The Long Road to Parenthood: Assisted Reproduction, Surrogacy, and Adoption Among US Surgeons.

OBJECTIVE: We sought to characterize demographics, costs, and workplace support for surgeons using assisted reproductive technology (ART), adoption, and surrogacy to build their families. SUMMARY BACKGROUND DATA: As the surgical workforce diversifies, the needs of surgeons building a family are changing. ART, adoption, and surrogacy may be used with greater frequency among female surgeons who delay childbearing and surgeons in same-sex relationships. Little is known about costs and workplace support for these endeavors. METHODS: An electronic survey was distributed to surgeons through surgical societies and social media. Rates of ART use were compared between partners of male surgeons and female surgeons and multivariate analysis used to assess risk factors. Surgeons using ART, adoption, or surrogacy were asked to describe costs and time off work to pursue these options. RESULTS: Eight hundred and fifty-nine surgeons participated. Compared to male surgeons, female surgeons were more likely to report delaying children due to surgical training (64.9% vs. 43.5%, P < 0.001), have fewer children (1.9 vs. 2.4, p < 0.001), and use ART (25.2% vs. 17.4%, P = 0.035). Compared to non-surgeon partners of male surgeons, female surgeons were older at first pregnancy (33 vs 31 years, P < 0.001) with age > 35 years associated with greater odds of ART use (odds ratio 3.90; 95% confidence interval 2.74-5.55, P < 0.001). One-third of surgeons using ART spent >$40,000; most took minimal time off work for treatments. Forty-five percent of same-sex couples used adoption or surrogacy. 60% of surgeons using adoption or surrogacy spent >$40,000 and most took minimal paid parental leave. CONCLUSIONS: ART, adoption, or surrogacy is costly and lacks strong workplace support in surgery, disproportionately impacting women and same-sex couples. Equitable and inclusive environments supporting all routes to parenthood ensure recruitment and retention of a diverse workforce. Surgical leaders must enact policies and practices to normalize childbearing as part of an early surgical career, including financial support and equitable parental leave for a growing group of surgeons pursuing ART, surrogacy, or adoption to become parents.

The financing need of equitable provision of paid maternal leave in the informal sector in Indonesia: a comparison of estimation methods.

BACKGROUND: Providing an enabling environment for breastfeeding is hampered by the inequitable implementation of paid maternity leave, primarily due to perceived or actual financial costs. To estimate the real cost of paid maternity leave requires using reliable methods. We compared methods utilized in two recent studies in Indonesia. Study A estimated the financial need of providing paid maternity leave in the formal sector with a 10-year forecast at 21% coverage of eligible mothers, while study B estimated similar costs for the informal sector at 100% coverage annually. Results are critical for guiding future application of either method to inform paid maternity leave policies. METHODS: We compared number of covered mothers working informally, total annual cost, and cost per mother. We modified some parameters used in study A (method A) to be similar to study B (method B) for comparison, namely the period of estimate (annual), coverage (100%), estimate of women potentially breastfeeding, exchange rate, female labor force participation rate, the percentage of women working in the informal sector, and adding administration cost. RESULTS: The methods differ in determining the number of mothers working in the informal sector who gave birth, the minimum wage as unit cost, and administrative cost. Both studies estimated the cost at various lengths of leave period. Method A requires more macro (e.g. national/regional) level data, while method B involves (e.g. individual) micro level data. We compared the results of method A with method B, respectively: 1) number of covered mothers working informally were 1,425,589 vs. 1,147,204; 2) total annual costs including administrative costs were US$650,230,167 vs. US$633,942,726, and; 3) cost/mother was US$456 vs US$553. CONCLUSION: Certain flexibilities can be applied to both methods, namely using parameters specific to respective regions (e.g. provincial level parameters), flexible period of analysis, and the use of administrative cost. In a setting where micro data is scarce and not easily accessible, method A provides a feasible approach, while method B will be most appropriate if suitable micro data is available. Future comparison studies in other settings are needed to provide further evidence on the strengths and weaknesses of both methods.

Paid maternal leave is associated with better language and socioemotional outcomes during toddlerhood.

The United States is the only high-income country that does not have a national policy mandating paid leave to working women who give birth. Increased rates of maternal employment post-birth call for greater understanding of the effects of family leave on infant development. This study examined the links between paid leave and toddler language, cognitive, and socioemotional outcomes (24-36 months; N = 328). Results indicate that paid leave was associated with better language outcomes, regardless of socioeconomic status. Additionally, paid leave was correlated with fewer infant behavior problems for mothers with lower levels of educational attainment. Expanding access to policies that support families in need, like paid family leave, may aid in reducing socioeconomic disparities in infant development.

Costs of maternity leave to support breastfeeding; Brazil, Ghana and Mexico.

OBJECTIVE: To develop a method to assess the cost of extending the duration of maternity leave for formally-employed women at the national level and apply it in Brazil, Ghana and Mexico. METHODS: We adapted a World Bank costing method into a five-step method to estimate the costs of extending the length of maternity leave mandates. Our method used the unit cost of maternity leave based on working women's weekly wages; the number of additional weeks of maternity leave to be analysed for a given year; and the weighted population of women of reproductive and legal working age in a given country in that year. We weighted the population by the probability of having a baby that year among women in formal employment, according to individual characteristics. We applied nationally representative cross-sectional data from fertility, employment and population surveys to estimate the costs of maternity leave for mothers employed in the formal sector in Brazil, Ghana and Mexico for periods from 12 weeks up to 26 weeks, the WHO target for exclusive breastfeeding. FINDINGS: We estimated that 640 742 women in Brazil, 33 869 in Ghana and 288 655 in Mexico would require formal maternity leave annually. The median weekly cost of extending maternity leave for formally working women was purchasing power parity international dollars (PPP$) 195.07 per woman in Brazil, PPP$ 109.68 in Ghana and PPP$ 168.83 in Mexico. CONCLUSION: Our costing method could facilitate evidence-based policy decisions across countries to improve maternity protection benefits and support breastfeeding.

The Cost of Maternity Leave for the Orthopaedic Surgeon.

INTRODUCTION: Maternity leave among orthopaedic surgeons is not well understood. This study seeks to quantify past and current maternal leave characteristics of female orthopaedic surgeons. METHODS: A survey was distributed to the members of the Ruth Jackson Orthopaedic Society and Women in Orthopaedics, an online group exclusive to female orthopaedic surgeons in practice or in training. The survey was open from April 2018 to October 2018 with access gained by way of a web-based link. Respondents were queried regarding demographics and maternity leave characteristics including age at conception, length of leave given/taken, and cost. RESULTS: A total of 801 surveys were completed with 452 surveys returning with information regarding past pregnancies. Of the 452 surgeons with children, the average leave offered was 4.6 ± 4.2 weeks for the first child, with 8.2 ± 7.4 weeks taken. A difference was observed (P < 0.001) between the amount of leave taken between residents (6.3 ± 5.0 weeks), fellows (8.3 ± 7.2 weeks), and practicing surgeons (9.6 ± 8.5 weeks). The average cost of the first leave was $40,932 ± 61,258. The average cost during training was different than during practice ($154 versus $45,350, P < 0.001). The length of leave offered (P = 0.05) and taken (P < 0.001) affects the cost, whereas delivery type, timing of stopping clinic, taking calls, and operating did not. Each additional week of leave offered saved a surgeon $2,583, and each additional week taken cost $3,252. DISCUSSION: Residents take shorter leaves than fellows and attendings. The cost of taking leave is substantial, and the cost during practice is higher than during training. The amount of leave taken is greater than the amount of paid leave offered.

Cash support vs. tax incentives: The differential impact of policy interventions on third births in contemporary Hungary.

Following steep falls in birth rates in Central and Eastern European countries during the economic and institutional restructuring of the early 1990s, governments made substantial efforts to stop or at least reduce the fertility decline. In Hungary, parents with three or more children could benefit from specific new policy measures: the flat-rate child-rearing support paid from the youngest child's third to eighth birthdays (signalling recognition of stay-at-home motherhood) and a redesigned and upgraded tax relief system. However, the success of these policy measures, if any, is difficult to detect in aggregate statistics. Analysing data from the Hungarian Generations and Gender Survey, we rely on event history methods to examine the policies' effects on third birth risks, especially among different socio-economic groups. The results indicate that while the child-rearing support increased third birth risks among the least educated, the generous tax relief had a similar effect for parents with tertiary education.

What Proportion of Orthopaedic Surgery Residency Programs Have Accessible Parental Leave Policies, and How Generous are They?

BACKGROUND: Parental leave during graduate medical education is a component of wellness in the workplace. Although every graduate medical education program is required by the Accreditation Council for Graduate Medical Education (ACGME) to have a leave policy, individual programs can create their own policies. The ACGME stipulates that "the sponsoring institution must provide a written policy on resident vacation and other leaves of absence (with or without pay) to include parental and sick leave to all applicants." To our knowledge, a review of parental leave policies of all orthopaedic surgery residency programs has not been performed. QUESTION/PURPOSES: (1) What proportion of orthopaedic surgery residency programs have accessible parental (maternity, paternity, and adoption) leave policies? (2) If a policy exists, what financial support is provided and what allotment of time is allowed? METHODS: All ACGME-accredited orthopaedic surgery residency programs in 2017 and 2018 were identified. One hundred sixty-six ACGME-accredited allopathic orthopaedic surgery residency programs were identified and reviewed by two observers. Reviewers determined if a program had written parental leave policy, including maternity, paternity, or adoption leave. Ten percent of programs were contacted to verify reviewer findings. The search was sequentially conducted starting with the orthopaedic surgery residency program's website. If the information was not found, the graduate medical education (GME) website was searched. If the information was not found on either website, the program was contacted directly via email and phone. Parental leave policies were classified as to whether they provided dedicated parental leave pay, provided sick leave pay, or deferred to unpaid Family Medical Leave Act (FMLA) policies. The number of weeks of maternity, paternity, and adoption leave allowed was collected. RESULTS: Our results showed that 3% (5 of 166) of orthopaedic surgery residency programs had a clearly stated policy on their program website. Overall, 81% (134 of 166) had policy information on the institution's GME website; 7% (12 of 166) of programs required direct communication with program coordinators to obtain policy information. Further, 9% (15 of 166) of programs were deemed to not have an available written policy as mandated by the ACGME. A total of 21% of programs (35 of 166) offered designated parental leave pay, 29% (48 of 166) compensated through sick leave pay, and 50% (83 of166) deferred to federal law (FMLA) requiring up to 12 weeks of unpaid leave. CONCLUSIONS: Although 91% of programs meet the ACGME requirement of written parental leave policies, current parental leave policies in orthopaedic surgery are not easily accessible for prospective residents, and they do not provide clear compensation and length of leave information. Only 3% (5 of 166) of orthopaedic surgery residency programs had a clearly stated leave policy accessible on the program's website. Substantial improvements would be gained if every orthopaedic residency program clearly outlined the parental leave policy on their residency program website, including compensation and length of leave, particularly in light of the 2019 American Board of Orthopaedic Surgery changes allowing time away to be averaged over the 5 years of training. CLINICAL RELEVANCE: Parental leave policies are increasingly relevant to today's trainees []. Applicants to orthopaedic surgery today value work/life balance including protected parental leave [].

Evaluation of the effectiveness and equity of the maternity protection reform in Chile from 2000 to 2015.

INTRODUCTION: According to the International Labor Organization, Maternity Protection (MP) policies try to harmonize child care and women's paid work, without affecting family health and economic security. Chile Law 20.545 (2011) increased benefits for economically active women and reduced requirements for accessing these benefits. The goals of the reform included: 1) to increase MP coverage; and 2) to reduce inequities in access to the benefits. METHOD: This study uses two data sources. First, using individual data routinely collected from 2000 to 2015, yearly MP coverage access over time was calculated. Second, using national representative household surveys collected before and after the Law (2009 and 2013), coverage and a set of measures of inequality were estimated. To compare changes over time, we used non-experimental, before-after intervention design for independent samples. For each variable, we estimated comparative proportions at 95% confidence interval before and after the intervention. Additionally, we included multivariate and propensity score analysis. RESULTS: Between 2000 and 2015, MP coverage grew from 24.4% to 44.8%. Using comparable 2009 and 2013 survey data, we observed the same trend, with 31.6% of estimated MP coverage in 2009, escalating to 39.5% in 2013. We conclude that: 1) after the reform, there was an increase in MP coverage; and, 2) there was no significant reduction of inequities in the distribution of MP benefits. DISCUSSION/CONCLUSION: Few scientific evaluations of MP reforms have been conducted worldwide; even fewer including an equity analysis. This study provides an empirically-based evaluation of MP reform from both a population-level and an equity-focused perspective. We conclude that this reform needs to be complemented with other policies to ensure maternity protection in terms of access and equity in a country with deep socioeconomic stratification.

Parental Leave for Residents at Programs Affiliated With the Top 50 Medical Schools.

BACKGROUND: Of the top 15 medical schools with affiliated graduate medical education (GME) programs, 8 offer paid parental leave, with an average duration of 6.6 weeks. It is not known how other GME programs approach parental leave. OBJECTIVE: We searched for the parental leave policies for residents in programs affiliated with the top 50 medical schools. METHODS: In 2019, we identified the top 50 medical schools designated by US News & World Report in the research and primary care categories (totaling 59 schools), and identified the associated GME programs. For each school, we accessed its website and searched for "GME Policies and Procedures" to find language related to maternity, paternity, or parental leave, or the Family Medical Leave Act. If unavailable, we e-mailed the GME office to identify the policy. RESULTS: Of 59 schools, 25 (42%) described paid parental leave policies with an average of 5.1 weeks paid leave; 11 of those (44%) offer ≤ 4 weeks paid parental leave. Twenty-five of 59 (42%) programs did not have paid parental leave, but 13 of these specify that residents can use sick or vacation time to pay for part of their parental leave. Finally, 13 of 59 (22%) offered state mandated partial paid leave. One school did not have any description of parental leave. CONCLUSIONS: While paid parental leave for residents has been adopted by many of the GME programs affiliated with the top 50 medical schools, it is not yet a standard benefit offered to the majority of residents.

The Role of Work-Family Balance Policy for Enhancing Social Sustainability: A Choice Experiment Analysis of Koreans in their Twenties and Thirties.

Korea is facing problems, such as inequality within society and an aging population, that places a burden on public health expenditure. The active adoption of policies that promote work-family balance (WFB), such as parental leave and workplace childcare centers, is known to help solve these problems. However, there has, as yet, been little quantitative evidence accumulated to support this notion. This study used the choice experiment methodology on 373 Koreans in their twenties and thirties, to estimate the level of utility derived from work-family balance policies. The results show that willingness to pay for parental leave was found to be valued at 7.81 million Korean won, while it was 4.83 million won for workplace childcare centers. In particular, WFB policies were found to benefit workers of lower socioeconomic status or belonging to disadvantaged groups, such as women, those with low education levels, and those with low incomes. Furthermore, the utility derived from WFB policies was found to be greater among those who desire children compared to those who do not. The results suggest that the proactive introduction of WFB policies will help solve problems such as inequality within society and population aging.

Costing a Maternity Leave Cash Transfer to Support Breastfeeding Among Informally Employed Mexican Women.

BACKGROUND: Investing in maternity protection for working women is an important social equity mechanism. Addressing the maternity leave needs of women employed in the informal sector economy should be a priority as more than half of women in Latin America, South Asia, and sub-Saharan Africa are employed in this sector. OBJECTIVE: To develop a costing methodology framework to assess the financial feasibility, at the national level, of implementing a maternity cash transfer for informally employed women. METHODS: A World Bank costing methodology was adapted for estimating the financial need to establish a maternity cash transfer benefit. The methodology estimates the cash transfer's unitary cost, the incremental coverage of the policy in terms of time, the weighted population to be covered, and the administrative costs. The 6-step methodology uses employment and sociodemographic data that are available in many countries through employment and demographic surveys and the population census. The methodology was tested with data for Mexico assuming different cash transfer unitary costs and the benefit's time coverage. RESULTS: The methodological framework estimated that the annual financial needs of setting up a maternity cash transfer for informally working women in Mexico ranges between US$87 million and US$280 million. CONCLUSIONS: A pragmatic methodology for assessing the costs of maternity cash transfer for informally employed women was developed. In the case of Mexico, the maternity cash transfer for women in the informal sector is financially feasible.

Who benefits from social investment? The gendered effects of family and employment policies on cardiovascular disease in Europe.

BACKGROUND: In the context of fiscal austerity in many European welfare states, policy innovation often takes the form of 'social investment', a contested set of policies aimed at strengthening labour markets. Social investment policies include employment subsidies, skills training and job-finding services, early childhood education and childcare and parental leave. Given that such policies can influence gender equity in the labour market, we analysed the possible effects of such policies on gender health equity. METHODS: Using age-stratified and sex-stratified data from the Global Burden of Disease Study on cardiovascular disease (CVD) morbidity and mortality between 2005 and 2010, we estimated linear regression models of policy indicators on employment supports, childcare and parental leave with country fixed effects. FINDINGS: We found mixed effects of social investment for men versus women. Whereas government spending on early childhood education and childcare was associated with lower CVD mortality rates for both men and women equally, government spending on paid parental leave was more strongly associated with lower CVD mortality rates for women. Additionally, government spending on public employment services was associated with lower CVD mortality rates for men but was not significant for women, while government spending on employment training was associated with lower CVD mortality rates for women but was not significant for men. CONCLUSIONS: Social investment policies were negatively associated with CVD mortality, but the ameliorative effects of specific policies were gendered. We discuss the implications of these results for the European social investment policy turn and for future research on gender health equity.

Laboring Until Labor: The Prevalence and Correlates of Antenatal Maternity Leave in the United States.

Introduction Most women in the U.S. are employed during pregnancy and work until the month of childbirth. For many, working throughout pregnancy poses little threat to their health; however, women experiencing difficult pregnancies and/or working in strenuous or inflexible jobs may benefit from taking time from work as they approach childbirth, but almost no empirical evidence examines antenatal leave (ANL). Methods Using a national survey of English-speaking women, this paper offers the first national description of ANL and examines state policy predictors of uptake. Results Thirty-seven percent of employed women worked until the week their baby was due. After controlling for characteristics of women and their jobs, living in a state with any or multiple leave laws increased the probability of ANL by 14 and 23% points, respectively. Women living in states with multiple leave laws stopped work almost 2 weeks earlier than women in states without a policy. Discussion Paid leave policies currently being considered at the federal, state, and local levels should consider the potential impact on antenatal leave, in addition to postnatal leave, and how they influence population health.

Paid Maternity Leave in the United States: Associations with Maternal and Infant Health.

Objectives The United States is one of only three countries worldwide with no national policy guaranteeing paid leave to employed women who give birth. While maternity leave has been linked to improved maternal and child outcomes in international contexts, up-to-date research evidence in the U.S. context is needed to inform current policy debates on paid family leave. Methods Using data from Listening to Mothers III, a national survey of women ages 18-45 who gave birth in 2011-2012, we conducted multivariate logistic regression to predict the likelihood of outcomes related to infant health, maternal physical and mental health, and maternal health behaviors by the use and duration of paid maternity leave. Results Use of paid and unpaid leave varied significantly by race/ethnicity and household income. Women who took paid maternity leave experienced a 47% decrease in the odds of re-hospitalizing their infants (95% CI 0.3, 1.0) and a 51% decrease in the odds of being re-hospitalized themselves (95% CI 0.3, 0.9) at 21 months postpartum, compared to women taking unpaid or no leave. They also had 1.8 times the odds of doing well with exercise (95% CI 1.1, 3.0) and stress management (95% CI 1.1, 2.8), compared to women taking only unpaid leave. Conclusions for Practice Paid maternity leave significantly predicts lower odds of maternal and infant re-hospitalization and higher odds of doing well with exercise and stress management. Policies aimed at expanding access to paid maternity and family leave may contribute toward reducing socio-demographic disparities in paid leave use and its associated health benefits.