Pregnancy and Residency: Program and ACGME Recommendations From the Council of Review Committee Residents Pregnancy in Training Task Force
Introduction
The increasing representation of women in medicine, now over 38% of the physician workforce and half of medical school graduates in the United States,1,2 highlights the importance of addressing pregnancy during medical training. Residency often coincides with peak childbearing years, with 20% to 30% of trainees becoming pregnant during their training.3-5 Despite the Accreditation Council for Graduate Medical Education (ACGME) mandating 6 weeks of paid medical, partner, and caregiver leave for residents, and the American Board of Medical Specialties (ABMS) allowing this leave without affecting board eligibility, gaps in comprehensive support exist, and there is a lack of comprehensive guidance for trainees and program directors.6-8
In May 2024, the ACGME Council of Review Committee Residents (CRCR) convened a Pregnancy in Training Task Force consisting of 11 members representing 11 different medical specialties and institutions. Using an iterative process, the CRCR evaluated pregnancy-related challenges during training and devised recommendations for trainees, program directors, and national policymakers to create a more supportive training environment. While this article primarily focuses on women trainees, it recognizes the experiences of gender-diverse individuals, who remain underrepresented in the literature.9,10 These recommendations aim to address the needs of all pregnant trainees, regardless of gender identity or specialty.
The Effects of Work as a Physician on Pregnancy
Physicians who become pregnant face unique challenges, including long work hours, shift work, and exposure to occupational hazards, all of which can increase obstetric risk. Unlike other professions, residents may work up to 80 hours per week, often exceeding this due to averaging rules.7 Further, they have limited control over their schedules, and this inflexibility combined with the high physical demand of training can pose significant risks, including miscarriage, preterm delivery, and intrauterine growth restriction. Pregnant physicians also experience higher rates of burnout, attrition, and postpartum depression.
Work Hours and Pregnancy Outcomes
Extended and irregular work hours have been linked to adverse obstetric outcomes. Several studies have found that working extended hours (>40 per week) increased the odds of miscarriage and preterm delivery risk.11-13 Studies on women surgeons found that operating for 12 or more hours per week during the third trimester was linked to a higher incidence of major pregnancy complications.14,15 Night shifts can disrupt neuroendocrine regulation, affecting fetal growth and delivery timing.11 Shift workers experience higher rates of infertility, and night shifts increase the risk of preterm delivery.11,16,17 High call burdens in residency also correlate with intrauterine growth restriction, miscarriages, hypertensive disorders, and miscarriage.18
Occupational Hazards in Medical Training
Physicians face exposure to bloodborne pathogens, teratogenic chemicals, anesthetic gases, and radiation.19 Exposure to patients with TORCH infections, parvovirus, and even COVID-19 can have larger potential harm to pregnant trainees as compared to peers.20,21 Physicians who work in procedural specialties must take additional precautions, as unscavenged anesthetic gases and radiation exposure can increase infertility, miscarriage, and fetal complications.19,22-25
Burnout, Mental Health Risk, and Attrition
Despite ACGME and ABMS parental leave mandates, gaps in consistent accommodations persist, contributing to burnout. Up to 40% of pregnant trainees consider leaving residency, and 30% would discourage women medical students from entering their specialty due to negative experiences during pregnancy.3,26-28 Short parental leaves (<6 weeks) are linked to higher burnout and postpartum depression rates.29 Many physicians report that inadequate leave resulted in career sacrifice or delayed training.27,29,30
Current Protection for Pregnant Individuals
Legal Protections
Several US laws provide some protection for pregnant workers, including physician trainees (Table 1). However, these protections lack clarity for medical trainees. The intersection of education and employment complicates legal applicability, often necessitating additional institutional policies.36
ACGME Requirements
ACGME requirements provide additional protection but lack specificity regarding pregnancy (Table 2).7,37
ABMS Parental Leave Policy and Specialty-Specific Guidelines
In 2021, the ABMS introduced a leave policy designed to provide trainees a minimum of 6 weeks of parental, caregiver, or medical leave without the use of vacation or sick time, or extension of training.6 This policy focuses on postnatal leave and does not offer guidance for prenatal accommodations.
To address this gap, several medical specialties developed position statements outlining the recommended support for pregnant trainees and physicians within their fields. These statements emphasize prenatal care access, accommodations for assisted reproductive technology (ART), schedule modifications, avoidance of teratogenic exposures, and board certification. Many address postnatal needs, including parental leave and lactation support (see online supplementary data).
CRCR Guidance for Trainees, Program Directors, and National Policymakers
Challenges for Pregnant Trainees
Pregnancy during medical training presents professional, cultural, and financial challenges. Many trainees delay childbearing due to unsupportive training environments, inaccessibility of childcare, and restrictive work schedules. Surveys indicate that 62% of trainees who postponed pregnancy were dissatisfied with doing so, citing fear of burdening co-residents and lack of institutional support.4,8 Delaying childbearing increases the risk of infertility and pregnancy complications, disproportionately affecting women physicians.14,38,39
Cultural bias, financial implications, and privacy concerns further complicate pregnancy during training. Many trainees report experiencing or witnessing negative comments about pregnant colleagues, and up to 60% of program directors believe pregnancy negatively affects performance.26,40-42 This bias may contribute to lower evaluations for pregnant trainees, impacting fellowship opportunities and career advancement.43 Extending training due to parental leave can delay board certification and entry into higher-paying attending positions, increasing debt accumulation.44 Additionally, board examinations offered at fixed intervals may lead to prolonged certification delays, further affecting career progression. Finally, resident schedules are often public, making it difficult for trainees to keep pregnancy-related absences confidential. Smaller programs may struggle to redistribute workloads, creating resentment among colleagues and discouraging trainees from taking advantage of available accommodations.
Guidance for Trainees on Family Planning During Residency
Trainees must navigate privacy concerns and institutional policies when considering pregnancy. Trainees are encouraged to proactively explore family planning policies within their programs and consider early discussions with leadership to provide clarity on support options and scheduling accommodations.
Pre-Matriculation Considerations:
Prospective residents should evaluate program policies on pregnancy by:
Engaging with current or former trainees who experienced pregnancy
Reviewing insurance coverage to assess for coverage of pregnancy and ART
Assessing program culture by asking about leave policies and schedule flexibility during interviews
Family Planning During Residency:
Trainees considering childbearing should feel encouraged to discuss their plans with trusted educational leaders, such as their program directors or a faculty mentor to:
Facilitate strategic scheduling of rotations and time off
Plan for potential impacts on board eligibility or training duration
Arrange appropriate accommodations based on individual needs
Empowerment and Advocacy:
Trainees should feel empowered to advocate for their health and family planning needs by:
Utilizing specialty society guidelines, ACGME policies, and health care professional recommendations
Understanding leave policies and proactively engaging leadership to minimize training delays
Reporting bias or mistreatment through institutional or ACGME reporting systems
Building a Support Network:
Seeking mentorship from peers and faculty who have navigated pregnancy during training provides guidance and emotional support. Additionally, those who have experienced pregnancy during residency are encouraged to advocate for institutional and national policy improvements to benefit future trainees.
Summary of Recommendations for Program Directors
Given that over half of medical trainees plan to become parents during residency and many plan to make decisions about program selection based on support for reproductive and obstetric health,4,45 program directors must proactively support family planning through inclusive policies and cultural shifts. These efforts should minimize stigma and prevent undue burden on other residents.
The CRCR recommends all programs have a policy that accounts for the needs of trainees through preconception, pregnancy, parental leave, lactation, and return to work. Such a policy should use non-gendered language, extend accommodations equally to childbearing and non-childbearing partners, and account for the needs of trainees who do not elect for childbearing during training to prevent undue work on these individuals. Program-specific policies are encouraged above and beyond the existence of a national, specialty-specific, or local GME policy to address program-specific structure and function.
Essential recommendations include:
Preconception Support
Provide protected time for fertility-related appointments and procedures (ART), without requiring vacation or sick leave.
Pregnancy Loss
Ensure access to bereavement leave and time for medical or mental health appointments.
Pregnancy Accommodations
Allow individualized scheduling, including elimination of overnight calls and shifts exceeding 24 hours during the third trimester for routine pregnancies, and other individualized needs for high-risk pregnancies.
Mitigate exposure to teratogenic risks with specialty-specific measures.
Maintain confidentiality regarding a trainee’s pregnancy or medical needs.
Parental Leave
Guarantee 6 weeks of paid parental leave for all parents, including adoptive, surrogate, and non-childbearing partners, independent of vacation or sick leave, with an option to extend up to 12 weeks under the Family and Medical Leave Act.
Ensure parental leave does not negatively impact progression, evaluation, and access to leadership roles.
Guarantee trainees are not required to make up missed call coverage.
Parents with infants requiring prolonged hospitalizations have unique needs that should be addressed individually.
Return to Work Support
Avoid assigning night shifts or overnight calls immediately upon return to allow for recovery and reintegration.
Protect time for postpartum medical and mental health appointments.
Offer proactive guidance on local childcare options, including affordability and availability.
Offer additional faculty support during the period of transition.
Lactation Accommodations
Ensure compliance with the Affordable Care Act by providing trainees with private, safe, and convenient spaces to express and store milk.
Develop protocols for trainees working in procedural or operative areas, ensuring adequate breaks.
Support the ability (as desired) to use wearable breast pumps in clinical areas.
Minimizing Scheduling Burden:
To prevent undue workload on other trainees, program directors are encouraged to consider:
Assigning trainees near the end of their pregnancy or those in the first few weeks of return from parental leave to rotations with minimal clinical impact due to absence, such as electives, research blocks, or home-based study options.
Utilizing advanced practice clinicians, faculty, or moonlighting residents to address gaps in clinical coverage to prevent undue coverage burdens on other trainees.
Advocating for Institutional Resources:
The ACGME has required recruitment and retention of a diverse and inclusive workforce, though at the time of this article’s publication, enforcement of this requirement is currently suspended.7 This workforce includes growing families. Programs, in partnership with sponsoring institutions, should provide information regarding insurance coverage for ART and childcare resources. Programs should additionally recognize that pregnant trainees are at high risk for bias and harassment.5,26 Therefore, program directors must advocate within their institutions for:
Institutional childcare resources, including 24-hour on-site care
Transparent policies regarding leave impact on board eligibility and training completion
Bias mitigation strategies, including faculty training and anonymous mistreatment reporting mechanisms
The Role of the ACGME in Supporting Pregnant and Lactating Trainees
The ACGME has played a pivotal role in protecting trainees through work hour restrictions and the standardization of 6 weeks of guaranteed parental leave. However, no current ACGME requirements explicitly address the unique needs of pregnant or lactating trainees beyond general provisions for medical care, family leave, and safe lactation spaces.
The CRCR strongly encourages the ACGME to address these gaps through revisions to the Common Program Requirements that explicitly address pregnancy and lactation.
Mandatory Pregnancy Policies for All Training Programs:
Each program must implement a written policy for the protection of trainees who become pregnant during their training, addressing the following:
Protected time for ART-related appointments, procedures, or prenatal care without use of vacation or sick leave
Ability to request reasonable schedule modifications, including adjustments to call shifts and work hours
Clear guidance on additional leave beyond the ACGME and ABMS-mandated 6 weeks, including implications for salary, benefits, board eligibility, or training extensions
Detailed information on specialty-specific occupational risks and strategies for mitigation
Assurance that trainees are not required to make up missed call shifts due to pregnancy or parental leave
Discussion of decompression strategies to prevent undue clinical burden on other trainees
Inclusive Language:
The ACGME and individual programs should ensure policies and protections recognize the diverse experiences of trainees.
All ACGME and program policies should adopt non-gendered language.
Protections for ART-related appointments, prenatal care, and parental leave must apply equally to childbearing and non-childbearing partners.
Policies should extend to those who become parents through surrogacy, fostering, or adoption.
Lactation Accommodations:
While current ACGME institutional requirements ensure access to lactation spaces,37 the ACGME should establish a Common Program Requirement mandating:
Protected time for trainees to express milk during clinical duties.
Policies supporting lactation in procedural or operative areas, including the use of wearable breast pumps if desired.
Addressing Cultural Change
The CRCR emphasizes that these requirements must be paired with efforts to shift programmatic culture. Program leadership should normalize pregnancy and parenting during training by fostering supportive environments, reducing stigma, and encouraging open discussions. All programs are encouraged to advocate for affordable high-quality childcare services, including 24-hour onsite childcare and sick care facilities to match trainees’ schedules. Policies promoting inclusivity and work-life balance help create sustainable solutions for the physician workforce.
Conclusion
Physicians face higher rates of infertility and obstetric complications compared to the general population, necessitating improved policies and cultural changes in medical training. Ensuring comprehensive pregnancy support benefits trainees and institutions by improving maternal health outcomes, reducing burnout, and fostering retention.
The CRCR strongly advocates for explicit protection for pregnant trainees, accommodations for ART, and lactation in the forthcoming revision of the ACGME Common Program Requirements. In the interim, programs must implement local policies that prioritize equitable and supportive training environments that meet the needs of today’s diverse physician workforce.
Author Notes
