If pediatrics board can’t lead with its maternity leave policy, it should at least follow

When my daughter started to reveal just how comfortable she was in utero, and wasn’t planning to leave any time soon, I immediately messaged my obstetrician: “I need to be induced.” I was worried about having enough leave from my fellowship in adolescent medicine.

She scheduled me for an induction within a few days, nodding kindly as she shared with me that she, too, went past her due date and watched her maternity leave tick away.

My resident and attending physician colleagues, nearly all of them women, were open about their own struggles as physician mothers. When I returned to work after six weeks, much to my colleagues’ surprise and sympathy, I explained that our program leadership — and my recovery — were at the behest of the American Board of Pediatrics.

This board, a licensing organization, has made a list of stringent policies for pediatric fellowships, including this one: a fellow cannot take more than 12 weeks leave without extending their three-year training program. Because maternity leave is counted as part of these 12 weeks, I made a calculated decision not to spend all my leave in one year. What if my daughter, Meera, got sick, or my parents or my husband’s? In a year where the unimaginable has become daily reality, I would be compelled to extend my training, which for adolescent medicine is already arguably too long.

The irony of the American Board of Pediatrics having this stipulation is not lost on trainees in the field who learn the benefits of breastfeeding, including counseling patients not to start pumping before six weeks. Keenly aware of the sand dwindling in the hourglass, I started pumping at three weeks, crying at the sight of how little milk I could produce.

I was also blissfully unaware of how hard my physical recovery from childbirth would be. I had run 4 miles a day through my 39th week of pregnancy, had normal blood pressures and reassuring prenatal testing slotting me as “low risk,” and even the induction was relatively smooth: Meera emerged after 1.5 hours of pushing. Yet a labial tear left me knock-kneed for weeks as I bled profusely. For more than a month it hurt to empty my bowels, urinate, laugh, and cough. To walk to the bathroom, I needed to brace myself along the wall.

Running has been my way of staying sane during my pediatrics training. In its absence, I found myself sobbing at how weak and bedridden I had become. I hated hearing that real physical and emotional trauma was called something as benign sounding as “baby blues.”

In any other context but childbirth, even the most negligent of attending physicians would hesitate to discharge a patient home from the hospital who could not walk, lost urinary continence, and soaked an industrial size pad with blood every hour. The physical and emotional difficulties continued over the next six weeks.

I remembered the countless times as a resident when I checked women for postpartum depression at their first newborn visit without ever having someone screen positive. Filling out my own form, I felt shame admitting depression when I had a healthy, beautiful baby. “Were my patients also scared to answer truthfully?” I wondered.

Even with my training in pediatrics, I never appropriately recognized how integral maternal health is to infant well-being — how laborious it is to breastfeed when you are, as a fellow new mom said, “soft and broken”; how long physical recovery can take when caring for a demanding newborn; and how much help new mothers need from family, friends, physical therapists, and other health care providers.

And even with all of the support I have, I still came to work overwhelmed and unprepared. I was lactating inopportunely, so I made sure to never leave the house without wearing a zip up jacket over my dress shirt. My hips felt loose, my gait unsteady. When I walked quickly, my bleeding also quickened, so I continued to wear postpartum pads to work. And my mind was split by postpartum anxiety and depression: Was I a good mom? Did my parents and in-laws judge me for leaving such a young baby? Could I make it through clinic without pumping? If I couldn’t, would my colleagues judge me?

It was difficult to attend to worried parents when fears of my own inadequate parenting generated their own static.

When the American College of Obstetricians and Gynecologists released guidelines on postpartum care in 2018, it acknowledged how remiss the nation’s policies have been in caring for those who literally deliver its future and reimagined postpartum care as more than a one-time clearance at six weeks where one crosses the Rubicon into normalcy. The guidelines recommend instead a 12-week interval of check-ins that are both more frequent and more meaningful than ensuring healed stitches — understanding the “fourth trimester” as a complex web of mental, social, sexual, and emotional changes that physician mothers aren’t exempt from.

It’s now been 13 weeks since Meera was born. She now sleeps for longer stretches (though we are certainly bracing ourselves for sleep regression). I can comfortably pump enough milk to last her when I am at work. I initiated a postpartum support group that I lean on for the hardest days. I can run again. And I have needed every one of these 90-plus days to heal.

There needs to be a policy change from the organization that advocates for the well-being of children. The total amount of leave allowed during a pediatric fellowship cannot be equal to a standard maternity leave of 12 weeks. Pediatric specialists are already in short supply due to extended training requirements and lower salaries. Women continue to be the majority of pediatric providers, and peak childbearing years overlap with fellowship training.

Rigorous fellowship training and maternity leave do not need to be mutually exclusive. There is no more rigorous training for a pediatrician than having a newborn page every two hours demanding you cobble together a differential diagnosis: sleepy, tired, hungry, wet. There are ways fellowships can allow for maternity leave to be structured meaningfully to meet programmatic requirements. My residency program at the University of New Mexico had a generous new-parent elective where residents could have a call-free month after using annual leave to discuss how parenting changed their approach to patients and families; their own challenges and biases; and their growth as parents over the month.

With fellowship training in pediatrics mandated to be three years, ample elective time could allow for a similar approach. In adolescent medicine, this could be a one-month elective during which new physician parents could virtually meet with teenage parents once a week. There are so few opportunities for patients and physicians to truly and speak as equals humbled by the same challenge. I can envision similar approaches where a mentor could lead other specialty fellows through cases around their areas of interest once a week to discuss how they might approach counseling, discussion of a diagnosis, and limitations on patient expectations differently with the experience of parenthood.

If we expect women to continue caring for children as physicians and parents, we cannot keep burdening them with impossible short maternity leaves. The American Board of Obstetrics and Gynecology offers up to 12 weeks of leave in a single year for their fellowships, a total of up to 20 weeks leave for three-year fellowships, and 16 weeks for its two-year fellowship. If the American Board of Pediatrics can’t be the leader on this issue, it at least needs to become a follower.

Megana Dwarakanath is a fellow in adolescent medicine at the University of Pittsburgh Medical Center.