The Fourth Trimester: Case Made for Paid, Job-Protected Leave for New Moms

Last Updated: Jul 12, 2018

By Sherry L. Blumenthal MD, MSEd, FACOG, Co-Chair, PAMED Women Physicians Caucus

Sherry-Blumenthal-MDAlison Stuebe, MD, “chaired the American College of Obstetricians and Gynecologists residential Task Force on Redefining the Postpartum Visit,” and wrote, “Last month, the American College of Obstetricians and Gynecologists (ACOG) issued recommendations, supported by the Society for Maternal-Fetal Medicine and the Academy of Breastfeeding Medicine, to change postpartum care from a one-off visit to a sustained period of support, spanning the ‘fourth trimester’ that extends through 12 weeks postpartum.” Job-protected leave for new mothers is also “a public health imperative,” Dr. Stuebe claimed. For example, “each 10 weeks of paid, job-protected leave is associated with a four to six percent reduction in infant mortality.” ACOG President Dr. Lisa Hollier said, “Our society must decide that the lives of women are worth saving.” This includes the lives of women physicians.

According to the American College of Physicians (ACP), the U.S. is the only developed nation and one of two countries out of 185 surveyed by the International Labour Organization that does not offer some degree of paid maternity leave. As of March 2016, only 13 percent of workers in the private sector had access to paid family leave, which includes parental leave. In addition, the rate at which new mothers with access to maternity leave use that leave has remained stagnant. A recent analysis showed no significant trend upward or downward in women who took maternity leave between 1994 and 2015, showing that 47.5 percent of women who took maternity leave in 2015 were compensated, an average increase of only 0.65 percent over nearly two decades.

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As physicians, we often feel guilty taking time off from seeing our patients and for imposing more work on our colleagues. Then we feel guilty leaving a newborn with caretakers. We feel over-burdened with trying to find time to “pump” milk during a busy workday or giving up on breastfeeding because it is just so difficult to manage the demands while working.

According to a Position Paper from the ACP published in Annals of Internal Medicine, May 28, 2018, “no federal laws require a standard level of paid parental or medical leave. The Family and Medical Leave Act (FMLA), signed into law in 1993, offers employees who meet certain requirements up to 12 weeks of unpaid, job-protected leave each year and requires employers to maintain the employee's health benefits during that time. “

“California, New Jersey, Rhode Island, New York, Washington, and the District of Columbia have passed laws requiring employers to make paid leave available for the birth or adoption of a child, for a disability (which often includes pregnancy), or to care for an ailing family member with a serious medical condition. California, New Jersey, and New York are the only states that currently offer paid family leave to residents, and Washington and the District of Columbia have passed laws that will take effect at a later date. Programs in California, New Jersey, Rhode Island, and New York are structured to coordinate with existing temporary disability benefits to support a longer duration.”

According to an article in the American Journal of Obstetrics and Gynecology, “The health and economic benefits of paid parental leave have been well documented. In 2016, the American College of Obstetrics and Gynecology (ACOG) released a policy statement on recommended parental leave for trainees, yet, data on adoption of said guidelines is nonexistent and published data on parental leave policies in Ob-Gyn is outdated. Sixty-five percent (163 of 250) of program directors completed the survey. Most (71%) were either not aware of or not familiar with the recommendations of ACOG’s 2016 policy statement on parental leave. Nearly all (98%) responding programs had arranged parental leave for one or more residents in the past 5 years. Formal leave policies for childbearing and non-childbearing parents exist at 83% and 55% of programs, respectively. Program directors reported that on average, programs offer shorter parental leaves than program directors think trainees should receive. Coverage for residents on leave is most often provided by co-residents (98.7%), usually without compensation or schedule rearrangement to reduce work hours at another time (45.4%). Most program directors (82.8%) felt that becoming a parent negatively affected resident performance and approximately half of program directors believed that having a child in residency decreased wellbeing (50.9%), while 19.0% felt that it increased resident well-being. Qualitative responses were mixed and highlighted the complex challenges and competing priorities related to parental leave.”

Physicians are in a unique position. We are self-employed or hospital-system employed, and subject to a variety of maternity leave policies, some of which may be supportive and some are punitive. Women in medicine are in our prime child-bearing years during residency and early medical practice. Some hospital systems have no policy and paid maternity leave is up to the individual departments. One hospital system, which not only has no paid leave but includes the time missed as decreased productivity for that year, may adjust the following year salary downward for that lack of “productivity.” Our private practice of seven women OB/GYNs gave six weeks paid leave and another six weeks unpaid if desired. While this was not as good as it should have been, it was what we could afford at the time. There was no “penalty” for taking leave in terms of productivity calculations. We understood the situation and accepted that we would work harder for a few weeks.

Some residents who had to take unpaid leave found the financial burden significant. According to my readings, many women are the caregivers and primary support for their families. Having no policy or a punitive, non-paid policy is grossly discriminatory in my view. And there is overwhelming evidence and opinion that the benefits of the post-partum period regarding bonding and breastfeeding are very important to the health of the woman and the newborn.

Because women bear children, we have the unique privilege and responsibility of being pregnant, giving birth, and breastfeeding. According to my readings, in two-physician families the majority of home and childcare duties are done by the woman. Women often sacrifice full-time employment and leadership advancement because of our biological imperatives. I maintain that those imperatives are important to the survival of our species!  

I encourage all women PAMED members to join the WPC at There is strength in numbers. We have unique and important issues, and we need an independent strong voice in PAMED! I welcome suggestions and interest in this issue.  Please contact me at

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