Supporting Lactation Within an Academic Anesthesia Department: Obstacles and Opportunities

Challenges of Motherhood for Anesthesiologists: A Scoping Review

Despite advancements in gender representation, female anesthesiologists continue to encounter challenges in career advancement that may be further impacted by motherhood. This scoping review examines personal and systemic barriers and facilitators to career advancement for anesthesiologists facing infertility, pregnancy, and childcare. The review identified 22 relevant studies across five themes: the timing of pregnancy and parental leave, breastfeeding and lactation needs, childcare and gender norms, job reentry and career advancement opportunities, and work-life balance and physician well-being. Recommendations from these studies include establishing clear parental leave policies, providing adequate lactation spaces and protected break times, addressing gender disparities in leadership roles, and prioritizing physician well-being. To implement these recommendations effectively, institutions and departments should develop and disseminate role-specific policies that promote career advancement and satisfaction through equitable support of pregnant and parent anesthesiologists.

One Pump at a Time: A Wearable Lactation Pump Pilot for Graduate Medical Education Trainees

Background: Despite the known benefits of lactation, lactating graduate medical education (GME) trainees encounter difficulties when returning to work. Wearable lactation pumps are known to be beneficial in lactating physicians, but the benefit for GME trainees in clinical care and education has not been explored. Objectives: The objective of this study was to examine the benefits of wearable lactation pumps on education and clinical care for GME trainees. Methods: In 2022-2023, all lactating GME trainees at a large academic center were invited to participate in a wearable pump pilot. Participants completed six baseline surveys with questions on lactation practices and individuals' perceptions before receiving the pump, repeated the six surveys after receiving the pump, and completed a monthly survey for 6 months after receiving the pump. A linear mixed methods model was used to compare reported experiences before and after receiving the wearable pump. Results: Twelve trainees participated in the pilot, with 10 completing pre- and post-surveys. When compared with experiences before receiving the wearable pump, there was a significant decrease in the perceived impact of lactation on clinical care (p = 0.03), medical education (p = 0.004), and missed pumping sessions (p = 0.02) after using the wearable pump. All participants who used the wearable pumps reported that it helped them to meet lactation goals. Conclusions: Wearable pumps are beneficial to trainees and may decrease the barriers to education and clinical care. GME sponsored pump programs may better support lactating trainees on their return to work.

Alleviating stressfeeding in the emergency department: Elucidating the tensions induced by workplace lactation space issues

Objectives

Women remain underrepresented in the emergency medicine (EM) workforce, academic EM, and institutional leadership. In order to support women physicians in EM, we must explore factors that contribute to attrition and workplace satisfaction. For example, tensions between workplace and familial roles are important to consider as women navigate careers in EM. The logistics and stressors of workplace lactation pose a particular challenge during an already stressful time for a new mother returning to work in a busy emergency department (ED), but limited empirical data exist regarding this experience. We aimed to explore the stressors associated with workplace lactation spaces in order to better inform the creation of lactation spaces for individuals working in EDs.

Methods

Our team used an exploratory qualitative design to investigate lactation-specific stressors and understand their relationship to individuals' needs when lactating in EM workplace environments. A total of 40 individuals were interviewed, highlighting post-pregnancy return-to-work (RTW) experiences of medical students, residents, advanced practice professionals, nurses, fellows, and faculty. Interviews were coded and analyzed using thematic analysis.

Results

We identified both tangible and intangible characteristics of lactation spaces that contribute to stress for lactating individuals. Additionally, we discovered that participants frequently noted a desire to work simultaneously while pumping in order to feel they were self-actualizing in their dual roles of parent and clinician. Among tangible items, access to a computer within lactation space was a key driver of ability to fulfill dual roles. Among intangible characteristics, we identified three distinct, yet interrelated, subthemes, including the need for lactation spaces to be respectful of individuals' time, privacy, and general health and well-being.

Conclusions

This study suggests that meeting basic lactation needs with thoughtfully designed lactation spaces can empower individuals in their roles both as a lactating parent and a clinician. EM leadership can evaluate existing lactation spaces to ensure they meet the tangible and intangible needs of lactating physicians, trainees, advanced practice professionals, and nurses.

Occupational Factors Associated With Time to Breastfeeding Discontinuation After Return to Work Among Female Anesthesiologists in China: A Nationwide Survey

BACKGROUND

Breast milk is of great benefit to both infants and mothers. Due to occupational barriers, female physicians are at high risk of unintentionally discontinuing breastfeeding. However, evidence among anesthesiologists was limited. The purpose of this study was to investigate occupational factors associated with time to breastfeeding discontinuation among female anesthesiologists following maternity leave in China.

METHODS

We conducted a nationwide survey of female anesthesiologists who had given birth since January 1, 2015. A 60-item anonymous questionnaire was developed to collect information regarding breastfeeding practices and related factors. The questionnaire was revised based on the recommendations of 15 experts and feedback from the pilot survey. The survey was distributed by the Chinese Society of Anesthesiology.

RESULTS

The completion rate was 57.9%. In total, 1364 responders were analyzed from all 31 provinces of Mainland China. In total, 1311 (96.1%) responders reported a reduction in breast milk supply on returning to work. Among the 1161 responders who discontinued breastfeeding, 836 (72.0%) did not achieve desired goals due to occupational factors. The median [interquartile range] of maternity leave length and breastfeeding duration were 5 [4-6] months and 10 [7-12] months, respectively. The following occupational factors were associated with longer time to breastfeeding discontinuation after adjusting for confounding effects of personal factors: length of maternity leave (hazard ratio [HR] per month 0.44; 95% confidence interval [CI], 0.36-0.54; P < .001), pumping breast milk during work time (HR, 0.04; 95% CI, 0.02-0.08; P < .001), support from colleagues (HR, 0.92; 95% CI, 0.86-0.99; P = .032), and additional nonclinical activities (HR, 0.87; 95% CI, 0.77-0.98; P = .022). Trainees under supervision (HR, 1.20; 95% CI, 1.06-1.43; P = .005) and the need to remain in the operating room during cases (HR, 2.59; 95% CI, 1.09-6.12; P = .031) were associated with shorter time to breastfeeding discontinuation. Approximately 899 (65.9%) responders pumped breast milk during work time. Among them, reduction in pumping frequency (HR, 1.17; 95% CI, 1.00-1.36; P = .049) and difficulty in finding opportunities for pumping (HR, 2.34; 95% CI, 1.36-4.03; P = .002) were associated with shorter time to breastfeeding discontinuation.

CONCLUSIONS

We identified modifiable occupational factors associated with time to breastfeeding discontinuation. These findings underscored the necessity of facilitating breastfeeding in the workplace, including encouraging longer maternity leave and breastfeeding breaks, considering the feasibility of pumping in daily case assignments, establishing supportive culture, providing lactation rooms, and offering nonclinical activities.

Survey of Lactating Anesthesiologists Using Wearable Breast Milk Pumps While Working in Operating Rooms and Other Clinical Settings

We performed a prospective Internet survey study of anesthesiologists lactating in 2022 or 2023. Approximately half (48%, 75 of 156) lacked convenient dedicated lactation space and approximately half (55%, 86 of 155) used a wearable breast pump. The vast majority using a wearable pump did so in clinical settings, including operating rooms (88%, 76 of 86). When using during cases, approximately half reported that milk production was sufficient to substitute for lactation pumping sessions (52%, 39 of 75). Based on probability distributions of surgical times, future research can evaluate the usefulness of wearable pumps based on the objective of reducing anesthesiologists' durations of lactation sessions to <15 minutes.

Lactation in Anesthesiology

There are several work-related barriers to breastfeeding among physician mothers including: lack of appropriate place for breastmilk expression, unpredictable and inflexible schedules, and lack of time to breastfeed or express milk. In a survey of physician mothers, those who were in surgical and procedural subspecialties, including anesthesiology, reported a lack of lactation facilities in close proximity to the operating room as a barrier to breastfeeding. Unlike other physicians and clinicians in different health care environments, anesthesiology is unique in that there is often no built-in time for breaks or a predictable end time to the operating room schedule. A break system is typically established, within an institution, for meal break relief for trainees, Certified Registered Nurse Anesthetist, and Anesthesia Assistants. This system for breaks may not be sufficient to accommodate the frequency or length required for lactation sessions. In addition, these break systems do not typically provide relief for supervising anesthesiologists for meals or lactation sessions. A study of physician mothers across specialties identified anesthesiologists as significantly more likely than women of other medical specialties to self-report maternal discrimination. The study defined maternal discrimination as discrimination based on pregnancy, maternity leave, or breastfeeding. As a workforce and specialty, we must support our breastfeeding anesthesiologists and facilitate lactation needs on return to the workplace.

Low Prevalence of Designated Lactation Spaces at Hospitals and Ambulatory Surgery Centers in Iowa: An Educational Tool for Graduates' Job Selection

Many anesthesiologists and nurse anesthetists want to continue breastfeeding their babies when returning to work from maternity leave. The cornerstone of breast milk supply maintenance is breast milk pumping sessions at regular intervals. These breast milk pumping sessions require time and private space for lactation. We surveyed Iowa hospitals and ambulatory surgery centers and created an educational spreadsheet to guide inquiry and postgraduate job selection of our anesthesiology residents and nurse anesthetist students (eg, when considering future family planning). The survey and spreadsheet showed a low prevalence of dedicated lactation space for anesthesia practitioners near the surgical suites.

The anesthetizing sites supervised to anesthesiologist ratio is an invalid surrogate for group productivity in academic anesthesia departments when used without consideration of the corresponding managerial decisions

When the anesthesiologist does not individually perform the anesthesia care, then to make valid comparisons among US anesthesia departments, one must consider the staffing ratio (i.e., how many cases each anesthesiologist supervises when working with Certified Registered Nurse Anesthetists [CRNAs] or Certified Anesthesiologist Assistants [CAA]). The staffing ratio also must be considered when accurately measuring group productivity. In this narrative review, we consider anesthesia departments with non-physician anesthesia providers and anesthesiology residents. We investigate the validity of such departments assessing the overall ratio of anesthetizing sites supervised per anesthesiologist as a surrogate for group clinical productivity. The sites/anesthesiologist ratio can be estimated accurately using the arithmetic mean calculated by anesthesiologist, the harmonic mean calculated by case, or the harmonic mean calculated by CRNA or CAA, but not by the arithmetic mean ratio by case. However, there is lack of validity to benchmarking the percentage time that anesthesiologists are supervising the maximum possible number of CRNAs or CAAs when some of the anesthesiologists also are supervising resident physicians. Assignments can differ in the total number anesthesiologists needed while every anesthesiologist is supervising as many sites as possible. Similarly, there is lack of validity to limiting assessment to the anesthesiologists supervising only CRNAs or CAAs. There also is lack of validity to limiting assessment only to cases performed by supervised CRNAs or CAAs. When cases can be assigned to anesthesiology residents or CRNAs or CAAs, increasing sites/anesthesiologist while limiting consideration to the CRNAs or CAAs creates incentive for the CRNAs or CAAs to be assigned cases, even when lesser productivity is the outcome. Decisions also can increase sites/anesthesiologist without increasing productivity (e.g., when one anesthesiologist relieves another before the end of the regular workday). A suitable alternative approach to fallaciously treating the sites/anesthesiologist ratio as a surrogate for productivity is that, when a teaching hospital supplies financial support, a responsibility of the anesthesia department is to explain annually the principal factors affecting productivity at each facility it manages and to show annually that decisions were made that maximized productivity, subject to the facilities' constraints.

Percentages of Cases in Operating Rooms of Sufficient Duration to Accommodate a 30-Minute Breast Milk Pumping Session by Anesthesia Residents or Nurse Anesthetists

INTRODUCTION

Accommodating breast milk pumping sessions is required by US federal statute, but fulfillment is challenging for US anesthesia providers (e.g., anesthesia residents and nurse anesthetists). Considerations of good anesthesia practices (e.g., being present for critical portions of cases, including induction and emergence) create limits on which procedures are suitable for such relief. Our objective was to quantify the minimum percentages of cases for which there could reliably (≥ 95%) be at least 30 minutes during the surgical time when the anesthesia provider could receive such breaks.

METHODS

We studied all surgical cases performed at an anesthesia department over four years, including its inpatient surgical suite, pediatric hospital, and ambulatory surgery center. The 5% lower prediction bounds of surgical times (surgery or procedure start to end) were calculated from three years of historical data (October 1, 2016, to September 30, 2019) based on two-parameter lognormal distributions. The prediction bounds were compared to actual surgical start times during the next one year (October 1, 2019, to September 30, 2020). We considered the interval available for a breast milk pumping session during a case to be from 15 minutes after the start of the surgical time (to allow completion of initial documentation, other activities, and hand-off to the relieving anesthesia provider) until the end of the surgical time.

RESULTS

The lower prediction bounds were accurate, with 4.9% (4.6% - 5.2%) of future cases' surgical times being briefer, matching the nominal 5.0% rate. Applying these bounds, approximately 39% of cases (99% confidence interval 39% - 40%) were reliably of sufficient duration for the anesthesia provider delivering care in that one operating room to receive a 30-minute break for breast milk pumping session between 15 minutes after the start of surgery and procedure end. This percentage (39%) was substantially less than the 72% of the surgical times that were observed, in retrospect, to be sufficiently long because the lower 5% prediction bounds accounted correctly for the uncertainty in the duration of each case. The observed 39% prevalence was significantly fewer than half the cases (P < 0.0001 vs. 50%) suitable for such relief.

CONCLUSIONS

Individuals making operating room assignments for anesthesia providers need to consider the 5% lower prediction bounds of surgical times for cases in the room when making such assignments for women who require time for breast milk pumping sessions. Such considerations will generally result in assignments to rooms with one or more long-duration cases. Such a strategy may involve changes in preferred assignments for the anesthesia providers and alteration in the order of rotations for anesthesia residents (e.g., palliative care rotation rather than transition to practice at a pediatric ambulatory surgery center). When making room assignments for anesthesia providers who are breastfeeding, our results show that the 5% lower prediction bounds of surgical times need to be calculated; relying on the average surgical times for procedures is insufficient. Our paper also shows how to perform the mathematics using a spreadsheet program or equivalent.