As a specialty, emergency medicine attracts physicians who run on variety and adrenaline. Of course, there are downsides, specifically related to the cumulative burdens of shift work and working nights. These risks are amplified for emergency physicians who become pregnant and continue to work clinically.

We wanted to further understand these risks so that departments can rely on data and adopt evidence-based practices. A working group of practicing emergency physicians was assembled for this project. The group included women who currently practice in academic and community settings (with diverse payer models) and who are members of several committees within various EM organizations (including FemInEM leadership). The group included some who have experienced childbearing and child rearing and others who have not. Our literature review (using Medline, Google Scholar, PubMed, and reference searches) and consensus-building methodology were modeled on best-practice procedures used for similar efforts in many areas of medicine, and it revealed four areas to focus recommendations: clinical scheduling during pregnancy, communication and training, span of parental leave, and the return-to-work period. For this column, we will focus solely on the best-practice recommendations for clinical scheduling during pregnancy.

Because night shift work can increase fatigue, decrease mental wellness, and cause physical ailments, investigators have evaluated the effects of night shifts on adverse pregnancy outcomes.^1,2 A meta-analysis published in 2000 in Obstetrics & Gynecology found that physically demanding work was associated with preterm birth, small gestational age, and hypertension or preeclampsia.3 Other occupational exposures significantly associated with preterm birth included prolonged standing (defined as more than three hours per day or the predominant occupational posture) (odds ratio [OR], 1.26; 95% CI, 1.13–1.40), shift and night work (OR, 1.24; 95% CI, 1.06–1.46), and high cumulative work fatigue score.³ In 2014, Stocker et al demonstrated that night shifts were associated with increased early spontaneous pregnancy loss (n=13,018; OR, 1.29; 95% CI, 1.11–1.50, I 0 percent).⁴ A more recent meta-analysis published in 2016 stated the weight of evidence begins to point to working at night, whether in fixed or rotating shifts, as a risk factor for miscarriage.⁵

Clinical Scheduling During Pregnancy

Because early spontaneous abortion, preterm labor, and other adverse pregnancy outcomes are associated with night shifts, we recommend that:

First-trimester pregnant physicians (12 weeks or fewer) and third-trimester pregnant physicians (28 weeks or more) have the option to opt out of night shifts.

Because physically demanding work is significantly associated with preterm birth and appropriate staffing of the department should be prioritized, we recommend that:³

In the event of staffing shortages, pregnant physicians in the third trimester have the option to remain exempt from mandatory addition of clinical hours (ie, mandatory overtime).

Scheduling for pregnant physicians in the third trimester should prioritize easily cancellable/coverable shifts to minimize departmental disruption in the event of medical necessity or early delivery.

These recommendations should not take the place of the pregnant physician’s preference. For example, physicians who work fixed night shifts for extended periods are likely to have chosen this schedule and may be a self-selected population with high tolerance for night shifts. This tolerance may be related to age, circadian preferences, or situational and psychological preferences specific to the individual. Furthermore, pregnant women preparing for an unpaid maternity leave may, in fact, be looking to work additional clinical hours. While it is optimal that such transient increases in clinical hours occur during the second trimester, a woman may choose to work additional hours well into her third trimester out of necessity or preference. Rather than instituting a blanket policy excluding night shifts or additional clinical hours, we recommend that pregnant physicians be allowed a degree of autonomy over whether night shifts or additional hours are right for them during the most vulnerable trimesters of pregnancy.

Feasibility and Financial Implications

Covering shifts with little notice, especially night shifts, can create a financial strain for emergency departments. Sites in which the trust level is high between providers and leadership will foster earlier notification of issues that impact the schedule, including pregnancy, and allow for creative solutions. Sites may choose to distribute the shifts among existing providers. For small groups, this may cause some shared sacrifice of increased shifts, yet individuals may realize that their temporary increased shift load may be offset by a reduction in the future due to unexpected illness or family emergency. Sites may consider hiring moonlighters who can be utilized during periods of staff shortages, which can include situations beyond pregnancy to include unexpected resignations, sabbaticals, and medical illnesses. At sites with a large academic or administrative load, these duties may be able to be shifted to gravid physicians requesting or requiring a reduced clinical load, and providers who typically do this type of work can be temporarily diverted toward more clinical work. This model can also be considered for other employees requiring limitations due to medical restrictions.

Thoughtful scheduling and planning during physician pregnancy stands to benefit all members of a department. While no single practice of emergency medicine is the same, it is imperative that departments and groups make evidenced-based policies to support emergency physicians during these transitional times. In reviewing the aforementioned recommendations, we hope that future scheduling policies for emergency physicians will use these data to promote healthy pregnancies, well-balanced physicians, and successful careers for our colleagues.

“The Equity Equation” is curated by Dara Kass, MD, and Uché Blackstock, MD.

Dr. Coldebella is clinical assistant professor of emergency medicine at the University of South Carolina School of Medicine in Greenville and an emergency physician at Prisma Health–Updstate.

Dr. Pilarski is associate professor of emergency medicine at Medical College of Wisconsin/Froedtert Hospital in Milwaukee.

References

1. Ferri P, Guadi M, Marcheselli L, et al. The impact of shift work on the psychological and physical health of nurses in a general hospital: a comparison between rotating night shifts and day shifts. Risk Manag Healthc Policy. 2016;9:203-211.
2. Akerstedt T, Wright KP Jr. Sleep loss and fatigue in shift work and shift work disorder. Sleep Med Clin. 2009;4(2):257-271.
3. Mozurkewich EL, Luke B, Avni M, et al. Working conditions and adverse pregnancy outcome: a meta-analysis. Obstet Gynecol. 2000;95(4):623-635.
4. Stocker LJ, Macklon NS, Cheong YC, et al. Influence of shift work on early reproductive outcomes: a systematic review and meta-analysis. Obstet Gynecol. 2014;124(1):99-110.
5. Fernandez RC, Marino JL, Varcoe TJ, et al. Fixed or rotating night shift work undertaken by women: implications for fertility and miscarriage. Semin Reprod Med. 2016;34(2):74-82.