Discussions around paid family leave have been buzzing since last year, when the Senate passed legislation—on a vote of 86 to 8—that provides federal workers with 12 weeks of guaranteed paid time off for parents following the birth, adoption, or fostering of a child.¹ This has been the first update to federal family leave policy since the U.S. Family and Medical Leave Act (FMLA) was enacted in 1993.² The United States is one of the few countries left in the world where parental leave is not an entitlement.³ Attitudes about parenthood and family leave, however, and particularly how they fit with a career in medicine, are rapidly changing. Women currently constitute more than half of all medical student matriculants, and 38 percent of all emergency medicine applicants are female.^4,5 Nationally, in 1980, only 13 percent of female graduate medical education trainees became pregnant during their training, but that number has nearly tripled to 35 percent, and, in some instances, that number is higher still.⁶ Seventy-seven percent of baby-boomer fathers believed that paternity leave is important, and now more than 93 percent of millennial-generation new fathers believe that it is.⁷ These changes all beg the question: What is emergency medicine’s ethical obligation to provide parental leave benefits?

The Ethics of Paid Versus Unpaid Leave

In the best of circumstances, emergency medicine, much like pregnancy, is physically demanding. Without paid leave, late-gestational female physicians must work through the strain of night shifts, lack of physical or nutritional breaks, and physically threatening patients, while striving to “bank shifts” and save any days off for after delivery. The United States is the only industrialized nation without legally protected paid maternity coverage resulting in a mere 11 percent of American women with access to paid maternity leave.⁸ Paid parental leave is demonstrated to lead to longer parental lifespans and improved parental mental health.⁹

Economically, it is expensive to develop a physician with years of education, training, and experience. Parental leave improves the likelihood of returning to full time work after delivery.¹⁰ Physicians are often the primary breadwinners for their family, making unpaid leave unviable. All the physical stressors of emergency medicine continue to be present after the arrival of a new child, compounded with sleep deprivation and the demands of providing care to an infant.

In addition to positive parental effects, there are known effects for the children. Maternity leave has been associated with as high as 10 percent decreased neonatal and infant mortality and a 9 percent lower mortality rate in children less than 5 years old.¹¹ This may be attributed to the increased likelihood of infants of mothers with access to paid maternity leave attending well-child appointments and getting vaccinations.¹² Another possible reason for the decreased mortality could be secondary to the increased rate and duration of breastfeeding, which was found to be twice as long in mothers who had paid leave as compared with mothers who did not take leave. Additionally, it was found that infants of mothers who took paid maternity leave had a 47 percent decrease in the likelihood of re-hospitalization when compared with women taking no or unpaid leave.¹³

Current Policies and Next Steps

FMLA requires that qualifying employees receive up to 12 weeks of unpaid, job-protected leave per year. It also requires that their group health benefits be maintained during the leave. American Medical Association (AMA) policy:

• encourages employers to offer and/or expand paid parental leave policies;
• encourages state medical associations to work with their state legislatures to establish and promote paid parental leave policies;
• advocates for improved social and economic support for paid family leave to care for newborns, infants and young children; and
• advocates for federal tax incentives to support early childcare and unpaid childcare by extended family members.¹⁴

Parental leave has implications for personal and group finances. FMLA does not guarantee paid parental leave. Families and individuals planning to have a child, adopt, or foster a child should know their group’s policies regarding parental leave and financial remuneration, if any. Some groups, especially small groups, may not have the financial resources to provide paid time off.

ACEP established a parental leave policy in 1990 and revised it in 2019 as a “Family and Medical Leave” Policy Statement.¹⁵ Briefly, it asserts that employers should have leave policies that are clearly written, well known, and free of undue administrative burden. Policies should offer family leave for health, including mental health and birth or adoption for both parents. According to the statement, employers “should take into consideration what can be done to support the individual financially, if needed, during the leave of absence.” Regarding birth or adoption, ACEP recommends 12 weeks leave for the primary caregiver with four weeks to other parents, and flexible work schedules.

This position should constitute a bare minimum. While considerations need to be made for smaller groups and unique employment scenarios, the described benefits dictate that for the well-being of the physician, their family, and patients, paid leave be provided wherever possible. As not all positions offer all benefits, a reasonable standard would be that family leave is comparable to short-term disability, so paid family leave should be offered whenever short-term disability is. As a profession that strives to be both evidence-based and beneficent, we should advocate for a policy at least as generous as the federal government provides its employees.

References

1. Iacurci, Greg. CNBC. Paid parental leave on tap for 2.1 million Americans as bill heads to White House. Available at: https://www.cnbc.com/2019/12/18/paid-parental-leave-is-coming-to-more-than-2-million-americans.html. Accessed Aug. 24, 2020.
2. S. Department of Labor: Family and Medical Leave (FMLA). Available at: https://www.dol.gov/general/topic/benefits-leave/fmla. Accessed Aug. 24, 2020.
3. Organisation for Economic Co-operation and Development. Parental leave system. Available at: https://www.oecd.org/els/soc/PF2_1_Parental_leave_systems.pdf. Accessed Aug. 24, 2020.
4. Parker RB, Stack SJ, Schneider SM, et al. Why diversity and inclusion are critical to the American College of Emergency Physicians’ future success. Ann Emerg Med. 2017;69(6):714-717.
5. American Association of Medical Colleges. 2018 fall applicant and matriculant data tables. Available at: https://www.aamc.org/system/files/d/1/92-applicant_and_matriculant_data_tables.pdf. Accessed Aug. 24, 2020.
6. Blair JE, Mayer AP, Caubet SL, et al. Pregnancy and parental leave during graduate medical education. Acad Med. 2016;91(7):972-978.
7. Harrington B, Van Deusen F, Eddy S, et al. The new dad: take your leave. Perspectives on paternity leave from fathers, leading organizations, and global policies. Available at: http://www.thenewdad.org/yahoo_site_admin/assets/docs/BCCWF_The_New_Dad_2014_FINAL.157170735.pdf. Accessed Aug. 24, 2020.
8. Desilver D. Access to paid family leave varies widely across employers, industry. Pew Research Center. Available at: https://www.pewresearch.org/fact-tank/2017/03/23/access-to-paid-family-leave-varies-widely-across-employers-industries/. Accessed Aug. 24, 2020.
9. Burtle A, Bezruchka S. Population health and paid parental leave: What the United States can learn from two decades of research. Healthcare (Basel). 2016;4(2):30.
10. Juengst SB, Royston A, Huang I, et al. Family leave and return-to-work experiences of physician mothers. JAMA Netw Open. 2019;2(10):e1913054.
11. Heymann J, Raub A, Earle A. Creating and using new data sources to analyze the relationship between social policy and global health: the case of maternal leave. Public Health Rep. 2011;126(Suppl 3):127-134.
12. Berger LM, Hill J, Waldfogel J. Maternity leave, early maternal employment and child health and development in the US. Econ J. 2005;115(501):F29-47.
13. Jou J, Kozhimannil KB, Abraham JM, et al. Paid maternity leave in the United States: associations with maternal and infant health. Matern Child Health J. 2018;22(2): 216-225.
14. American Medical Association: Parental Leave H-405.954. Available at: https://policysearch.ama-assn.org/policyfinder/detail/parental%20leave?uri=%2FAMADoc%2FHOD-405.954.xml. Accessed Aug. 24, 2020.
15. Family and medical leave. Available at: https://www.acep.org/patient-care/policy-statements/family-and-medical-leave/. Accessed Aug. 24, 2020.

Dr. Clayborne is adjunct assistant professor at the University of Maryland School of Medicine.

Dr. Hoke is an emergency medicine physician in Birmingham, Alabama.

Dr. Knowles is an emergency medicine physician in Fort Worth, Texas.

Dr. Marco is professor of emergency medicine and surgery at Wright State University in Dayton, Ohio.

Dr. McGrath is assistant professor of clinical emergency medicine at Georgetown University Hospital & Washington Hospital Center in Washington, D.C.

Dr. Wong is assistant professor or emergency medicine at Beth Israel Deaconess Medical Center in Boston.