Introduction

Creating lactation-friendly work environments is necessary for recruiting and retaining high-caliber female urologists. The WHO recommends newborns be exclusively fed breast milk until 6 months old. Lactating women returning to work must express milk by pumping for 15-20 minutes up to every 3 hours to maintain a supply of milk. While breast pump technology has progressed significantly with the advent of wearable breast pumps, which allow for hands-free pumping, there is still a need for dedicated time and space to support breastfeeding women. In recognition of this need, Congress passed the Break Time for Nursing Mothers law, which requires employers to provide “reasonable break time for an employee to express breast milk for her nursing child for 1 year after the child’s birth.”

Nevertheless, the AUA Resident Census found that only 57% of urology residents had a workplace policy regarding time to pump, and only 1.4% of urology residencies provided information about lactation accommodations on their website.^1,2 Despite 95% of female surgeons considering breastfeeding important, 58% stopped earlier than desired due to inadequate support at work.³ As the number of female urologists increases,⁴ developing comprehensive lactation policies should be a priority for employers. We highlight some of the challenges of pumping as a surgeon and provide recommendations for policies to better support lactating urologists.

The Trainee Experience

I had to pump 6 times a day for a year to maintain my milk supply. Dedicated pumping space was far from the operating rooms (ORs), so I pumped in the locker room, where the lack of privacy made me feel exposed and vulnerable. Wearable pumps were liberating but had limits; they leak if you lean too far forward, and once a sudden move by the robotic arm knocked my pump off while bedsiding. Despite significant discomfort, I sometimes kept my pumps on far longer than normal to avoid leaving a case.

There were stretches when I didn’t see my daughter awake for days. Providing milk was one thing that only I could do for her, and at times, pumping was the only thing that made me feel like her mother. Although my performance reviews did not show it, I felt like a worse resident because of the time required to pump.

I struggled with pumping as a busy surgical trainee, even in a supportive environment. Many trainees do not have this level of support and face criticism for requesting time to express milk or using shared facilities when dedicated space is unavailable. Multiple female residents have reported that pumping was the hardest part of residency and made them consider quitting. We need to better support these residents.

The Attending Experience

There is no single experience of breastfeeding as an attending. Just as each urologist practices in a different setting—private practice, hospital-employed, or academics—each breastfeeding urologist experiences different challenges. I aim to highlight the experiences of multiple urologists so we can understand the needs for policy improvement.

While being an attending allows more control over your schedule and time, the decision to pump can impact your practice flow and income in a way it does not as a resident. Finding time to pump is challenging. A Veterans Administration urologist explained, “I would pump in between patients and the patient would wait a little bit. It was easier than making a big ripple with the administration.” She felt the bureaucratic burden to set aside time to pump was greater than the time pressures in her practice. A urologist in private practice explained, “I can’t sneak much time in between patients so I would block 15 minutes in a.m. and p.m. clinic, and also pump during lunch. I saw fewer patients, which affected my income, but it was worth it.” While clinic is predictable, much of urology is not. Another urologist explained, “I would pump driving to the hospital, between cases on OR days, and while driving around on call.” Ultimately, all the women who pumped as attendings felt that “a supportive environment is the most important, and that comes from the top.”

Policy Recommendations

Written, accessible lactation policy

Policies should be provided in contracts, easily searchable online, and posted in lactation rooms. They should include standardized methods for notifying employers of lactation needs and requesting protected pumping time. A strong parental leave policy is also necessary, given that early return to work (6 weeks) is associated with premature cessation of breastfeeding⁵ (the average maternity leave among urology trainees is 5.9 weeks¹).

Structured break times

Figure 1. Pros and cons of wired vs wireless breast pumps.

Figure 2. An average pumping session can take 15-20 minutes, but this can vary from person to person. These are some variables that may contribute to the length of break time required by a lactating employee. Time between sessions is likewise individual, but is usually required every 2-3 hours for maintaining milk supply. 1 May include a wait time before accessing the space. 2 Even spaces that provide shared equipment for use still require retrieval of personal attachments. 3 The efficiency of the pump used and individual lactation dynamics can affect the duration needed. 4 May include time to find a sink if one is not accessible in the pumping space.

Figure 3. Sample pumping space setup.

Employees should have structured breaks tailored to their needs (Figure 2). Expectations for communication with office staff and coworkers regarding timing of breaks should be outlined in advance, recognizing that many trainees feel uncomfortable asking for time for milk expression.³ Proactive communication allows for better planning of patient flow in the office and arranging coverage in the OR if necessary.

Lactation setup

Lactation spaces should be close to ORs and clinics, and include necessary equipment (Figure 3). Mamava pods or similar portable spaces are good options if built-in space is unavailable.

Accommodations for testing

Any required training or work activities, such as in-service or board examinations, should include a lactation plan with designated breaks and access to pumping spaces.

Nondiscrimination

Finally, there should be a zero-tolerance policy for discrimination or harassment regarding lactation requests and needs.

Once these minimum requirements are met, employers may consider more comprehensive policies to tackle other challenges associated with pumping. For instance, adjustments to relative value unit targets for lactating surgeons and/or relative value unit credits for pumping time⁶ can reduce stress over lost income or productivity. Applying educational funds toward lactation equipment may allow trainees greater flexibility by purchasing wearable pumps. Additionally, supporting lactating employees to attend conferences by reimbursing for milk-shipping services can promote career development.

Conclusion

Breastfeeding experiences vary among urologists, but insufficient support is a common theme contributing to burnout and departure from the workforce. Implementing formal lactation policies can improve employee retention,⁷ demonstrate commitment to staff, and benefit providers at all levels of urology.