If Roe v. Wade falls later this year, abortion will become illegal in about half of states. So will learning how to perform one.
Obstetrician-gynecologists perform most surgical abortions, and medical residency programs for these specialties are required to have training on how to provide abortion care. But about 45 percent of those residency programs and young doctors enrolled in them are in states certain or likely to ban abortion if the Supreme Court overturns Roe, according to an analysis published late last month.
The court’s decision is expected in late June or early July, but a leaked draft of the majority opinion suggests the landmark ruling will be overturned. Virtually overnight, it would become illegal for roughly 2,600 of the 6,000 OB-GYN residents nationwide to learn a skill their accreditation body deems essential. While programs are scrambling to develop workarounds, the likely end of a national right to abortion threatens to shrink the pool of doctors who can perform the procedure — limiting access even in states where abortion remains legal.
“The overturning of Roe will have an immediate impact on patients but also a reverberating impact on the next generation of healthcare providers,” said Kavita Vinekar, an obstetrician-gynecologist at the University of California, Los Angeles School of Medicine, who co-authored the recent analysis. “A large portion of the next generation of providers may not have adequate training in basic skills that are helpful, not only in abortion care, but also in a gamut of other essential reproductive health services.”
While medical students can get some exposure to abortion training, most clinicians learn and practice the procedure during their four-year residency. The Accreditation Council for Graduate Medical Education (ACGME), requires OB-GYN programs to provide training or access to training, though residents can opt out if they morally object. Training can take anywhere from a couple of weeks to months and covers more than just abortions. Residents also learn how to manage miscarriages and other pregnancy complications.
Miscarriage is common, and complications can be serious. As many as 26 percent of pregnancies end with miscarriage, and follow-up care can sometimes involve surgery to remove tissue from the mother to prevent infection. “Residents report a significantly higher self-assessed competence in providing all aspects of miscarriage care when they receive routine abortion training,” said Sarah Horvath, an obstetrician-gynecologist at Penn State University who studies abortion care. “We’re talking about a loss of skills across reproductive health.”
Alhambra Frarey, an assistant professor of obstetrics and gynecology at the University of Pennsylvania and a fellow with Physicians for Reproductive Health, completed her medical school and residency at the University of Kansas, which does not offer abortions at its medical center except in case of emergencies. As a result, she only performed two abortions at the site of her residency. She sought abortion training elsewhere: briefly at a local Planned Parenthood clinic where a University of Kansas faculty member worked and through a month-long externship at an out-of-state hospital.
Even with that additional training, Frarey still completed her residency feeling ill-equipped to perform abortions beyond the first trimester. “Really the reason I could do first-trimester abortions is because it’s quite similar to managing a miscarriage,” she added. A friend who graduated from the same residency a year before Frarey later found herself confronted with hemorrhaging in a person who was 15 weeks pregnant. That young doctor needed to call in another physician for support, because she didn’t feel she had the training to provide the lifesaving care.
“If physicians don’t have the training to do these types of [non-abortion] emergencies, you’re going to have unsafe situations and complications,” said Scott Sullivan, an obstetrician-gynecologist and leader on the Council on Resident Education in Obstetrics and Gynecology. “We think more people are going to die because of these rules, which is horrifying.”
Despite the training requirement, about 8 percent of residents reported they had no access to such instruction in a 2020 survey. For the most part, that’s because some states and religious hospitals already effectively ban abortion, forcing residents who want to learn the procedure to travel out of state.
“When it was a relatively small number of states, we had this idea that trainees could just go to other places,” Sullivan said. “But how could we do that for half of our trainees? It’s a logistical nightmare. Nobody really knows where that money would come from or how that would be accomplished.”
The scramble has already started
The situation in Texas — which effectively banned abortion training last September — offers a preview of the challenges to come. The Ryan Residency in Training Program, which supports residency programs in providing abortion training across the country, scrambled to connect medical residents in Texas with programs in other states. “It was a big logistical match program,” said Jema Turk, director of evaluation for the program. Ideally, these doctors in training would spend around four weeks at another institution. But coordinating exchanges that worked for both the resident and the program proved challenging.
“Right now we have 37 Texas residents matched with an out-of-state rotation,” she said. They’re aided by an anonymous grant that allows between $1,500 and $1,800 per resident for their travel and lodgings, “which definitely didn’t cover everything,” Turk said.
Scaling this kind of program up will be difficult. “We barely got 40 in place this past year,” Turk said. “If it’s going to be something like 600 each year, it’s an incredible challenge.”
Many trainees simply won’t be able to up and move across the country for weeks, and programs can only absorb so many residents, she said. Hospitals in restrictive states may also be reluctant to lose residents for weeks at a time, as they’re a key part of providing care.
While medical residents can move, residency programs cannot, and the likely overturning of Roe also raises the possibility that 44 percent of OB-GYN residency programs could lose their accreditation. That’s highly unlikely, Sullivan said, but “it puts almost half of our programs and trainees in a real bind.”
It also calls into question the long-term viability of those programs, as students and faculty may not want to go to programs where abortion training is illegal. “There is definitely a worry [among] programs in these states that good applicants are going to pass them over,” Sullivan said.
Medical students are already taking this into account when considering residency programs, said Pamela Merritt, executive director of Medical Students for Choice. In recent discussions “whether or not they were gonna be able to get abortion training in a residency program was a big deal for them,” she said. “Because we don’t know what some states are gonna do. People just skipped over those programs. There’s also the issue of accreditation … people don’t want to leap into a residency program that may or may not be accredited in 2023.”
Whether that could happen widely remains unclear. “Should it become illegal in some states to perform aspects of family planning, the ACGME is exploring alternative pathways for completing this training,” the accreditation group told Grid in a statement. “At this time, the ACGME requirements remain the same.”
To comply, some programs are exploring virtual abortion training, Sullivan said, where residents could learn basic skills without actually carrying out abortions. “There’s videos, interactive simulations and anatomy models which are better than they’ve ever been,” he said. “A simulation is better than nothing, but it’s not a substitute for actual patient care. I would not want somebody operating on me who’d only done it as a simulation.”
A diminished reproductive care workforce
The fallout from any training shortage is likely to be large and long-lasting, said Horvath. “There are large regions of this country where the skills and deep knowledge of abortion care and also miscarriage management and other early pregnancy complications are going to be significantly damaged,” she said.
Maternal mortality is already higher in states with restrictive abortion care. That disparity could widen if Roe is overturned.
States that protect abortion rights won’t be immune from the training crunch. “Physicians don’t stay put. We often move from where we were trained,” Vinekar said. “We may have a serious workforce issue even in states where abortion is protected because there just aren’t enough physicians trained in abortion care.”
An abortion training shortage would mean fewer providers and less access to abortion care for everyone — and a medical workforce less equipped to deal with miscarriage and other reproductive health issues. “It’s going to have a major impact on patients,” Vinekar said, in both the short and long term.
Travel rotations or virtual training programs “are just mitigation strategies,” she said. “Patient care is not going to be ideal unless we solve the bigger picture of abortion access in this country.”
An earlier version of this article misstated Alhambra Frarey's title. This version has been corrected.
Thanks to Alicia Benjamin for copy editing this article.