The question: When should we have children?
Medical education encompasses so many hours and days and years of life. At the beginning, we are hopeful students; on the other side, we are physicians.
And somewhere in the middle, as the years go by, that half-wondered thought blooms into an inescapable question—“When should we have our children?”
Everyone has an opinion about this- from the old standby, “There’s never going to be a perfect time- just do it,” to, “You don’t HAVE to have children, you know.”
My own advice to others is that it’s much better to do it in residency, which is going to be hard anyway.
This is not an idle question and should not be a surprising one.
Doctors have children at a different age
The average age of medical school matriculation is 24 for both men and women, as of 2018 data collected by the Association of American Medical Colleges (AAMC).[1] This means that the average age of US medical graduates in the United States is 28 years old. And by extension, the expected age of completion for residency training is 31 to 35 years, accounting for 3-7 years of total training time (residency alone or residency and fellowship).
According to Centers for Disease Control (CDC,) the mean age for first child in the United States 26.5.[2] In fact, more women are having children later in life- the proportion of women aged 30 and older having first children increased from 23.9% in 2000 to over 30% by 2014. The mother’s age when she has her first child is crucial for epidemiologists and those who study populations, as age affects fertility, maternal and fetal morbidities and complications, birth rates, and the total number of births a woman has over her lifetime.
What about physicians?
One study[3] surveyed six hundred female physicians who graduated from medical school between 1995-2000. These women graduated medical school on average at age 27.5 and completed residency at mean age of 31.6 years.
The study calls this timing “collision of biologic and professional clocks,” which I find both poetic and distressing.
The women who answered the questionnaires were specifically targeted by researchers through the AMA Masterfile, which encompasses physicians throughout the United Sstates. The particular cohort of women were chosen since they had already likely completed childbearing (which researchers expected to be ages 25-35). Indeed, the average age of the physician respondents was 43. They were nearly all (over 99% of them) still practicing medicine. Eighty-two percent of them had children.
First time pregnancy among these female physicians was 30.4 years, fully four years older than the mean US average, and falling square inside the time most physicians remain in residency. The study itself notes that female physicians have children 7 years later than the national average.
Other salient facts:
- Nearly one quarter of female physician respondents were diagnosed with infertility.
- Nearly 15% of them had terminated at least one pregnancy, mostly citing career as a major factor. (Compare this to incidence rate of 27 per 1000 women, or 2.7% in developed countries)[4]
- One fifth of women (21%) reported taking greater than one year to conceive and nearly a quarter (24%) were diagnosed formally with infertility.
- Nearly one fifth of them was considering another pregnancy.
- Only 4% of women respondents were members of surgical specialties.
The article goes on to cite other important concerns:
- Resident physicians have higher rates of obstetric complications including preterm labor and placental abruption.
- There is a perception that residency program directors actively discourage pregnancy due to its representing “a hardship on other residents and an interference on the smooth functioning of the department.”
- Physicians outside of the subspecialty routinely underestimate the effect of age on fertility and do not understand the lack of effectiveness of interventions such as in vitro fertilization (IVF).
Doctors and parental leave
In another study published recently in JAMA Network we see that resident physicians take six weeks and attending physicians take eight weeks of maternity leave.[5] However, the majority of physicians desired more leave time, ideally 4-6 months. Present leave time includes a patchwork of sick leave, vacation time, accrued paid time off, followed by unpaid family leave. Many women, particularly trainees, are pressured to limit time off due to need to “make up” missed training time and thereby prolong residency.
Then there is the immediate transition and return to work, which has been described in one book as “the fifth trimester” and represents a hectic, exhausting time for families. Most families use some form of non-family childcare including daycare (42%) and hired help (37%), which can be costly enough to rival college education. Nearly all physicians (94% of first time physician mothers) breastfed or pumped at work, but 40% reported insufficient facilities and 47% reported insufficient time for pumping.
These concerns are staggering.
Female doctors delay childbearing more than other women, often to the point of infertility. When they finally have children, despite themselves representing the arbiters of health and wellness, they have inadequate family leave. Female physicians are more than 1.5 times more likely to be divorced than male physicians of a similar age, working similar hours, according to a recent Harvard Medical School study.[6]
While I deeply crave the optimism that drives women and especially women doctors to push harder, to never accept that we should not strive for more, the reality is that female physicians still do not have it all figured out.
I am writing here as a woman, as a physician, and as a student of this current era. I hope in the future to reflect that the struggles I and my colleagues have faced as women and physician-mothers are bygone artifacts of a less enlightened time.
References:
[1] Age of Applicants to US Medical Schools, 2014-2015 through 2017-2018. <https://www.aamc.org/system/files/d/1/321468-factstablea6.pdf>
[2] Mean Age of Mothers is On The Rise: United States 2000-2014. < https://www.cdc.gov/nchs/products/databriefs/db232.htm>
[3]Stentz, NC et al. 2016. Fertility and childbearing among American female physicians. Journal of Women’s Health. 25:10,1059-1065.
[4] Singh et al 2017. Abortion worldwide 2017: uneven progress and unequal access. Guttmacher Institute. <https://www.guttmacher.org/report/abortion-worldwide-2017>
[5] Juengst et al 2019. Family leave and return-to-work experiences of physician mothers. JAMA Net Open. 2019;2(10):e1913054.
[6] Ly, DP et al 2015. Divorce among physicians and other healthcare professionals in the United Staes: analysis of census survey data. BMJ 2015; 350:h706
