Parental Leave Policies in Canadian Residency Education

In recent decades, the gender makeup of residency trainees has moved from highly male-dominated to something more closely resembling parity. In 1990, just over one-third (38%) of Canadian medical residents were female; since 2010, 53% to 55% of residency trainees have been female.¹  Residency training frequently coincides with prime childbearing years for female residents, and the average age of childbirth for both mothers and fathers aligns closely with the age of Canadian medical residents.^2,3 

Cross-national studies have consistently shown the benefits of paid parental leave.⁴  Paid leave is associated with lower infant mortality and morbidity,^5,6  improved maternal health outcomes,⁷  and lower rates of intimate partner violence.⁸  There are also economic benefits, with higher rates of participation in the labor force and increased wages for women with paid leave.⁴  Paternal leave has also been associated with improved maternal health outcomes, improved childhood educational outcomes, lower rates of divorce, and improved paternal engagement in the child-parent relationship.^9–11  While there is the impression that taking parental leave has a negative effect on a physician's career and colleagues, physicians view their colleagues taking leave less negatively.¹²  Institutional culture also likely plays a significant role in how physicians view the impact of parental leave.

Maternity and parental leave protections for Canadian resident physicians fall under the purview of provincial regulation and are governed by the employment standards of individual provinces.¹³  Canadian provincial housestaff organizations (PHOs) negotiate on behalf of all residents with academic hospital employers in their province(s) regarding income, work policies, and additional entitlements in their respective collective agreements. These cover items such as complete duration of maternity and parental leave, supplemental employee benefits (SEB, or “top-up” above the standard employment insurance [EI] benefit entitlements), as well as rights regarding workload modification during pregnancy.

Several US studies have recently been published examining the prevalence of parental leave policies in resident medical training. However, the American landscape is quite different from the Canadian context as there is no paid federally protected leave in the United States (though there is protected leave without pay).¹⁴  Many other countries such as Australia and countries in the European Union have national leave policies which apply to their medical trainees.^11,12  There is a paucity of similar Canadian literature around parental leave policies for medical trainees and Canadian provincial or federal policies do not universally apply to medical residents.

Despite numerous benefits to residents and their families associated with parental leave, many residents still face challenges in taking parental leave. A recent survey showed that the majority of residents felt that they should delay childbearing due to a variety of reasons.¹³  Our goal was to provide a comprehensive review of maternity and parental leave policies in all residency education programs in Canada, to highlight gaps that might be improved or areas in which Canadian programs excel.

We conducted a textual analysis review of the collective agreements of all PHOs in Canada, focusing on the sections pertaining to parental and maternity leave policies.

Collective agreement documents were extracted from PHOs on January 15, 2020. We searched websites of the 8 PHOs for information regarding pregnancy workload accommodations, pregnancy leave, and parental leave policies as of January 2020. We also reviewed the PHO websites on June 5, 2020 to confirm that there were no changes during the period of our analysis. Where available, full-text collective agreements were obtained. Where these were not available, all text was extracted from each PHO website pertaining to the above policies.

Two data extractors (T.S., L.C.C.) collected the following variables for analysis: duration of maternity leave (applicable to pregnant residents during and after pregnancy); duration of parental leave (applicable to both parents); amount (if any) of supplemental income provided to the resident by the academic hospital, Ministries of Health, or other provincial organization in addition to federal EI income; time at which a resident is eligible to start maternity leave; work accommodations (if any) provided to pregnant residents including but not limited to excusal from 24-hour or longer call shifts, night shifts, and weekend shifts; gestational age at which a pregnant resident was eligible for work accommodations; and agreement dates of each PHO-Ministry of Health collective agreement. The full text of relevant policy sections was collected for readability analysis.

We conducted a series of simple descriptive statistics on the extracted data and presented the summary in a tabulated form. The data was then used to construct various visualizations including comparison tables. To assess if there could be comprehension problems with the collective agreements, we analyzed the readability of all parental and maternity leave sections of the PHO agreements using the Flesch Reading Ease (FRE) score,¹⁴  which is commonly used for health literature, and completed a word count of the relevant policy sections. This article was generated based on publicly available data or policy documents, so it was not subject to Institutional Review Board approval.

We found a total of 8 collective agreements, which were all openly available as public documents. This collection of documents represented all PHOs in Canada, and by extension all residents training in Canada. Notably, one collective agreement encapsulated 3 provinces (New Brunswick, Nova Scotia, and Prince Edward Island) as there is only one medical school within those provinces. There were no collective agreements for Northwest Territories, Yukon, and Nunavut; trainees who rotate there are generally based out of one of the provinces and would use the PHO agreement related to that particular province. There were no disagreements between the 2 independent data extractors and all areas of extraction were completed.

A summary of all extracted variables for the different collective agreements are provided in tables 1 and 2. The domain with the least provincial variability was time offered for maternity leave: most agreements offer about 17 weeks of leave. With regards to parental leave, every organization offers at least 35 weeks of total combined leave (maternity and parental), while only 3 (Alberta, Ontario, and Saskatchewan) offer extended leave of up to 63 weeks, in accordance with the recent change in federal parental leave policy.

While all but 2 collective agreements (Newfoundland and Labrador, Manitoba) offered SEB for residents, some of these were restricted only to maternity leave (British Columbia, Saskatchewan). Residents in Manitoba—while not offered a SEB via their collective agreement—are offered supplemental income through the provincial physician organization (Doctors Manitoba), which covers both staff and resident physicians.

Collective agreements do only provide a top-up for parental leave for a portion of the total leave, after which the regular EI rate applies. When offered, the SEB top-up is most often 90% of expected income or higher. Every collective agreement provides call-related accommodations for pregnant residents with some variation in the gestational age at which accommodations are applied. Only half of the collective agreements specify whether accommodations are to be made regarding evening and weekend work.

A more detailed written summary and link to the electronic document of each province's agreement can be found in the online supplementary data.

Table 3 shows the word counts and FRE scores for each of the policies. The documents were highly variable in their word count, ranging from 228 to 4241 words. The average FRE score for the documents was 37.9 (SD 9.4). There was significant heterogeneity in both word count and FRE between different collective agreements. While this does not reflect heterogeneity in content (tables 1 and 2), it demonstrates the differences in written construction of the respective collective agreements.

This article illustrates that even in a single payer health care system, where resident work policies are made at a provincial level instead of a university or hospital level, policies surrounding maternity and parental leave still have a high degree of variability. There was significant variation in most of the examined leave categories. Few programs have an option to extend one's leave to 69 weeks, meaning that the majority of agreements are presently not in line with the national standard.¹⁵  However, all but one collective agreement were negotiated prior to the change in federal policy in March 2019. Supplemental employee benefits were also quite variable in amount and duration though most collective agreements offered some supplemental income. It was uncommon for collective agreements to be fully equitable in their treatment of both parents for any given supplemental income. All collective agreements provide accommodations to pregnant residents, typically from their late second or third trimester onward. This may help mitigate some of the negative effects that overnight and call shifts have on pregnant residents^16,17 ; however, further research would be warranted to see if Canadian residents are using these accommodations during pregnancy.

With regard to readability, all the collective agreements required a high education level for comprehension. Most residents would have the required education levels to comprehend these documents. However, an easily readable document is considered to have a FRE score of higher than 60,^18–20  a standard which none of the collective agreements met. The length of parental leave sections in the collective agreements varied substantially, and on the upper end exceeded 4000 words, which can be quite onerous for a resident to read. While many PHOs have produced more concise summary documents for residents to review the simplification of legal language is known to increase comprehension to non-experts without compromising integrity.^21–23  Supporting physicians as parents is a critical component of resident wellness²⁴ ; both residency programs and PHOs have roles to play in creating supportive, non-stigmatizing environments for trainees who become parents. The creation of clear, consistent policies that support the physical, mental, and financial well-being of residents is paramount.

Beyond the challenges residents face with regard to taking parental leave, resident parents face many challenges upon their return to work.²⁵  The time taken for leave results in an extension of residency training and may result in residents being “off-cycle” from their initial residency cohort (ie, peers in the same year of residency training) for educational opportunities (eg, fellowships) or for being hired as staff physicians. Furthermore, residents' work schedules, which often include weekend, evening, and extended hour on-call duties, create additional challenges around parenting young children. At present, it is not commonplace for Canadian residency programs to have specific alternative work models for return after leave (or these issues explicitly addressed by the collective agreements). We do note that some PHOs have provisions to address part-time residents, but these sections are typically quite limited. The above challenges may be addressed by models that provide more flexibility²⁶  and may warrant consideration by PHOs in their future collective agreements.

Limitations of this present study include that our authorship group is not trained in reading legal documents and policies, and our analysis may be less robust than if we had involved specialized legal expertise. One key limitation is that this study is a textual analysis and therefore may not fully reflect the lived experience of trainees. There may be a gap between these policy documents and real trainees' experiences, which cannot be discerned by our present design. In terms of readability, we also did not look at PHO summary documents that aim to provide simplified conclusions for their members.

In order to explore specific challenges of parenting in residency, areas of further study could include reviews of breastfeeding policies, illness leave, and parenting policies. Surveys or qualitative interviews of residents could further investigate the theory that residents may experience confusion or cultural barriers related to taking parental leave and elucidate the role of collective agreements, PHOs, residency programs, and GME offices as sources of support or barriers.

There is significant variability among the different Canadian provincial agreements in terms of length of leave, financial support during leave, and type and length of accommodations provided for pregnant residents. Only a minority of collective agreements offer extended parental leave that matches the recent changes to federal EI parental benefits. The pertinent sections in the full-text collective agreements are generally difficult to read, potentially leading to confusion regarding the full leave benefits provided.

The authors would like to thank all of the resident champions and administrative staff who have worked so hard to negotiate the collective agreements of Canadian residents over the years. There is no doubt that their tireless work has impacted countless trainees, children, and families.