In the politically and emotionally charged atmosphere surrounding abortion in the United States, education about abortion may be neglected. Medical schools may include little if any education on the practical aspects of abortion and its complications. Although no inventory currently exists documenting the degree of exposure to and education about abortion in U.S. medical schools, administrators at the American Medical Women’s Association believe that the majority of medical schools provide insufficient formal teaching about abortion.1 The association publishes the Reproductive Health Initiative curriculum, available in written form and online, which facilitates the teaching of abortion in the context of a fourth-year reproductive health elective rotation. Currently, over 60 U.S. medical schools use this curriculum. A minority of medical students may participate, due partly to the limited number of students who may be accommodated on such electives as well as limited time for electives in the fourth year. The students who choose such electives may be those who are already more knowledgeable about and supportive of abortion.
A multidisciplinary group of women’s health educators was convened in 2000 and developed guidelines for women’s health competencies for undergraduate medical education. These guidelines were distributed to every medical school in the United States and Canada.2 The competencies include a section on abortion education with the requirements to understand surgical and medical abortion, to know complications of abortion, and to know how to counsel women about the pregnancy options. The Association of Professors of Gynecology and Obstetrics, a professional organization that develops guidelines specifically for education in obstetrics and gynecology (Ob/Gyn) clerkships, includes abortion care as a core learning objective for medical students during the third-year Ob/Gyn clerkship.3 However, unlike most common obstetric and gynecologic services for women, abortion care services are rarely performed in the hospital setting, where most medical students receive the majority of their clinical experience. In the United States, 70% of abortions are performed in specialized clinics and only 7% are performed in hospitals.4 Frequently, the topic of abortion is covered in lecture format or may not be covered at all. A clinical exposure to abortion care may be the optimal approach to educate students about abortion.
Until 1998, no formal abortion education occurred in any part of the University of New Mexico School of Medicine (UNMSOM) curriculum. In 1998, a half-day experience at a Planned Parenthood facility in Albuquerque was initiated for third-year Ob/Gyn medical students to observe choice counseling, abortion counseling, and abortion procedures. Our study aimed to identify student acceptance of the abortion care experience, to rate its value, and to assess whether attitudes about abortion changed as a result of the clinical exposure.
We obtained approval for the study from the Human Research Review Committee at the University of New Mexico. All 145 students who rotated through the eight-week Ob/Gyn core clerkship between March 2000 and March 2002 were given the option of spending one-half day at a Planned Parenthood facility that provides abortion care services. During this half-day, students worked with the medical provider and counseling staff and observed counseling sessions, procedures, and examination of the products of conception. Students were scheduled to attend the clinic in pairs, giving them the opportunity to debrief with each other at the conclusion of the morning.
We developed an 11-item, confidential, self-administered questionnaire and provided it to all students who completed the Ob/Gyn clerkship, regardless of whether they participated in the optional clinical experience. Students who elected not to participate in the experience answered a question about their reasons for declining the clinical experience. They were given several choices including religious objections, fear of harassment, and scheduling conflicts, as well as the opportunity to fill in reasons not listed. Students were asked to mark as many responses as applied.
Students who elected to participate in the abortion care experience answered questions about their reactions to the half-day experience. Students used a Likert scale to comment on the appropriateness of the amount of time allotted to the clinical experience, how strongly they would or would not recommend the experience to another student, and how strongly they felt the experience would improve their ability to counsel women about abortion. Students were given several choices to describe the best and the worst parts of the clinical experience and were asked to mark as many responses as applied. Students were also able to write in their own responses. Finally, students who participated in the clinical experience were asked to check one of three responses about the impact of the clinical experience on their previously held attitudes about extending abortion services to women. The responses were: “No, my previous feelings about this issue remain unchanged,” “Yes, this experience has made me more supportive of access to abortion services for women,” and “Yes, this experience has made me less supportive of access to abortion services for women.”
All students answered questions on a Likert scale indicating their attitudes about the appropriateness of including abortion as part of women’s health care services and about including an abortion care experience in medical student education.
On the questionnaire, we also asked all the students for demographic information.
All data were entered into Epi-Info 6.2 (Centers for Disease Control and Prevention, Atlanta, Georgia). We reviewed questionnaires and entered data every six months. Data from the questionnaires of three clerkship groups were entered at a time to preserve the confidential nature of the responses. We determined frequencies and used chi-square and t test to assess associations between demographic variables and several independent variables.
Of the 145 students who completed the Ob/Gyn rotation during the study period, 126 (87%) filled out a confidential questionnaire. A total of 86 (68%) students participated in the half-day abortion care experience and 40 (32%) did not. Table 1 compares the demographic characteristics of students who did not participate with those who did participate. No significant differences were noted between the two groups. The gender proportions reflect the makeup of the UNMSOM student body, with more women (59%) than men (41%). Only 78 of respondents answered the optional question on ethnicity. For this study, we defined minority ethnicity as Hispanic, Native American, black, and Asian; nonminority ethnicity as non-Hispanic white (Caucasian). The proportion again roughly corresponded to the self-reported ethnicity–minority (35%) versus nonminority (65%), of the UNMSOM student body.
Gender was unrelated to the likelihood of participating in the clinic experience (p = .24). Similarly, the odds of participating in the clinic experience were unrelated to age (p = .73) or ethnicity (p = .20).
Religious objections and a desire to spend more time on other aspects of Ob/Gyn were the leading reasons students gave for declining participation in the half-day abortion care experience, cited by 14 students and 16 students respectively. Nine cited scheduling conflicts and 11 cited personal negative views about abortion as a reason for declining the experience. Four students declined participation because they felt they had sufficient previous clinical experience with abortion. No students cited fear of harassment or personal injury as reasons for declining participation in the clinical experience. Students were instructed to mark as many reasons as applied; only 22 of the 40 students who declined the experience gave reasons for their decision.
Many of the 86 students who participated in the clinical experience checked more than one response for the “best” part of the experience. Observing the counseling sessions and observing the actual abortion procedure were selected as best by 43 and 46 students, respectively. Seeing what women go through physically and what they go through emotionally were selected as best by 31 and 38 students, respectively. Three students wrote in that examining the products of conception was the best part of the experience.
Students gave varied responses for the “worst” part of the experience. Seven indicated that observing the abortion procedure was the worst part and 12 indicated a personal negative reaction to the experience. Eight students wrote in that “down time” or waiting for counseling sessions and procedures was the worst part of the experience, whereas six wrote in that examining the products of conceptions was the worst. Finally, seven students wrote in that the presence and actions of the protestors at the clinic was the worst part of the experience.
After the first six months of the study, when we first reviewed the data, we found that five men and no women had indicated that patients were declining to allow them to observe counseling sessions and procedures. We raised this concern with clinic staff. Staff verbalized their desire to minimize trauma to patients; several felt that having a man in the room could worsen the patients’ experience. However, it was acknowledged that excluding them from this experience could have a negative impact on the male students’ understanding of and support for the procedure. This clarification of values appeared to have a beneficial effect as no further male participants indicated a suboptimal experience after we held the discussions with the clinic staff.
The attitudes of students who participated in the clinical abortion care experience were highly favorable (see Table 2). Those who participated were more likely to consider abortion services an integral part of women’s health care and also to support including abortion education in the medical school curriculum (see Table 3).
Of the 86 participants in the abortion care experience, 53 (62%) did not change their previously held attitudes about abortion, either supportive or not supportive. However, in the participants whose attitudes changed, the abortion care experience appeared to change attitudes in favor of supporting abortion access; of the 33 participants (38%) whose attitudes were changed, 31 (94%) became more supportive. Two participants (6%) became less supportive.
The most important finding of our study is the acceptability of an abortion care clinical experience for third-year medical students. Previous studies have demonstrated that the majority of medical students are pro-choice. Stennet and Bongiovi5 surveyed 197 medical students at Columbia University and found that 85.8% described themselves as pro-choice. Rosenblatt et al.6 surveyed first- and second-year medical students at the University of Washington and found that 58.1% believed that elective, first-trimester abortion should be accessible under most circumstances, and an additional 34.6% believed that it should be accessible with some limitations. Fully 43% of students in Rosenblatt et al.’s study who planned a career in family medicine (FM) anticipated they would offer abortion as part of their practice. Our study indicated that the majority of medical students in the Ob/Gyn core clerkship at the University of New Mexico during our study period believed that elective abortion should be considered an integral part of women’s health care services and that education about abortion should be included in the medical school curriculum.
Written comments by students indicated that the half-day clinic had a strong emotional impact on many, mostly related to observing women’s experience with abortion. Students appreciated going to the clinic in pairs to talk about their feelings about the experience. Although protestors were typically present outside the clinic, no students reported feeling unsafe, nor did any episodes of clinic violence occur during the study period. Despite several episodes of abortion clinic violence in other areas of the United States that were publicized nationally during the study period, no students declined participating because of safety concerns. Observing the actual abortion procedure and examining the products of conception was reported by a number of students to be both the “best part” and the “worst part” of the experience.
The University of New Mexico student body has a diverse ethnic and age composition that was reflected in the demographics of our respondents. The fact that students of all ages and ethnicities as well as both genders were as likely to participate in the optional clinical experience and to find it valuable highlights its wide applicability. The cross-cultural appropriateness of this clinical experience was confirmed by the questionnaire results and supports our conclusion that these experiences should be made widely available to all students.
Similarly, our study showed no difference based on age or gender in the likelihood of supporting access to abortion as part of women’s health services. Other studies5,6 have suggested that women and students older than age 30 are more likely to support the availability of abortion than are men and students younger than age 25. In our study, only students who declined participation in the clinical experience were less likely to support abortion access for women, and those students were similar in age, gender, and ethnic background to those who participated.
Another important finding of our study was that a sizable minority of students’ attitudes about abortion changed as a result of the experience. Student comments suggest some reasons why students became more supportive. While some expressed in the comments that they had been passively prochoice in the past, they became more actively prochoice after meeting women who were undergoing abortion and after hearing the circumstances of their unintended pregnancies and the often difficult circumstances under which they had made the decision about abortion. Although our students are taught that over a third of all women in the United States will have had an abortion by age 45,4 some students still expressed in their comments feelings that women who chose an abortion were somehow “different.” The experience of actually meeting and empathizing with those women seemed to be a crucial part of improving attitudes toward abortion access.
In addition to our study, only one other study has reported on changes in attitude toward abortion over the course of medical school. Stennet and Bongiovi5 reported that 19.8% of students changed their attitudes, the majority during the clinical years. They reported that the majority of those who changed became less supportive of abortion access. No mention was made of how abortion was covered in the school’s curriculum. Dans7 conducted a survey at Johns Hopkins University in 1992 and found that little change occurred in student attitudes about the appropriateness of abortion over the four years of medical school. Again, no mention was made about abortion education in the curriculum. We believe that the clinical experience afforded at our institution through the participation of Planned Parenthood—where students not only see procedures but also meet the women who undergo them—is the primary reason for the positive change in attitude of some participants in our study.
Our study had limitations. First, the students may have felt pressure to participate in an optional activity that was sponsored through the Ob/Gyn department. However, we made it clear to students that their grades would not be affected by their choice. Also, students were reassured that their questionnaires would contain no personal identifiers and would be read and analyzed only every six months so that individuals could not be identified on the basis of their handwriting. Second, the abortion care experience we provided was homogeneous—students rotated at a single Planned Parenthood clinic and were usually assigned to the same provider throughout the two years. Therefore, our findings may not be generalizable to all abortion care clinic experiences.
Assuring the future of comprehensive reproductive rights for women in the United States requires trained providers willing to perform abortions. Education at the medical student level may promote favorable attitudes and result in more providers including abortion as part of their practice. Abortion has become increasingly marginalized in our health care system, most often limited to dedicated clinics, away from venues where medical students typically receive training. Our study demonstrates the acceptability of a clinical experience in abortion care and shows that attitudes may become more favorable toward abortion services as a result of the experience. We conclude that clinical experiences in abortion care should be made more widely available to medical students across the country.
The authors wish to gratefully acknowledge the collaboration of Dr. Diana Koster and the entire staff of Planned Parenthood of Albuquerque, New Mexico, without whose participation this educational offering could not have been made available to our medical students.