Over the New Year’s weekend, I spent some time with a friend who is an OB/GYN, and happens to be in her third trimester of pregnancy. We went to the playground with our toddler kiddos, and she remarked how amazing it was that her charming, hilarious three-year-old – who generously shared her toys with my 18-month-old son, who isn’t exactly good at sharing – had been born at 29 weeks.
Her daughter is now a healthy and growing little one, but my friend confessed that she was feeling anxious about her current pregnancy.
“My goal was just to stay pregnant until 2023,” she told me – a modest goal, clearly tempered by her past experiences, given that her due date is in February.
“You have the curse of the OB,” I said.
What is the curse of the OB, you might wonder? Wouldn’t OB/GYNs have access to the best prenatal care, the most up-to-date science, all the off-the-record tips?
Yes, but they also work in conditions that, it seems, can be really dangerous in pregnancy.
This was always the lore that permeated the labor and delivery floor when, in residency, I used to deliver babies. I remember a few residents from my cohort – now all of them parents to healthy, thriving children, thanks to modern medicine – who had dramatic preterm deliveries that were stressful and heartwrenching to hear about. I remember the OB/GYN attending whose water broke, early, while she was operating on a patient.
In the United States, OB/GYNs work crazy hours. Residents, in particular, work especially crazy hours: many do a Q4 or Q3 call schedule, which means they work for 24-hours straight every 3 or 4 days. (Yep! That person doing your C-section may have been awake for 24 hours!)
My residency, in family medicine, was a bit more humane – I only had to work a Q4 schedule for a few months in the beginning of residency, not for months on end. But surgical specialties – including OB/GYN – are known for brutal schedules, routinely asking their residents to work more than 80 hours a week, with frequent 24-hour shifts where residents don’t get to sleep. (And, in addition to the sleep deprivation, are expected to take care of patients.)
It’s a deeply ingrained part of the workplace culture, necessitated in part perhaps by the unpredictable nature of medical emergencies, but it’s also a clear choice that we in medicine make. We could hire more residents, but we don’t. We could set caps on the number of consecutive hours a doctor could work without sleep, but we don’t. We push and push and push ourselves, until something breaks.
Lots of things might be breaking in medicine, but I want to focus on how this culture of workaholism affects pregnant doctors and their babies. The “curse of the OB” – that being an OB/GYN is truly a risk factor for pregnancy complications – is thought to be related to sleep deprivation, standing for long periods in the operating room, and exposure to chronic stress. On more than one occasion have my OB/GYN friends commented on the irony of the prenatal advice they dole out – eat healthy, get plenty of sleep, regular exercise – and the prenatal advice they follow – work for 24 hours without sleep, eat junk food from the hospital cafeteria, remain standing for hours at a time in the operating room.
There’s some research to back up the lore. This classic 2003 paper – which my pregnant OB/GYN friend quoted to me from memory – compared pregnancy outcomes for OB/GYN residents to pregnancy outcomes of the spouses of OB/GYN residents. (i.e. Did working 24 hour shifts cause problems in your pregnancy, or did being partnered with someone working those crazy hours?)
Luckily everyone, ultimately, seemed to do fine – pregnant people, babies, and presumably their partners. But the pregnant residents – the ones staying up all night, standing in the operating rooms – definitely were at higher risk for serious problems in pregnancy, like pre-eclampsia, fetal growth restriction, and preterm delivery. The fact that ultimately, outcomes were good is important, but undermines just how traumatic it can be to have a difficult, complicated birth. Or how traumatic it can be to have a baby in the NICU.
A more recent paper compared pregnancy and birth outcomes between doctors and non-doctors. Important caveat: this was in Canada, where apparently they have more humane residency work schedules, and it wasn’t looking specifically at trainees – who are usually the ones working the craziest hours. They just compared pregnancies amongst doctors to pregnancies amongst a comparable cohort of non-doctors.
Interestingly, the researchers did find that pregnant doctors were slightly more likely than non-doctors to have serious complications in their pregnancies, although the researchers thought it might have been related to the fact that doctors tend to delay their pregnancies more than non-doctors. The average pregnant doctor they studied was 34 when giving birth, and the average non-doctor was 32.
I gave birth at 35, at a time in my professional life that worked out really well – I was an attending primary care doctor, and I am so glad I was able to wait to have my son until after residency. I have a pretty regular, predictable schedule, and I don’t have to work overnight shifts any more. I’ve gotten a lot better about managing my stress, and I don’t have to do any physically grueling work, like standing in an operating room. Still, I’m sure waiting until 35 came with some drawbacks, and I did have some high blood pressure readings in pregnancy – a complication that is more likely in older patients.
But doctors shouldn’t have to wait to have a baby, and we should do a much better job of protecting pregnant residents so they’re safe and supported during their pregnancies. I think it’s unlikely we’ll see an overhaul of residency work hours anytime in the near future – more on that later.
So we need to make some short-term changes. That could look like protecting pregnant residents from 24-hour shifts – especially in the third trimester. It could look like assigning them away from night shifts or from surgical rotations with prolonged standing.
More importantly, it could look like paying other health care providers, either attendings or advance practice providers, to do this work – not just dumping it all onto the other residents.
And it also could look like protecting attending doctors, too. My pregnant friend is several years out of residency, and she still routinely does 24-hour shifts as an attending. (She just doesn’t have to do as many of them as she did in residency.) We should direct this kind of work away from pregnant health care workers, and pay – I can’t emphasize this enough – additional health care workers to fill the gap.
Thanks for reading. Let me know what you think!