 83% as shown in Fig. 1B). All resident mothers breastfed (or planned to) for at least 6 months. The majority (n = 9 of 12 responses, 75%) breastfed for 12 months or greater (or planned to breastfeed until child was 12 months old).

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FIG. 1.

Resident mother difficulties in breastfeeding in the first 4 weeks and upon returning to work. Results are presented for the following statements on a Likert scale on the x-axis and the y-axis showing percentage of respondents. (A) Did you have difficulties in breastfeeding? (B) How often did breastfeeding difficulties affect your mood?

The most common challenge that breastfeeding residents encountered was not enough time to pump. Other common issues were inadequate storage space for breast milk, inadequate resources to continue working in the space provided to pump (e.g., phone, computer), inefficient or ineffective pumping felt to be related to maternal stress, and inadequate milk supply overall. The majority of breastfeeding mothers felt that they were not able to pump as often as they would have liked (Fig. 2A). The majority of breastfeeding mothers felt that attending and coresident attitudes toward their pumping were neutral to positive (n = 8 of 10 responses, 80%, Fig. 2B). When resident mothers were asked about specific rotations or clinical settings that were most and least accommodating, there was a wide range of opinions (Fig. 2C). Less structured experiences (such as night coverage) were generally felt to be better while high-intensity environments (emergency department, procedural settings) were less accommodating. Residents had mixed opinions about outpatient clinics, indicating the variability of each resident's experience. Unanimously, all breastfeeding mothers felt that their ability to attend educational opportunities was affected by pumping. Breastfeeding residents were concerned that their pumping negatively influenced their clinical functioning. Forty percent of breastfeeding residents felt that their team was negatively affected by their pumping and 10% felt that patient care was impacted.

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FIG. 2.

Resident mother perspectives with breastfeeding during residency. Results are presented for the following statements on a Likert scale on the x-axis and the y-axis showing percentage of respondents. (A) I was able to pump as much as I wanted. (B) Pumping was encouraged. (C) Resident mothers were asked to identify the most and least accommodating hospital settings to pump along the x-axis and the percentage of respondents is graphed on the y-axis.

Coresident experiences of working with a breastfeeding resident are largely positive

The majority of all residents in this survey (n = 61 of 82 responses, 74%) have worked with another resident who was breastfeeding on their team. Additionally, resident mothers were also allowed to provide responses about working with other breastfeeding residents. A small fraction (n = 3 of 82 responses, 4%) were uncertain if they had worked with a breastfeeding resident. In comparison to breastfeeding residents, their coresidents felt that team efficiency (n = 48 of 63 responses, 76% as shown in Fig. 3A) and patient care was not compromised by their coworkers' pumping (n = 59 of 63 responses, 94% and shown in Fig. 3C). Coresidents of breastfeeding residents reported that they were available by pager or phone while pumping (n = 46 of 63 responses, 73% as shown in Fig. 3B). Very few respondents (n = 3 of 63 responses, 5%) reported that a coresident pumping created more work for them (Fig. 3D). Seventy percent of coresidents (n = 44 of 63 responses, 70%) reported that they would feel comfortable if their coresidents pumped in their same team room.

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FIG. 3.

Resident mothers and coresident perspectives regarding pumping during work hours. Results are presented for the following statements on a Likert scale on the x-axis and the y-axis showing percentage of respondents. Black bars denote coresidents. Open bars denote resident mothers. (A) Team efficiency was negatively affected by pumping. (B) My coresident was readily available for questions while pumping (by phone, pager). (C) Patient care was negatively affected. (D) Among coresidents, a breastfeeding mother created more work for me.

Discussion

Our survey identified common themes about breastfeeding in residency both from the perspective of resident mothers and their coresidents. The majority of survey respondents were not mothers but had worked with breastfeeding mothers. Among the breastfeeding residents, a number of residents felt that their pumping was detrimental to their job and their team performance. However, their coresidents felt that pumping has no major setbacks to team efficiency, additional work, or patient care. Sharing this information with breastfeeding residents may help alleviate some of their self-imposed fears about the impact of their pumping on their work and their teams. This may make it easier for these residents to take sufficient time to pump, making it possible to continue to breastfeed longer. Understanding the attitudes of breastfeeding residents and their teammates may have important implications for residency programs and hospital systems as they create policies to promote and support breastfeeding. There is evidence that having breastfeeding policies increases rates of successful breastfeeding during residency. ¹⁶ Policies may help alleviate the perception of resident mothers that they are creating a burden, while setting expectations for resident teams.

Resident mothers are motivated to breastfeed based on the universal rates of breastfeeding initiation and self-reported pressure to breastfeed throughout infancy. At our institution, respondents were largely successful at breastfeeding when returning to work despite difficulties and were much more successful than the national average rate of physicians who breastfeed their infants at 6 and 12 months of age. ² More than half of the breastfeeding resident respondents were from Pediatrics and Family Medicine, the two specialties that are most likely to be proponents of benefits of breastfeeding for children. The large degree of variability in clinical settings/rotations that were perceived to be best and worst for accommodating breastfeeding suggests that each breastfeeding resident has worked out a different system/method to pumping while at work.

Our study has limitations. Based on the demographics of respondents, the attitudes presented in this survey may represent supportive female coresidents rather than a true cross-sectional view of all coresidents. This was a voluntary survey without monetary incentive for a group of individuals who may not have free time to complete an online survey. The residents who chose not to complete the survey are potentially less supportive of breastfeeding in general. Additionally, there were no respondents who were resident mothers who chose not to breastfeed. Finally, not all residency programs at our institution participated in the survey including many surgical specialties that traditionally are considered to be male-dominated subspecialties.

Challenges such as feeling like there was no time or environment suitable to pump identified by this survey affected the majority of breastfeeding residents. Fortunately, commonality of challenges means that interventions would like benefit the majority of breastfeeding residents. Specifically creating a standardized policy including guidelines for times that residents can pump would be an actionable improvement to supporting breastfeeding residents. Other improvements include improved resources in pumping areas (e.g., phone, computer) and dedicated storage space for breast milk. ¹⁶

Conclusions

Our data show that the difficulties that breastfeeding residents encounter affect their mood and perhaps their milk supply and breastfeeding success. Improvements to the breastfeeding residents' experiences would be beneficial to both maternal and infant well-being. As more attention and efforts are done to support physicians—in-training and prevent burnout and mental health difficulties, ensuring effective support for breastfeeding residents is clearly an area that could have significant benefit.