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Contents: Current Commentary

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

Vinekar, Kavita MD, MPH; Karlapudi, Aishwarya BS; Nathan, Lauren MD; Turk, Jema K. PhD, MPA; Rible, Radhika MD, MSc; Steinauer, Jody MD, PhD

Author Information
doi: 10.1097/AOG.0000000000004832

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.

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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.

REFERENCES

1. Guttmacher Institute. An overview of abortion laws. Accessed March 16, 2022. https://www.guttmacher.org/state-policy/explore/overview-abortion-laws
2. Guttmacher Institute. 26 states are certain or likely to ban abortion without Roe: here's which ones and why. Accessed November 23, 2021. https://www.guttmacher.org/article/2021/10/26-states-are-certain-or-likely-ban-abortion-without-roe-heres-which-ones-and-why
3. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in obstetrics and gynecology. Accessed December 9, 2021. https://www.acgme.org/globalassets/pfassets/programrequirements/220_obstetricsandgynecology_2021.pdf
4. Horvath S, Zite N, Turk J, Ogburn T, Steinauer J. Resident abortion care training and satisfaction: results from the 2020 Council on Resident Education in Obstetrics and Gynecology in-training examination survey. Obstet Gynecol 2021;138:472–4. doi: 10.1097/AOG.0000000000004512
5. American Medical Association. FREIDATM AMA residency & fellowship programs database. Accessed December 9, 2021. https://freida.ama-assn.org/
6. RHEDI. Family medicine residencies with abortion training. Accessed March 17, 2022. https://rhedi.org/resources/residency-training/#rhediprograms
7. Jones RK, Witwer E, Jerman J. Abortion incidence and service availability in the United States, 2017. Guttmacher Institute; 2019. doi: 10.1363/2019.30760
8. Dalton VK, Harris LH, Bell JD, Schulkin J, Steinauer J, Zochowski M, et al. Treatment of early pregnancy failure: does induced abortion training affect later practices? Am J Obstet Gynecol 2011;204:493.e1–6. doi: 10.1016/j.ajog.2011.01.052
9. Horvath S, Turk J, Steinauer J, Ogburn T, Zite N. Increase in obstetrics and gynecology resident self-assessed competence in early pregnancy loss management with routine abortion care training. Obstet Gynecol 2022;139:116–9. doi: 10.1097/AOG.0000000000004628
10. Steinauer JE, Hawkins M, Turk JK, Darney P, Preskill F, Landy U. Opting out of abortion training: benefits of partial participation in a dedicated family planning rotation for ob-gyn residents. Contraception 2013;87:88–92. doi: 10.1016/j.contraception.2012.09.002
11. Steinauer JE, Turk JK, Preskill F, Devaskar S, Freedman L, Landy U. Impact of partial participation in integrated family planning training on medical knowledge, patient communication and professionalism. Contraception 2014;89:278–85. doi: 10.1016/j.contraception.2013.12.012
12. Upadhyay UD, Johns NE, Cartwright AF, Franklin TE. Sociodemographic characteristics of women able to obtain medication abortion before and after Ohio's law requiring use of the Food and Drug Administration protocol. Health Equity 2018;2:122–30. doi: 10.1089/heq.2018.0002
13. Redd SK, Rice WS, Aswani MS, Blake S, Julian Z, Sen B, et al. Racial/ethnic and educational inequities in restrictive abortion policy variation and adverse birth outcomes in the United States. BMC Health Serv Res 2021;21:1139. doi: 10.1186/s12913-021-07165-x
14. Mosley EA, Redd SK, Hartwig SA, Narasimhan S, Lemon E, Berry E, et al. Racial and ethnic abortion disparities following Georgia's 22-week gestational age limit. Women’s Health Issues 2022;32:9–19. doi: 10.1016/j.whi.2021.09.005
15. Coles MS, Makino KK, Stanwood NL, Dozier A, Klein JD. How are restrictive abortion statutes associated with unintended teen birth? J Adolesc Health 2010;47:160–7. doi: 10.1016/j.jadohealth.2010.01.003
16. Marrast LM, Zallman L, Woolhandler S, Bor DH, McCormick D. Minority physicians’ role in the care of underserved patients: diversifying the physician workforce may be key in addressing health disparities. JAMA Intern Med 2014;174:289-91. doi: 10.1001/jamainternmed.2013.12756
17. United States Census Bureau. TIGER/Line shapefile United States. Accessed December 15, 2021. https://catalog.data.gov/dataset/tiger-line-shapefile-2017-nation-u-s-current-state-and-equivalent-national/resource/ea102089-f1df-453f-beb7-b002cfebc2fe
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