P0904 - Assessing Family Leave Policies and Pregnancy Outcomes Among Gastroenterologists: A Survey of Physicians in the American College of Gastroenterology

Award: Outstanding Research Award in the Practice Management Category
Award: Presidential Poster Award

Award: Outstanding Research Award in the Practice Management Category

Award: Presidential Poster Award

Shazia Ali, MD¹, Reezwana Chowdhury, MD², Krystle Bittner, MPH³, Amy S. Oxentenko, MD, FACG⁴, Shivangi Kothari, MD, FACG^5
1The Permanente Medical Group, San Jose, CA; ²Johns Hopkins University School of Medicine, Columbia, MD; ³University of Rochester Medical Center, Rochester, NY; ⁴Mayo Clinic, Rochester, MN; ⁵University of Rochester Medical Center, Strong Memorial Hospital, Rochester, NY

Introduction: Paid parental leave has been endorsed to be essential by the American College of Obstetricians and Gynecologists, including maintenance of full pay and benefits for at least six weeks. There is significant variability in parental leave policies in gastroenterology (GI) and very little data regarding its effects on the GI community. The American College of Gastroenterology (ACG) Women in GI committee conducted a survey to assess parental leave policies and pregnancy outcomes in GI.

Methods: An electronic survey was sent to all ACG members and non-members from November 2020 to April 2021. The survey included questions regarding demographics, fertility, pregnancy outcomes, and parental leave policies.

Results: A total of 796 individuals responded (response rate 4%), with a female majority (n = 417; 52.5%) between the ages of 30-45 years (n = 464; 58%). Respondent demographic and practice information is summarized in Table 1. In total, 57% (n = 340/601) of respondents chose to delay and/or defer having a child, with no significant difference seen between men and women (p = 0.252). The most frequent reason for delay included, “I was busy with training” (n = 241; 71%), followed by “due to busy work demands and/or schedule” (n = 132; 39%). Approximately 20% (n = 139/672) required assisted reproductive therapy. There was a high reported complication rate of 68% (n =177/260), with 49% requiring cesarean section, 21% pre-term birth, 20% post-partum depression, and 36% difficulty with breastfeeding. With regards to parental leave, 35% (n = 186/536) took less than 4 weeks of leave. The majority of respondents (n = 320/475; 67%) felt there would be negative consequences of taking parental leave, including self-pressure to return (60%) and pressure from work to return (50%). Up to 62% of respondents did not feel supported by their program of their pregnancy/adoption or their need for parental leave (n = 320/513).

Discussion: Our data suggests a strong need to standardize and comply with recommendations for parental leave. Many GI physicians delay having children during critical child-bearing years during training and early career, with a higher rate of infertility noted compared with the general population (2%). We also note a higher pregnancy complication rate than reported in a 2017 survey of cardiologists (40%). Though further study is needed, this survey highlights the need to develop practice policies that support the health and well-being of our GI colleagues and families.

Table 1: Survey Responses
	Total Population = 796 n (%) or x̄ (SD)
Age (at time of survey completion), years 20-29 30-34 35-40 41-45 46-50 50-55 56+	13 (1.6%) 137 (17.2%) 217 (27.3%) 110 (13.8%) 74 (9.3%) 64 (8.0%) 181 (22.7%)
Sex1 Male Female	377 (47.5%) 417 (52.5%)
Primary Specialty (at time of survey completion)2 General Gastroenterology (GI) Advanced Endoscopy Hepatology Inflammatory Bowel Disease Motility Other3	539 (67.8%) 72 (9.1%) 47 (5.9%) 88 (11.1%) 28 (3.5%) 21 (2.6%)
Time spent in clinic, % of total FTE’s4 Range (%)	40.7 (21.7) 2 - 100
Time spent in endoscopy, % of total FTE’s5 Range (%)	41.0 (18.7) 2 – 100
Research time, % of total FTE’s6 Range (%)	19.0 (21.2) 1 – 99
Teaching Activities, % of total FTE’s7 Range (%)	12.9 (13.3) 1 – 94
Administrative time, % of total FTE’s8 Range (%)	13.0 (12.1) 1 – 80
Type of Practice Setting (at time of survey completion)9 Hospital-employed Private Practice Multi-specialty group practice Academic Faculty Self-employed/Solo Gastroenterology Practice Advanced Practice Provider Gastroenterology Fellow	102 (12.9%) 173 (22.0%) 59 (7.5%) 327 (41.5%) 23 (2.9%) 19 (2.4%) 85 (10.8%)
Geographical Location (at time of survey completion)10 US11 Southeast US Northeast US Southwest US Midwest US Mid-Atlantic US Pacific US Rocky Mountain US Puerto Rico US Hawaii Non-US/International12	115 (4.5%) 221 (27.8%) 71 (8.9%) 145 (18.2%) 52 (6.5%) 92 (11.6%) 33 (4.2%) 3 (0.5%) 1 (0.1%) 62 (7.8%)
Type of work (at time of survey completion)13 Full-time, with benefits Part-time, with benefits Locums or Part-time, no benefits Other14	704 (88.7%) 57 (7.2%) 13 (1.6%) 20 (2.5%)
Number of people sharing call (in current setting)15 None 1 – 4 5 – 9 10+	81 (10.3%) 141 (17.8%) 260 (32.9%) 308 (39.0%)
Household Income (at time of survey completion)16 Dual-Income Single-Income	509 (64.3%) 283 (35.7%)
Do you currently have a child and/or children?17, 18 Yes, I have a child and children No, but we want to have and/or have tried to have No, I do not want a child and/or children	649 (81.6%) 114 (14.3%) 32 (4.0%)
Does your current employer offer paid parental leave?19 Yes No Unknown/Not Sure	416 (52.4%) 247 (31.1%) 131 (16.5%)
Has the COVID-19 pandemic impacted your choice to have children?20 Yes No	108 (13.6%) 683 (86.2%)
If “yes”, how has the COVID-19 pandemic affected your decision?21,22 Delayed/Deferred pregnancy Hesitation to conceive and/or scared of risk to fetus due to exposure Changes in patient care/volume Childcare issues (cost/accessibility) Fertility treatment delays and/or less surrogacy options available Decided to not have any other children, at all Can’t afford to expand family and/or partner lost their job Waiting for vaccine and/or herd immunity Conceived due to pandemic (more downtime/less patient volume) Impact on income due to pandemic (related to patient volume) Increased work demands due to pandemic Unsure if pregnancy would prevent eligibility for vaccine Changes in insurance coverage through employer/cutbacks None provided	30 (27.8%) 4 (3.7%) 1 (0.9%) 4 (3.7%) 13 (12.0%) 4 (3.7%) 3 (2.8%) 6 (5.6%) 3 (2.8%) 3 (2.8%) 1 (0.9%) 1 (0.9%) 1 (0.9%) 34 (31.5%)
Did you defer and/or delay having a child?23,24 Yes No	340 (56.6%) 261 (43.4%)
If you chose to defer and/or delay, what was the reason(s)?25,26,27 I was busy with training I did not yet have a partner My partner was in another location Infertility concerns Due to other medical conditions I was worried about finding and/or negotiating a job while expecting Due to busy work demands and/or schedule Did not have any protected parental leave Fear of career progression (e.g. making partner/promotions) Loans and/or other financial constraints Fear of career repercussions/setbacks Other28	241 (70.9%) 47 (13.8%) 41 (12.1%) 57 (16.8%) 11 (3.2%) 60 (17.6%) 132 (38.9%) 49 (14.4%) 54 (15.9%) 37 (10.9%) 57 (16.8%) 3 (0.9%)
Did you or your partner use assistive medicine to try to get pregnant?29 Yes No	139 (20.7%) 533 (79.3%)
If you answered “yes” to use of assistive medicine, what type was used?30,31,32 Intrauterine insemination (IUI) In Vitro Fertilization (IVF) Clomid	76 (56.3%) 86 (63.7%) 80 (59.3%)
How long did you or your partner try to become pregnant?33 Less than 1 year 1-2 years 2+ years Not Applicable	360 (52.6%) 102 (14.9%) 100 (14.6%) 122 (17.8%)
At what age was your first child born or adopted (years)?34 22-29 30-34 35-39 41-45	124 (19.5%) 319 (50.2%) 163 (25.7%) 29 (4.6%)
At what stage of your career was your first pregnancy or adoption?35 Prior to Medical School Medical School Residency Fellowship Less than 3 years into practice 3-10 years into practice 10+ years into practice	2 (0.4%) 18 (3.4%) 90 (16.8%) 189 (35.3%) 137 (25.6%) 90 (16.8%) 10 (1.9%)
When your first child was born or adopted, what was your practice setting?36 Hospital-employed Private Practice GI group Academic Faculty Resident Self-Employed/Solo GI practice GI Fellowship Multi-specialty group Medical Student Other37	45 (8.5%) 63 (12.0%) 131 (24.9%) 66 (12.5%) 4 (0.8%) 166 (31.5%) 31 (5.9%) 12 (2.3%) 9 (1.7%)
How many total weeks of parental leave did you take?38,39 Less than 4 weeks 4-6 weeks 7-8 weeks 9-11 weeks 12 weeks Greater than 12 weeks Other40	186 (34.7%) 84 (15.6%) 59 (11.0%) 17 (3.2%) 92 (17.2%) 21 (3.9%) 77 (14.4%)
Were you allowed to take more than 12 weeks of parental leave?41 No Yes, paid Yes, unpaid	366 (70.9%) 17 (3.3%) 133 (25.8%)
For paid parental leave ONLY, what was the maximum time allowed?42 I did not receive any leave Less than 6 weeks 6-8 weeks 9-11 weeks 12 weeks Greater than 12 weeks Other43	92 (18.9%) 162 (33.3%) 92 (18.9%) 6 (1.2%) 57 (11.7%) 7 (1.4%) 24 (4.9%)
For paid parental leave ONLY, did you receive full pay and benefits?44 Yes No Partial pay45	292 (73.6%) 69 (17.4%) 36 (9.1%)
For paid parental leave ONLY, how many weeks of vacation did you use?46 Range	2.5 (2.6) 0 – 24
For paid parental leave ONLY, how many weeks of sick time did you use?47 Range	1.8 (2.6) 0 – 20
How much unpaid leave were you allowed to take?48 Less than 6 weeks 6-8 weeks 9-11 weeks 12 weeks Greater than 12 weeks Other49	201 (47.9%) 43 (10.2%) 6 (1.4%) 64 (15.2%) 31 (7.4%) 75 (17.9%)
Did you have to extend your training as a result of pregnancy/adoption?50 Yes No	37 (12.5%) 259 (87.5%)
Did you feel like your program was supportive of your pregnancy/adoption and parental leave/time away?51 Yes No	320 (62.4%) 193 (37.6%)
Were there any consequences of taking parental leave?52 Yes No	320 (67.4%) 155 (32.6%)
If there were consequences of taking parental leave, what were they?53,54,55 Social pressure to return to work (from self) Social pressure to return to work (from work) Financial pressure to return due to lost wages or bonuses Financial pressure to return due to need to cover overhead Financial pressure to return due to need to pay back practice Financial pressure to return due to decreased referrals Financial pressure to return due to deferred or delayed partnership Difficulty finding coverage Extra call early on and/or later on Worse performance evaluations post-pregnancy or adoption Lost opportunities for career advancement (e.g. promotion/raises) Other56	191 (59.7%) 160 (50.0%) 106 (33.1%) 30 (9.4%) 14 (4.4%) 9 (2.8%) 14 (4.4%) 69 (21.6%) 128 (40.0%) 27 (8.4%) 75 (23.4%) 27 (8.4%)
What is your overall satisfaction with parental leave in your GI practice?57 Not satisfied/very dissatisfied Slightly dissatisfied Neither satisfied nor dissatisfied Slightly satisfied Satisfied/very satisfied	108 (20.8%) 84 (16.2%) 148 (28.5%) 72 (13.9%) 107 (20.6%)
Were you exposed to fluoroscopy during pregnancy?58,59 No, I was able to opt out Not applicable, not usually exposed Yes, I was exposed throughout pregnancy	103 (36.9%) 131 (47.0%) 45 (16.1%)
Did you experience any pregnancy complications?60 Yes No	177 (68.1%) 88 (31.9%)
If you experienced pregnancy complications, which one(s)?61,62,63 C-section Hyperemesis Bedrest Pre-eclampsia HELLP Syndrome Pre-term birth Low birth weight Unable to perform job functions Infant born necessitating NICU-level care Post-partum hemorrhage Lacerations/difficulty healing Urinary and/or fecal incontinence Post-partum depression Difficulty breastfeeding Gestational diabetes Placenta Previa Multiple births Other64	87 (49.2%) 13 (7.3%) 17 (9.6%) 15 (8.5%) 5 (2.8%) 37 (20.9%) 30 (16.9%) 5 (2.8%) 33 (18.6%) 11 (6.2%) 18 (10.2%) 12 (6.8%) 35 (19.8%) 64 (36.2%) 20 (11.3%) 9 (5.1%) 6 (3.4%) 21 (11.9%)
Did you experience difficulties with accommodations during or after pregnancy?65 Yes No	134 (51.9%) 124 (48.1%)
If you experienced difficulties with accommodations, which were difficult?66,67, 68 Time off for prenatal appointments Time off for pregnancy complications Adjusting procedure and/or clinic schedule for physical needs Abstaining from ERCP or fluoroscopy while pregnant Breastfeeding time and/or space Using parental leave Other69	49 (36.6%) 19 (14.2%) 52 (38.8%) 20 (14.9%) 102 (76.1%) 35 (26.1%) 4 (3.0%)
When you returned to work, were you given time to breastfeed and/or pump?70,71 Yes, but a limited period of time Yes, for the entire time I chose to breastfeed No, not given any dedicated time	35 (15.5%) 87 (38.5%) 104 (46.0%)
When you returned to work, were you given a private space to breastfeed and/or pump?72 Yes No	121 (55.5%) 97 (44.5%)

¹N = 794 responses for this question; ²N = 795 responses for this question; ³”Other” included: GI psychologist (1), Hereditary Cancers (1), Internal Medicine (1), Pancreatology (2), Functional GI (2), Fellowship notated with no specific specialty indicated (3), Esophageal Diseases (3), Nutrition (3), and Pediatric GI (5); ⁴N = 757 for this question; ⁵N = 690 for this question; ⁶N = 348 for this question; ⁷N = 373 for this question; ⁸N = 414 for this question; ⁹N = 788 responses for this question; ¹⁰N = 795 responses for this question; ¹¹US = United States; ¹²Responses were received from: Bangladesh (4), Middle East region (9), Mexico (3), Canada (9), South America (7), Pakistan (4), Western Europe (6), Eastern Europe (3), India (9), Southeast Asia (4), Dominican Republic (2), and Jamaica (2); ¹³N = 794 responses for this question; ¹⁴”Other” included self-employed (16) or retired (4); ¹⁵N = 790 responses for this question; ¹⁶N = 792 responses for this question; ¹⁷N = 795 responses for this question; ¹⁸Participants were exited from the survey if they answered “no, I do not want a child and/or children” to this question; ¹⁹N = 794 responses for this question; ²⁰N = 792 responses for this question; ²¹N = 108 “yes” responses for this question; ²²Free-text comments included: “pay disparity for female providers”, “lack of family planning education”, and “impact of volume/RVU forgiveness and impact on parental leave”;²³N = 601 responses for this question; ²⁴A chi square analysis (n = 599) was performed to determine if there was a difference in the decision to delay and/or defer by sex, revealing there is no significant association (p = 0.252; 54.0% male and 58.7% of female respondents chose to defer/delay); ²⁵N = 340 individuals that answered, with N = 192/340 providing multiple reasons for delay and/or deferring having a child; ²⁶Total number of responses received = 789 ;²⁷Percents were calculated using the number of individuals for each reason provided, thus the total for this cell will be larger than 100% (as there were a large number of multiple responses); ²⁸”Other” responses included: “COVID-19 delayed fertility treatments”, “Females in GI are judged very differently, I was asked at my Fellowship interview if I planned on becoming pregnant”, “I had a child before Fellowship, it was very difficult and restrained career choices”;²⁹N = 672 responses for this question;³⁰N = 135 individuals that answered, with 97/135 indicating they used more than one type of assistive medicine; ³¹Percents were calculated using the total number of individuals for each type of assistive medicine, thus the total for this cell will be higher than 100%; ³²Total number of responses received = 242; ³³N = 684 responses for this question; ³⁴N = 635 responses for this question; ³⁵N = 536 responses for this question; ³⁶N = 527 responses for this question; ³⁷”Other” responses included: prior to Medical school (3), Not working (1), Military (3), Veterans Affairs’ (1), and Clinical NIH Associate (1); ³⁸N = 536 responses for this question; ³⁹A chi square analysis (n = 534) was performed to determine if there was a difference in the length of leave (0-6 weeks, 7-12 weeks, 12+ weeks, or “other”) and sex, revealing there is a significant association (p < 0.001; 68.3% male and 34.4% female respondents indicating they took 6 or less weeks of parental leave; 9.1% male and 51.1% female respondents indicating they took 7-12 weeks of parental leave) between sex and length of parental leave taken; ⁴⁰The majority of “other” responses indicated that no leave was taken (47) and use of vacation time instead of parental leave (5); ⁴¹N = 516 responses for this question; ⁴²N = 486 for this question; ⁴³The majority of “other” responses indicated that vacation and/or PTO was used instead of parental leave (16), selected other comments included: “Because our child was adopted, this was not covered by the institutional leave policy”, and “I was in Fellowship and risked losing my spot in the program if I took leave”; ⁴⁴N = 397 responses for this question; ⁴⁵For partial pay, the mean reported percentage was 54.5% of salary benefits (SD = 17.1), with a range of 20-85%; ⁴⁶N = 320 responses for this question; ⁴⁷N = 218 responses for this question; ⁴⁸N = 420 responses for this question; ⁴⁹The majority of the “other” responses indicated that no unpaid leave was taken (46), selected other comments included: “I was afraid to take any extra leave”, and “I did not want to take unpaid leave because I would have had to “make up” or delay my training/graduation (3)”; ⁵⁰N = 296 responses for this question; ⁵¹N = 513 responses for this question; ⁵²N = 475 responses for this question; ⁵³N = 320 individuals answered, with 227/320 indicating they incurred more than one consequence as a result of taking parental leave; ⁵⁴Percents were calculated using the total number of individuals for each consequence reported, thus the total for this cell will be higher than 100%, ⁵⁵Total number of responses received = 690; ⁵⁶Selected “other” comments include: “I was threatened in my Fellowship that I would not be allowed to graduate if I took leave”, and “I didn’t receive training in fluoroscopy because I took leave”;⁵⁷N = 519 responses for this question; ⁵⁸N = 279 responses for this question; ⁵⁹A chi square analysis was performed to determine if there was an association between fluoroscopy exposure and subsequent pregnancy complication, revealing there is no significant association between fluoroscopy exposure and subsequent pregnancy complication(s) (p = 0.383; 76.4% of women exposed to fluoroscopy experienced a complication vs. 65.9% of women not exposed/opted out); ⁶⁰N = 260 responses for this question; ⁶¹N = 177 individuals answered, with 118/177 indicating they experienced more than one pregnancy complication; ⁶²Percents were calculated using the total number of individuals for each pregnancy complication reported, thus the total for this cell will be higher than 100%; ⁶³Total number of responses received = 438; ⁶⁴”Other” responses included: Carpal tunnel (2), Pulmonary Emboli (2), Oligohydraminos (2), Hypotension (1), Retrovaginal fistula (1), Pubic symphysis dysfunction (1), Fetomaternal hemorrhage (1), Recurrent vaginal bleeding (1), Post-partum anxiety (1), Placental abruption (1), Premature rupture of membranes (1), Intra-abdominal abscess (1), Intrauterine Fetal Demise (1), Norovirus from occupational exposure (1), Micro-preemie (1), Gestational hypertension (1), Fetal Cystic lesions (1), COVID-19 (1); ⁶⁵N = 258 responses for this question; ⁶⁶N = 134 individuals answered, with 73/134 indicating they had difficulty with more than one accommodation during or after pregnancy; ⁶⁷Percents were calculated using the total number of individuals that reported experiencing difficulty with accommodations during or after pregnancy, thus the total for this cell will be higher than 100%; ⁶⁸Total number of responses received = 281; ⁶⁹Selected other comments include: “Would breastfeed in closets”, and “no time off for infant or post-partum appointments”; ⁷⁰N = 226 responses for this question; ⁷¹86.8% of women (N = 231/266) reported that they breastfed; ⁷²N = 218 responses for this question.




Disclosures:
Shazia Ali indicated no relevant financial relationships.
Reezwana Chowdhury indicated no relevant financial relationships.
Krystle Bittner indicated no relevant financial relationships.
Amy Oxentenko indicated no relevant financial relationships.
Shivangi Kothari indicated no relevant financial relationships.


Shazia Ali, MD¹, Reezwana Chowdhury, MD², Krystle Bittner, MPH³, Amy S. Oxentenko, MD, FACG⁴, Shivangi Kothari, MD, FACG⁵. P0904 - Assessing Family Leave Policies and Pregnancy Outcomes Among Gastroenterologists: A Survey of Physicians in the American College of Gastroenterology, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.