When Qaali Hussein, MD, was just a few months into her intern year, she received some exciting news: she was pregnant.
"Besides wanting to be a surgeon, the one thing I always wanted to be was a mother," Hussein, a trauma surgeon in Florida, told 番茄社区app.
She informed her supervisors that she was going to have a baby, so scheduling adjustments could be made. But Hussein did not expect the response she received.
"I was told, 'This has never been done, it will never be done, so you should think about your priorities and whether you want to continue on this road,'" Hussein said.
Some suggested she look into other specialties, take a year off, or do research. One of her chief residents said that training would always be difficult, and encouraged her to pursue her passion. But there was no maternity leave policy, and little to no work accommodations for pregnant residents. Hussein was the first PGY-1 to get pregnant in her program's history.
Pregnancy during medical training was difficult, Hussein said. The surgeon and mother of six finished residency in 2013; she had three pregnancies during her training.
At one point, she worked overnight calls once every four nights mid-pregnancy. Other times she worked an overnight shift every other night. And she didn't let her pregnancy stop her from operating for 10 hours at a time -- even at nearly 8 months.
Aside from physical stress, Hussein added that she struggled with priority conflicts, especially during earlier pregnancies. She felt torn between her duties to co-residents, and those to her family and health.
"I almost felt like every time I had to tell people, 'Hey, I'm pregnant,' I felt guilty," Hussein said.
As more women enter the medical field, training programs are attempting to create more optimal work environments for residents like Hussein. Indiana University's emergency and internal medicine programs have introduced flexible scheduling policies for pregnant residents, which prevent them from having to work demanding overnights and long shifts during trimesters that pose the highest risk.
IU's emergency medicine program drafted a flexible scheduling policy for pregnant residents last fall, which stated that residents in their first and third trimesters could opt-out of scheduled overnights and 28-hour shifts.
The policy, recently published in , also instituted 6 weeks of flexible scheduling for all new parents, and clarified sick call options to include miscarriage and sick childcare.
"This was a resident-driven initiative," said Kimi Chernoby, MD, JD, the policy's lead author and former chief resident of emergency medicine at IU.
Chernoby told 番茄社区app that she and co-residents initiated this change after new literature detailed obstetric risks of working conditions that included overnight and long shifts -- essentially, being a resident.
"As a chief, I could not in good conscience schedule my colleagues for these shifts that I knew were going to have these horrible outcomes for their pregnancies," Chernoby said.
She drew evidence from a recent review published in the , which found that women who worked rotating or fixed night shifts, as well as long hours, were more likely to suffer adverse pregnancy outcomes.
Working long hours was associated with higher rates of miscarriage, while some evidence showed that rotating night shifts increased risk of preterm delivery, small for gestational age infants, preeclampsia, and gestational hypertension.
Other research supports these risks. A survey of 238 medical and surgical residents in the found that nearly 50% of those who worked more than six night calls a month and 40% who spent more than 8 hours weekly in the operating room had adverse pregnancy outcomes. This was compared with 26% who worked less than six monthly overnights and 8% who spent less than 8 hours a week operating.
But the evidence is not conclusive.
"Just from the strict medical question of whether long hours or working night shifts is actually associated with adverse pregnancy events, it is very muddled," said David Hackney, MD, director of the maternal-fetal medicine program at University Hospitals in Cleveland.
Hackney said that separating long hours and night shift work from the socioeconomic factors like income, race, and barriers to care -- all of which are associated with adverse pregnancy events -- make it difficult to conclude that long hours associated with medical training are harmful to pregnancy.
The published a survey of more than 8,000 pregnancies in 1990 that showed no differences in preterm birth, miscarriage, ectopic pregnancy, or stillbirth between pregnant residents and spouses of male residents. It suggested that "working long hours in a stressful occupation has little effect on the outcome of pregnancy in an otherwise healthy population of high socioeconomic status."
But Hackney said that avoiding the night shift, long hours, and physical stress placed on pregnant residents promotes more humane working conditions and gender equity in the workplace, even if physical harms are unproven.
Other programs at IU are now following suit. Anesthesiology is in the midst of creating a policy, and internal medicine recently passed its own.
Anthony Wood, MD, a former internal medicine chief resident at the school, found out that his program had seen two residents go into labor after working demanding hours. So he researched flexible scheduling policies at more than 100 universities across the country. Only a few -- including the University of Michigan and the University of Wisconsin -- had a written policy in place.
Following the lead of emergency medicine, Wood helped craft an opt-out policy that prevented pregnant residents from being scheduled for overnight shifts or shifts longer than 14 hours during the last trimester and 2 months postpartum.
While the majority of other residents and institutions were supportive, Wood said the only concerns he received were about payback -- whether pregnant residents would have to make up overnight shifts upon returning from leave -- and scheduling accommodations for smaller programs. The internal medicine flexible scheduling policy will not require pregnant residents to make up overnight shifts.
As medical training programs become more diverse and continue to change old rules, Hussein said that her institution has made changes of their own, allowing 7 weeks of maternity leave during training. She added that it's crucial to push for systemic changes as programs continue to attract more women, and people of color.
And while becoming a mother during residency was difficult, she said that the old notion of motherhood and training being incompatible is completely wrong. "For me, having kids and prioritizing my family made me a much better physician."