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Abortion Training and Education in a Post-Dobbs Landscape

Position Statement

February 6, 2025

Background

Abortion is an essential component of comprehensive, evidence-based medical care. Abortion is common, and approximately one in four people who can become pregnant will access abortion care in the United States1. It has been well-established that restrictions to abortion access are associated with higher rates of maternal morbidity and mortality, which disproportionately affect communities that already face health care and socioeconomic inequities2,3. Knowledge of abortion care, how to provide such care, and the related complexities of the legal landscape in which it is provided is essential for any health care professional caring for people who could become pregnant. Since the 2022 Dobbs v. Jackson Women’s Health Organization decision, which overturned the constitutional right to abortion, the landscape of abortion access and training has drastically changed in the United States. Several states essentially have banned abortion care, while other states have restricted abortion care to the first trimester. (Visit the Guttmacher Institute for up-to-date state laws concerning abortion care and reproductive health.) Access to abortion care has been considerably further restricted for many individuals, and, without a constitutional right to abortion care, more patients face barriers related to geographic location and ability to travel, ability to obtain medications, and the availability of a trained clinician. This further exacerbates existing socioeconomic disparities in care.

A patchwork of state abortion bans, many written in nonmedical language, include vague and ambiguous exceptions, resulting in confusion for clinicians and patients4. The resulting confusion leads to delayed and sometimes denied care, and the effects of these bans are seen across the spectrum of reproductive care. In addition to creating situations in which patients may fear legal prosecution for seeking care for early pregnancy loss and obstetric complications, legal restrictions hinder clinicians’ ability to make timely decisions in patient care. When clinicians have to consult lawyers and institutional boards, delaying needed care, the management of early pregnancy loss, ectopic pregnancy, and induced abortions required to save the life of the pregnant person all become more dangerous for the patient3. The harms caused by abortion bans cannot be separated from the harms caused across the spectrum of reproductive care.

The Effects of Abortion Care Restrictions on Health Care Education, Training, and the Future Workforce

The downstream effects of these bans on abortion care not only affect physicians who provide abortion care but also trainees (eg, resident physicians and medical students), advanced practice clinicians, and other health care professionals who care for individuals who can become pregnant. Training in abortion care, which faced limitations even prior to Dobbs, is now dependent on location and efforts by the trainee and training program to seek this education. Restrictions on training have substantial and far-reaching effects on the health care workforce, especially obstetrician–gynecologists. For example, a national survey of obstetrician–gynecologists reported that the majority of respondents believe post-Dobbs restrictions have negatively affected the ability to attract new health care professionals to the field5. Additionally, family planning fellowship program directors have reported concerns about insufficient resident training due to restrictions, as well as very real challenges recruiting new faculty in states with restrictive laws6.

The number of trained clinicians providing abortion care is dependent on exposure to abortion training and the desire to provide this essential care. Medical school is a vital time for exposure to all aspects of pregnancy management. Studies show that exposure to abortion care during undergraduate medical education is associated with an increased desire to provide clinical abortion services in the future7. However, it is estimated that approximately 48% of medical students will receive their education in a state with restricted abortion access after the Dobbs decision, which may impose barriers to education on the full spectrum of reproductive care8. The Association of Professors of Gynecology and Obstetrics’ educational objectives for abortion care state that students should be knowledgeable about its public health importance, as well as abortion methods and patient safety implications9. Although the American College of Obstetricians and Gynecologists has long called for the inclusion of abortion education in all medical school curricula, abortion education is not required for medical school accreditation from the Liaison Committee on Medical Education. Data from prior to the Dobbs decision demonstrated that 15% of medical schools lacked clinical training on abortion10, and among programs that did offer clinical experiences, 45% of medical students reported dissatisfaction with the available opportunities11.

Training in abortion provision is an essential skill in ob-gyn residency, yet it is estimated that about one in six residency programs have lost access to local abortion training after the Dobbs decision12. Since 1996, the Accreditation Council for Graduate Medical Education (ACGME) has required integrated opt-out abortion training as a routine experience for ob-gyn residency programs13. The Kenneth J. Ryan Residency Training Program in Abortion and Family Planning was established in 1999 to support residency programs in meeting these ACGME requirements and has helped train over 7,000 residents to provide abortion care14. Abortion training not only equips obstetrician–gynecologists with fundamental and life-saving procedural skills, but also improves proficiency in core skills needed by clinicians who may not ultimately provide abortion care in their practices, including pregnancy options counseling, ultrasonography evaluation, and uterine evacuation15. Routine abortion training is associated with improved competence in all management options of early pregnancy loss and preparedness in managing early pregnancy loss complications16,17.

In 2022, the ACGME revised its guidance to address abortion training in states with restrictions, stating that residents “must receive support to obtain clinical experience in induced abortion in another jurisdiction”13. For those institutions that are unable to offer abortion training for their trainees, identifying and supporting alternate options in a different state is resource intensive. In addition to the cost of resident physician salaries and benefits, programs also must consider the cost of rooming and transportation, medical malpractice coverage, and medical license fees18. Additionally, residents must be able to leave families (including spouses, children, pets, etc.) for weeks at a time while their home institutions must still function during the residents’ absences. Trainees may be learning these skills during a short-term rotation later in residency, rather than integrating them throughout a 4-year residency program19. Delays in abortion training have serious consequences, as learning these foundational skills later in residency results in delayed proficiency. In addition to the logistical burden, trainees and their supervising faculty are subject to moral injury, as trainees are not able to provide evidence-based patient care, and faculty are not able to teach that care20.

Existing disparities in abortion training and provision will continue to worsen as state-specific restrictions and limitations on abortion training opportunities lead to shifts in where individuals choose to attend medical school, residency, and fellowship, and where they will eventually practice medicine. In a 2022 survey of third- and fourth-year U.S. medical students applying to residency programs, 77% of respondents across all specialties reported considering changes in state abortion access when choosing the location of residency applications21. According to data from the Association of American Medical Colleges, residency applications of U.S. MD program seniors across all specialties in the 2023–2024 application cycle decreased in states with abortion bans, with a decrease of 6.7% seen among applicants in obstetrics and gynecology22. The downstream implications of these changes on abortion training and the ob-gyn workforce are not yet known and warrant further monitoring23. Data also show that the Dobbs decision affects where graduating ob-gyn residents decide to practice; in a 2023 survey of ob-gyn residents graduating from an institution with Ryan Program abortion training, 17.6% indicated that the Dobbs decision changed their intended location of future practice or fellowship plans24. A 2022 March of Dimes report found that 35% of counties in the United States already are classified as “maternity care deserts,” meaning there is not a single birthing facility, obstetrician–gynecologist, or certified nurse–midwife25.

Restrictions on abortion care have major consequences for fields beyond obstetrics and gynecology and affect all health care professionals who work with patients who can become pregnant. Importantly, restrictive laws affect clinicians providing care for those who may need abortion care, obstetric care, options counseling, or management of early pregnancy loss and ectopic pregnancy, such as clinicians in family medicine, emergency medicine, anesthesiology, pediatrics, and advanced practice8,26.

Recommendations

The American College of Obstetricians and Gynecologists supports equitable and timely access to abortion care, which depends on the availability of sufficient numbers of trained clinicians to provide that care. To support this goal, ACOG makes the following recommendations:

  • Abortion training should be universally incorporated into the curricula of all medical schools, with an opt-out structure available for clinical portions of training.

  • Residency programs in states supportive of abortion with sufficient clinical volume to train their own learners and traveling learners should develop formal relationships with residency programs in less supportive states.

  • Medical schools and residency programs in all states should make accessible trainings available to trainees.

  • Education-focused nonprofit and philanthropic organizations should prioritize programs that support abortion training for residents in restrictive states.

  • Obstetrician–gynecologists are encouraged to advocate for access to abortion training whenever possible.

  • Short- and long-term post-Dobbs outcomes, including severe maternal morbidity and mortality, workforce shortages, and access to comprehensive reproductive care, should be monitored and assessed.

Educational and Training Resources

Implementing Progress in Abortion Care and Training (IMPACT)

The American College of Obstetricians and Gynecologists’ IMPACT Program seeks to improve access to abortion care in the United States by providing hands-on clinical and operational support training, along with web-based resources and technical assistance.

Patient-Centered Abortion Care Education (PACE) Curriculum

The American College of Obstetricians and Gynecologists has collaborated with the Council on Resident Education in Obstetrics and Gynecology (CREOG), Innovating Education in Reproductive Health, and the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning on an abortion care essentials curriculum available to all ob-gyn residents and residency programs across the United States. The comprehensive, web-based PACE curriculum focuses on the essentials of abortion care education, including medical knowledge, technical skills, and evidence-based counseling and practices.

Innovating Education in Reproductive Health: A Project of the Bixby Center for Global Reproductive Health

This program generates, curates, and disseminates free curricula and learning tools about sexual and reproductive health, including abortion, in order to transform health professions education.

Training in Early Abortion for Comprehensive Healthcare (TEACH)

TEACH offers abortion training, mentorship, and curriculum development, including an interactive curriculum with tools to train new reproductive health clinicians to competence, as well as workshops and simulations.

Society of Family Planning

A source for abortion and contraception science, the Society of Family Planning offers a library of clinician guidance.

The Ryan Residency Training Program

The Ryan Program works directly with ob-gyn residency programs to integrate training in abortion and contraception care as a required rotation. All programs establish or expand abortion services in their teaching hospitals and may also create new partnerships with local clinics to train residents.

References

  1. Jones RK, Jerman J. Population group abortion rates and lifetime incidence of abortion: United States, 2008-2014. Am J Public Health 2022;112:1284–96. doi: 10.2105/AJPH.2017.304042r
  2. Redd SK, Rice WS, Aswani MS, Blake S, Julian Z, Sen B, et al. Racial/ethnic and educational inequities in restrictive abortion policy variation and adverse birth outcomes in the United States. BMC Health Serv Res 2021;21:1139. doi: 10.1186/s12913-021-07165-x
  3. Stevenson AJ, Root L, Menken J. The maternal mortality consequences of losing abortion access. Preprint. Posted online June 29, 2022. SocArXiv. doi: 10.31235/osf.io/7g29k
  4. Chervenak FA, Moreno JD, McLeod-Sordjan R, Bornstein E, Katz A, Pollet SL, et al. Addressing challenges related to the professional practice of abortion post-Roe. Am J Obstet Gynecol 2024;230:532–9. doi: 10.1016/j.ajog.2023.10.026
  5. Frederiksen B, Ranji U, Gomez I, Salganicoff A. A national survey of obgyns’ experiences after Dobbs. Kaiser Family Foundation; 2023. Accessed January 16, 2025. https://www.kff.org/womens-health-policy/report/a-national-survey-of-obgyns-experiences-after-dobbs/ 
  6. Vachon D, Hildebrand MC, Averbach S, Turk J, Steinauer J, Mody SK. The impact of Dobbs v. Jackson on abortion training in obstetrics and gynecology residency programs: a qualitative study. Contraception 2024:110808. doi: 10.1016/j.contraception.2024.110808
  7. Farmer LE, Clare CA, Liberatos P, Kim H, Shi Q. Exploring barriers to abortion access: medical students' intentions, attitudes and exposure to abortion. Sex Reprod Healthc 2022;34:100790. doi: 10.1016/j.srhc.2022.100790
  8. Stephenson-Famy A, Sonn T, Baecher-Lind L, Bhargava R, Chen KT, Fleming A, et al. The Dobbs decision and undergraduate medical education: the unintended consequences and strategies to optimize reproductive health and a competent workforce for the future. Undergraduate Medical Education Committee of the Association of Professors of Gynecology and Obstetrics. Acad Med 2023;98:431–5. doi: 10.1097/ACM.0000000000005083
  9. Association of Professors of Gynecology and Obstetrics. APGO medical student educational objectives. 11th ed. APGO; 2019. Accessed January 7, 2025. https://cdn.ymaws.com/apgo.site-ym.com/resource/resmgr/apgo-11th-ed-mso-book.pdf 
  10. Heger JA, Young BJ, Richards LR, Carrasquillo O, Kenya S. Abortion education: what are future physicians learning in medical school? Contraception 2024;130:110293. doi: 10.1016/j.contraception.2023.110293
  11. Tocce K, Sheeder J, Vontver L. Failure to achieve the association of professors in gynecology and obstetrics objectives for abortion in third-year medical student curriculum. J Reprod Med 2011;56:474–8.
  12. Vinekar K, Karlapudi A, Bauer CC, Steinauer J, Rible R, Brown K, et al. Abortion training in U.S. obstetrics and gynecology residency programs in a post-Dobbs era. Contraception 2024;130:110291. doi: 10.1016/j.contraception.2023.110291
  13. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in obstetrics and gynecology. ACGME; 2023. Accessed January 7, 2025. https://www.acgme.org/globalassets/pfassets/programrequirements/220_obstetricsandgynecology_2023.pdf 
  14. UCSF Bixby Center for Global Reproductive Health. The Ryan Residency Training Program. Accessed January 7, 2025. https://www.ryanprogram.org/
  15. Steinauer JE, Turk JK, Fulton MC, Simonson KH, Landy U. The benefits of family planning training: a 10-year review of the Ryan Residency Training Program. Contraception 2013;88:275–80. doi: 10.1016/j.contraception.2013.02.006
  16. Horvath S, Turk J, Steinauer J, Ogburn T, Zite N. Increase in obstetrics and gynecology resident self-assessed competence in early pregnancy loss management with routine abortion care training. Obstet Gynecol 2022;139:116–9. doi: 10.1097/AOG.0000000000004628
  17. Steinauer JE, Turk JK, Zite N, Ogburn T, Horvath S. Routine abortion training correlates with obstetrics and gynecology program directors' assessment of graduating residents' skills. Am J Obstet Gynecol 2024;231:e186–9. doi: 10.1016/j.ajog.2024.07.020
  18. Cutler AS, Hartenbach E. Dobbs revisited - addressing effects on resident training in obstetrics and gynecology. N Engl J Med 2024;391:1073–5. doi: 10.1056/NEJMp2407390
  19. Grimes CL, Halder G, Beckham AJ, Kim-Fine S, Rogers R, Iglesia C. Anticipated impact of Dobbs v Jackson Women's Health Organization on training of residents in obstetrics and gynecology: a qualitative analysis. J Grad Med Educ 2023;15:339–47. doi: 10.4300/JGME-D-22-00885.1
  20. Mengesha B, Zite N, Steinauer J. Implications of the Dobbs decision for medical education: inadequate training and moral distress. JAMA 2022;328:1697–8. doi: 10.1001/jama.2022.19544
  21. Traub AM, Mermin-Bunnell K, Wang K, Aaron B, King LP, Kawwass JF. How Dobbs may influence the geographic distribution of medical trainees in the United States. Health Educ Behav 2024:10901981241292280. doi: 10.1177/10901981241292280
  22. Orgera K, Grover A. States with abortion bans see continued decrease in U.S. MD senior residency applicants. Association of American Medical Colleges; 2024. Accessed January 7, 2025. https://www.aamcresearchinstitute.org/our-work/data-snapshot/post-dobbs-2024
  23. Hammoud MM, Morgan HK, George K, Ollendorff AT, Dalrymple JL, Dunleavy D, et al. Trends in obstetrics and gynecology residency applications in the year after abortion access changes. JAMA Netw Open 2024;7:e2355017. doi: 10.1001/jamanetworkopen.2023.55017
  24. Woodcock AL, Carter G, Baayd J, Turok DK, Turk J, Sanders JN, et al. Effects of the Dobbs v Jackson Women's Health Organization decision on obstetrics and gynecology graduating residents' practice plans. Obstet Gynecol 2023;142:1105–11. doi: 10.1097/AOG.0000000000005383
  25. March of Dimes. Nowhere to go: maternity care deserts across the US: 2024 report. Accessed January 7, 2025. https://www.marchofdimes.org/maternity-care-deserts-report
  26. Cahill EP, Meza PK. The ongoing crisis of abortion care education and training in the United States. Curr Opin Obstet Gynecol 2022;34:373–8. doi: 10.1097/GCO.0000000000000825

Approved by the Board of Directors: February 2025