Maternal wellbeing and pregnancy outcomes in anaesthetic trainees

Introduction

Work in medicine is known to be both physically and psychologically demanding at times, which may in turn impact the wellbeing of the health professional.^1,2 Poor maternal health and certain occupational exposures have the potential to adversely influence pregnancy outcomes, especially during critical periods of foetal growth and development.

The gender mix in anaesthesia continues to equalise. Of the Fellows of the Australian and New Zealand College of Anaesthetists (ANZCA) 33% are female, although gender proportions are balanced in 31–35-year-old Fellows, while 43% of trainees in 2018 were female. ³ Accordingly, this increasing proportion of younger females in the profession will undoubtedly continue to stimulate interest in this area.

Because each pregnancy experience is individual and highly variable, it can be hard to make generalisations about what the needs of the pregnant worker may be, and therefore levels of support do vary considerably. ⁴ Satisfaction with support received during pregnancy and on return to work from parental leave has not been formally investigated. It is also unknown whether any adverse maternal or pregnancy outcomes result from or are contributed to by working conditions experienced by Australasian anaesthetic trainees. While local data are scant, general inferences can be drawn from research based in other specialties, undertaken overseas and outside of medicine.

Background

In response to the increasing proportion of female doctors in the workforce, publications investigating the association between occupational hazards in medicine and adverse pregnancy outcomes emerged in the 1970s. A specific interest was taken in women in anaesthetic practice and the potential impact of exposure to anaesthetic gases. These women were found to have a higher proportion of smaller babies, increased stillbirth rates and more congenital malformations of the cardiovascular system when compared with other female doctors during the 1950s, 60s and 70s. ⁵ The relevance of this is limited due to different exposures and working conditions today, however exposure to what is known as ‘waste anaesthetic gas’ (which may contain nitrous oxide and/or volatile agents) has been reported to increase the risk of early miscarriage by as much as 50%.^6–8 This is especially relevant in settings where scavenging systems may either be absent or insufficient, such as endoscopy suites, birth suites, post-anaesthetic care units and during inhalational inductions which are commonly performed in paediatric anaesthesia.^9,10 Concerns still remain over resultant low birth weight and congenital abnormalities in children born to exposed mothers. A recent article suggests that consideration should be given to the use of total intravenous anaesthesia in operating rooms where a pregnant staff member is working. ⁶ There is, however, no evidence of adverse effects from volatile anaesthetics when environmental levels can be maintained below their legal thresholds. ¹¹

Other occupational hazards relevant to healthcare workers impart known risks to the foetus. These include exposure to communicable diseases, cytotoxic agents, ionising radiation and methylmethacrylate (a component of bone cement).^12–15 There is currently no evidence of harm to the foetus with exposure to magnetic resonance imaging (MRI), however it is recommended that pregnant personnel do not stay in the MR imaging bore or magnet rooms during data acquisition or imaging.^16,17

‘Unfavourable working conditions’ are associated with preterm birth (PTB) and low birth weight, and include shiftwork, working nights, long periods of sitting or standing, trunk bending, heavy lifting, exposure to chemicals, long working hours and high job demands.^18–22

Pregnancy during specialist training

A landmark literature review by Finch examined pregnancy during ‘residency’ from 1984 to 2001, and found all reports suggested an increased risk of complications, particularly during late pregnancy. The evidence was strongest for premature labour, however PTB, low birth weight, intrauterine growth restriction (IUGR), hypertensive disorders of pregnancy, placental abruption, hyperemesis and stillbirth were also implicated. ²³ Postulated mechanisms include decreased uterine blood flow mediated by catecholamines and postural effects. ²⁴ Some authors have suggested that doctors be considered and treated as a high-risk obstetric group. ²³

A small proportion of studies have demonstrated contradictory results, including a Finnish nationwide population-based study which only examined birth registry details from 1990 to 2006. In this study, work as a doctor was not related to gender of the newborn or to any increased risk of PTB, small for gestational age, or perinatal death compared with the reference group of ‘upper white-collar workers’. ²⁵

A 2015 study by Behbehani and Tulandi found that residents in North America had a higher rate of IUGR, miscarriage, hypertensive disorders of pregnancy and placental abruption when compared with National data. An overall complication rate of 34% was found, although this was adjusted to 26% for those with up to six nights on call per month versus 49% for those with more than six nights on call per month. Most of the surveyed residents rated their stress level as moderate. ²⁶

With regard to lactation practices; the majority of residents initially breastfeed their babies, however a study in Pediatrics in 1996 showed that only 15% were still breastfeeding at six months. ²⁷ A 2017 survey of female surgical trainees in the USA found that, while 95% felt breastfeeding was important, 58% ceased earlier than they wished because of poor access to lactation facilities and challenges leaving the operating room to express milk. ²⁸

Psychological impact on maternal wellbeing and pregnancy outcomes

While postnatal depression has a higher awareness profile, anxiety and depression during pregnancy occur at the same rates and severity. ²⁹

Sources of chronic stress (such as exposure to racism) and depressive symptoms are associated with lower birth weight, while perinatal anxiety is associated with shorter gestation and adverse foetal neurodevelopmental and child outcomes. More specifically, ‘pregnancy anxiety’ seems particularly potent. ³⁰ Pregnancy anxiety is closely associated with state anxiety but in the context of concerns around the current pregnancy.

Women with high stress, anxiety and depressive symptoms in pregnancy are more likely to be affected in the postpartum period, with resultant compounding negative effects on infant development. ³⁰

Work stress (both physical and psychological) results in adverse pregnancy outcomes, including increased risk for miscarriage, preterm labour and PTB, through negative impacts on foetal growth and development.^19,24,31

Pregnancy discrimination may result in feelings of guilt and vulnerability, while overcompensation for perceived limitations may contribute to adverse pregnancy outcomes.^19,24 Interestingly, it has been shown that a lack of sense of control is implicated.^18,21,30,32 Working as a trainee may diminish this sense of control, and it is this internal locus of control that has been found to be central to the concept of resilience. ³³ Psychosocial stressors including low job control and work-life imbalance have been shown to result in doctors’ poorer self-reported health status in a large, longitudinal study conducted in Australia. ²¹

The National Mental Health Survey of Australian doctors and medical students comprised over 12,000 respondents and was reported in October 2013. In this study, young female doctors carried the highest risk of anxiety, depression and burnout. Of all females surveyed, 37% reported pressures around managing study or career and family duties, with 20% of female doctors having experienced stressful life events in the last year. Anaesthesia rated highly in many areas including measures of burnout (25% for emotional exhaustion, 32% cynicism, 14% low professional efficacy). Again, the younger age groups and more junior also rated highly, while female gender alone imparts an odds ratio (OR) of 1.34 for high or very high psychological distress in doctors. Measures of burnout in isolation were associated with even greater risk of psychosocial distress; OR were 4.2 for emotional exhaustion, 2.98 for depersonalisation and 1.73 for low professional efficacy. Female doctors reported higher rates of current psychosocial distress (4.1% versus 2.8%), minor psychiatric disorders (34% versus 23%), and current mental health diagnoses (8.1% versus 5% for depression, 5.1% versus 2.9% for anxiety). Suicidal thoughts were reported as 11% for female versus 10% for males in the last 12 months, and 29% versus 22% in the time prior to the previous 12 months. This data was matched to 2011 general population census results. ³⁴

Castanelli and colleagues found that, of 281 Victorian anaesthetic trainees surveyed in 2016, 67% displayed evidence of burnout in at least one domain, most commonly emotional exhaustion (49%) and depersonalisation (42%). ³⁵ The welfare of anaesthesia trainees survey conducted in 2015 and published in Anaesthesia and Intensive Care in 2017 found that of 428 respondents, 28% indicated either high or very high levels of psychological distress. ³⁶ Neither of these studies explored in any depth the effect of non-work roles on trainees’ wellbeing, nor any potential impact on reproductive outcomes.

Burnout and reproductive health

In an online Hungarian survey assessing burnout in 2013, Gyorffy and colleagues found that female doctors, when compared to the general population, had more high-risk pregnancies, time-to-pregnancy interval >1 year and infertility treatments, as well as miscarriages. High-risk pregnancies and miscarriages were strongly associated with burnout, and measures of burnout had the highest scores in the youngest group of female doctors (aged 24–35 years). ³²

Effect of maternal stress on foetal health and development

Barker first proposed the ‘foetal origins of adult disease’ theory, using the term ‘intrauterine programming’ ³⁷ to explain the induction of lifetime effects on metabolism, growth and neurodevelopment that occur in utero. Low birth weight (and particularly small-for-gestational-age) is now known to be associated with increased risks for some adult diseases including coronary heart disease, hypertension, type 2 diabetes and stroke.^37–40

There is now a substantial evidence base for the effects of maternal stress, anxiety and depression in pregnancy on adverse neurodevelopmental outcomes for the child.^29,30 The key postulated mechanism for this is dysregulation of the maternal and foetal hypothalamic-pituitary-adrenal (HPA) axis. Pregnant mothers with comorbid anxiety and depression have been shown to have higher cortisol levels when compared with healthy controls. Ten to 20% of maternal cortisol passes through to the foetus—which may be sufficient to exert long-term effects on the developing foetal brain. Maternal cortisol levels have been found to be related to increased foetal activity, and inversely related to estimated foetal weight. Autonomic nervous system indicators such as foetal heart rate show responsiveness to maternal psychological state, such as prolonged foetal tachycardia in a stressed mother. In addition, it has been shown that there is continuity in foetal-to-infant neurobehaviour. It has been suggested that noradrenaline is a likely mediator via sympathetic-adrenal activation, although the HPA axis may still play a role.^29,30

A subset of research is examining the effect of prenatal exposure to disasters (as a measurable single stressful life event), which may have implications for exposure to stressful events in other settings. One study found that high levels of maternal stress predicted worse theory of mind at 30 months (an aspect of child development that is predictive of social functioning and is impaired in children with autism). ⁴¹ Studies have shown that infant motor and cognitive development may be impaired following prenatal maternal exposure to stress or post-traumatic stress disorder.^42–44

Attitudes to pregnancy during specialist training/residency

In both 2008 and 2015, residents across a range of specialties in the USA were surveyed on attitudes toward pregnancy during training. A persisting negative stigma was found, although improving support for pregnancy was reported over time. Surgical residents perceived the lowest levels of support, while female leadership within programmes resulted in a higher level of reported support for pregnancy. ⁴⁵

Perhaps due to the extreme nature of surgical training or residency, and issues such as a high attrition rate, many of the more recent studies revolve around women in the surgical specialties. In an article recently published in the American Journal of Surgery, Rangel and colleagues found that over 200 surgical trainees in the USA ⁴⁶ identified six recurring themes:

the desire for work modifications during the late stages of pregnancy due to health concerns;

These issues encompass many of the sentiments that anecdotally are encountered during discussion around this subject. In another recent, but smaller survey of pregnant surgical residents, Shifflette and colleagues found that around a third of these residents reported in-training exam scores which suffered, and some respondents felt that they received less teaching during their pregnancies. Many of them felt that returning to work with a child at home posed the greatest difficulty, however 95% stated they would become parents again during residency, given the opportunity. ⁴⁷

In Australia in 2012 the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) undertook a survey of current trainees and Fellows who had graduated in the last six years, in relation to pregnancy and parental leave. More male registrars reported being inconvenienced due to their colleagues taking parental leave (73% of men and 38% of women reporting adverse roster changes such as more night shifts, with a significant reported impact on recreational and other leave). Of the females who took parental leave, 42% reported negative comments from consultants about their leave, and there were also reports of employers and fellow registrars making negative comments; 26% reported questioning regarding future pregnancy plans during job interviews. At the time of publication of their results 80% of new RANZCOG trainees were female. The authors asserted that parental leave must be regarded as an integral part of their training programme, and urged employers to ‘develop strategies to ensure service requirements can be met without impacting adversely on those registrars remaining in the health service’. ⁴⁸

Anaesthetic trainee experience

A survey of 53 anaesthetic trainees’ experiences with regard to stopping clinical work from five London schools of anaesthesia was presented at the Association of Anaesthetists of Great Britain and Ireland Group of Anaesthetists in Training Annual Scientific Meeting in 2012. Findings included the median gestation at cessation of night duty was 30 weeks, while for daytime shifts it was 32.5 weeks gestation. The main reason for ceasing night duty was most commonly concern for tiredness and ability to concentrate (18) followed by physical difficulty (10), maternal complication (7), own concern for baby (5) and departmental guidance (5). Only three stopped nights at the start of maternity leave (i.e. all others ceased prior to planned maternity leave). Stated reasons for stopping days were most frequently own concern for tiredness and ability to concentrate (17) followed by physical difficulty (11) and starting maternity leave (11). ⁴⁹

A pilot survey of 66 female anaesthesiologists and trainees in the USA on childbearing and parental leave experiences found that 51.8% of mothers gave birth to their first child as trainees. Of respondents, 52% felt parental leave was sufficient, while 45% found lactation facilities were appropriate upon return to work, with 58% reporting an adequate duration of lactation. Of the 37 who had a child during training, 13.8% considered leaving their training programme at the time, and 26% felt that a delay in training due to childbearing affected their seniority at work. Medical appointments were skipped by 21% of respondents due to work demands, and almost 20% had complicated deliveries (although pregnancy complications were not reported). Only 45% felt that their colleagues’ and superiors’ handling of maternity and/or lactation needs were satisfactory. ⁵⁰

Guidelines: Pregnancy and work

The Royal Australasian College of Physicians (RACP) has published the Australasian Faculty of Occupational and Environmental Medicine’s Guide to Pregnancy and Work in November 2017. This document includes information to assist in the recognition of early warning signs that physical activity may be too strenuous, educate on the potential impacts of work on the mother and foetus during each trimester, and advise on potential workplace hazards, risk assessment and risk control.

There is a recommendation that pregnant employees consult with their doctor if their work involves certain activities, which include: working more than 40 hours per week, shiftwork, lifting more than 23 kg after 20 weeks, 11 kg after 24 weeks, or any heavy items after 30 weeks gestation. ⁵¹

Legal and industrial issues

Anti-discrimination legislation includes the Sex Discrimination Act 1984 and the Disability Discrimination Act 1992. ⁵² Every employer and employee is subject to The Fair Work Act 2009, within which is provision for maternity and parental leave. All employees in Australia are entitled to 52 weeks of parental leave (which may be paid or unpaid). Issues of bullying and harassment are also addressed in the Fair Work Act 2009. ⁵³ Each state or territory health service (or private employer) have their own awards and parental leave policies. Statewide enterprise bargaining agreements (such as the Medical Officers Certified Agreement in Queensland) may also make reference to leave policies. ⁵⁴

It is unknown whether all relevant entitlements are either understood or are being accessed appropriately. These include parental leave, prenatal leave (to attend medical appointments) and provision for suitable duties if appropriate. There is often confusion regarding entitlements due to the nature of contract-to-contract work and issues of secondment during specialist training in Australia, however leave policies have in many instances been adjusted to broaden and clarify criteria for ‘eligible employees’ in order to protect the rights of workers such as doctors in specialist training. In Queensland these definitions are found in section 16 of the Industrial Relations Act 1999. ⁵⁴

The Australian Health Practitioner Regulation Agency—Medical Board of Australia (or AHPRA) regulates requirements for re-entry to practice; in general, up to and including 12 months is accepted without additional requirements for continuing professional development, supervision or other special requirements to maintain registration. ⁵⁵ ANZCA also has policies in relation to interrupted training and return to work.

How to best support pregnant workers

The Harvard Business Review published an article entitled ‘The right and wrong ways to help pregnant workers’ by Clair and colleagues in 2016. ⁴ Apart from discussion around ongoing stigma and discrimination, some interesting facts were raised. Included were the results of a study that found the more ‘help’ women received at work while pregnant, the more likely they were to want to quit their jobs, even at nine months postpartum. ⁵⁶ These women tended to develop greater negative self-views about their potential to be good workers and working mothers. One theory from psychology—‘threat-to-self-esteem-model’—could explain this: help may be perceived as threatening if it is interpreted as implying a lack of competence.^4,56

Most women are highly motivated to maintain their professionalism during pregnancy and may worry about their capabilities during this time. In balancing the competing demands of their jobs, care requirements related to their pregnancy, and pregnancy symptoms; any existing strains may be compounded in this setting. This is a reminder that the goal of support for pregnant workers (and those returning from maternity leave) is to increase rather than decrease their confidence in their abilities to manage the demands of work and non-work roles.

With a view to improving maternal and infant health outcomes and improve workplace conditions for women, Salihu and colleagues recommended shifting organisational culture to support women in pregnancy, in addition to conducting early screening of occupational risk during preconception and monitoring manual labour conditions. ¹⁹

Clair states employers ‘should make no assumptions about the kind of help that a pregnant worker wants or needs – instead they should ask questions, maintain an open dialogue, and be open and flexible to the unique needs of pregnant workers’. ⁴

Benefits of a pregnancy-friendly workplace

The RACP/Australasian Faculty of Occupational and Environmental Medicine’s Guide to Pregnancy and Work states that, in addition to meeting legal obligations, benefits of a pregnancy-friendly workplace include:

supporting healthy pregnancies and healthy babies;

Rationale for further research

In conclusion, a final observation on the link between doctor wellness and the functional status of their workplace is presented. In an article published in the Lancet in 2009, Wallace reviewed the work stresses faced by doctors, the barriers to attending to wellness and the consequences of unwell doctors on individuals and healthcare systems. Wallace argues that not only should doctors’ wellbeing be used as an indicator of organisational health, it is an integral component of quality healthcare delivery and should be routinely measured. ⁵⁷ Despite the challenges such an endeavour may provide, it is vitally important that we gauge the impact of specialist training on maternal wellbeing and pregnancy outcomes. Without a baseline, future attempts at quality improvement may not be appropriately targeted, and the size of any resultant effect cannot be accurately measured.