The US Supreme Court’s overturning of Roe v. Wade could fragment the nation’s medical education system and slash the number of new obstetricians and gynecologists who are trained to perform abortions.
Abortion is likely to become illegal in about half the US following the high court’s June 24 ruling that struck down a constitutional right to the procedure. The impact will be felt nationwide as universities and doctors grapple with how to reconcile new state laws with medical school accreditation requirements.
“We need to train about 650 residents each year in abortion care at the programs in the states that are likely to ban abortion,” said Jody Steinauer, a professor of obstetrics and gynecology at the University of California-San Francisco, and director of the Bixby Center for Global Reproductive Health.
“How on earth are we going to do that? How will we be able to ensure they have the skills to be competent Ob-Gyns?” Steinauer said.
Around 45% of the nation’s 292 OB-GYN residency programs are located in states that are either certain or likely to ban abortion post-Roe, according to research scheduled for publication in the August issue of Obstetrics and Gynecology.
To maintain accreditation, the programs have been required since the early 1980s to provide routine access to abortion training, with an opt-out provision for students with religious or moral objections, according to the Accreditation Council for Graduate Medical Education. ACGME accreditation provides assurance that a program meets the quality standards of the specialty for which it prepares its graduates, according to the council.
The ACGME proposed revisions to its requirements after the ruling to address the challenges programs may face in states where abortion is likely to become illegal. It’s accepting comments on the proposal through Aug. 8.
Such programs would have to provide access to clinical training “in a jurisdiction where no such legal restriction is present” under the proposal. They would also have to provide residents unable to travel with “a combination of didactic activities, including simulation, and assessment on performing a uterine evacuation (surgical and medical) and communicating pregnancy options.”
The proposal would help ensure OB-GYN residency programs give residents “the knowledge, skills, and abilities necessary to practice comprehensive reproductive health care in the United States,” the ACGME said.
“The proposed revisions will achieve this goal without resulting in any resident, physician educator, or residency program violating the law, including any legal restrictions regarding induced abortions in the jurisdiction in which a residency program is located,” it said.
Twenty-two states are certain to ban abortion with Roe v. Wade overturned, and another four are likely to ban the procedure, according to the Guttmacher Institute, a pro-choice research organization.
Nine states have an abortion ban still on the books from before Roe v. Wade, 13 have trigger bans that are now set to take effect, and five states enacted near-total bans after Roe that can now take effect.
Eleven states have six-week bans that now can become effective, not including Texas, which already has a six-week ban in effect. One state has an eight-week ban not yet in effect, and four have constitutional provisions barring abortion, according to the Guttmacher Institute. Some states have several bans at once.
Many residency programs will respond by doing “everything possible within the limits of the legal landscape,” to provide abortion related training, including classroom instruction and simulation exercises, said Carrie Cwiak, a professor in the department of gynecology and obstetrics at the Emory University School of Medicine.
That will include encouraging students to engage in advocacy related to the impact of abortion restrictions on the health of their patients, she said.
“It is very clear that when you restrict access to health care, like abortion, you adversely impact patient health,” Cwiak said. “So it’s important that we as physicians do what we can to promote the health of our patients and the way to do that is to support policies that promote their health.”
Professors and doctors say that abortion training is an important part of preparing physicians for patients’ other obstetric needs, including complex miscarriage management and direct patient counseling.
“There’s a common idea out there that abortion care and general obstetrics and gynecology are mutually exclusive of one another, and that is simply wrong,” said Eric Strand, a professor of obstetrics and gynecology at Washington University School of Medicine in St. Louis.
“The skills you learn when caring for patients proceeding with abortion are extremely important in other clinical situations,” he said. “This ruling will have the inevitable result that we’ll have fewer providers who are skilled enough to care for all of their patients, those seeking abortion and others too.”
Of 6007 current obstetrics and gynecology residents, 2,638, or 44%, are certain or likely to lack access to in-state abortion training, Steinauer said before the high court delivered its ruling.
A recent survey of OB-GYN residents showed that 60% were in programs that met the ACGME’s abortion training requirement, and another 29% were in programs that provided access to the training on an opt-in basis. Around 8% were in programs that provided no access to abortion training.
There are currently around 51,000 obstetricians in the US, according to the Health Resources and Services Administration.
Impact on Care
The loss of experience provided in abortion rotations will have a broad impact on obstetrical care, Cwiak said.
“The procedures and techniques I teach related to abortion care are the same procedures and techniques used for patients who have early pregnancy loss or are dealing with obstetric complications,” she said.
“If our trainees are limited in the the type of learning experience that they can have, it impacts their ability to provide safe and quality care for early pregnancy loss and obstetric complications as well as abortion care,” Cwiak said.
Donna Harrison, an OB-GYN and CEO of the American Association of Pro-Life Obstetricians and Gynecologists, disputed that training for residents will suffer from an abortion ban.
“There really should be no impact at all, because OB-GYNs are trained to empty a uterus at any gestational age as part of their normal training,” Harrison said. “The difference is that, with an elective abortion, those techniques are used to empty the uterus when the child is alive. But residents receive the training they need for the unfortunate case where the baby has already died.”
Some professors say that medical programs could develop travel-rotation programs in which residents in states with abortion bans can travel to programs in other states for training.
But setting up such programs isn’t easy, said Kathryn Dielentheis, an OB-GYN and associate director of an OB-GYN residency program in Wisconsin.
“Some residency programs could partner with programs in states that won’t have these restrictions, but there’s finite resources for something like that,” she said. “And there is no way that the remaining 56% of residency programs in the country will be able to absorb the amount of training that all of the residents in the country are going to need.”
“I wish I could tell you that the programs have some brilliant plan of what they’re going to do, but it’s really hard when the well starts to run dry,” Dielentheis said.