Journal of Pregnancy and Child Health
Open Access

Breastfeeding; Physicians; Residents; Female Physicians; Barriers

Introduction

Throughout history, breastfeeding and its role in infant survival has been appreciated [1]. The WHO, American Academy of Pediatrics [AAP], and American Academy of Family Physicians [AAFP] all recommend exclusively breastfeeding for the first six months of life to achieve optimal growth and nutrition [2,3]. Professional support from physicians trained in lactation support and counseling promotes prolonged breastfeeding [4]. The 2020 CDC Breastfeeding Report Card found in 2017 that 84.1% of mothers in the USA initiated breastfeeding and that 58.3% were breastfeeding at six months [5].

Barriers to breastfeeding exist outside of maternal or infant factors. Jones report barriers such as lack of social, work, and cultural acceptance/ support, language and literacy barriers, lack of maternal access to information that promotes and supports breastfeeding, acculturation, need to return to work, and lifestyle choices including tobacco and alcohol use dissuade low-income women from breastfeeding [6, 7]. Challenges in breastfeeding, unsuccessful attempts, and failure to initiate breastfeeding with the first child have been associated with failure to initiate breastfeeding with subsequent births. Higher levels of education are associated with a higher likelihood of both breastfeeding initiation and continuation. Highly educated mothers with higherpaying jobs may have more flexible work schedules, providing the opportunity to breastfeed longer [7]. However, lower breastfeeding initiation and duration rates are also associated with women working outside the home [8]. As such, female medical students, residents, and attendings are a high-risk group for early unintended weaning from breastfeeding [9]. As the number of female physicians in the US continues to increase, creating a culture of support in the medical community for breastfeeding physicians will be a critical component of physician wellness [10, 11]. This manuscript, therefore, reviews literature regarding barriers that female physicians may face should they choose to breastfeed.

Benefits to Mother and Baby

Breast milk contains many components that formula milk does not, which makes it a more beneficial form of food for infants. Breast milk contains long-chain polyunsaturated fatty acids, which form the main structures of neuronal membranes and play critical roles in nervous system functioning by aiding brain development [12]. Improved cognitive performance in breastfed children is likely due to the fatty acids in breast milk and their effect on brain development during infancy, especially in the growth of white matter tracts [12]. Deoni provided MRI evidence that breastfed infants exhibit better development in specific brain areas associated with language and visual reception abilities than formula or formula-supplemented infants [13]. Breast milk provides infants with the best nutrition, immune protection, and regulation of growth, development, and metabolism [14]. Breast milk is key in compensating for delays in the development of the neonatal immune system and is responsible for preparing the intestines for life after breastfeeding [14]. The beneficial gut bacteria that results from breastfeeding protects the infant from pathogenic bacteria and aids in synthesizing essential nutrients, namely vitamins B12, B6, folate, and K [14]. Moreover, immune protection provided by breast milk is associated with reduced asthma in children [14]. Bachrach and colleagues found in an analysis of studies from 1980- 2001 that breastfed infants had a 72% lower risk of hospitalization from respiratory infections than non-breastfed infants [14].

For the mother, breastfeeding aids in postpartum weight loss, reducing the risk for hypertension, diabetes, hyperlipidemia, and cardiovascular disease [14]. In a large prospective cohort study, Baker showed that greater exclusivity and duration of breastfeeding were associated with more significant weight loss at six and 18 months postpartum [14]. Because African American and Hispanic women have increased obesity, diabetes, and cardiovascular disease rates, breastfeeding among these groups is particularly important in mediating long-term health risk factors [14, 15]. Studies have suggested that breastfeeding reduces breast cancer risk, including invasive breast cancer, and reduces the risk for both endometrial and ovarian cancers [15]. Research shows that breastfeeding influences mood, affect, stress, and maternal care for the infant by significantly reducing the mother’s physiological and subjective stress, facilitating positive effects, thus improving maternal sensitivity and care for the child [12].

Physicians/Resident Physicians and Breastfeeding

In a survey by Nakar over 90% of physicians agreed that breastfeeding women need encouragement, and physicians must provide encouragement for women to breastfeed [16]. However, female attending physicians and resident physicians face unique barriers to breastfeeding. Intense, unpredictable work schedules, limited support in the clinic and hospital workspaces for pumping, minimal time for maternity leave, and intense pressure between career development and childcare responsibilities pose risks to early, unintentional weaning of their infants [9, 17]. In a 2018 study of 927 members of the AAP Section on medical students, residents, and fellows, 33% reported they did not meet their goal for exclusive breast milk feeding, and 24% did not meet their lactation duration goal [17]. Moreover, another survey of resident physicians in 2020 found that 73% felt residency limited their ability to lactate, and 37% stopped before they reached their duration goal [17]. Since returning to work is a critical point for the breastfeeding mother. It is important to increase awareness, supervision, guidance, and overall support of the mother’s decision to breastfeed as the mother transitions back into the workforce [16]. As the proportion of female physicians has increased from 28.3% in 2007 to 36.3% in 2019 and is projected to continue upward, it is essential to support lactating women to develop an overall healthier medical workforce [9]. According to a recent study, more resident physicians are planning to become pregnant. These rates increased from 13% in 1983 to 30% in 2016 [9]. There is an overall need to raise awareness of the needs of breastfeeding female physicians, and institutional support is needed to alleviate some of the barriers breastfeeding physicians face in their careers and the workplace [9, 17]. The following section will examine the studies that detail possible barriers to breastfeeding in physician mothers.

Clinical Studies

Numerous studies detail the barriers physician mothers face when breastfeeding upon returning to work and are summarized in Table 1. These studies emphasize the importance of breastfeeding to the health of a newborn and the breastfeeding mother [18]. The Center for Disease Control references the AAP: a recommendation for exclusive breastfeeding for at least six months, after which breast milk from a pump can be implemented [19]. Physicians especially understand this importance through their medical training. However, physicians who would like to breastfeed or pump breast milk for their children often experience barriers to breastfeeding in the workplace. Negative breastfeeding experiences can lead to less favorable interactions when counseling their patients on breastfeeding. It is important to address the multiple barriers to breastfeeding and find solutions to improve the experience of breastfeeding physicians. Improving the physicians’ experiences will extend to the patients’ experience. These improvements could include establishing and implementing breastfeeding policies, designating specific time and space for pumping, and extending time off or leave time for breastfeeding mothers.

Many manuscripts have highlighted physician mothers who breastfed that could not meet their breastfeeding duration goal. Riggs found that 98% of physician mothers initiated breastfeeding [20]. The rate of breastfeeding at 12 months was 12% among respondents compared to the Healthy People 2020 goal of 32% [20]. 76% of physician mothers reported challenges with breastfeeding; 27% of respondents were unable to resolve these challenges [20]. 24% of physician mothers did not reach their lactation goal [20]. In another study, though 41.7% of physician mothers reported being able to sustain breastfeeding for at least 12 months, only 28% of these women reported that reaching their breastfeeding personal goal was the main reason to discontinue breastfeeding [18]. In a study conducted by Mc Donald, respondents reported a breastfeeding duration goal of 7.1 ± 4.1 months, with the actual duration of breastfeeding as 5.8 ± 4.0 months [21]. Sattari found that 78.15 of respondents reported the intention to breastfeed for at least 12 months, with only 55.4% reporting breast feeding at 12 months [22].

The evidence that the obstacles presented to physician mothers who decide to breastfeed are overwhelming. Multiple studies report discontinuation of breastfeeding or pumping earlier than the desired goal. Inadequate time and space for breastfeeding were high among the reported barriers to breastfeeding in most papers [18, 23-25]. In a survey conducted by Ramsey 88% of survey residents agreed that 20-30 minutes every 2-3 hours should be provided for them to pump. Still, only 18% felt comfortable asking for schedule changes to accommodate their needed time to pump [17]. Therefore, many residents and attending physicians do not meet the recommended or their personal lactation goals due to a lack of time in the workplace [17].

Melnitchouk performed a cross-sectional survey with 1606 respondents. They reported that most mothers in their study pumped breast milk in their office, and following that, most pumped in various rooms around the workplace, including closets [18]. 28.0% reported discontinuation of breastfeeding due to reaching the lactation duration goal, and 49.1% reported the intention to breastfeed longer if the workplace had offered more accommodation [18]. Peter showed that 73% of residents reported a limited lactation duration due to residency demands, with 37% of residents unable to meet their lactation duration goal [26]. This survey found that 60% of surveyed resident physicians reported not having a place to store breast milk at work [26]. The same survey found that 21% of residents reported the availability of a lactation room in the hospital of their training, with 12% reporting a computer in the room to continue working [26]. Another study identified that 92% of mothers experienced breast feeding difficulties upon returning to work, and 40% of physician mothers reported concern that their pumping negatively affected their team, with 10% expressing a possible impact on patient care [25]. Work hours and returning to work was also reported to be an obstacle to breastfeeding. Ersen found that 23.6% of respondents listed their most common reason for discontinuing breastfeeding as workplace-related conditions [27]. Many papers focused on resident experiences rather than staff or student physician experiences. However, Frolkis did find that residents generally seemed to breast feed less than their staff physician counterparts [24].

> 90% of trainees and physicians reported intent to breastfeed in all surveys that collected this information. However, > 75% of trainees and physicians reported initiation of breastfeeding [24]. These authors also concluded that the consequences of these barriers included low milk supply and early discontinuation of breastfeeding [24].

The emotional impact of navigating barriers to breastfeeding was mentioned in several studies as a factor in the early discontinuation of breast feeding. Riggins reported that 26% of their respondents reported facing breastfeeding difficulties we're unable to work through them, and many reported feeling negative emotions, including disappointment, sadness, and failure [20]. Eren mentioned physician mothers felt guilt regarding taking full maternity leave. They found that 67% of respondents reported returning to work due to negative emotions [e.g., feeling guilty] associated with ending their leave [28]. In a cross-sectional survey of 312 women performed by Peters 56% of residents reported that their mental health was affected by challenges with breastfeeding during their residency [26]. 40% of the respondents also reported that their faculty and/or co-residents made them feel guilty about their decision to breastfeed [26].

Physician mothers were also concerned about the perception of breastfeeding in the work place and the additional burdens it could potentially cause to the team. Orth focused on the perception of the burden regarding breastfeeding from the physician mother and colleague standpoint. In their study, more than 1/3 of breastfeeding mothers felt as though they were burdening colleagues. Interestingly, 80% of colleagues reported not feeling burdened by the extra demands of breastfeeding residents [29]. However, Mills et al. did find that 10.9% of breastfeeding residents reported hearing a staff physician commenting on their breastfeeding in a derogatory manner [23]. Another study showed that 40% of residents reported feelings of guilt regarding their decision to breastfeed due to interactions with faculty and colleagues [26].

Even specialty choices play a factor in breastfeeding barriers faced by female physicians. Surgical specialties especially report meeting their breastfeeding duration goal even less than breast feeding physicians in non-surgical specialties. Eren mentioned specialty as a factor in breastfeeding, noting that mothers in surgical specialties did not continue breastfeeding as long as mothers in medical specialties [28]. Mills conducted a cross-sectional survey with 110 respondents of residents in Alberta, Canada. They reported that only 40% met lactation duration goals in surgical specialties compared to 80% in the non-surgical specialty [23]. Residents in Mills’ study reported that they stopped breastfeeding earlier than they desired due to the lack of adequate space [48.7%, n=19] and lack of time [57.1%, n=24] [23]. Twelve participants [10.9%] reported hearing a derogatory comment from a staff physician about their breastfeeding [23]. Wynn performed a study to see how many orthopedic surgery residency program websites included a breastfeeding policy and found that only 2.8% had written breastfeeding policies mentioned online [30].

All studies emphasized the importance of increasing support and resources for breastfeeding women in the medical field would enhance the breastfeeding experience for mothers and offered various suggestions on how to do so. One study suggests that providing a designated breastfeeding location other than a bathroom stocked with appropriate resources that could aid in the breastfeeding experience is important to encourage breastfeeding in the workplace [20]. Orth propose implementing a breastfeeding policy to decrease feelings of the burden physician mothers feel to their colleagues and increase flexibility when it comes to returning to the workplace [29]. Another study points out that the practice of medicine is becoming more team-oriented. Thus, for breastfeeding policies to be successful, the attitudes of both the breastfeeding mothers and their colleagues towards breastfeeding or pumping at work should be considered [25].

Multiple manuscripts have noted that the impact of breastfeeding experiences on physician mothers would likely affect how they counseled their patients in the matter. Some even went so far as to mention the potential consequences not addressing the issue could cause. Riggins stressed the importance that if these needs are not addressed, the lack of support and resources for physician mothers who breastfeed will bring unfavorable outcomes to both the mother and their child and patients advised by these physician mothers. This is contributed to the fact that mothers who encounter negative breastfeeding experiences may have more difficulty counseling other patients who are mothers [20]. Eren included that positive breastfeeding experiences by physician mothers would also improve advocacy for breastfeeding and their patients [28].

One study details the availability of support systems outside of the workplace. Riggins surveyed mothers to investigate whom patients seek breastfeeding advice from and discovered that only 32% sought advice from obstetricians and 27% from pediatricians, with the majority [76%] seeking advice from breastfeeding books. This study commented that this seemed unusually low and emphasized the importance of strengthening inter-physician support. Notably, breastfeeding initiation was mentioned as more a result of effective promotion, perhaps due to physicians having been taught the importance of breastfeeding in training. Still, that continuation of breastfeeding was largely due to support received [20].

Some studies mention that even though a policy might be in place, awareness implementation of the policy can affect whether the policy is appropriately implemented. Eren conducted a study comparing experiences before and after a new law on breastfeeding was implemented in Turkey. They included awareness of rights in their study and found that 78% of mothers reportedly were aware of their legal rights while 35.8% of mothers continued working without changing their work hours. It was also reported that most mothers used their maternity leave [88.1%], yet only 29.4% exercised their legal right to leave work 1.5 hours early or work fewer days per week, as was stated in the new law [28-30]. Ersen showed that 43.6% of participants could not exercise their breastfeeding leave rights in part or completely [27].

Conclusion

The benefits of breastfeeding are emphasized and well understood by mothers who are physicians. Yet, physician mothers are a highrisk group for early unintended weaning due to the nature of their profession. As the number of female physicians continues to rise, combined with the increase in the percentage of resident physicians who plan to become pregnant, identifying the obstacles they face is of the utmost importance.

The current national rates of breastfeeding initiation and duration at three months among all mothers are 81% and 44% at the three months, respectively. Physician mothers have higher rates of breastfeeding initiation and duration compared to the national average, likely due to their greater understanding of the benefits, with 41% of resident physician mothers reporting breastfeeding duration through 12 months rather than three months.

Physician mothers face many barriers preventing sustained rates of breastfeeding, including time, an inconsistent and unpredictable work schedule, and an appropriate space to breastfeed or pump in while at work. These barriers are further exacerbated by a lack of a support network in hospital systems. Only 18% of resident mothers reported feeling comfortable asking for changes in their work schedule for time to pump. Furthermore, resident physicians report that they feel residency limits their ability to lactate, and across numerous studies, approximately 30% of resident physicians reported they did not meet their breastfeeding goals.

Developing a support network in hospital systems for resident mothers is a viable intervention to prevent unintentional weaning. Providing a designated breastfeeding location stocked with appropriate resources, an open line of communication about changes in work schedule, strengthening inter-physician counseling and education, and supporting shorter workdays postpartum are all practical options to help prevent unintended weaning in resident physicians and creating an environment of physician wellness in hospitals.

Acknowledgement

Not Applicable

Conflict of Interest

The authors declare that they are no conflict of interest.

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