Abortion bans could leave close to half of US obstetrics residents with inadequate training

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With the overturning of Roe v. Wade on Friday, almost half of the nation's medical residents in obstetrics and gynecology are certain or likely to lack access to in-state abortion training.

That opens questions about how those programs can be accredited when a procedure required to be taught is illegal where they are based.

"Part of being an OB-GYN is being able to safely remove a pregnancy to save someone's life. It's our job as educators to ensure that everybody has those skills," said Dr. Jody Steinauer, a professor of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco.

"What's going to happen when we have 44% of medical residents in states where it's illegal?"

Accreditation rules require obstetrics-gynecology medical residencies to provide training or access to training on the provision of abortions, said Dr. Janis Orlowski, chief health officer for the Association of American Medical Colleges.

The Accreditation Council for Graduate Medical Education already is exploring alternative pathways for completing training. It requires programs to have a curriculum for family planning, including training in the complications of abortions, and the opportunity for direct procedural training in terminations of pregnancy.

More: Ruling overturning Roe v. Wade sparks debate about Supreme Court's legitimacy amid partisan passions

Anti-abortion protesters gather outside the Supreme Court in Washington on Friday, June 24, 2022. The Supreme Court has ended constitutional protections for abortion that had been in place nearly 50 years, a decision by its conservative majority to overturn the court's landmark abortion cases.
Anti-abortion protesters gather outside the Supreme Court in Washington on Friday, June 24, 2022. The Supreme Court has ended constitutional protections for abortion that had been in place nearly 50 years, a decision by its conservative majority to overturn the court's landmark abortion cases.

The Guttmacher Institute, an organization that works to advance sexual and reproductive health and rights worldwide, says 26 states are certain or likely to ban abortions now that the Supreme Court has struck down federally protected abortion rights.

Thirteen states have "trigger laws" that took effect automatically or will be quickly acted upon as soon as Roe no longer applies, according to the reproductive health research and policy organization.

They are Arkansas, Idaho, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, Utah and Wyoming.

Louisiana State University's OB-GYN residency program already has decided how it will deal with the new state reality.

"Should Roe v. Wade be overturned, LSU Health would arrange for such resident training to occur out of state," spokeswoman Leslie Capo said before the court's ruling.

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Other schools are considering their options, including the University of Kentucky School of Medicine.

"In the event of a ruling by the Supreme Court, our providers and administration will need time to analyze all aspects of the decision," said spokeswoman Hilary Brown.

Losing access to such training is dangerous because it's not just used for abortions, said Orlowski, with the Association of American Medical Colleges.

"The technical procedure for providing an abortion – dilation and curettage – is the same procedure that is performed after a miscarriage, or in some cases, to treat excessive bleeding or take a biopsy from the uterus," Orlowski said.

Medical residents who have religious or moral objections may opt out and must not be required to participate in the training or perform elective abortions, she said.

Accrediting bodies are now working to change their requirements in light of the Supreme Court’s ruling last week.

The Accreditation Council for Graduate Medical Education this week proposed revised requirements for obstetrics and gynecology residency programs in light of the Supreme Court ruling.

All medical education programs accredited by the council must offer a curriculum in family planning that includes the chance to train in how to terminate pregnancies. However, the revision would allow programs in jurisdictions that legally restrict such clinical experience to let residents travel to be trained in jurisdictions where abortion is legal.

If a resident can’t travel to be trained, the programs must instead offer lectures and training on simulation models. Residents who have religious or moral objections may opt out of the training.

Workaround programs already exist but will need to be ramped up to deal with demand, said Steinauer, who leads the Bixby Center for Global Reproductive Health at UCSF. The Ryan Residency Training Program based at the center provides obstetrics and gynecology residents opportunities to travel to programs in states where they can receive training and education in abortion and contraception care.

When Texas passed one of the most restrictive abortion laws in the country last year, OB-GYN residents there began looking elsewhere for the training they needed.

"We've supported 50 Texas residents to travel to other states," Steinauer said. "Before, only about 20 residents a year reached out to us because they weren't in a program that offered the training. It was a real challenge to add 50 students all at once."

A study published in April found that in 2020, 92% of obstetrics and gynecology residents reported having access to some level of abortion training. The study predicted that if Roe v. Wade were overturned, the number would fall to at most 56%.

Not being able to get trained in such techniques will harm patient care, said co-author Dr. Kavita Vinekar of the department of obstetrics and gynecology at the University of California, Los Angeles.

“The public separates abortion from the rest of OB-GYN care, which it’s not at all,” she said. “Those skills are translatable to other parts of OB-GYN work, and if you don’t master them then you probably won’t be as competent in miscarriage management.”

Practicing on papayas

Training for nurses, especially advanced practice clinicians such as nurse practitioners, nurse midwives and physicians' assistants, is equally affected

Though doctors are most often cited when restrictions on abortion are discussed, nurses oversee many medication abortions. In 12 states, those health care providers are able to provide medicinal and in some cases aspiration abortions.

More: Abortion by pill figures to rise if Supreme Court overturns Roe v. Wade

They include California, Colorado, Maine, Massachusetts, Montana, New Hampshire, New York, Oregon, Vermont, Virginia, Washington, Washington, D.C., and West Virginia, according to a list maintained by several nurse practitioners and nurse-midwives.

Training is already difficult to come by, said Amy Levi, a certified nurse-midwife and nurse practitioner. To deal with that, training conferences have begun to include demonstrations of the procedure using papayas or dragon fruit.

Using fruit at least gives students a sense of how the procedure is done, said Levi, a professor of midwifery at the University of New Mexico.

The training is important because nurse practitioners and nurse-midwives can provide miscarriage support. In states where licensing allows it as part of their practice, some provide abortion services.

"In Planned Parenthood, almost all medication abortions, over 95%, are done by advanced practice clinicians in states where it's legal," said Debbie Bamberger, a nurse practitioner with Planned Parenthood Mar Monte, which operates in California and Nevada.

Lack of training will hurt all women seeking gynecological care because the lines between what constitutes an illegal act and what constitutes pregnancy management are not always clear, Vinekar said.

"It may include miscarriage management, it may include ectopic pregnancy management," she said. "The standard of care for miscarriage is the same standard of care we use for abortion."

A previous version of this story incorrectly attributed a quote about a technical procedure for providing an abortion – dilation and curettage – being the same as that sometimes performed after a miscarriage. The quote was from Dr. Janis Orlowski, chief health care officer of the Association of American Medical Colleges.

This article originally appeared on USA TODAY: Abortion bans may leave some OB-GYN residents with poor training