A decision by the US Supreme Court to overturn Roe v Wade could have far-reaching impacts on residents in ob/gyn medical programs across the country, from learning simple procedures like ultrasounds to how to manage miscarriages.
On Monday, Politico published a leaked initial draft majority opinion written by Justice Samuel Alito, which declares Roe unconstitutional. The actual opinion is due at the end of June. If all the justices keep their positions for that vote, the 1973 court case that legalized abortion rights in the United States would no longer keep states from banning the procedure before viability, which is defined as 24-26 weeks into a pregnancy.
Loss of federal protections provided by Roe would leave a patchwork of states where providers would have to change reproductive health practices. Medical schools in those states would also have to curtail any abortion care training, experts told Medscape Medical News.
Constance Bohon, MD, co-chair of the Legislative and Liability Committee of the American College of Obstetricians and Gynecologists (ACOG), said: “As a profession, we are concerned about the possibility that there will be ob/gyn residents who graduate without the experience and training needed to care for a patient who has complications from an abortion or a missed abortion. We are very concerned that without adequate training and access to care for these patients, the maternal mortality rate will rise.”
The loss of Roe “means that sadly, and realistically, many residents just won’t get the training or we will need to think about mitigation strategies like providing simulation training,” said Kavita Vinekar, MD, MPH, assistant clinical professor in the Department of Obstetrics and Gynecology at the David Geffen School of Medicine at UCLA. “I can assure you that without access to abortion training, the quality of ob/gyn training will absolutely suffer.”
Twenty-two states, including large swaths of the south and Midwest, already have laws that would go into effect immediately to ban abortion in the absence of Roe. Four states, including Florida, Montana and Indiana, would likely ban abortion, according to an analysis from the Guttmacher Institute.
Most reproductive healthcare training lasts between 1-2 months during residency, and includes instruction on ultrasounds, best practices in managing pregnancy complications, learning how to safely evacuate a uterus in the event of a stillbirth or miscarriage, and counseling for family planning options.
I can assure you that without access to abortion training, the quality of ob/gyn training will absolutely suffer.
A Glimpse at the Future
The potential for a new reality is already playing out in Texas, where a law banning abortions after 6 weeks in pregnancy took effect last September 1. The Ryan Program, a national initiative to teach abortion care to medical school residents, started a pilot to match resident physicians in Texas with hospital programs in other states without abortion restrictions.
The Ryan Program has matched over 40 residents since the law took effect, according to Jody Steinauer, MD, PhD, who oversees the Ryan Program at the Bixby Center for Global Reproductive Health at the University of California San Francisco. Matching students is an arduous and timely process because students have hectic schedules, and state licensure and other regulatory issues must be worked out, she said.
“It will take a while to get systems in place to really support resident travel, and not every resident is going to be able to travel, so I’m just worried about the future impacts on patient care,” Steinauer told Medscape Medical News. “We have hundreds of residents who are not learning the skills they need, and they’re not going be able to provide evidence-based, patient-centered care.”
But Bohon expressed skepticism that the Ryan Program and other initiatives to provide training for travel residents would be sufficient. “Unfortunately, it is anticipated that this program will not be sufficient to provide training for all of the ob/gyn residents who do not have access to abortion training because of the state where their residency is,” she said. “There are residency programs that have the capacity to have ob/gyns get training at their programs but there is a limited number of these positions available as well.”
She added that the Council on Resident Education in Obstetrics and Gynecology is actively pursuing options to provide abortion training for residents for whom such training is not available.
Healthcare professionals in states without restrictive abortion laws will also see an increase in patients seeking abortion-related care. This spike already is happening in New Mexico, which borders not only Texas, but Oklahoma and Arizona — states that have severely restricted abortion rights.
“It’s difficult in the states that will be overloaded with additional abortion care, to then incorporate learners on top of that,” said Eve Espey, MD, MPH, distinguished professor and chair of the Department of Obstetrics and Gynecology at the University of New Mexico in Albuquerque. “Logistically, to fill that gap in care and train at the same time will be really challenging.”
Espey said the UNM Center for Reproductive Health has already seen patients from Texas who would likely fall under an exemption in that state’s law that allows abortions if a patient faces a medical emergency if the pregnancy continues.
“Providers are so afraid of these laws, and if they’re risk adverse, they’re always going to err on the side of not taking care of the patient if you think you can get in trouble,” Espey said, pointing to patients who presented with lethal fetal anomalies or ruptured fetal membranes early in pregnancy that might fall under the medical emergency exemption.
Steinauer with the Ryan Program said that many Texas residency program directors have told her they’ve heard from applicants who are giving low ranks to residency programs in the state.
“They’re saying, ‘If we want to be able to be trained as an ob/gyn, why would we want to go to a program with such significant restrictions?’ ” Steinauer said. “That is a real worry.”
Most ob/gyn medical residency programs now provide built-in abortion training, which the Accreditation Council for Graduate Medical Education mandated in 1995. A small majority do not. According to a 2020 research letter from the ACOG, about 11% of ob/gyn residents said their programs hypothetically offer training without a clear process to obtain it, and 8% reported that their programs offered no such training at all.
Residents can also opt out of abortion training, although students increasingly are choosing to only opt out of certain parts, such as training for abortions provided later in pregnancies, according to Steinauer.
A Looming “Pipeline Problem”
There were about 3550 abortion service clinicians in 2020, 72% of whom were ob/gyns, followed by family medicine doctors and advanced practice registered nurses, according to research published in March in JAMA Internal Medicine. This number is likely not an accurate tally, however, because the authors queried a national medical claims database that did not include self-pay patients.
Julia Strasser, DrPH, MPH, a senior research scientist at The George Washington University Milken Institute School of Public Health in Washington, DC, who led the study, said states could create policies to broaden access to abortion for patients and training for medical residents.
Those include expanding laws to allow advanced practice clinicians to provide abortion care, allowing state Medicaid programs to opt-in for abortion payment, and establishing abortion care continuing medical education requirements for state boards of medicine for both ob/gyn and primary care.
“Providers that practice in those restricted states will not only stop providing care there, but also won’t be able to train the next generation of workforce to be able to provide that care,” Strasser said. “It’s a pipeline problem.”
States also could encourage their medical residency programs to not hold slots open for students who want to opt out of abortion care training. The University of Washington in Seattle in 2000 eliminated slots it had been holding open for opt-out students because the state does not have restrictions on abortion.
As abortion becomes increasingly restricted across the country, Strasser said, for medical schools in “a state that continues to make abortion available, it’s essentially their duty to make that training available.”