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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, Tennessee; and the American College of Obstetricians and Gynecologists, Washington, DC.
Address reprint requests to: Steven G. Gabbe, MD, Vanderbilt University Medical Center, D-3300 Medical Center North, Nashville, TN 37232-2104; E-mail: steven.gabbe{at}vanderbilt.edu.
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ABSTRACT |
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METHODS: A questionnaire-based study was administered to residents taking the 2001 Council on Residency Education in Obstetrics and Gynecology examination.
RESULTS: More than 90% of the residents reported that their institution had a maternity leave policy. The leave was usually 4–8 weeks long and was paid. Nearly 95% of residents reported that they had to take over the work of residents on maternity leave. Most women residents worked more than 80 hours weekly throughout pregnancy, and few took time off before delivery. Most pregnancies occurred during the fourth year of training and did not seem to be adversely affected by the long work hours.
CONCLUSION: This study, performed before the institution of the new Accreditation Council for Graduate Medical Education resident duty hour policies, demonstrated that, although women house officers continued to work more than 80 hours per week during pregnancy, most had a good pregnancy outcome. Nevertheless, there was a higher frequency of preterm labor, preeclampsia, and fetal growth restriction in female residents than in spouses or partners of male residents.
Recent reviews have addressed the consequences of long work hours and fatigue on the health and performance of house officers. To reduce this stress, the Accreditation Council for Graduate Medical Education instituted substantial changes in scheduled work hours for residents, effective July 1, 2003.1,2 This policy includes a work week of no longer than 80 hours, one 24-hour day free every 7 days, shifts of no longer than 30 hours, and at least 10 hours off between duty periods. To assess the present status of resident duty hours in obstetrics and gynecology, a questionnaire was administered to residents throughout the country as part of the annual Council on Residency Education in Obstetrics and Gynecology examination in 2001. At the time of the study, women represented more than two thirds of all residents in obstetrics and gynecology. This analysis was undertaken to 1) assess the present status of work hours for residents in obstetrics and gynecology during pregnancy, 2) identify existing policies concerning work schedules during pregnancy, and 3) evaluate pregnancy outcome in female house officers and spouses or partners of male house officers.
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MATERIALS AND METHODS |
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The data were analyzed with a personal computer–based software package (SPSS 10.0, SPSS Inc., Chicago, IL). Descriptive statistics were computed for the measures used in the analyses, which are reported as mean ± andard error. Differences on categoric measures were assessed by 
2 analysis. All analyses were tested for significance (
= 05).
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RESULTS |
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). The largest proportion of women residents were in their first year of training (73.5%, 808 of 1100), whereas the largest number of male house officers were in the fourth year (34.2%, 376 of 1101). Of those residents recording an institutional affiliation (4157 of 4357, 95.4%), nearly two thirds were at university hospitals (65.9%).
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). Data on spouse or partner resident specialty or hours worked by spouses or partners in different professions were not collected. Half of the pregnant residents were between 26 and 29 years old at the time of gestation, and one third were in their early 30s. Nearly two thirds of the spouses or partners (64.5%) of male residents were younger than 30, compared with 58.2% of women residents (P = .008).
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Pregnancy was recorded most often in the fourth year of residency training for both women residents and spouses or partners of male residents (46.5%, 197 of 424, and 41.4%, 146 of 353, respectively). Relatively few pregnancies were reported in the first year of residency training for both women house officers and spouses or partners of male residents (Table 3).
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The modal work schedule for both male and female residents during a pregnancy was 81–100 hours. For men, the proportion that worked 81–100 hours per week varied little (42.1%, 39.4%, and 39.0%, for the first, second, and third trimesters, respectively). A higher proportion of women worked 81–100 hours per week during the first two trimesters (57.0%, 53.0%, 42.5%, for the first, second, and third trimesters, respectively). A consistently greater proportion of women residents reported that they worked more than 100 hours per week throughout pregnancy (women: 15.2%, 15.5%, and 16.4% compared with men: 13.8%, 14.7%, and 13.4%, for the first, second, and third trimesters, respectively).
Nearly 25% of women residents (24.7%) said that they were required to make up time they had missed at work after they completed their maternity leave. The time was made up most often when the resident returned from maternity leave or at the end of residency training. Nearly 95% of the respondents, both women and men, reported that they had to take over the work of a resident who was absent for maternity or paternity leave. More than three quarters of the women residents (76.5%) who reported a pregnancy outcome during training took no days off before delivery, whereas 10.3% missed 1–3 days of work before birth.
Pregnancy outcome was reported by 302 female residents (71.2%) and 274 male house officers (77.6%). Among residents who reported a pregnancy outcome, a singleton live birth occurred in 92.1% of women residents and 93.8% of spouses or partners of male residents (Table 4). A multiple gestation was reported in 11 women residents (3.6%) and in nine spouses or partners of male residents (3.3%). When compared with the spouse or partners of male residents, female residents were significantly more likely to report the following complications of pregnancy: premature labor (P = .03) but not preterm birth, preeclampsia (P = .01), and fetal growth restriction (FGR), defined as a birth weight below the tenth percentile for gestational age (P = .002). Stillborn fetuses occurred in only two female house officers and one spouse or partner of a male resident. When the hours worked by those female residents who had adverse pregnancy outcomes were examined, no statistical relationship was observed. For female residents reporting a singleton live birth, nearly 80% (221 of 278, 79.4%) had a spontaneous vaginal or assisted vaginal delivery, whereas 13.3% (37 of 278) underwent a primary cesarean delivery. For spouses or partners of male residents, these figures were 80.1% (206 of 257) and 10.1% (26 of 257), respectively.
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DISCUSSION |
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Most women residents reported working more than 80 hours per week throughout pregnancy. A Council on Residency Education in Obstetrics and Gynecology survey conducted in 2000 also found that the modal work week for all residents was 81–100 hours per week, and that 75.5% worked between 61 and 100 hours per week.7 The proportion of residents reporting 81–100 hours per week in that survey (42.5%) was virtually identical to the proportions in this survey of male residents whose spouse or partner was pregnant and pregnant women residents in their third trimester, but less than the proportions of pregnant women residents in their first and second trimesters. Thus, it would seem that pregnant women residents, but not male residents with pregnant spouses or partners, are increasing their work hours during a pregnancy, at least during the first two trimesters.
Women residents have several work-related concerns regarding pregnancy.8 Although their institution is likely to grant them maternity leave, that time is generally required to be made up. Also, the women are aware that their peers are going to have to shoulder their work load during their leave. The data from this study imply that many women adopt a strategy of working long hours up to delivery. It is a reasonable hypothesis that this behavior is an adaptation to those two concerns. The new policy of restricting work hours will complicate this potential strategy for dealing with the time constraints of pregnancy during residency. Women will not be able to increase their work hours during pregnancy to accommodate the need to make up for maternity leave, yet how are other residents going to cover for residents on maternity or paternity leave if they are restricted to 80 hours per week?
Our data suggest that, for most female house officers, the long working hours associated with residency training in obstetrics and gynecology do not have an adverse affect on pregnancy outcome. More than 90% of women residents who provided information on pregnancy outcome indicated they had had a singleton live birth, and only two stillborn fetuses were described in this population. However, although the frequencies were relatively low, the rates of preterm labor, preeclampsia, and FGR were significantly higher for women residents when compared with the spouses or partners of male house officers. In 1990, Klebanoff et al9 performed a national questionnaire-based survey and reported pregnancy outcomes in 1293 women residents and 1494 wives of male residents. That study included 139 pregnancies in female residents in obstetrics and gynecology. The authors concluded that working long hours had little effect on pregnancy outcome in house officers. However, women residents were more likely to report preterm labor and preeclampsia, as observed in our study, but experienced no increase in preterm birth or FGR. We found no statistical association between hours worked and adverse pregnancy outcomes, most likely because most women worked long hours throughout pregnancy and because some complications resulted in the female house officer working fewer hours. It is of concern that pregnancy outcomes were not reported by 28.8% of female residents and 22.4% of male house officers. Given the extremely low rates for preterm labor, preeclampsia, and FGR in the spouses or partners of male residents, it is likely that significant underreporting complicates the interpretation of these data.
In summary, our data demonstrate that most women residents are working more than 80 hours per week during pregnancy and take little time off before their delivery. Most have a paid maternity leave of 4–8 weeks, and some are required to make up the time they have missed while on maternity leave. Nearly all residents reported they assumed the call missed by residents on pregnancy leave. How such coverage will impact the limitation on resident work hours set by the new Accreditation Council for Graduate Medical Education policy remains to be seen. In the future, it will be important to monitor the impact of the Accreditation Council for Graduate Medical Education requirements on resident duty hours, maternity and paternity leave, and pregnancy outcome.
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Footnotes |
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Received April 7, 2003. Received in revised form July 9, 2003. Accepted July 17, 2003.
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REFERENCES |
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2. Philibert I, Friedmann P, Williams WT. New requirements for resident duty hours. JAMA 2002;288:9.
3. Gaba DM, Howard SK. Fatigue among clinicians and the safety of patients. N Engl J Med 2002;347:16:1249–55.
4. Weinstein DF. Duty hours for resident physicians–tough choices for teaching hospitals. N Engl J Med 2002;347:16: 1275–7.
5. Steinbrook R. The debate over residents’ work hours. N Engl J Med 2002;347:16:1296–302.
6. Drazen JM, Epstein AM. Rethinking medical training–the critical work ahead. N Engl J Med 2002;347:16:1271–2.
7. Defoe DM, Power ML, Holzman GB, Carpentieri A, Schulkin J. Long hours and little sleep: Work schedules of residents in obstetrics and gynecology. Obstet Gynecol 2001; 97:1015–8.
8. Finch SJ. Pregnancy during residency: A literature review. Acad Med 2003;78:418–28.[Medline]
9. Klebanoff MA, Shiono PH, Rhoads GG. Outcomes of pregnancy in a national sample of resident physicians. N Engl J Med 1990;1040–5.
This article has been cited by other articles:
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  J. van Dis Residency Training and Pregnancy JAMA, February 4, 2004; 291(5): 636 - 636. [Full Text] [PDF]
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