The advancement of women leaders in obstetrics and gynecology does not reflect the changes in the physician workforce seen over the last 50 years. A core value of our culture in obstetrics and gynecology must be gender equity. Departmental, institutional, and professional society efforts should explicitly prioritize and demonstrate a commitment to gender equity with tangible actions. This commentary from the American Gynecological and Obstetrical Society synthesizes available information about women holding academic leadership roles within obstetrics and gynecology. We propose specific principles and leadership practices to promote gender equity.
The advancement of women in academic medicine, including in obstetrics and gynecology, does not reflect the changes in the physician workforce seen over the last 50 years. Obstetrics and gynecology, which is largely for and comprises women, should be an unsurpassed example of gender equity in academic medicine. A key responsibility of obstetrics and gynecology leadership is to recognize and acknowledge that gender equity is essential to achieving the full potential of our workforce. We should not see gender equity as optional. Addressing gender equity within departments, institutions, and professional societies and across academic medicine requires an intentional approach and strong actions to meaningfully address the persistent inequities ( Box 1 ). This special report from leaders within the American Gynecological and Obstetrical Society (AGOS) proposes specific principles and leadership practices to minimize gender inequity within obstetrics and gynecology departments and home institutions and beyond institutional walls to include professional societies and medicine broadly.
The Problem: Advancement of women leaders in obstetrics and gynecology does not reflect the changes in the physician workforce seen over the last 50 y.
The Solution:
This call to action from the American Gynecological and Obstetrical Society
synthesizes available information about women holding academic leadership roles within obstetrics and gynecology and offers recommendations for principles and leadership practices which, when implemented, can meaningfully reduce gender inequity in obstetrics and gynecology.
We recognize the significant contributions from individuals identifying across the full spectrum of gender identities. Unfortunately, we found that nearly all the existing gender data in academic medicine are reported dichotomously. With that limitation, the terms “female” for women and “male” for men within this report utilize the existing terminology from cited reference reports, including the Association of American Medical Colleges (AAMC). The 1975 AAMC estimated that only 16% of obstetrics and gynecology residents were female. By 1986, this proportion reached 51% and has remained well above 50% since then. Although the current AAMC data indicate that 83% of residents and 58% of obstetrician gynecologists are female, the academic milestones and metrics show significant gaps and disparities by gender. We would expect women to account for >50% of the full professors in obstetrics and gynecology, because most of the obstetrics and gynecology trainees for at least 30 years have been women. However, females accounted for only 36% of the full professors in academic obstetrics and gynecology departments in 2018, and males held most of the leadership positions and senior faculty ranks ( Table ). Only 28% of the 154 obstetrics and gynecology departments in the United States have female chairs.
| Designation | 2007 | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| All academic | 49 | 52 | 47 | 53 | 54 | 56 | 57 | 59 | 60 | 61 | 61 | 64 |
| Assistant professor | 42 | 59 | 60 | 61 | 62 | 64 | 66 | 66 | 68 | 70 | 70 | 71 |
| Associate professor | 40 | 42 | 45 | 42 | 43 | 44 | 46 | 49 | 50 | 52 | 56 | 57 |
| Full professor | 21 | 22 | 24 | 28 | 26 | 28 | 29 | 29 | 31 | 33 | 35 | 36 |
| Chair | 19 | 18 | 21 | 22 | 24 | 24 | 25 | 28 | 28 | 29 | 28 | 28 |
Within Department
The department leaders are responsible for ensuring a departmental culture that provides equitable opportunity and instills the confidence that each faculty member and trainee can reach their highest potential without gender-associated limitations ( Box 2 ). We expect leaders to model and prioritize equity, inclusion, diversity, excellence, civility, safety, honesty, and respect. The leaders must implement timely corrections for the individuals who chose to deviate from the existing rules, procedures, practices, and respectful interactions, as these individual behaviors can seriously undermine an equity culture. In a 2019 AAMC survey, 17.4% of women and 1.2% of men felt that they were disrespected in the workplace because of their gender. Over 90% of pregnant or nursing physicians experienced disrespectful comments, with 50% receiving negative comments about breastfeeding. Regrettably, recent reports confirm ongoing concerns in the field of obstetrics and gynecology. For example, surveys from the American Association of Gynecologic Laparoscopists and the Society of Gynecologic Oncology find high rates of sexual harassment among the female members. The leaders can address accountability and provide support for the department members who have experienced harassment, endured disrespect, or have been subjected to bias. These efforts must be supported by reporting systems and complemented with the necessary conversations to detect and address gender inequity.
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Gender equity is required within departments, institutions, professional societies, and throughout medicine.
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Gender equity should be an explicit core value of our culture in obstetrics and gynecology associated with demonstrable practices.
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Department leaders must model and cascade leadership principles of equity, inclusion, diversity, excellence, civility, safety, honesty, and respect to all department members.
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All trainees/faculty in obstetrics and gynecology should have effective mentoring and sponsorship that includes gender-specific barriers.
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Leaders should regularly and intentionally review their leadership rosters to optimize gender equity and inclusion.
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Leaders should facilitate career progression with flexible promotion policies. Flexibility and responsiveness to pandemic challenges is prioritized.
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Leaders should be strong advocates for on-site lactation rooms, childcare, and sick child options to eliminate pregnancy, parenting, and lactation discrimination in medicine.
Continued excellence within our specialty requires the active promotion of women into obstetrics and gynecology leadership roles. , All the trainees and early career physicians in obstetrics and gynecology benefit from effective mentoring and sponsorship. This is especially critical for women who are considering or planning academic careers, as there are clear societal and professional barriers for women. Societal expectations and uneven home responsibilities impact the ability of women to rise to academic leadership roles. Prior studies have identified that women in medicine are less likely than men to have a stay-at-home spouse and are more likely to have a partner who is also working full-time. , In addition, women spend more hours per day on domestic tasks, including childcare, than male colleagues. Because of societal expectations regarding family obligations, women have been more likely to prioritize flexible schedules over higher pay. For example, women parents may choose to reduce their work hours when their children are younger. The consequence of this inequity is that 40% of women are reducing their work hours to part time or are leaving medicine after over a decade of education and training. The leaders are responsible for creating and fostering an environment where all physicians can thrive in their academic career and personal life. The leaders must advocate for and effectively implement family-friendly policies that foster timely academic progression and reduce discordance among work and family roles. These policies should apply equally to all the faculty members; for example, allowing any new parent additional time away from work when a new child joins the family.
Academic and societal structures have disadvantaged the professional advancement of women in academics. The COVID-19 pandemic has magnified the existing vulnerability, exposed the precarious nature of progress to date, and justifiably created a sense of urgency. As with health and economic disparities, the disparity in domestic responsibilities has also been amplified, with women remaining vulnerable to external events of this nature. The consequences of school closings and the loss of childcare and after-school programs are disproportionately affecting women, despite reports that men have been more engaged during the pandemic. , Although the domestic burdens may negatively impact the progress of early career faculty who seek academic or clinical recognition, opportunities, and promotion, it is essential that leaders avoid assumptions about the preferred workload (ie, preference for part time status) for individuals such as women who are parents. The department leaders must respond sensitively and effectively to support academic progression and ensure that opportunities and sponsorship continue to be available. It is especially important to avoid protective hesitation and assumptions about any woman’s ability to engage in academic opportunities. Well-intentioned deferrals of appropriate academic opportunities (often on the basis of an external impression of “too much on her plate”) are generally inappropriate; instead, the opportunity should be discussed directly. For example, a faculty member being considered for a new academic role is passed over because someone has a perception that she will be unable to take on a particular responsibility because she is expecting her third child. Instead, the leader should ensure that all faculty members are offered opportunities for progression and promotion without presumptions regarding their interest or willingness to accept the responsibility.
We propose the following policies for adoption by all the departments. Leaders should regularly and intentionally review their leadership rosters to optimize gender equity and inclusion. This is especially important for department succession planning. We recommend that fixed, renewable terms with escalating levels of review be implemented to ensure that opportunities for academic advancement will be available within a department. We recommend cross-coverage for leadership meetings, as this is an important opportunity for emerging leaders to develop department relationships and leadership skills. Finally, we recommend that the search processes (both internal and external) be used to facilitate the expression of interest in leadership positions.
Leaders commonly write letters of support for trainees and faculty members within their departments. There is clear evidence that the language used in the letters of recommendation often reflect gender differences that disadvantage women. , We recommend that all leaders plan for time to reread the letters to assess for and mitigate such bias and ensure that the strengths of the individual are described in a professional language, avoiding common pitfalls such as men being more commonly referred to as “leader” or “exceptional” and women as “delightful” or “compassionate.”
Within Institution
Institutions need focused, intentional efforts to prevent the reversal of gains achieved by women in medicine. , A key short-term metric utilized to evaluate the impact of the COVID-19 pandemic on the gender gap has been publications. Even if an increase in publication submissions has been seen overall, women scientists and physician scientists, especially those with young children, have seen a decrease in research time, total publications, and first author publications. Preparing publications, much like grant submissions and other “academic” pursuits, requires focused time. These activities are difficult to accomplish while working at home when children require home schooling and care throughout the day. The pandemic has highlighted the vulnerabilities faced by women physicians and scientists, especially those with young children; these women will remain vulnerable to the next crisis that impacts childcare unless we make significant changes at the institutional level. Institutions should support women faculty with innovative approaches that reduce the pull between work and family. Strong advocacy for on-site lactation rooms, childcare, and sick child options is required to eliminate pervasive pregnancy, parenting, and lactation discrimination in medicine. Support for career progression should be demonstrated with flexible promotion policies that are responsive to the challenges of the pandemic. The leaders should highlight the extraordinary contributions by so many faculty members (especially medical directors and education leaders) during the pandemic to propose accelerations to their promotion process.
Institutional policies often fail to support the reality of the culture that is desired. Within an institution, gender equity is an obligation for every leader. Healthcare systems and institutions have not adequately addressed the structural and cultural hierarchies within them to effectively mitigate blatant and implicit discrimination and inequity. Certain institutional cultures will continue to propagate gender inequity until the unwritten rules of top-down decision making, unfair allocation of resources, and exclusion of diverse voices and perspectives are replaced with policies, guidelines, and best practices that promote gender equity, including but not limited to pay equity and a zero tolerance for sexual harassment. Although a growing number of healthcare organizations are creating policies and offering training to reduce gender bias, there is much more to be done.
Beyond-Within Professional Societies
Leaders often have the opportunity, to recommend trainees or faculty members for opportunities outside their department and institution. This form of sponsorship contributes to academic progression of the individual and addresses the gender inequity commonly associated with consensus statements, editorial boards, speaker panels, and grant study sections. Having a heightened awareness of gender equity in professional societies is a shared responsibility of society officers and all members, as the pervasive lack of the recognition of women’s academic contributions continues to propagate gender inequity.
Beyond-Within Academic Medicine
The academic gaps seen within obstetrics and gynecology are not unique to our specialty. The AAMC data record that only 38% of full professors are female, suggesting that there are barriers and structures within academic medicine that make it more challenging for women to achieve traditional academic success milestones and metrics. Changing the culture of medicine is essential to prevent the propagation of unprofessional and inequitable environments.
Medicine has much work to do to achieve overall equity, defined as fairness and justice. Gender inequity is one important aspect of equity. It intersects with other critically important inequities, including race, class, sexual orientation, gender identity, and disability. Leaders need to prioritize solutions to address the gender equity challenges associated with intersectionality (by race, sexual orientation, disability status, socioeconomic status, and academic pedigree). It is an abrogation of leadership to delegate the important work of equity by simply appointing a committee, creating a new title position or drafting new language for mission, vision, and strategies without a meaningful, actionable commitment, including resources.
We wish to briefly note that in response to the acute focus on racism in our country following the unconscionable police murders of numerous innocent Black people, the healthcare institutions responded by recognizing the importance of meaningful inclusion within a diverse and equitable culture. These institutions typically responded by appointing new “diversity, equity, and inclusion” positions within hospital executives and department vice chairs. Numerous events—including gatherings, book clubs, and committees—were held with the goal of raising awareness in our departments, medical schools, and hospitals. However, this awareness must be accompanied by a culture that unmistakably embraces and upholds racial and ethnic diversity and gender equity. Leaders, especially at the chair, dean, and president levels must be held accountable for this equity culture.
This call to action is intended to urge all of us to take responsibility for the future of our field by ensuring equity and actively implementing the recommendations set forth in this commentary. We believe that focused intention can make meaningful changes. A previous AGOS white paper on research in women’s health led to the formation of the Women First Research Coalition. The initiatives of this coalition include the fiscal year 2021 report language on the National Institute of Health’s women’s health research funding, which will result in a consensus conference being held in fall 2021, meetings with heads of the NICHD, NIDDK, NCI, ORWH, and the Biden transition team, and successful lobbying to change the percent effort on K-awards for obstetrician-gynecologist at NCI. The leaders in obstetrics and gynecology must ensure that these opportunities are made available to women seeking K-award support.
Principles and practices
Strong action is needed. We recommend that academic leaders start their gender equity work with several principles ( Box 2 ) and leadership practices ( Box 3 ) for consideration. Our specialty can achieve a more equitable culture and should lead with the adoption of these principles and the implementation of these practices. We recommend these principles and practices to support accelerating work that will result in gender equity within our obstetrics and gynecology departments, our institutions, our professional societies, and indeed, throughout academic medicine. The principles and practices outlined here serve as an important beginning to a path that will end with gender equity becoming a reality.
