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Background Women and minorities remain underrepresented in orthopaedic surgery. In an attempt to increase the diversity of those entering the physician workforce, Nth Dimensions implemented a targeted pipeline curriculum that includes the Orthopaedic Summer Internship Program. The program exposes medical students to the specialty of orthopaedic surgery and equips students to be competitive applicants to orthopaedic surgery residency programs. The effect of this program on women and underrepresented minority applicants to orthopaedic residencies is highlighted in this article. Questions/purposes (1) For women we asked: is completing the Orthopaedic Summer Internship Program associated with higher odds of applying to orthopaedic surgery residency? (2) For underrepresented minorities, is completing the Orthopaedic Summer Internship Program associated with higher odds of applying to orthopaedic residency? Methods Between 2005 and 2012, 118 students completed the Nth Dimensions/American Academy of Orthopaedic Surgeons Orthopaedic Summer Internship Program. The summer internship consisted of an 8-week clinical and research program between the first and second years of medical school and included a series of musculoskeletal lectures, hands-on, practical workshops, presentation of a completed research project, ongoing mentoring, professional development, and counselling through each participant’s subsequent years of medical school. In correlation with available national application data, residency application data were obtained for those Orthopaedic Summer Internship Program participants who applied to the match between 2011 through 2014. For these 4 cohort years, we evaluated whether this program was associated with increased odds of applying to orthopaedic surgery residency compared with national controls. For the same four cohorts, we evaluated whether underrepresented minority students who completed the program had increased odds of applying to an orthopaedic surgery residency compared with national controls. Results Fifty Orthopaedic Summer Internship scholars applied for an orthopaedic residency position. For women, completion of the Orthopaedic Summer Internship was associated with increased odds of applying to orthopaedic surgery residency (after summer internship: nine of 17 [35%]; national controls: 800 of 78,316 [1%]; odds ratio [OR], 51.3; 95% confidence interval [CI], 21.1–122.0; p < 0.001). Similarly, for underrepresented minorities, Orthopaedic Summer Internship completion was also associated with increased odds of orthopaedic applications from 2011 to 2014 (after Orthopaedic Summer Internship: 15 of 48 [31%]; non-Orthopaedic Summer Internship applicants nationally: 782 of 25,676 [3%]; OR, 14.5 [7.3–27.5]; p < 0.001). Conclusions Completion of the Nth Dimensions Orthopaedic Summer Internship Program has a positive impact on increasing the odds of each student participant applying to an orthopaedic surgery residency program. This program may be a key factor in contributing to the pipeline of women and underrepresented minorities into orthopaedic surgery. Level of Evidence Level III, therapeutic study.

Background Orthopaedic surgery lags behind other surgical specialties in terms of gender diversity. The percentage of women entering orthopaedic residency persistently remains at 14% despite near equal ratios of women to men in medical school classes. This trend has been attributed to negative perceptions among women medical students of workplace culture and lifestyle in orthopaedics as well as lack of exposure, particularly during medical school when most women decide to enter the field. Since 2012, The Perry Initiative, a nonprofit organization that is focused on recruiting and retaining women in orthopaedics, had conducted extracurricular outreach programs for first- and second-year female medical students to provide exposure and mentoring opportunities specific to orthopaedics. This program, called the Medical Student Outreach Program (MSOP), is ongoing at medical centers nationwide and has reached over 300 medical students in its first 3 program years (2012–2014). Questions/purposes (1) What percentage of MSOP participants eventually match into orthopaedic surgery residency? (2) Does MSOP impact participants’ perceptions of the orthopaedics profession as well as intellectual interest in the field? Methods The percentage of program alumnae who matched into orthopaedics was determined by annual followup for our first two cohorts who graduated from medical school. All program participants completed a survey immediately before and after the program that assessed the impact of MSOP on the student’s intention to pursue orthopaedics as well as perceptions of the field and intellectual interest in the discipline. Results The orthopaedic surgery match rate for program participants was 31% in our first graduating class (five of 16 participants in 2015) and 28% in our second class (20 of 72 participants in 2016). Pre/post program comparisons showed that the MSOP influenced students’ perceptions of the orthopaedics profession as well as overall intellectual interest in the field. Conclusions The results of our study suggest that The Perry Initiative’s MSOP positively influences women to choose orthopaedic surgery as a profession. The match rate for program alumnae is twice the percentage of females in current orthopaedic residency classes. Given these positive results, MSOP can serve as a model, both in its curricular content and logistic framework, for other diversity initiatives in the field.

Background Although women account for approximately half of the medical students in the United States, they represent only 13% of orthopaedic surgery residents and 4% of members of the American Academy of Orthopaedic Surgeons (AAOS). Furthermore, a smaller relative percentage of women pursue careers in orthopaedic surgery than in any other subspecialty. Formal investigations regarding the gender discrepancy in choice of orthopaedic surgery are lacking. Questions/purposes (1) What reasons do women orthopaedic surgeons cite for why they chose this specialty? (2) What perceptions do women orthopaedic surgeons think might deter other women from pursuing this field? (3) What role does early exposure to orthopaedics and mentorship play in this choice? (4) What professional and personal choices do women in orthopaedics make, and how might this inform students who are choosing a career path? Methods A 21-question survey was emailed to all active, candidate, and resident members of the Ruth Jackson Orthopaedic Society (RJOS, n = 556). RJOS is the oldest surgical women’s organization incorporated in the United States. An independent orthopaedic specialty society, RJOS supports leadership training, mentorship, grant opportunities, and advocacy for its members and promotes sex-related musculoskeletal research. Although not all women in orthopaedic practice or training belong to RJOS, it is estimated that 42% of women AAOS fellows are RJOS members. Questions were formulated to determine demographics, practice patterns, and lifestyle choices of women who chose orthopaedic surgery as a specialty. Specifically, we evaluated the respondents’ decisions about their careers and their opinions of why more women do not choose this field. For the purpose of this analysis, the influences and dissuaders were divided into three major categories: personal attributes, experience/exposure, and work/life considerations. Results The most common reasons cited for having chosen orthopaedic surgery were enjoyment of manual tasks (165 of 232 [71%]), professional satisfaction (125 of 232 [54%]), and intellectual stimulation (123 of 232 [53%]). The most common reasons indicated for why women might not choose orthopaedics included perceived inability to have a good work/life balance (182 of 232 [78%]), perception that too much physical strength is required (171 of 232 [74%]), and lack of strong mentorship in medical school or earlier (161 of 232 [69%]). Respondents frequently (29 of 45 [64%]) commented that their role models, mentors, and early exposure to musculoskeletal medicine were influential, but far fewer (62 of 231 [27%]) acknowledged these in their top five influences than they did the more “internal” motivators. Conclusions To our knowledge, this is the largest study of women orthopaedic surgeons regarding factors influencing their professional and personal choices. Our data suggest that the relatively few women currently practicing orthopaedics were attracted to the field because of their individual personal affinity for its nature despite the lack of role models and exposure. The latter factors may impact the continued paucity of women pursuing this field. Programs designed to improve mentorship and increase early exposure to orthopaedics and orthopaedic surgeons may increase personal interest in the field and will be important to attract a diverse group of trainees to our specialty in the future.

Background Orthopaedic fellowship training is a common step before becoming a practicing orthopaedic surgeon. In the past, fellowship decisions in orthopaedics were made early in the residency and without a formal match. The process was disorganized, often not fair to the applicants or fellowship programs. More recently, there has been an organized match process for nine different disciplines in orthopaedics. Although the numbers of women applicants into orthopaedic residency has been reported and is the target of efforts to continue to improve gender diversity in orthopaedics, the numbers regarding women in orthopaedic fellowships have not been known. Other details including if there is a difference in match rate between male and female fellowship applicants and what discipline they choose to pursue across orthopaedic surgery has not been reported. Questions/purposes (1) How have the numbers of women applying to orthopaedic fellowships changed over a 5-year period? (2) Is gender associated with fellowship match success? (3) Which subspecialties have greater proportions of female applicants? Methods Available orthopaedic residency match data regarding number of applicants and number of female residents between 2010 and 2014 were obtained. For fellowship data, our method was a review of the applicants who submitted rank lists and the number of applicants who matched in all subspecialties through San Francisco Match and from the American Shoulder and Elbow Society from 2010 to 2014. For each year, the number of females versus males applying was abstracted. The total number of females versus males who matched was then obtained. For each subspecialty represented in this article, the number of female applicants and matches was compared with the male applicants and matches. Results The proportion of fellowship applicants who are female ranged from 7% to 10% annually, and the percentage of matched female applicants ranged from 8% to 12%. Overall, combining results from 2010 to 2014, female fellowship applicants had a higher proportion of match success when compared with men (women: 320 of 335 [96%]; men: 2696 of 3325 [81%]; p < 0.001). Pediatric orthopaedic fellowships had the highest proportion of women (79 of 318 [25%] followed by foot and ankle (42 of 311 [14%]; spine had the lowest (15 of 525 [3%]). Conclusions Women applicants for advanced orthopaedic training matched at a higher proportion than men in fellowship training. Pediatrics has a higher proportion of women applicants and fellows. Orthopaedics should be a model for other surgical specialties by encouraging women to successfully pursue advanced training.

In the United States, the Great Recession was marked by severe negative shocks to labor market conditions. In this study, we combine longitudinal data from the Fragile Families and Child Wellbeing Study with U.S. Bureau of Labor Statistics data on local area unemployment rates to examine the relationship between adverse labor market conditions and mothers' experiences of abusive behavior between 2001 and 2010. Unemployment and economic hardship at the household level were positively related to abusive behavior. Further, rapid increases in the unemployment rate increased men's controlling behavior toward romantic partners even after we adjust for unemployment and economic distress at the household level. We interpret these findings as demonstrating that the uncertainty and anticipatory anxiety that go along with sudden macroeconomic downturns have negative effects on relationship quality, above and beyond the effects of job loss and material hardship.

Background Despite global and national recommendations, exclusive breastfeeding (EBF) remains suboptimal among formally employed mothers in Indonesia. Although legal protections exist, real-world barriers persist that complicate the breastfeeding journey for working women. This study explored factors barriers or facilitators to exclusive breastfeeding among formally employed mothers in urban Indonesia. Methods A qualitative exploratory design was employed using a constructivist paradigm to explore the experiences of formally employed mothers in sustaining exclusive breastfeeding while working. A total of 12 participants were interviewed through theoretical sampling. They were aged 25–36 years and had infants aged 6–12 months. Data collection was conducted via in-depth semi-structured interviews held online. The interviews were analyzed using inductive thematic analysis with the aid of ScreenQ (qualitative analysis software), which generated 131 initial codes, 23 categories, 7 subthemes, and two overarching themes: internal and external factors influencing breastfeeding continuation. Results Internal facilitators included maternal knowledge, self-efficacy, and adaptive breastfeeding practices, while internal barriers involved fatigue, self-doubt, and difficulty translating knowledge into practice. External facilitators encompassed partner and coworker support, flexible workplace policies, and lactation-friendly facilities. Conversely, barriers included inflexible schedules, short maternity leave, stigma, and inconsistent caregiving. Conclusions Exclusive breastfeeding (EBF) among working mothers is shaped by complex interactions between individual strengths and structural conditions. Supportive policies and environments are essential to help bridge the gap between mothers’ intentions and practical realities. Implementation of enforceable workplace protections and extension of maternity leave are essential to sustain EBF in Indonesia. It is equally important to establish employer accountability mechanisms—such as government monitoring and enforcement of workplace lactation rooms and breastfeeding breaks—that can be implemented in the short term. Key Messages • What is already known:   Exclusive breastfeeding rates are lower among working mothers due to occupational andstructural challenges. •  What this paper adds: This study identifies both internal (e.g., self-efficacy, knowledge) and external (e.g., workplacesupport, caregiver reliability) factors that act as barriers or facilitators to EBF among formallyemployed mothers in Indonesia. •  Implications for practice and policy: Workplace accommodations, extended maternity leave, consistent caregiver training, andculturally sensitive breastfeeding education are essential to sustain EBF in working mothers. Stakeholders must prioritize breastfeeding as a collective societal responsibility, not just amaternal task.

This analysis uses March Current Population Survey data from 1999 to 2010 and a differences-in-differences approach to examine how Californias first in the nation paid family leave (PFL) program affected leave-taking by mothers following childbirth, as well as subsequent labor market outcomes. We obtain robust evidence that the California program doubled the overall use of maternity leave, increasing it from an average of three to six weeks for new mothers—with some evidence of particularly large growth for less advantaged groups. We also provide evidence that PFL increased the usual weekly work hours of employed mothers of 1-to 3-year-old children by 10 to 17 percent and that their wage incomes may have risen by a similar amount.

Background Relatively little is known about changes in women’s working conditions despite increases in labour force participation in recent decades. This study examines trends in adverse working conditions among Australian women in paid employment and identifies the factors associated with adverse working conditions. Methods Longitudinal population-based data from the Australian Longitudinal Study on Women’s Health, following a cohort of women aged 18–23 years at baseline (1996) through to ages 40–45 years (2018). Mixed-effect regression examined the factors associated with long working hours and shift work. Results The proportion of women working long hours increased from 23.7% in 1996 to 36.1% in 2018. By 2018, women had 1.77 times higher odds of working long hours compared to 1996 (95% CI: 1.58–1.97). Factors associated with long working hours included a degree/higher degree [AOR 1.91, 95%CI, 1.76–2.07]and being non-partnered [AOR 1.45, 95%CI, 1.37–1.53]. The proportion of women engaged in shift work declined from 24.9% in 1996 to 10.1% in 2018. By 2018, the adjusted odds of working shifts were significantly lower than in 1996 [AOR: 0.20 (95% CI: 0.16–0.24)]. Factors associated with a higher likelihood of shift work included blue-collar occupation [AOR 1.41, 95%CI, 1.06–1.33], and holding a degree/higher degree [AOR 1.27, 95%CI, 1.10–1.45]. Conclusion Between 1996 and 2018, working conditions for a cohort of Australian women of reproductive age changed significantly. There was a notable decline in shift and night work, alongside a significant increase in long working hours. The results likely reflect a combination of modified working conditions, women’s career transitions and changes in personal/caring responsibilities. The potential health implications of long working hours require careful monitoring.

Objectives The United States is one of only three countries worldwide with no national policy guaranteeing paid leave to employed women who give birth. While maternity leave has been linked to improved maternal and child outcomes in international contexts, up-to-date research evidence in the U.S. context is needed to inform current policy debates on paid family leave. Methods Using data from Listening to Mothers III, a national survey of women ages 18–45 who gave birth in 2011–2012, we conducted multivariate logistic regression to predict the likelihood of outcomes related to infant health, maternal physical and mental health, and maternal health behaviors by the use and duration of paid maternity leave. Results Use of paid and unpaid leave varied significantly by race/ethnicity and household income. Women who took paid maternity leave experienced a 47% decrease in the odds of re-hospitalizing their infants (95% CI 0.3, 1.0) and a 51% decrease in the odds of being re-hospitalized themselves (95% CI 0.3, 0.9) at 21 months postpartum, compared to women taking unpaid or no leave. They also had 1.8 times the odds of doing well with exercise (95% CI 1.1, 3.0) and stress management (95% CI 1.1, 2.8), compared to women taking only unpaid leave. Conclusions for Practice Paid maternity leave significantly predicts lower odds of maternal and infant re-hospitalization and higher odds of doing well with exercise and stress management. Policies aimed at expanding access to paid maternity and family leave may contribute toward reducing socio-demographic disparities in paid leave use and its associated health benefits.

Background Although the number of women in surgical specialties has increased dramatically over the past two decades, little research exists regarding how a surgeon’s gender impacts job selection and practice models. Because the number of women specializing in pediatric orthopaedics continues to increase, it is important to understand how one’s gender affects practice choices and how this may affect the future workforce. Questions/purposes (1) Among pediatric orthopaedic surgeons, is gender associated with choice of practice type (academic, private practice, hospital-based, solo)? (2) For men and women, what are the most common reasons for choosing a job? (3) For new graduates, do men and women have equal starting salaries? (4) Do men have a higher chance of getting job offers? (5) Is there a difference in workload (call frequency and surgical case volume) for men and women? (6) Finally, is there a difference in imminent retirement plans for men and women? Methods The 2015 Pediatric Orthopaedic Society of North American (POSNA) Needs Assessment Survey was sent to POSNA members and a special 36-question survey was sent to recent pediatric orthopaedic fellowship graduates. Both surveys included questions about self-reported gender, practice type, reasons for job selection, and call frequency. In addition, the new graduates’ survey also included questions about starting salary, job offers, and number of additional fellowships completed. Responses were analyzed by gender. Chi-square and Fisher’s exact tests assessed for statistical significance. Results Among the new graduates, women are more likely to choose academic practice (women: 13 of 18 [72%], men: 21 of 44 [48%], odds ratio [OR], 3.10 [confidence interval {CI}, 0.86–11.10], p < 0.001), whereas men are more likely to choose private practice (men: 14 of 44 [32‰], women: one of 18 [6%], OR, 0.12 [CI, 0.015–1.001], p < 0.001). The primary reasons for choosing a job were not different between men and women. Among the new graduates, geography/family considerations were reported as being highly important when selecting a job (men: 33 of 44 [75%], women: 16 of 18 [89%]) followed by academic opportunities (men: 24 of 44 [55%], women: 14 of 18 [78%]). Interestingly, a higher percentage of males reported finances as being important when selecting a job (men: 23 of 44 [52%], women: five of 18 [28%]). For the current POSNA members, the most important reasons when choosing a job for both men and women were quality of partners (men: 168 of 408 [41%], women: 66 of 122 [54%]) and an interesting practice (men: 155 of 408 [38%], women 54 of 122 [44%]. As a result of our small sample size, there was no difference in starting salaries between men and women (< USD 350,000: men 22 of 44 [50%], women 12 of 18 [67%]; USD 350,000-450,000: men 11 of 44 [25%], women six of 18 [33%]; > USD 450,000: men eight of 44 [18%], women zero of 18 [0%], p = 0.131). When stratified by practice type, for private practice starting salaries, over half of men (seven of 13 [54%]) placed in the highest category of > USD 400,000, whereas the single woman respondent placed in the lowest category of < USD 300,000. Men were more likely to report having job offers before starting their fellowship (men: 24 of 44 [54%], women: eight of 18 [44%], OR, 0.67 [CI, 0.22–2.0], p = 0.042). Finally, among POSNA members, women reported a lower weekly surgical case volume compared with men. Of the men, 108 of 408 (26%) reported performing more than seven surgeries per week compared with 12 of 122 women (10%; OR, 3.4 [CI, 1.8–6.44], p < 0.001). Conclusions Although the numbers are small given the specialized nature of pediatric orthopaedic surgery, this study has uncovered some initial gender differences regarding practice characteristics and job opportunities among pediatric orthopaedic surgeons. As more men plan to reduce their workload or retire in the next 5 years, there may be further increases in the percentage of women surgeons in the workforce, so it is important that we begin to understand what effect, if any, gender has on practice patterns, job selection, and opportunities. Also, the finding that among the new graduates more women than men are choosing careers in academic practice over private practice suggests an extraordinary opportunity to develop more female leaders and role models at major pediatric orthopaedic centers.