Projected Implications of Overturning Roe v Wade on Abortion Training in U.S. Obstetrics and Gynecology Residency Programs

Abstract

In June 2022, the U.S. Supreme Court is expected to issue a decision on Dobbs v Jackson Women's Health Organization, a direct challenge to Roe v Wade. A detailed policy analysis by the Guttmacher Institute projects that, if Roe v Wade is overturned, 21 states are certain to ban abortion and five states are likely to ban abortion. The Accreditation Council for Graduate Medical Education requires access to abortion training for all obstetrics and gynecology residency programs. We performed a comprehensive study of all accredited U.S. obstetrics and gynecology residency programs to assess how many of these programs and trainees are currently located in states projected to ban abortion if Roe v Wade is overturned. We found that, of 286 accredited obstetrics and gynecology residency programs with current residents, 128 (44.8%) are in states certain or likely to ban abortion if Roe v Wade is overturned. Therefore, of 6,007 current obstetrics and gynecology residents, 2,638 (43.9%) are certain or likely to lack access to in-state abortion training. Preparation for the reversal of Roe v Wade should include not only a recognition of the negative effects on patient access to abortion care in affected states, but also of the dramatic implications for obstetrics and gynecology residency training.

In Brief

If Roe v Wade is overturned, at least 43.9% of U.S. obstetrics and gynecology residents are predicted to lack abortion training.

On December 1, 2021, the U.S. Supreme Court heard oral arguments in Dobbs v Jackson Women's Health Organization, a direct challenge to Roe v Wade. A decision is expected in June 2022. In a landmark 1973 ruling, Roe v Wade determined the constitutional right to an abortion, prohibiting state or federal entities from excessively restricting abortion access. Though current restrictions limit people from accessing services, abortion remains legal in every state.¹ However, several states have passed legislation (sometimes referred to as “trigger laws”) intended to reflexively ban abortion if Roe v Wade were to be overturned.² If Roe v Wade is overturned in 2022, 21 states are certain to ban abortion and five are likely to do so, according to a detailed policy analysis from the Guttmacher Institute.²

The Accreditation Council for Graduate Medical Education requires that all obstetrics and gynecology residents have access to abortion training.³ In 2020, 92% of residents reported having some level of access to abortion training.⁴ However, it is not known how a reversal of Roe v Wade may affect abortion training in residency. We sought to understand the potential implications of overturning Roe v Wade for the availability of abortion training in obstetrics and gynecology residency programs.

METHODS

We used a publicly available comprehensive database of all accredited obstetrics and gynecology residency programs in the United States, generated by the American Medical Association.⁵ We abstracted program information, including program address and the number of residents per year. When this information was unavailable in the database, we searched residency program websites. If data were absent from the website, we contacted the program offices by email or telephone.

We used publicly available policy analyses from the Guttmacher Institute to identify states certain or likely to ban abortion if Roe v Wade is overturned.² The methods used by the Guttmacher Institute to determine these classifications are described in detail elsewhere.² The predictive assessment incorporated information about unenforced pre–Roe v Wade abortion bans that would come into effect if Roe v Wade is overturned, reflexive abortion bans (“trigger laws”) intended to go into effect immediately if Roe v Wade is overturned, and constitutional amendments expressly stating that abortion would not be a protected right if Roe v Wade is overturned.²

We geocoded (obtained latitude and longitude coordinates) and mapped all obstetrics and gynecology residency sites. We then reported on programs and residents located in states certain or likely to ban abortion.

All geospatial mapping was performed in QGIS 3.4, and program and resident quantifications were performed in Stata 16. The study protocol was reviewed by the Institutional Review Board at the University of California, Los Angeles, which determined that this study did not meet the definition of human subjects research and did not require formal exemption or approval.

RESULTS

Of 292 total U.S. obstetrics and gynecology residency programs, five are new programs with no current residents and one was excluded owing to lack of available information. A total of 286 programs were included. Of these, 128 (44.8%) are in states certain or likely to ban abortion if Roe v Wade is overturned (Fig. 1). More specifically, 111 programs (38.8%) are in states certain to ban abortion and 17 (5.9%) are in states likely to ban abortion.

Fig. 1.: Obstetrics and gynecology residency programs⁵ in the United States¹⁷ by projected legal status of abortion if Roe v Wade is overturned.² Total U.S. obstetrics and gynecology programs in 2022 (N=286); obstetrics and gynecology residency programs located in states certain or likely to outlaw abortion if Roe v Wade is overturned (n=128; 44.8%).

There are 6,007 residents in accredited U.S. obstetrics and gynecology programs, and 2,638 (43.9%) train at programs in states that are certain or likely to ban abortion if Roe v Wade is overturned. Of these, 2,306 (38.4% of all residents) are at programs in states certain to ban abortion and 332 (5.5% of all residents) are in states likely to ban abortion.

DISCUSSION

In this study of the projected implications of overturning Roe v Wade on current U.S. obstetrics and gynecology residency training, we found that 43.9% of residents currently train in states predicted to outlaw abortion, a component of obstetrics and gynecology residency required for accreditation. In 2020, 92% of obstetrics and gynecology residents reported having access to some level of abortion training.⁴ We predict that, if Roe v Wade is overturned, this would plummet to at most 56%. This likely underestimates the training implications of overturning Roe v Wade, in that residencies outside of obstetrics and gynecology, such as family medicine, were not included in the study. At least 42 family medicine residency programs include abortion training (onsite or travel rotations).⁶

Abortion training provides future obstetrician–gynecologists with procedural and counseling skills to care for the one in four patients who will have induced abortions during their reproductive years.⁷ Abortion training has also been shown to improve general skills and confidence in uterine evacuation and miscarriage management.^8,9 Furthermore, though some residents choose not to participate fully in abortion training on religious or moral grounds, partial participators in programs that offer routine abortion training benefit from improved procedural, ultrasonography, and pregnancy-counseling skills.^10,11 Thus, the ramifications of this chasm in training will extend beyond induced abortion care.

Abortion restrictions disproportionately harm communities of color.^12–15 Future studies will be needed to assess whether abortion restrictions (and, most extremely, a reversal of Roe v Wade) would disproportionately affect training for obstetrics and gynecology residents identifying with racial and ethnic groups underrepresented in medicine, because they are more likely to provide care to underserved populations.¹⁶ Although resident race and ethnicity information was not available for this study, we plan to explore this in future work.

This study provides a glimpse into the potential implications of a Roe v Wade reversal on resident training. It is, however, not without limitations. We used a detailed policy analysis by a leading reproductive policy institute, but our findings are based on projections and are therefore speculative. We were limited in our ability to include family medicine and other non–obstetrics and gynecology residency programs that may incorporate abortion training into their residency programs. Finally, given the lack of available information pertaining to routine abortion training at individual residency sites, we did not account for the current state of abortion training in each program; therefore, we cannot conclude how many residents will lose routine abortion training if Roe v Wade is overturned. We intend to perform a more extensive study characterizing site-specific training opportunities in future research.

Our findings demonstrate a large gap in obstetrics and gynecology residency training that will exist if Roe v Wade is overturned. One strategy to consider in addressing this need is the establishment of travel rotations for residents to obtain abortion training in states with protected abortion access. However, it is unlikely that travel rotations will be feasibly arranged for nearly 44% of all U.S. obstetrics and gynecology residents, given the resources this requires and the disruption that resident absences can pose to clinical care. Clinician educators may need to explore robust formalized miscarriage training, simulation, or remote learning as options for mitigating the lack of abortion training.

Preparation for the overturning or dismantling of Roe v Wade should include not only a recognition of the negative effects on patient access to abortion care in affected states, but also of the seismic implications for training. Such a change could leave nearly one half of U.S. obstetrics and gynecology residents without access to this fundamental facet of reproductive care, thus affecting care for future patients.