Opinion
VIEWPOINT
Pregnancy and the Surgeon—Too Many Opinions,
Too Little Evidence
Ailín C. Rogers, PhD The number of female medical graduates is increasing,
Department of General with women accounting for greater than 50% of the
and Colorectal Surgery, medical workforce younger than 35 years of age in many
Beaumont Hospital,
countries, including the United States. This has trans-
Dublin, Ireland.
lated into increasing numbers of female surgical train-
Deborah A. ees across the world, yet the numbers of female staff sur-
McNamara, MB geons are proportionately lower. A gender gap continues
(Hons), FRCSI, MD to exist in many subspecialties of surgery, often consid-
Department of General
ered a profession more suitable to men because of physi-
and Colorectal Surgery,
Beaumont Hospital, cally demanding working conditions and long hours not
Dublin, Ireland; and always conducive to family life. Many studies cite this per-
Royal College of ceived conflict as the principal reason a career in sur-
Surgeons, Dublin,
Ireland. gery is avoided by female graduates. At a time when sur-
gery is faced with recruitment challenges globally,1
addressing factors that make surgery less appealing is
critical if surgery is to continue to attract the best phy-
sicians, irrespective of sex.2
A surgical career is associated with physical and
mental stressors that differ from those experienced in
other specialties and professions; their effects on a sur-
geon’s workplace performance and quality of life have
been recognized. The impact, if any, of these same fac-
tors on fertility, pregnancy, and early motherhood is
poorly characterized. Female surgeons are less likely to
become a parent compared with male contemporaries,
and they tend to start their families later than the gen-
eral population, with resultant negative effects on
fertility.3 The paucity of literature on the subject, allied
with the reported absence of workplace policies to sup-
port female surgeons during pregnancy, may result in fe-
male medical graduates and surgical trainees opting out
of a surgical career because it seems incompatible with
their desire to become a parent. This Viewpoint refer-
ences relevant literature regarding adverse pregnancy
outcomes among surgeons and surgical trainees, and it
highlights some related international workplace poli-
cies for pregnancy, with a discussion of their implica-
tions on service provision and female surgeons.
Recognized workplace hazards, such as anesthetic
gases and ionizing radiation, have well-established safe-
guards in place to ensure protection during pregnancy.
However, other surgeon-specific occupational stress-
ors may carry a risk to the pregnant surgeon for which
evidence-based guidelines are lacking. Some stressors
relevant to surgical practice have been evaluated by
meta-analyses in other fields, assessing negative end
points in pregnancy such as rates of miscarriage, pre-
Corresponding
Author: Deborah A.
term labor, and small for gestational age (SGA). Long
McNamara, MB(Hons), working hours, shift work patterns, lifting and manual
FRCSI, MD, Beaumont handling, prolonged periods of standing, physically de-
Hospital, Dublin
manding work, and psychological stress all contribute to
D09Y177, Ireland
(deborahmcnamara adverse pregnancy outcomes: working in excess of 39
@rcsi.ie). hours per week is associated with increases in the risk
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for preterm birth, and shift work, especially overnight
work, increases the risk for miscarriage.4,5 Surgical prac-
tice combines many of these physical characteristics with
a level of individual responsibility not typical of occupa-
tions studied to date; yet high-quality data on surgeon-
specific pregnancy outcomes are lacking, although there
is evidence to suggest that female surgeons have worse
pregnancy outcomes than the general population.6,7
Most meta-analyses in the field cite odds ratios (ORs) be-
low 1.5 as low-moderate risk and above this as moder-
ate risk for the impact of occupational factors on nega-
tive pregnancy outcomes. There are differences between
authors in inferring at what point an acceptable rise in
OR becomes a workplace concern or hazard, a consid-
eration that is central to understanding the relative oc-
cupational hazards of practicing surgery during preg-
nancy. Certain meta-analyses suggest that the risks of
occupational factors, where the ORs of preterm labor,
SGA, and miscarriage are less than 1.5, are essentially
negligible.4,5,8 This seems to be an arbitrary nomencla-
ture and is in sharp contrast to other risk factors, such
as smoking, which has a well-established negative risk
profile in pregnancy, but has an OR for miscarriage of 1.3
(95% CI, 1.2-1.4)9 and for SGA of 1.8 (95% CI, 1.2-2.6).10
It is important that the actual risks in pregnant sur-
geons are quantified, but also that the values at which
each risk is deemed significant are established before oc-
cupational protocols are developed.
The heterogeneity of the measured observations
between existing studies is also reflected in inconsis-
tencies in guidelines between countries and among pro-
fessions, despite citing the same evidence base for their
protocols. Legislation relating to the protection of preg-
nant workers globally usually places the onus for assess-
ment of workplace risk on the employer. It is challeng-
ing for individual surgeons, their supervisors, and their
employers to assess the risk, if any, of the surgical work-
place. Ireland, the United States, the United Kingdom,
and Australia have no mandatory workplace restric-
tions, but national workplace safety organizations in
all these locations suggest adopting “sensible ap-
proaches” and encourage individualized risk assess-
ment. In countries without formal regulations, this of-
ten means that the pregnant surgeon herself must
decide when and how to address her working condi-
tions, often continuing to work without restriction un-
til late in the third trimester, lest she be perceived as a
liability by colleagues and employers. Most hospital in-
frastructures do not provide locum replacement and in-
stead may require peers to perform additional on-call
shifts or theater work.
Conversely, some countries have adopted more for-
mal protocols. The Netherlands has implemented re-
997
 Opinion Viewpoint

strictive regulations precluding overnight shifts from 20 weeks’ ges-
tation onwards and limiting consecutive standing after 30 weeks to
a maximum of 1 hour, which restricts operative surgery. Similarly, and
based on the same evidence, Germany introduced workplace re-
strictions through the Maternity Protection Act (Mutterschutz) of
2002. The most notable facet of these prohibits German surgeons
from operating at all from 21 weeks of pregnancy onwards. This has
led to significant disquiet among surgical trainees in particular, who
want the choice to be theirs.
Recent years have seen an increase in the number of women
entering the field of surgery. Prominent female surgical role mod-
els, stronger mentor networks for women, the Association of Women
Surgeons, the WomeninsurgeryAfrica.org initiative, and social me-
dia campaigns such as “#ilooklikeasurgeon” all have a valued role to
play in supporting this social change. Academic departments of sur-
gery, professional bodies, and employers must also evolve to en-
sure that the surgical arena is one in which women surgeons can
thrive, and this includes facilitating their safety during pregnancy and
beyond. While the onus is rightly on employers to assess and insti-
tute evidence-based guidelines on workplace safety for all work-
ers, clearly a balance is required between mandating absence from
practice and continuing with full duties right up to delivery. There
are obviously financial implications associated with offering work-
load reduction and locum replacements in pregnancy that may need
to be considered; however, the cost-effectiveness of these are yet
to be validated in the evaluation of pregnancy-associated risks to
surgeons.
Surgeons require specific evidence so that they may accu-
rately define the associated risks, as the existing literature to date
comes from other disciplines. A first step would be a cross-
sectional study of female surgeons with age-matched comparators
examining rates of successful conception, miscarriage, preterm la-
bor, and incidence of SGA. It is only then that policy makers and in-
dividual surgeons can make informed decisions regarding the ef-
fects of surgical practice on pregnancy. In the interim, it is incumbent
on professional bodies to provide leadership in both the acquisi-
tion and interpretation of evidence as well as the development of
pragmatic solutions and targeted supportive investments that can
enable a new generation of surgeons to combine a fulfilling surgical
career with parenthood.

ARTICLE INFORMATION
Published Online: August 23, 2017.
doi:10.1001/jamasurg.2017.2892
Conflict of Interest Disclosures: Dr McNamara is a
council member of the Royal College of Surgeons in
Ireland. No other disclosures were reported.
Additional Contributions: We gratefully
acknowledge editorial contributions to earlier
versions of the manuscript from John P. Burke, PhD,
FRCSI (Beaumont Hospital, Dublin), Ann M. Hanly,
MD, FRCSI (St Vincent’s Hospital, Dublin), and
Declan J. Magee, FRCSI (Royal College of Surgeons,
Dublin). They did not receive compensation.
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