While female representation in urology is increasing, the 2022 AUA Census reported that women only represent 11.6% of practicing urologists.¹ Prior studies have shown that women may be discouraged from pursuing surgical fields such as urology due to concerns regarding gender stereotypes and disparities.² In particular, the challenges of balancing surgical training and a surgical career with pregnancy, maternity leave, and breastfeeding may cause apprehension for many women interested in pursuing surgery.³

The American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life as well as continued breastfeeding with complimentary foods for 2 years.⁴ An American Academy of Breastfeeding Medicine 2022 position statement emphasizes that the ability to safely breastfeed is a basic human right.⁵ The academy urged more research on breastfeeding policies and laws to ensure proper protection of lactating mothers. Similarly, the WHO and the Office of the United Nations High Commissioner for Human Rights issued a statement in 2016 that declared breastfeeding as a human rights issue for both the child and mother, highlighting the need for increased efforts to protect and support breastfeeding.⁶ The Fair Labor Standards Act from the United States Department of Labor requires employers to provide employees with reasonable break time and a safe space for lactation other than a bathroom that is shielded from view.⁷ The right should be available for up to 1 year after the child’s birth. Furthermore, the Accreditation Council for Graduate Medical Education mandates that medical trainees have clean and private lactation facilities including refrigeration with proximity to their clinic duties.⁸

Despite these guidelines designed to protect employed lactating women, physicians are particularly vulnerable to challenges finding lactation support at work. A large survey-based study of female physicians in 2018 demonstrated fewer than one-third of respondents were able to sustain breastfeeding to their personal goals, and nearly half reported they would have breastfed longer if their job had been more accommodating.⁹ Another survey-based study of 312 female resident physicians found that 60% of lactating residents did not have a place to store breast milk, and only 21% had a usable lactation room.¹⁰ Over half of the respondents reported their struggles with breastfeeding affected their mental health during residency.

Urologists and other surgeons face unique barriers to breastfeeding including long working hours, lengthy surgical cases without breaks, and demanding call schedules. Furthermore, while a hospital may have dedicated spaces for lactation, the spaces are not always located near the operating room, making it difficult to express milk between or even during surgical cases. Surgical specialties also tend to be male dominated, particularly in leadership positions, and may not be as sympathetic to the unique needs and time requirements of breastfeeding and lactation.¹¹ Despite clear national laws and regulations mandating safe space and time for lactating women, very little research has been conducted to analyze if lactating physicians are supported at their institutions. Few studies have evaluated breastfeeding policies and barriers for physicians, and even fewer have specifically analyzed barriers to breastfeeding for surgeons.

We are currently conducting a study investigating institutional support, resources, and lactation policies for residents, fellows, and attending physicians. An anonymous, voluntary survey was administered to physicians through private female physician social media groups from April to July 2023. The survey assessed demographic information, institutional lactation policy information, and personal perception of lactation resources and support. Responses were compared between urologists and other surgical subspecialists using t tests and Fisher exact tests. A total of 724 surgeons completed the survey, including 61 (8.4%) urologists. Among urologists, the mean age was 39 years (SD 5.9), 95% had breastfed, and 56% worked in an academic setting. A mere 23% of urologists reported a formal lactation policy at their institution. Only 66% reported protected space, 31% were offered adjusted work hours, and 6.5% were offered relative value unit goal adjustments for lactation. Fifty-one percent of urologists felt they had adequate time for lactation, and 64% felt they had adequate space for lactation. Although 91% of urologists reported achieving their breastfeeding goals, only 11% were satisfied with lactation policies at their institutions. There was no statistical difference in these parameters between urologists and other surgeons (Table).

Table. Lactation Support Among Female Surgeons

These results demonstrate urologists and other surgeons are struggling to find sufficient institutional support for lactation. Very few institutions had formal lactation policies in place, and participants were not satisfied with the policies offered. These findings emphasize the need for institutions to create clear lactation policies with improved spaces and better time allocation to support lactating surgeons. With the impending shortage of urologists in the workforce, it is paramount that we increase attraction of medical trainees to the field.¹² By creating an environment that supports family planning and lactation support, we can encourage more female medical students to pursue urology. As we work to improve gender diversity in urology, we must improve resources available to female urologists as they navigate unique challenges such as breastfeeding.