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Career Focus

Returning to work after maternity leave

BMJ 1998; 316 doi: (Published 02 May 1998) Cite this as: BMJ 1998;316:S2-7141

Children change everything. Jackie Cassell discusses the personal and professional issues for new parents who are also doctors

  1. Jackie Cassell, specialist registrar
  1. 35 Spences Lane, Lewes, East Sussex BN7 2HF

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    Working mothers have recently had their anxieties increased by the Louise Woodward case, which provided ammunition for those who think we should not leave the home. In our society the return to work after childbirth is a time of guilt and uncertainty, though more mothers go out to work than ever before. This article addresses what I and other medical mothers have experienced as major preoccupations and problems in planning a return to work. It should not be forgotten, though, that the challenges of returning to work after maternity leave concern all doctors. Women doctors, of course, spend most time and energy on this problem. But most male doctors will also experience these issues in relation to their families or colleagues. If maternity leave and working relations are not to be spoilt by worries about returning, we should all try to be aware of what is involved in becoming a working mother.

    Changing role at home

    The demands on a working mother inevitably change the equilibrium between you, your partner, and your child. You will almost certainly have been the centre of the home during maternity leave, with your partner playing a secondary role in child care and domestic activities, perhaps under your direction. Most likely, you have done more than your pre-pregnancy share of the chores. Reallocation of household work is best done before your return to minimise minor disasters like forgetting the week's shopping. Who will be responsible for cooking, cleaning, washing, bathing the baby, putting him or her to bed, buying the baby food? Who will be “on call” for emergencies, such as when the baby or childminder is ill?

    Your loss of control at home, just as you give your child up to strangers, may be difficult to cope with. Expect this to be destabilising and try to share experiences with other couples who have been through this process, during which a relationship may be vulnerable. You may feel displaced both by your partner and child carers, even if you feel entirely happy about the hours you are working and the job you are returning to. Try to experience the positive side - such as your baby developing a richer relationship with your partner and spending time with other children. You may be appreciated more as your partner takes on jobs that went unnoticed when you did them. And prepare for separation by leaving the baby for lengthening periods with your partner, family, and child carer well before starting work.

    Child care

    For most doctors with families, child care is the most pressing practical concern. Unless you are lucky enough to have relatives who can help, there will be three main options: registered childminders, nurseries, or nannies. In many areas there are long waiting lists for the first two, so it is worth looking into provision as early as you can.

    Registered childminders are screened by the local social services department, which will provide a list of minders on request. Each childminder's home is inspected for safety and suitability each year, and a police check is undertaken. Childminders offer a flexible option, a local home environment possibly with other children, and a carer who often has many years' experience. However, the minder need have no formal child care qualifications, although many local authorities require attendance at a preregistration course. Depending on the locality, a full time place will cost £50-£120 a week.

    Nurseries are another popular option. They provide a child centred environment, which is inspected and registered by social services. There are statutory minimum ratios of staff to children for each age group, and this results in few nurseries accepting children under 2 years old. Usually, many or all staff will have child care qualifications, but this varies. The cost may be up to £200 per week at a private nursery, but is often much less at workplace nurseries. Unfortunately, even NHS nurseries sometimes have opening times convenient only for those who work from 9 am to 5 pm.

    The third option is a nanny, who will care for the child in your own home. This can be an expensive option with one child, but a live-in nanny in particular can offer the flexibility that most doctors need. Nannies are not registered or checked by social services, and you will have to check references carefully and decide for yourself whether an interviewee is competent and reliable. You may wish to stipulate that the nanny has a child care qualification, such as NNEB.

    The list at the end gives sources of further information on these and other options. Factors to consider in making your choice include the hours you are working, stability of care, location, your and your partner's timetable, whether you wish your child to have a sole carer or to be with other children, your child's special needs, and financial considerations. Whichever you choose, make sure your child starts before you go back to work, so that you are both settled into the new routine.

    Returning to work

    Many women doctors express anxiety about their continuing ability to do their job, often out of proportion to the length of a career break. This perhaps reflects the ambivalence with which “time out” for family is often regarded in the profession - and which women doctors may themselves share. These feelings can sap self esteem if they are not recognised and addressed at an early stage.

    What can be done to build up your confidence and knowledge before returning? You may enjoy attending conferences, lectures, and grand rounds before you return in order to refamiliarise yourself with medical culture. Such a re-initiation will also remind you how much you know - important when, as you change the sixth nappy of the day and mop up sick, medicine seems distant. Subscribe to a journal you would like to be familiar with and keep up to date with the BMJ and Lancet. Renew contacts at work and arrange a reorientation period on your return. Try to get hold of all the protocols and policy documents that have come out in your absence, so you will have a clear grasp of what has and has not changed. Find out who the new members of staff are and try to meet them when you call in. All this should make the early days less intimidating.

    Breast feeding

    No article on returning to work would be complete without mention of breast feeding. For most of us, feeding is a major source of guilt and feelings of inadequacy, as witnessed by a number of recent articles in the BMJ. Feeding your own child involves elemental feelings - well recognised by older children, who are adept at using food refusal to upset mother. Depending on when you return to work, these feelings can easily dominate your life. Doctors are aware of the health benefits of continued breast feeding, but many medical posts have time- tables which make the use of expressed milk very difficult. Expressing milk is itself not always easy, and some babies do not accept a bottle.

    If you decide to return to work while breast feeding, enlist all the support you can get.

    Juggle your commitments as far as possible to make protected gaps in the day for expressing milk and make sure that your colleagues are aware of the need for this. It is important to be aware that you have a right to alternative employment during breast feeding, just as during pregnancy, if your job is incompatible with feeding.(1) Talk to your occupational health service about your needs if you anticipate problems.

    Many sources of help and advice are available if you decide to take this course. Health Visitors, the National Childbirth Trust's breastfeeding counsellors, and the La Leche League offer a wealth of information on the practicalities as well as encouragement. In some areas there are breast feeding support groups run by the local health authority, and these can be a useful resource. However, if you find that formula feeding is the best option for you and your child, then have confidence in this decision and enjoy its benefits without guilt.

    Career plans

    For many doctors, maternity leave is a time when career options and objectives are reappraised. This may result in a renewed commitment to earlier plans. If so, make this clear to senior colleagues, particularly those who have made apparently well meaning comments about how your priorities will change after pregnancy. For trainees with a settled career plan, flexible training may provide a balance between work and new commitments (and remember that it is available for fathers too). But for some this is not an option; perhaps your partner doesn't earn enough, or you prefer full time work. When considering the options, try to draw on the experience of others. Your specialty adviser for flexible training or the postgraduate dean responsible for flexible training in your region may be able to put you in touch with other working mothers.

    If things are not so clear, you may be in the uncomfortable position of returning to a job that you feel is taking you in the wrong direction and away from your child. Even if you know what career you want, flexible training at the level of senior house officer can be hard to arrange. In this case, you will need to consult widely about your options. It may be inadvisable to express misgivings about a current career path to your seniors, although many can be helpful and supportive. You will be the best judge of this. Impartial advice is always available further afield, through specialty advisers and other doctors with children. Hard though it may be, try to attend all the informal gatherings that you can where there is an opportunity to network and gather ideas from people with diverse career histories.

    Personal feelings

    Finally, there is the question of what you feel about your new status as a working mother. Inevitably, we all feel a need to justify the decision to be working mothers. Having a baby brings us up against a wide array of strongly held opinions and unsolicited advice on upbringing, lifestyle, working mothers, breast feeding, baby massage, aromatherapy, the evils of the medical profession, and whether to use cotton or disposables. We wonder who we are in this different, less familiar world.

    As I write, I am sitting in my study close to midnight, my unsettled baby dozing in a sling, her perfect tiny hand moving against me from time to time. What is at stake in my decision to leave her and return to work part time in a few days? Will she be permanently scarred by my neglect? For me, as for my mother, work is one of the perspectives of my life. My mother's job, as a teacher, formed much of my world as a child; through it I made friends, developed interests, went to new places, and read certain books and not others. I hope my work will have the same place in my daughter's life.


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