Acknowledgements

Thank you to Dr. Jordan White, whose compassionate mentorship and guidance made this handbook possible. Thank you to Jeannette Gonzales Wright for the creation of the handbook cover, and to Kira Neel and many other students for critical review of the handbook. Lastly, thank you to the Alpert Medical School administrators in the Office of Student Affairs, the

Office of Medical Education, the Office of Financial Aid, the Office of Diversity and Multicultural Affairs, and the Office of Records and Registration, who graciously shared the

knowledge contained within this book.

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Contents

1. Introduction 3

2. Section I: Pre-Baby

a. Planning for a Baby: Is there a Right Time? 4

b. Financing Parenthood 7

3. Section II: Pregnancy

a. Pregnancy and Parenthood in Medical School: Know Your Rights 10

b. Structuring Maternity/Paternity Leave in Medical School 12

c. Pregnancy Self Care during Medical School 15

4. Section III: Parenthood

a. Lactation in Medical School 18

b. Juggling Student and Parenthood Responsibilities 20

5. Local Resources 22

6. Suggested Reading 25

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Introduction

Becoming a parent can be simultaneously one of the most joyful and challenging experiences that life has to offer. Caring for a child while meeting the many demands of medical education is a distinctly difficult task, but one that is very possible with support and guidance. This handbook will clarify the Alpert Medical School (AMS) options for leave, accommodations, and parenting resources. It will present the many things to think about when planning for medical school with a baby. It will also help students who are deciding whether and when to expand their family to understand the process behind doing so during medical school. This is not meant to be a guide to general pregnancy and childcare, but is rather a handbook for navigating the unique challenges of being both a parent and a medical student. The majority of this handbook is targeted towards students who are planning for parenthood. Yet not all situations can be planned for. Indeed, parenting is all about constant change and uncertainty. Moreover, each individual student and family is unique and faces their own challenges. Similarly, given the rapid and cumulative nature of the AMS curriculum, each student will need to consider the unique accommodations available to them depending on the timing of their baby’s arrival. This handbook will attempt to provide general information for a broad range of situations while presenting further resources for individual circumstances. It is meant to enhance, but not replace, meaningful conversations with administrators and other supportive staff in the medical school. Please note that while parts of this handbook apply specifically to students who are pregnant or delivering a child given the complex physical and emotional nature of these experiences, most of the handbook pertains to parents of all gender identities as well as those who may be considering adopting a child. We hope that this guide will answer many questions about parenting during medical school, and will help you feel supported in your family’s unique journey. If you have any suggestions for revisions to the handbook, please contact Dr. Jordan White, Assistant Dean for Student Affairs, at Jordan_white@brown.edu.

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Planning for a Baby: Is There a Right Time?

The answer to this question is an individual one. While there is no one best time to enter into parenthood, there might be a good time for you. Sections I through III will highlight some considerations to take into account when planning for a child at any stage in your medical education and training. Each of these components will be addressed further within the handbook. Sections IV and V address commonly considered best times in the medical school curriculum for having a child with and without extending training time. These may not be the best times for you, or the considerations discussed here might not be important to you. While recognizing that each decision is highly individual, and that planning is often not possible, this section presents some considerations for making these decisions during medical school.

I. Extending Training Time Given the intensity and nature of the medical school curriculum, the school is usually unable to accommodate a similar parental leave to what may be offered in the workforce. There are certain times during training when there is less flexibility for a time away, meaning that any break from classes would need to become an entire year. Given the variability in pregnancy timing within the curriculum, it is not possible to outline here which exact points in the curriculum would be inflexible for a shorter duration of time away. If timing is a concern for you, consider seeking more specific advice from Dr. Jordan White, Assistant Dean for Student Affairs. For students who want to take some time away but do not wish to extend their training by an additional year, creative timing will be necessary. There are also options that allow for flexible time away from the curriculum while completing a scholarly project. See “Structuring Maternity/Paternity Leave in Medical School” on page 12 and below sections IV through V for more information.

II. Flexible Accommodations During medical school, leave can easily be taken for an extended period of time (one or more years), which is typically not possible during residency or as a practicing physician. In residency or as a practicing physician, flexible options for family leave vary considerably depending on the position.

III. Work-Life Balance Some new parents find that having a baby shifts their priorities towards finding work-life balance and spending time with their child. From a medical student perspective, this can be a positive force in shaping future goals and choosing a specialty or residency that aligns with your values. Yet medical school is also the beginning of many years of long hours spent in the hospital away from family, often with little

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control over scheduling and hours. In this way, having children at the end of residency or as a practicing physician may have the advantage of increased scheduling autonomy.

IV. Best Times in Medical School: Without Extending Training Time The first best time to have a baby in medical school without taking additional time away is during the summer between the first and second year. There are currently ten weeks between the end of the first year and the beginning of the second year of school, allowing for a break from school responsibilities. Of course, this would require excellent timing, which babies do not often have. The next best time is during the fourth year. The fourth-year curriculum has some built-in flexibility with few requirements (sub-internships, interviews, Step 2, and electives). It is possible to take a break (i.e. six weeks) without extending training time. If you are considering this option, speak with Jordan White, Assistant Dean for Student Affairs, in January of the second year when planning curricular options for the clinical years. When planning to have a baby during the clinical years, there are some intersections between the curriculum and the more challenging periods of pregnancy to take into account. Such periods may include morning sickness and fatigue in the first trimester, fatigue and difficulty standing for long periods in the third trimester, appearing very pregnant in the third trimester, and postpartum stress or depression. It may be a good idea to determine your top priorities for the clinical years, consider how pregnancy or parenting may impact those priorities, and discuss timing or additional support that can help you meet your goals. In this section, the fourth-year schedule is assumed to consist of sub-internships and important electives during the summer, interviews in the late fall and early winter, and more flexible time for electives in the spring. Students who plan to be pregnant or parenting in the clinical years may want to consider the timing of these components. One option is to have the baby during elective or vacation time in the spring. However, if you hope to give birth after interview season, consider the issues of travelling in the third trimester, appearing very pregnant during interviews, and the potential for pre-term birth during interview season. Also, if planning to have a baby later in the spring, consider the stress of potentially moving your family during the first weeks or months of the postpartum period, and beginning the most demanding year of residency with a new baby. Similarly, if planning to give birth before interview season, you may be in the exhausting third trimester of pregnancy during your important sub-internships. Some parents have had their babies before interview season, and then brought the baby (and a caretaker travelling with them) during interviews. But it is hard to know how stressed or sleep deprived or prepared for interviewing you will be during that time.

V. Best Times in Medical School: With Extended Training Time

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Leave can be taken at any time, either as a Leave of Absence (LOA) or through the Academic Scholar Program (ASP). For more information on leave options, see ‘Structuring Maternity/Paternity Leave in Medical School’ on page 12. In general, good ‘stopping points’ in the curriculum for taking a leave are between the second and third years (following Step I), between the third and fourth years (following required clerkships) or starting in May or November (these are the semester breaks) of the third and fourth years.

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Financing Parenthood

Sections I through III describe the major expenses to consider when planning for a child. Sections IV and V include student options for financial assistance.

I. Baby Expenses

It is no secret that babies are expensive. From nursery furniture to diapers, and car seats to childcare, the cost of caring for a child can be enormous. If you do not already have a budget for yourself and your family, see the Office of Financial Aid for assistance building one. Consider adding the following minimum items and estimated costs to a monthly budget, depending on your individual resources and needs:

ü Disposable Diapers & Toiletries $15/week ü Feeding

o Formula $25/week o Lactation variable- may include the cost of a

pump (may be covered by insurance), bottles, and pumping supplies o Food for Baby (age 4+ months) $20+/week

ü RI Childcare (not nanny) $250/week ü Medical copays / Expenses variable – see “Health Care Expenses” below

The expenses listed here are based on this author’s experience as a medical student parent in 2017. Each budget will be unique depending on your baby’s needs, but this list is a good place to start. Detailed budgeting tools and other examples of baby expenses can be found online. Other gear and furniture, and even toys and clothes, can very often be borrowed or are gifted at baby showers. The website babybargains.com offers up-to-date baby gear reviews and bargains along with a running list of store discounts. Check out What to Expect the First Year for a quick guide to what you do and do not actually need to purchase before baby arrives. Reach out to support networks of local parents, like MomDocFamily (see “Local Resources” on page 21), or to other medical student parents, with your borrowing needs.

II. Health Care Expenses Depending on your insurance plan, pregnancy and childbirth can be very expensive. If you are planning to have a baby, it is a good idea to compare plans early. Keep in mind that you will need a plan to cover both yourself and your baby.

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Aside from the Brown Student Health Insurance Plan, you may be eligible for Medicaid, plans on the HealthSource RI insurance market, or for other private plans. Keep in mind that whichever plan you choose must be comparable to the Brown SHIP and a waiver must be submitted to the Brown Insurance Office by the summer deadline. Determine the base cost (plus copays and deductibles) of each plan and which pregnancy, childbirth, and pediatric services it covers, including: prenatal care, birth and childcare classes, pump, lactation consults, etc. For specific services, ask about the documentation needed for coverage. For example, some plans may cover high-quality pumps in full with a physician’s prescription, and some plans may cover birth classes with documentation of attendance. Birth is a qualifying event and thus you can sign your new baby up for a plan at any time, regardless of the enrollment period. However, enrollment must occur within a specified time period from the birth, and requires documentation (the baby’s birth certificate) to be sent to the insurer. Make sure to inquire with the insurance provider about these requirements before the birth. Since receiving a birth certificate can often take time, ask your hospital provider for an interim birth record before discharge if the insurance company needs proof within a short time period (i.e. 30 days).

III. Financial Considerations of Leave There are two options for taking a year or more of leave: the Academic Scholars Program (ASP) and a Leave of Absence (LOA). These options are discussed further under ‘Structuring Maternity/Paternity Leave in Medical School’ on page 12 and in the Alpert Medical School student handbook available on the Office of Student Affairs website. From a financial aid perspective, students in the ASP are designated as full-time students, have access to all student services, are eligible for student loans, and pay 1/40th of tuition for the year. As a full-time student, during the ASP loans continue to be deferred and interest on some loans will accumulate for an additional year. In contrast, the clock on loan grace periods will start once a student enters into a Leave of Absence, meaning that loans with a 6-month grace period would come due during a one year leave. The grace period also does not reset once full-time status is again achieved, so payments on these loans will be due immediately once training is completed.

IV. Financial Aid Each student’s need is determined by the formula: Need = Cost of Attendance – Family Contribution. Need is first met with a base loan amount and need remaining after the base loan is met with AMS scholarship. High need aid applicants may also receive AMS loan funding. Note that if a student is married, the student's parent income and asset information is still used in the formula for determining family contribution. The student and spouse's income and assets are considered as well. The addition of a child will reduce the student's contribution. Whether eligible for AMS funding or not, students can borrow up to the total cost of attendance (COA) with two different federal loan programs, the

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Federal Direct Unsubsidized loan and the Graduate Federal PLUS loan programs. Additionally, the Office of Financial Aid can add up to $5,000 to the Cost of Attendance for yours or your child’s expenses. However, note that this additional funding cannot be used to cover expenses for a pregnant spouse/partner.

V. Financial Assistance Programs The Brown University Childcare Subsidy provides support, to a limited number of applicants, for up to $4,000 in childcare expenses for children up to age 6. Eligible students must meet certain income and spousal employment requirements, and apply by a certain date. However, the application can be filled out only after the child is born and enrolled in childcare. For assistance with food expenses for low income women and children, see the RI Women Infants & Children (WIC) program. WIC subsidizes certain food items for women during pregnancy and postpartum, for baby formula and food, and food for children up to age 5. Nutritional guidance is also provided. WIC recipients may also be eligible to receive a free Medela double electric pump and kit through the WIC Pump Program from Healthy Babies, Happy Moms. Applying early in pregnancy maximizes the length of benefits. Lastly, if you or your partner is employed and earning income, there are tax credits that either reduce your taxable income or provide a tax refund that can be used to pay for your child’s expenses. These include the Child Tax Credit, the Additional Child Tax Credit, The Child and Dependent Care Tax Credit, and the Adoption Tax Credit.

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Pregnancy and Parenthood in Medical School: Know Your Rights

I. Title IX of the Education Amendments of 1972 The main legal protection for pregnant and parenting students is Title IX. The following is a summary of the Title IX provisions specific to pregnant and parenting students. For further detail, see the Brown Title IX Policy or medical student-specific Title IX materials on ‘The Learning Environment’ Canvas page. Read more at thepregnantscholar.org or at the U.S. Department of Education Office for Civil Rights. No person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any education program or activity receiving Federal financial assistance. Title IX makes it illegal to discriminate against students on the basis of sex or gender characteristics. On any part of the Brown campus, students have the right to freedom from harassment, intimidation, or discrimination because of pregnancy, parenting, or related medical conditions. Such conditions may include lactation, miscarriage, abortion, or recovery from childbirth. Harassment includes negative comments related to any of these conditions. Students must be given reasonable accommodations and reasonable medical leave, cannot be penalized for leave, and must be able to return to the same student status following leave. Students must also be given the opportunity to make up missed work and obtain information missed due to related absences. All schools are required to provide the same accommodations to pregnant and parenting students as those provided for students with temporary disabilities. These stipulations are the same for people of all gender identities.

II. Lactation Regulations Schools are not required under Title IX to provide a lactation room for students, although this accommodation is encouraged by the Department of Education. However, lactation and medical conditions related to lactation are included under Title IX protections. For example, lactating students must be allowed excused absences to pump, without penalties, and with the ability to make up missed work. As another example, in the event of mastitis or other lactation-related medical condition, the student must be allowed the same accommodations given for other medical conditions. Under Title IX, students must not be harassed due to their lactation status, and all lactating students must be given the same accommodations, including any lactation spaces or milk storage. A list of lactation rooms on the Brown campus and affiliated hospitals can be found in the Lactation during Medical School section on page 17.

III. Reporting Discrimination

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To make a complaint about a Title IX violation or for questions related to the complaint process, contact the Title IX Coordinator for Alpert Medical School, Lindsay Orchowski, at Lindsay_orchowski@brown.edu, the Title IX advisor for Alpert Medical School, Dr. Jordan White, or the Title IX Program Officer for Brown University, Rene Davis, at titleixoffice@brown.edu. For detailed information about what the Title IX complaint process looks like, see the Brown Title IX Office website. For confidential help in deciding what to do about potential mistreatment, including deciding whether or not to submit a complaint or how to write the first contact message, consult any of the following options. Note that speaking with any of these people does not mean that you are reporting to Brown or Alpert Medical School.

§ Brown University Ombuds Office (401-863-6145) § SHARE Advocates (401-863-2794) or the sexual assault response line

(401-863-3000), which is available 24 hours a day § Office of the Chaplains and Religious Life (401-863-2344) § Counseling and Psychological Services (CAPS) (401-863-3476)

o Laurice Girouard, CAPS therapist for AMS students (call CAPS to make an appointment)

§ Joanna MacLean, Director of Psychological Support Services at AMS (joanna_maclean@brown.edu)

Based on the promotion of a positive learning environment, Alpert Medical School defines mistreatment as “any behavior that is harmful or offensive to an individual student and interferes with the student’s learning.” Mistreatment can be reported either anonymously or confidentially through the Mistreatment Form located on The Learning Environment Canvas page.

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Structuring Maternity/Paternity Leave in Medical School In this section, ‘leave accommodations’ refers to maternity leave wherein a few (or more) weeks are taken off with makeup work later, but without extending training time an additional year. This type of leave is sometimes available to medical students, depending on timing. A year (or longer) leave is always available in the forms of a Leave of Absence or through the Academic Scholar Program. Decisions on leave and other accommodations are made together by the course/clerkship/elective director, the Assistant Dean for Medical Education, the Assistant Dean for Student Affairs, and the Associate Dean for Medical Education. The days and weeks following the arrival of a new baby can be extremely challenging. During this time, you are learning how to care for everything that your baby needs, often doing so with very little sleep, and you may also be recovering from delivery. There is very little semblance of a schedule, and many parents find that these first weeks are just a blur of round the clock feeding, crying, comforting, and naps. This time is also different for every baby and every parent. While it is difficult to predict how much leave you will want or need after the baby arrives, remember that if plans for staying on track with schoolwork fall through, a leave of absence can be started at any time.

I. How Leave Accommodations are Determined Leave accommodations are based on timing within the medical curriculum. To begin this process, speak with Dr. Jordan White, Assistant Dean for Student Affairs, who has been designated as the point person for these conversations, or with any trusted advisor. Dr. Joanna MacLean, Director of Psychological Support Services at AMS, or Laurice Girouard, CAPS Therapist for medical students, are also both available for confidential discussions on how to approach this topic and planning for the amount of leave that is right for you, and are not involved with any student performance evaluations. Any of these individuals can help you identify which accommodations you may need and help you approach administrators to ask for these accommodations. For details on steps to seek an accommodation, see thepregnantscholar.org. Many newly pregnant individuals and partners wait until the end of the first trimester to begin discussing a pregnancy, when the risk of early pregnancy loss is reduced, but this is a completely individual decision. If you do experience loss, Dr. Jordan White or other advisors are also available to offer support and to help coordinate any time away from school responsibilities as needed. However, given the number of administrators who need to be involved with this decision and the amount of time that it takes to discuss and approve the options, it is often best to start as early as you feel comfortable.

II. Leave Options Some blocks of the preclinical medical school curriculum are able to accommodate a

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short leave without extending training time, but this is entirely dependent on exact timing. For example, some blocks within the second semester of the first year may allow for make-up over the summer break while others are the foundation for succeeding blocks and cannot be missed. It is unlikely that leave with summer make-up work could reasonably be granted in the first semester of the first year, as this foundational material is essential to the second semester blocks. Second year blocks are again dependent on exact timing, but the attendance requirements for small groups and Doctoring in this year make leave accommodations unlikely. Again, this decision will be made on an individual basis. The clinical curriculum is potentially more flexible for short (a few weeks/ less than one year) leave accommodations. Since the clinical years are a series of distinct clerkships, they may be arranged to allow time off and/or less demanding electives following the baby’s arrival. To plan for these accommodations, talk with Dr. Jordan White or with Alex Morang, Director of Career Development. As noted above, there are two extended (one year or more) leave options available for any year: Leave of Absence (LOA) and Academic Scholars Program (ASP). While LOA is a full, temporary leave from the medical school, students in the ASP are considered full-time students. The ASP allows for completion of a research or scholarly project under an advisor, and can be used to benefit the students’ portfolio. Since the medical school curriculum is structured into cumulative years, leave will always total one year (or more) in length. ASP must be at least one full semester, but the remaining semester can be either LOA or ASP. Some students may decide that a full leave is the best option for them and their families, while others may feel more fulfilled working on a project during this time. In the case of parental leave, taking either an LOA or ASP will not have a negative impact on a residency application. For more details on leave options, see “Section XII: Time Away from Medical School” in the AMS Student Handbook or speak with the AMS Records and Registration System Manager, Eileen Palenchar. It is also helpful to speak with the Office of Financial Aid to discuss the financial implications of an LOA versus an ASP.

III. Unexpected Leave Unexpected situations are par for the course with pregnancy and parenting. Birth dates may be earlier or later than expected, pregnancy complications can happen, or you or your child may need extra care. Even if you have a planned leave accommodation, it is a good idea to think about how your plans might change in the case of an emergency or if you decide you want more time off with your baby. The best option for leave in an emergency is an LOA since it could be difficult to coordinate an ASP project at the last minute. However, it is possible within a one-year leave to take six months of LOA, during which a project could be planned, followed by six months of ASP to complete the project. If an emergency requires leaving in the middle of a preclinical block, whether or not that entire block will need to be made up will depend on the exact timing. These decisions are

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made on a case-by-case basis.

IV. Other Accommodations For your or your child’s brief or occasional illness, excused absence and extension policies apply. See “Section IV: Attendance Policy” of the AMS Student Handbook. Pregnant or lactating students may request a protective mask to minimize formaldehyde exposure in the anatomy lab. These can be obtained through the Environmental Health & Safety (EHS) department on the main Brown campus. After contacting EHS, the process consists of a Respiratory Medical Evaluation at Concentra Urgent Care in Providence, and an appointment with EHS for a fit test and training. The mask is paid for by the Department of Medical Education. For more information and to start the process, contact Dr. Dale Ritter, Anatomy Director. This and other potential occupational hazards, including radiation and infectious diseases, and how to minimize risk, should be discussed with your physician. Talk with clerkship directors and/or with Dr. Jordan White regarding exposure risk reduction during clinical rotations.

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Pregnancy Self-Care During Medical School

I. Working Through Exhaustion & Morning Sickness Unfortunately, it is impossible to know how your body will react to pregnancy until you experience it. The first trimester may be accompanied by nausea and exhaustion, the second trimester may be a time of energy and wellbeing, and the third trimester may bring a second wave of physical exhaustion along with swelling, sleep disturbance, and difficult mobility. Or, you may experience none of these things! In the clinical years, you could try to schedule the most demanding rotations during the second and early third trimesters, when you are most likely to feel the best. If possible, you can try to schedule less demanding rotations for your return from leave to ease the transition back. This may be especially important if you are planning to pump during rotations. Of course, maintaining academic excellence through months of nausea and exhaustion is very difficult. It is important to be honest and compassionate with yourself and what you need. During this time, consider excusing yourself from extracurricular activities and reducing any unnecessary workload. Recruit friends and family to help around the house so that you can get some much-needed rest. Remember to stay hydrated and to eat healthfully. Most importantly, remember that if you need help, ask. Reach out to Dr. Jordan White, Assistant Dean for Student Affairs, Dr. Joanna MacLean, Director of Psychological Support Services at AMS, Laurice Girouard, CAPS therapist for AMS students, or another trusted advisor for help in managing the challenges of pregnancy during medical school. In clinical rotations, you can notify clerkship directors of your pregnancy so that appropriate accommodations can be made on the wards. Or, contact Dr. Jordan White for assistance in doing so. And in an emergency, refer to the absence and leave policies in the AMS Student Handbook.

II. Choosing a Care Provider Medical students may feel apprehensive about delivering at Women and Infants’ Hospital, which is also Brown’s main OB teaching hospital. If your provider delivers at WIH and you are concerned about privacy, talk to them about options, including requesting that no residents or students be involved in your care. You may also choose to find a provider who is not affiliated with Brown’s teaching program. There are also multiple other hospitals throughout Rhode Island with labor and delivery units, including Landmark Hospital in Woonsocket, Kent Hospital in Warwick, South County Hospital in Wakefield, and Newport Hospital in Newport. Keep in mind that if you are looking for a specific hospital to deliver at, your provider will need to be affiliated with that hospital.

III. Mental health resources

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Delivering and/or parenting a new baby is an incredibly demanding experience, and one that can quickly become overwhelming. Many new parents struggle with postpartum blues or postpartum depression, anxiety, and/or feelings of isolation during this difficult time. Trans* individuals may also face unique mental health challenges related to pregnancy and parenthood. There are multiple local mental health resources specifically for new parents, including but not limited to the list below. Multiple support groups are also listed under Local Resources on page 21, but are not a replacement for quality mental health care. § Women’s Medicine Collaborative: This collaborative group provides comprehensive

care for women including obstetrics and gynecology, primary care, and behavioral medicine. Psychiatrists at Women’s Behavioral Medicine manage mood and anxiety disorders during pregnancy and postpartum, pregnancy loss, and infertility. Also at this site is a Circle of Moms group for mothers and babies up to one year old, with the aim of helping women cope with the emotional challenges of transitioning to motherhood. The group is led by AMS’ Director of Psychological Support Services, Dr. Joanna MacLean.

§ WIH Center for Women’s Behavioral Health: Outpatient psychiatry and psychology is also available through WIH.

§ WIH Day Hospital Partial Program: For women needing more intensive pregnancy or postpartum behavioral support, the day program offers short-term, intensive mental health care provided by specialists in perinatal mental health. Women are welcome to bring their newborns with them to the program.

§ Amanda Vaughn, Therapist: Marriage and Family Therapist specializing in prenatal and postnatal mental health, infertility, grief and loss.

§ Thundermist Trans* Health Access Team: This group of medical, behavioral health, and allied service professionals provides culturally and clinically competent healthcare for the trans* community. They can also serve as a good resource for people who are looking to talk with a medical provider about family planning. In order to receive behavioral health care, you must also see a Thundermist Primary Care Provider. A comprehensive list of additional resources for trans* individuals, created by the RI Trans* Health Initiative, can be found here.

IV. Pregnancy Loss and Complications Medical students are often witness to pregnancy loss and or pregnancy and birth-related complications. Pregnant or expecting students may be especially concerned about the possibility of personally experiencing these tragedies. Keep in mind that complications are the exception, not the norm. In the event of pregnancy loss or other complications, or for help navigating concerns about complications you may have witnessed in others,

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contact Dr. Jordan White for assistance.

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Lactation In Medical School

I. Benefits and Challenges to Lactation in Medical School The many benefits of nursing for both parents and babies are well known and often cited. Specific to medical students, nursing can allow for taking time out of a busy schedule to be present with your child. It can enhance bonding between you and your baby when you are otherwise spending long hours apart. Medical students also face unique challenges to lactation. First, if you decide to exclusively nurse and thus need to pump while away from your baby, you will need about a 30-minute break every three hours to pump. Such regularity is needed to maintain a milk supply. At the same time, foregoing pumping sessions can be uncomfortable, stressful, and can lead to a decreased milk supply. While this may be feasible in the preclinical years, it could be difficult on certain clinical rotations. Lactation room availability varies with each rotation and will require conversations with each clerkship director. Another consideration is traveling for residency interviews or going to different clinical sites; it can be logistically difficult to find a private space for pumping while away from a lactation space or travelling, and storing milk appropriately can also be a challenge. Program directors recommend contacting the residency coordinator in advance to request pumping accommodations. The coordinator can likely arrange breaks for you during the interview day as needed. This all being said, many parents who exclusively nurse put undue pressure on themselves not to supplement with formula, and this can become incredibly stressful and frustrating, especially if busy schedules lead to supply issues. Have compassion for yourself and don’t be afraid of supplementing with formula if something just has to give. You can still nurse your baby at home, giving both you and baby the benefits of nursing, while supplementing with formula while you are away. Remember that the goal is a healthy and happy baby and parent, and flexibility is a key component in reaching this goal. If you have any concerns about lactation or want to talk through options for giving your baby excellent nutrition while attending to your physical and mental health, consider contacting Kathy Moren of Healthy Babies, Happy Mom (see Local Resources, page 21), or any lactation consultant. In addition, Danika Wynn is a local lactation consultant with chest feeding expertise for trans* individuals, and can be contacted at danikawynn@gmail.com. Additional lactation resources can be found on page 21.

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II. Lactation Rooms Workplace laws maintain that lactation rooms must be non-bathroom private spaces with locked doors. Ideally, lactation spaces will also have a comfortable chair, table, outlet for plugging in the pump, refrigerator for storing milk, and sink for rinsing pump parts. Helpful items to have as a student using multiple lactation room sites are 1) pump part wipes for when sinks are not available and/or waterproof refrigeration bags to hold dirty pump parts at a safe temperature for multiple uses, and/or extra sets of pump parts 2) a freezer bag for milk for when a refrigerator is not available, and 3) a battery adapter for the pump when an electrical outlet is not available. It is also helpful to carry a paper sign that says “Room in Use” with tape for those times when you do not have a locked room to pump in or when the room has frequent visitors. There are lactation rooms throughout the Brown campus, with a list found here. The lactation room on the medical school campus is located in Rm 203 of 233 Richmond St, across the road from Alpert Medical School. This room, and its associated Google schedule, can be accessed by contacting Barbara Dickinson in BioMed’s Department of Facilities Planning and Operations at Barbara_dickinson@brown.edu. A comprehensive listing of lactation rooms at hospital and clinical sites is maintained by MomDocFamily and The Rhode Island Breastfeeding Coalition and is found in an attachment on the MDF website here. If there are any questions or concerns, reach out to Dr. Jordan White for clarification. In the event that you are at an outpatient site without a designated lactation room, speak with the clerkship director and/or the physician with whom you are working. Physicians are often very receptive to pumping breaks and may provide locked offices or designated spaces for doing so. In any situation, talk with the physician that you are working with to clarify your needs at the beginning of the rotation or day. Make sure to speak up for yourself when you need a pumping break, and offer to make use of that time with multi-tasking charting or notes when needed.

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Juggling Student & Parenthood Responsibilities

I. Maximizing Work-Life Balance The definition of ‘balance’ is an individual one. But one thing is for sure: being a medical student and taking care of a baby makes for a very full life. Efficiency in work and life is important, and allows for more time with your baby. Again, self-compassion is crucial. Lean on your supports when you need to and be vocal with friends and family about what you need. Define your top priorities and don’t be afraid to just be “good enough” in low-priority areas. Lastly, when you are with your baby, try not to think about work- protect the time that you have to be present with your family. Here are a few life hacks to consider: 1) meal plan so that you can shop once a week, and then make large amounts of healthy meals once a week and freeze family-sized portions for later; 2) get everything for the next day ready at night so that you can get yourself and baby ready in the morning in a flash; 3) automate everything that you can- place a recurring diaper order on Amazon Prime, and sign up for automatic bill pay online. Sometimes there are small areas where you can cut back financially (i.e., make your lunch and coffee at home instead of paying to drink/eat out, and use the money instead for help with life tasks such as cleaning your home. Remember that there may be a period of training when you feel you have little control over your time, but this can lead to careful planning about the kind of practice and balance that you hope to have. The life of a physician-parent can be incredibly rewarding.

II. Creative Childcare The key to work-life balance is having quality, reliable childcare for all the hours that you need it. This is often easier said than done due to the high cost of childcare and the often nontraditional hours of training. Ideally, family in the area can assist with some childcare, but this is not always an option. It is a good idea to formulate a childcare plan starting in your first trimester, especially since childcare centers in the Providence area have long waiting lists and good nannies are higher cost and can be hard to find. For paid childcare options, you might consider the following options, from least to most expensive:

§ Occasional Babysitter § Childcare (home or center) § Nanny § Live-in Nanny

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Generally, childcare centers are open about 7AM through 5:30PM, often with financial penalties for late pick-ups, though some may open earlier or close later. You may also need to factor in the time needed to get yourself and your baby ready in the mornings. Keep in mind that most childcare centers will not allow a child to stay if they are febrile (or febrile in the past 24 hours), vomiting, or otherwise moderately sick. Many childcare centers also close on holidays. If a partner or support person has more flexible hours, consider a childcare option that is most convenient for that person for pickups and drop-offs. However, you may also want to consider having the baby near enough to you so that you can stop in to nurse when you want or are able to. You may also need to consider creative options for getting the baby to and from childcare when you have early or late rotations. It is possible to find a babysitter who could work very early or very late hours only as needed, but such odd jobs usually come at a premium price. To secure reliable nannies, you should plan to pay them 52 weeks per year and ideally include benefits. Some families guarantee a certain number of weekly hours for these types of sitters so that the position is more regular and desirable. Other families use a nanny share option, in which the cost of the nanny is split between the families and the nanny either watches all of the children together or the schedule is split between the families. This option has the added benefit of a parent support system and may help to manage unexpected nanny needs. Perhaps the most flexible, but also most expensive, option is a live-in nanny or au-pair, which would leave a responsible adult home with your children at unusual hours if need be. However, if a nanny quits or is sick, this may leave you without childcare quite suddenly. With all nannies, leaving a baby alone with one adult requires a tremendous amount of trust. Having as many options for back-up childcare as possible will help when you are in a pinch. The Brown Graduate School has a list of recommended childcares here. The MomDocFamily Listserv is also an excellent source of advice on daycare or creative childcare options, and members often post nannies available for work.

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Local Resources

I. Support Groups & Networking AMS Student Parent Support Network: Beginning in 2017, a list of past and current student parents will be maintained by the Office of Student Affairs. These students are interested in supporting other student-parents through mentorship, discussion, resources, or other areas of need. Contact Dr. Jordan White, Assistant Dean for Student Affairs, to access the list. MomDocFamily (MDF): This listserv joins together a network of medical student and physician mothers in Rhode Island and Southeastern Massachusetts with the goal of mentoring and supporting one another personally and professionally. Members send out messages seeking parenting advice, donating children’s items, looking for nanny recommendations, consultations, and much more. There is an option to receive one daily ‘digest’ email with all of the day’s messages included. To join, email Dr. Lynn Taylor at ltaylor@lifespan.org or Dr. Alice Kim at aykimmd14@me.com with your medical student status and the age (or due date) of your child(ren). Dr. Jordan White, Assistant Dean for Student Affairs, is also on the advisory board of MDF and can help answer any questions about this resource. RI New Moms Connection: Provides pregnancy and new (or second time) mother support groups for a fee. Sessions have specific topics and are designed to facilitate friendship and discussion between new mothers and reduce the isolation and anxiety that can accompany pregnancy and motherhood. The website also includes a list of holistic local resources for mother and baby. Families First RI: This free service connects individual new mothers with mentor mothers for weekly support through the challenges of motherhood. Hospital Support Groups: Women & Infants Hospital offers a wide range of free support groups for pregnant women and parents, including groups for pregnancy loss, new mothers, and lesbian couples. Kent Hospital offers a support group for new mothers, and South County Hospital has support groups for lactation, new mothers, and pregnancy loss. Newport Hospital also offers a lactation support group. Circle of Moms Group: Women’s Behavioral Medicine at the Women’s Medicine Collaborative offers a support group for new mothers (up to 1 year postpartum and can bring baby) to help mothers cope with the emotional challenges of transitioning to motherhood. This group is run by AMS’ Director of Psychological Support Services, Dr. Joanna MacLean.

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Trans/Gender non-conforming/ non-binary Support Group: Fenway Health in Boston offers this free monthly drop-in group for parents and prospective parents who are transgender or gender variant, and their partners.

II. Childbirth and Preparation Classes Women & Infants Hospital, Landmark Medical Center, Kent Hospital, Newport Hospital, and South County Hospital offer classes to prepare for birth, lactation, caring for a baby (or two) and more. You do not have to deliver at the hospital to benefit from these classes. Rachelle Friesen GentleBirth Childbirth Preparation Workshops: GentleBirth workshops provide expectant moms and partners in the RI area easy to learn brain training techniques including Mindfullness, Cognitive Behavioral Therapy, Sports Psychology and Medical Hypnosis along with tools, information, and techniques to prepare for the most positive birth possible. Bradley Method Classes: The Bradley Method is a series of natural childbirth classes that teach women and their partners how to be active, informed, and relaxed participants in the natural birth process. Classes are offered by local doulas Lauren Amand of Gentle Beginnings and Mimi Desjarlais of Natural Births of RI. The Motion Center Workshops: This wellness center offers a variety of classes including “Birthing: Body, Breath, Heart & Mind: a Contemplative Workshop,” a workshop for healing scars from Cesarian section, episiotomy, and tearing, a class on infant massage, and classes on newborn care and nursing.

III. Exercise for Pregnancy The Motion Center: In addition to the classes mentioned above, this studio offers dance and yoga classes to pregnant mothers and mother/baby pairs. Oh Baby! Fitness RI: This studio offers prenatal fitness classes as well as a Mommy & Baby Stroller Workout. Prenatal Yoga: Many yoga studios in RI offer prenatal yoga classes. Studios include Providence Power Yoga, Breathing Time Yoga in Pawtucket, Bellani Maternity in Warwick, and Newport Community Yoga in Newport (also offers Mom & Baby Yoga and a Mom & Baby Bootcamp).

IV. Doulas & Birth Providers Doulas of Rhode Island (DoRI): This doula network provides a list of birth doulas and postpartum doulas. If you are interested in either option, start early in pregnancy so that

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you can find the doula that works for you and get to know them before the birth. The best way to do this is to attend one of the Meet the Doulas Night events hosted every few months by DoRI. Doulas are usually paid for out of pocket, and can range from free-about $800, depending on the doulas experience, and on your financial situation. Talk with DoRI about what you can realistically afford.

RI Birth Network: This group assists pregnant mothers in making informed choices about birth by providing information on childbirth options including types of providers, birth locations, local provider listing, and more. The website also includes a comprehensive list of resources, including books on the birth process for mothers and partners. Trans Birth: This site includes a state-by-state directory of midwives, OBGYNs, and doulas for trans* and gender nonconforming individuals.

V. Lactation and New Baby Support Healthy Babies, Happy Mom: The local lactation guru, Kathy Moren, provides lactation consulting services, lactation support, sleep consults, nutritional consults, and classes on all of these topics, along with in-home infant phototherapy. She also sells high quality Medela nursing products and accepts insurance. See the website here or contact Kathy at 401-884-8273. WIH Warmline: This free hotline is answered by nurses and lactation consultants at Women & Infants Hospital, and answers any and all of your lactation and newborn care questions. They even provide lactation support for free over the phone or can make an appointment for you with a lactation consultant at WIH. Other birthing hospitals in RI also have Warmlines, with numbers listed here. Dr. Milk (Mothers Interested in Lactation Knowledge): This website and facebook group is specifically for nursing physician and medical student mothers and includes tons of information and discussion on lactation, including supply issues. Join the facebook page through a request on the website. La Leche League: This local branch of the international nonprofit organization provides detailed information on any and all lactation questions, nursing support, lactation consults, and lactation groups. Sweet Pea Breastfeeding: This website features lactation resources for same-sex couples, trans* individuals and adoptive parents, include a comprehensive guide called “Breastfeeding Without Birthing” for adoptive and intended mothers.

Your pediatrician or family physician can also be an invaluable source of information and support. Remember there are no “stupid” questions when you are a first-time parent. All your concerns are valid, and as you ask your own questions, you are also learning much about how patients ask questions and receive answers from the health care system.

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Suggested Reading

I. What to Expect When You’re Expecting / What to Expect The First Year by Heidi Murkoff & Sharon Mazel This classic and very detailed book follows you and your baby’s growth in month-by-month guide, describing stages of growth and common concerns at each stage.

II. Baby 411: Clear Answers and Smart Advice for Your Baby’s First Year�by Ari Brown & Denise Fields This is a great quick reference guide to everything baby-related. It is a detailed and evidence-based compilation of current information about important topics like nursing, sleep, and hygiene. It is broken down into readable sections for a quick reference of any topic. For the sleep-deprived, check out the section on sleep training, which rates all of the current theories on sleep along with a brief description of each. There are copies available for borrowing in Dr. Jordan White’s office.

III. Trans Bodies, Trans Selves Edited by Laura Erickson-Schroth This is a resource guide on transgender health and wellness and includes sections on mental health, sexual and reproductive health, as well as a section on parenting.

IV. The Pediatrician’s Guide to Feeding Babies & Toddlers: Practical Answers to Your Questions on Nutrition, Starting Solids, Allergies, Picky Eating, and More By Anthony Porto, MD, MPH & Dina Dimaggio, MD This up-to-date, evidence-based guide includes all of the practical guidelines and realistic advice on feeding children (and yourself!).