Creating a Lactation-Friendly Learning Environment for Medical Students and Residents: A Northern Canadian Perspective

The medical learning environment

Despite advancements in breastfeeding policies and campaigns to increase support and protection for lactation, there is minimal literature on breastfeeding policies specifically for medical students and residents within the learning environment. The medical learning environment both at the level of the student and resident is fast paced and competitive. ¹⁸ Medical students and residents constantly face numerous challenges and stressors personally and professionally. Trainees also have to balance wanting to be an eager, engaged learner who is dedicated, while finding personal time without missing valuable learning opportunities.^18,19 The medical learning environment can be stressful knowing that you have a finite amount of time to gather the knowledge and skills to become an independent practitioner. ²⁰ This has created a culture where medical learners may sacrifice bodily necessities and personal time in exchange for increased learning opportunities. ²¹ The case may be magnified in competitive medical and surgical training programs such as general surgery, orthopedics, and internal medicine. ¹⁹ Although the medical learning environment has taken great strides to shift toward wellness and work-life balance, the intrinsic demands of medicine may lead students to feel as though they are sacrificing their learning for necessary bodily functions, including lactation. ²¹

Students and residents who find themselves back in the medical learning environment postpartum, can find it challenging to acquire dedicated time for milk expression. Because of the past culture of medicine prizing those who sacrifice sleep and personal time for work time, it is no surprise that lactating learners may fear asking older superiors who trained in a different era for dedicated lactation time. ²¹ Asking for dedicated lactation time may make learners feel as though they appear uninterested, lazy, or inadequate in comparison with colleagues who are not lactating. This may lead medical learners and residents to give up lactation in efforts to further their learning experiences and thus miss out on both the maternal and infantile benefits of breastfeeding. A solution to this complex problem may be to implement medical school institutional policy that permits dedicated time for milk expression within the learning environment for both medical students and residents. Furthermore, a policy would standardize the accessibility of lactation for all medical trainees, thereby eliminating the need for each learner to have to negotiate their own requirements to support breastfeeding after return to school or residency training.

Breastfeeding in northern, rural, and remote areas

Although our lactation policy was developed at a northern medical school serving northern, rural, and remote areas of Ontario, our policy does serve as a model for uptake in medical schools and residency programs across North America. Nonetheless, the body of literature concerning breastfeeding and milk expression in northern and rural areas in general is extremely limited. Owing to the geography of our medical school being located and serving the north, our students and residents are aware of the complex realities that impact breastfeeding and milk expression rates in corresponding areas. In addition, medical students and residents serve as role models and leaders for health promotion regardless if they see themselves as so. This adds to the argument for lactation policy implementation at medical schools and residency programs across North America. How can medical students and residents be expected to promote breastfeeding initiation and continuation among their patients if they do not even have protected time for this bodily necessity? Enabling and empowering medical students and residents to dedicated lactation time through policy implementation has the potential to translate to marginally increased lactation uptake and continuation through medical learner and residents, as future physicians, sharing their personal experiences, struggles, and the barriers they overcame in breastfeeding. Therefore this section of the article is fitting to serve as initial insights into the landscape of breastfeeding and lactation within northern and rural areas of Canada and North America and may be expanded upon in future reviews.

Within the context of health care, individuals living in northern, rural, and remote areas face the realities of increased mortality and morbidity because of a variety of health conditions in comparison with southern, urban counterparts.^22,23 This is not only limited to northern areas having higher rates of obesity, heart disease, smoking, alcohol, and substance use in their general population.^22,23 In fact, northern rural and remote areas also see increased burdens of maternal mortality, morbidity, substance use, and lower rates of breastfeeding in comparison with southern, urban counterparts.^16,24–26 Compared with nonrural areas, rural communities contain a greater proportion of individuals who are sick, less educated, and poor. ²² In corresponding northern geographical centers medical resources, addiction services, and specialists, as well as health promotion supports including lactation consultants are often lacking because of low population densities.^24,26 Lack of medical care in the geographically diverse north has also been cited as a facilitating factor to reduced prenatal care among women in isolated rural areas.^24,26 This is of importance, as women who receive little antenatal care have exceedingly lower rates of breastfeeding initiation and continuation. ²⁷ In addition, it is well-known that within first-world countries breastfeeding rates are highest among those who have attained the higher levels of education. Origins and causes of lower rates of breastfeeding among northern women are complex and multifactorial, but of the little evidence available, this is thought to be in part to lower levels of education and decreased lactation support.

Current breastfeeding policy

Breastfeeding has been internationally recognized by the United Nations (UN) as a human right of women and children as early as 1979 and 1989, respectfully.^28,29 Canada has ratified UN conventions facilitating breastfeeding rights and correspondingly has given support for the UN Baby-Friendly Hospital Initiative (BFI). ³⁰ The BFI provides an evidence-based framework for health care settings to promote breastfeeding of all mothers by providing education and support for breastfeeding establishment, infant needs, and creation of an enabling environment for these practices. ³⁰

Canadian women are legally supported in breastfeeding under the Canadian Charter of Rights and Freedoms based on sex-based discrimination. ³¹ However, with the exception of the provinces of Ontario and British Columbia, this right does not apply to all settings, such as places of employment or schools. Both Ontario and British Columbia also require institutions to provide parents with accommodations surrounding their usual demands of work or education to breastfeed in said environments.^32,33 In addition, learners in medical undergraduate and postgraduate programs are overwhelmingly of reproductive age, during which time many students become parents.^17,33 As learners pass through both didactic and clinical learning environments during their training, the line distinguishing employees and students can become blurred. This is because medical students and residents are covered by school policies, but under some areas may be subject to hospital staff policy such as in occupational health, whereas in other areas students and residents may not have any pertaining policies as they are not staff nor are they contracted by the hospital. As such, laws regulating students' rights to breastfeed can also become unclear.

Residency and undergraduate medical programs often offer support for student parents under the auspices of their affiliated universities. Many universities publish listings of facilities hosting lactation rooms. ³⁴ As an example, residency programs in the United States require resident mothers to have accessible lactation facilities to obtain program accreditation. ³⁵ Such accreditation requirements do not exist among Canadian medical schools. Furthermore, of the medical training facilities in the United States with lactation faculties per accreditation requirements, few take steps in actually advocating for protected medical student and resident lactation time. Several studies have cited that <10% of universities across North America have developed a student-specific breastfeeding policy. ³⁴ With this, one may wonder if an alternative to school-specific lactation policy may be blanket hospital BFI policy implementation at hospitals that host medical learners. But again owing to students and residents not being considered as patients, hospital employees, or independent contractors, medical learners find themselves in the gray area of even BFI policy, and thus school-specific policy may be the best level at which to support these learners. By extension, medical trainees working in BFI hospitals may not have access to increased breastfeeding services despite this initiative promoting workplace policies and supports for breastfeeding mothers. ³⁶ Additional strain may be placed on students rotating through smaller medical centers as these secondary hospitals are less likely to have breastfeeding services and supports than primary teaching hospitals. ³⁶ This can create added barriers for those lactating in such resource-limited areas, which tend to be in northern and rural locations.

Canadian medical trainees are disadvantaged in comparison with their American counterparts given that there are no national requirements for students to receive breastfeeding supports from their universities at any level of education. Across the country, only 5 of the 17 faculties of medicine have a publicly available breastfeeding policy: NOSM, McGill, Sherbrooke, Dalhousie, Memorial. Many of the existing policies do not include the recommendations of the University of Michigan Medical School for medical student lactation policies: a dedicated time to express milk, a dedicated place to express milk in a nonbathroom location, a dedicated place to store milk, and an open culture of communication around lactation. ³⁷ Following a 2016 Ontario Medical Student Association (OMSA) review of Ontario medical school parental leave and breastfeeding policies, the OMSA proposed the six Ontario Faculties of Medicine improve support of student parents by increasing curricular flexibility, improving accessibility and transparency regarding parental leave policies, and providing access to accommodations such as breastfeeding and pumping facilities. To date, only the NOSM has responded to the OMSA's request by becoming the sole Ontario medical school to create a breastfeeding policy.

NOSM Lactation Policy: A Model

As discussed in a previous section, a lactation policy has recently been developed and implemented at both campus sites of NOSM. Our two central campus hospitals serve as the main northern referral centers for all of Northern Ontario with a catchment area of 830,000 residents. However, as part of our distributed learning environment our medical learners can find themselves at any one of our 130 northern, rural, and remote learning sites throughout the province. Our newly developed lactation policy was created by a senior medical student. The policy was implemented at the school level and thus covers our students and residents at all our 130 learning sites throughout the province.

Prior research into the development of the policy was initiated following research ethics board approval from a tertiary hospital in Northern Ontario to conduct a small convenience sampling survey. The purpose of this sampling survey was to determine staff support for the implementation of a formalized breastfeeding policy that would provide protected and designated breaks for the purposes of lactation. The response was overwhelmingly positive, with 98% of the respondents (n = 100) stating that they would support such a policy. The policy was subsequently presented in a meeting to a group of individuals from the hospital, which consisted of managers from the women and children program, human resources, occupational health and safety, the chief nursing officer, and supervisor of clinical and administrative services. As previously mentioned, the BFI for hospitals is increasing in popularity across North America yet is not required by hospitals, and as such the hospital at which this survey was completed declined to pursue the implementation of a formalized lactation policy. For this reason, the NOSM was approached to discuss the possibility of implementing this novel policy at the medical school level as opposed to the local hospital. Overall, it was felt that a school-wide formalized policy would be beneficial because of the unpredictable nature of medicine as the clinical workplace poses several obstacles and may be a hindrance to the success of lactation.

Once NOSM's dean of medicine provided their support for this endeavor, a small group began meeting throughout the remainder of 2019, and into the early months of 2020 to collaborate on making final revisions before the policy was officially approved and implemented in April 2020. This group consisted of the dean of learner affairs, staff from human resources, and a physician representative of the Professional Association of Residents of Ontario. Once the policy revisions were complete, the policy was approved by the associate dean, the dean of undergraduate medical education, the dean postgraduate medical education, and finally, by the NOSM executive group. The executive group is the most senior administrative body for operational matters at the NOSM and is responsible for overseeing the operational, financial, and academic administrative aspects of the medical school. At present, the policy is scheduled for re-review in March 2023.

The lactation policy itself was drafted by a senior medical student based on legal considerations of the Ontario Human Right's Commission (OHRC) ³¹ and considerations from the University of Michigan, Department of Surgery Residency Program, which was developed in 2018 to support the wellness of lactating surgical residents. ³⁷ The writer aimed to use both clear and protective language to describe the multitude of environments and situations medical learners often face and how their right to lactation would be upheld in that given situation. The policy also delineates procedures pertaining to storing milk, selecting an appropriate place to pump, and the responsibilities of the lactating learner and supervisors. The policy, which is attached in Supplementary Appendix SA1, provides NOSM learners with a 20-minute lactation break for every 4-hour period of clinical or academic work. The policy further establishes the requirement that facilitates provision of learners with a clean nonbathroom space to pump, and also determined that breast milk is not biohazardous and can be stored in designated refrigerators in the hospital or workspace.

The American Academy of Family Physicians (AAFP) published information to provide guidance for medical training programs and hospitals wishing to develop a lactation policy. ³⁸ They describe which criteria need be met to provide an adequate lactation facility, and recommendations pertaining to the scheduling of protected time for the purposes of breast milk expression. Finally, they also explain the roles and responsibilities for the medial trainee, administrator, and supervisor to delineate the requirements of a pro-breastfeeding culture. ³⁸ The AAFP resource is free to access, and is an excellent resource to review before developing a lactation policy.

Concluding comments

In summary, this article establishes that breastfeeding and/or lactation policy is a necessary component of medical learning, especially those programs in northern and rural areas. In the future, we endeavor to undertake a policy-influence evaluation to study and determine if NOSM's lactation policy correlates with increased access to lactation among medical learners, and how it has been perceived by students so that on-going adjustments can be made.