Australian women, it seems, have had enough. Last week, politicians, a cricketer, and a specialist medical college apologized for sexist comments. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) recently got into trouble for planning a debate called Membership Before Maternity Leave: Should Every Registrar Have a Mirena to be discussed at a scientific meeting in February. The college argued that the title was intentionally provocative and it believed no one would take it seriously. Most of those responsible for publicised sexist comments respond with a similar theme—it was a joke; light-hearted; or tongue-in-cheek.

But there is nothing light-hearted about inequality, the result of sexism.

To their credit the RANZCOG have published Clinical Training Whilst Pregnant to assist women, but in the statement there is no mention of the role of hospitals should take as employers. The main message is that a female doctor should discuss pregnancy plans with her supervisor. A well-recognised feature in healthcare is that guidelines are not always followed, and if they are, they tend to be modified to suit the local environment. Many female trainees choose to take unpaid leave of absence for a year rather than succumb to the rocky pathway of negotiating maternity leave with hospitals and upsetting their colleagues who are left with an additional workload.

The RANZCOG was more than on the ball about the female experience of specialty training when they made a submission to the Royal Australasian College of Surgeons inquiry into sexism in surgical training last year. In their submission, the college said that employing hospitals had a pivotal role in combatting sexism. They also have a role in ensuring trainees that who are employed by hospitals are entitled to the same rights as others in the community—i.e. the right not to be discriminated against because of pregnancy. Has anyone asked the question why so few trainees ever apply for maternity leave? In medical school many women identify a career in surgery as their first preference, but when it comes to the time to choose, the numbers significantly drop. Have the colleges asked why?

Evidence based medicine finds the safest time for having a healthy baby is before a woman reaches 35. If women are to complete their specialty training before starting a family then they are placing themselves and their baby at risk of genetic defects because medical school and training to become a specialist combined takes up to 16 years full time. The optimal reproductive time for women therefore falls within their training years. Yet the culture within medical specialty training encourages, in fact requires, uninterrupted training. The impact of this mindset on female trainees is overlooked, ignored and unspoken. That females only comprise 10 percent of Australian surgeons in part reflects the choice by women to forego surgical training because of the perceived (and real) conflict with having a family.

This inequality surfaces when women wanting children have to weigh up conflicting demands during training; their male peers have no such demands. Organising rosters and overtime during specialty training already requires negotiation, cooperation, and flexibility—having a colleague absent for extended periods of time adds to this burden and increases the anxiety of the pregnant trainee. This leads to understandable reticence in disclosing pregnancy to supervisors and employers. Most female trainees have their children during their training, but at a cost. Rather than exercise their rights to maternity leave, many women choose to take 12 months unpaid leave. This may suit the employing hospital and college who can replace the trainee, but it puts the trainee at a financial disadvantage with no income for the year. In other professions these women are provided maternity leave and have the comfort of financial security.

The structure of training is one of the impediments to routine maternity leave for trainees. Registrars are rotated through the terms to different hospitals and each hospital is responsible for their pay, holidays, and leave entitlements. Maternity leave is available on paper, but getting it is problematic and often impossible because a trainee works for many hospitals; getting anyone of them to accept responsibility is a serious challenge for busy registrars.

There are two main barriers to improving pregnancy choices for females undertaking specialty training. The first relates to the costs of maternity leave. Taxpayers, through the Ministry of Health, pay the salaries of trainees. If the Department of Health centralized maternity leave associated costs for trainees one barrier would be removed. Women would not have to fight for their right to maternity leave by negotiating with each of the many hospitals she has worked with to get someone to accept her entitlement. Another barrier is that the legitimacy of maternity leave during training is not properly accepted. While there is no rule preventing women from starting a family there is also no encouragement. The status quo remains leaving female trainees with difficult decisions about if and when to start a family; decisions males do not have to make.

Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

Merrilyn Walton is professor of medical education (patient safety) at the University of Sydney and has been working to improve standards in the medical profession for over 30 years.