Roe 2022: It's Not 1972.

The recent U.S. Supreme Court decision cannot take obstetricians and gynecologists back to 1972, because abortion practice, training, and research have made 50 years of progress. During this past half century, safe and effective medication and surgical abortion have helped millions of patients, thousands of obstetrician-gynecologists have been trained in more than 100 programs, and thousands of clinical, epidemiologic, and sociologic studies have demonstrated the importance of abortion to personal and public health. Obstetrician-gynecologists must support one another in amending or defying laws that subvert the principles of medical practice, training, and evidence.

Professionalism in Family Planning Care Workshop.

INTRODUCTION: When clinicians feel negative emotions toward patients, providinge patient-centered care can be difficult. This can occur in family planning scenarios, such as when a provider is uncomfortable with a patient choosing abortion. The Professionalism in Family Planning Care Workshop (PFPCW), framed around professionalism values, used guided reflection to foster self-awareness and empathy in order to teach future providers to provide patient-centered care. METHODS: In the PFPCW, learners discussed challenging patient interactions and family planning scenarios to develop self-awareness and identify strategies for maintaining therapeutic relationships with patients when they experience negative feelings toward them. We implemented the workshop across the United States and Canada and collected pre- and postsurvey data to evaluate program outcomes at Kirkpatrick evaluation levels of participant reaction and effects on learners' attitudes. RESULTS: A total of 403 participants participated in 27 workshops in which pre- and postworkshop surveys (70% and 46% response rates, respectively) were administered. Sixty-five percent of the participants were residents, and 36% had previously participated in a similar workshop. The majority (92%) rated the PFPCWs as worthwhile. Participants valued the discussion and self-reflection components. Afterward, 23% reported that their attitudes toward caring for people with unintended pregnancy changed to feeling more comfortable. Participants said they would employ self-reflection and empathy in future challenging interactions. DISCUSSION: In this pilot implementation study, our workshop provided learners with strategies for patient-centered care in challenging family planning patient interactions. We are currently modifying the workshop and evaluation program based on feedback.

Twenty Years of the Ryan Residency Training Program in Abortion and Family Planning.

OBJECTIVE: To summarize the effects of routine, opt-out abortion and family planning residency training on obstetrics and gynecology (ob-gyn) residents' clinical skills in uterine evacuation and intentions to provide abortion care after residency. METHODS: Data from ob-gyn residency programs supported during the first 20 years of the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning were analyzed. Postrotation surveys assessed residents' training experiences and acquisition of abortion care skills. Residency program director surveys assessed benefits of the training to residents and the academic department from the educators' perspectives. RESULTS: A total of 2775 residents in 89 ob-gyn programs completed postrotation surveys for a response rate of 72%. During the rotation, residents - including those who only partially participated - gained exposure to and skills in first- and second-trimester abortion care. Sixty-one percent intended to provide abortion care in their postresidency practice. More than 90% of residency program directors (97.5% response rate) reported that training improved resident competence in abortion and contraception care and 81.3% reported that the training increased their own program's appeal to residency applicants. CONCLUSION: Over 20 years, the Ryan Program has supported programs to integrate abortion training to give ob-gyn residents the skills and inspiration to provide comprehensive reproductive health care, including uterine evacuation and abortion care, in future practice. Residency program directors noted that this integrated training meets resident applicants' expectations. IMPLICATIONS: Ryan Program residents are trained to competence and are prepared, both clinically and in their professional attitudes, to care for women's reproductive health.

Abortion Policies in U.S. Teaching Hospitals: Formal and Informal Parameters Beyond the Law.

OBJECTIVE: To evaluate the prevalence and features of policies regulating abortion in U.S. teaching hospitals. METHODS: In this mixed-methods study, we conducted a national survey of obstetrics and gynecology teaching hospitals (2015-2016) and qualitative interviews (2014 and 2017) with directors at obstetrics and gynecology residency programs. We asked participants about hospital regulations on abortion and their perceptions of the nature and enforcement of these policies. Interview analysis was conducted with a grounded theoretical approach and informed development of the survey. The prevalence of policies was described using survey data; differences in policy structures by region were analyzed using a series of logistic regression models. RESULTS: Directors from 169 of 231 eligible training programs responded to the survey (73%). Institutional policies limited abortion beyond state law in 57% of teaching hospitals, most commonly in the Midwest and South (odds ratio [OR] 4.3, P<.01 for Midwest; OR 4.0, P=.001 for South vs Northeast). Policies varied in form (written and unwritten) and restricted abortion based on the indication for the procedure and gestational age. Nonmedically indicated, or "elective" procedures were more commonly restricted (48% of sites reporting any policy and 25% prohibiting these abortions altogether) than medically indicated ones (28% of sites reporting any policy.) Policies were created by those with institutional power, including hospital leadership and obstetrics and gynecology department chairs, and were perceived to be motivated by personal beliefs and a desire to avoid controversy. Rules were commonly enforced by medical specialists, hospital ethics committees, and department chairs. Qualitative data highlighted the convoluted nuances of these policies, which often put clinicians at odds with their professional mandates. DISCUSSION: Reportedly driven by broader institutional interests, obstetrics and gynecology teaching hospital policies often restricted abortion beyond state law to the detriment of abortion access and training opportunities. Vague or unwritten abortion policies, although difficult to navigate, gave health care providers some agency and flexibility over their practices.

Interprofessional Abortion Opposition: A National Survey and Qualitative Interviews with Abortion Training Program Directors at U.S. Teaching Hospitals.

CONTEXT: Hospital policies and culture affect abortion provision. The prevalence and nature of colleague opposition to abortion and how this opposition limits abortion care in U.S. teaching hospitals have not been investigated. METHODS: As part of a mixed-methods study, a nationwide survey of residency and site directors at 169 accredited obstetrics-gynecology training programs was conducted in 2015-2016, and 18 in-depth interviews with program directors were conducted in 2014 and 2017. The prevalence and nature of interprofessional opposition were examined using descriptive statistics, and regional differences were investigated using logistic regression. A modified grounded theoretical approach was used to analyze interview data. RESULTS: Among the 91% of survey respondents who reported that they or their colleagues had wanted or needed to provide abortions in the prior year, 69% faced opposition from colleagues. Most commonly, opposition came from nurses (58%), nursing administration (30%) and anesthesiologists (30%), manifesting as resistance to participating in or cooperating with procedures (51% and 38%, respectively). Fifty-nine percent of respondents had denied care to patients in the prior year because of colleagues' opposition. Respondents in the Midwest and South were more likely than those in the Northeast to deny abortion care to patients because of such opposition (odds ratios, 3.2 and 4.4, respectively). Interviews revealed how participants had to circumvent opposing colleagues, making abortion provision difficult and leading to delays in and, infrequently, denial of abortion care. CONCLUSIONS: Interprofessional opposition to abortion is widespread in U.S. teaching hospitals. Interventions are needed that prioritize patients' needs while recognizing the challenges hospital colleagues face in their abortion participation decisions.

Racial diversity in abortion education and intention to provide abortion in postresidency practice: data from the Ryan Program.

BACKGROUND: In 2011, 38% of US reproductive-aged women lived in the 89% of counties with no abortion provider. Physicians from racial and ethnic minority backgrounds (black, Latino, Native American, and Asian American) are more likely than white physicians to practice in underserved areas and serve patients who are poor or minorities. Abortion patients are racially diverse. However, we know little about racial and ethnic makeup of abortion providers and the differences in physicians' interest in providing abortions. OBJECTIVE: The objective of the study was to examine racial differences in participation in abortion training and intention to provide abortion in postresidency practice. STUDY DESIGN: This is a cross-sectional study of Ryan Program residents after completing a family-planning rotation. The Ryan Program supports obstetrics-gynecology residency programs to incorporate routine abortion care into training. Since 2003 the Ryan Residency Program has administered postrotation resident surveys, and race/ethnicity was added in 2015. We assessed correlates of intention to provide abortion, specifically comparing minorities with whites and whether training participation varied by race. We conducted a modified mediation analysis to assess the role of potential mediators in the relationship between race and intention to provide abortion. RESULTS: A total of 777 residents (79.0%) responded from September 2015 through August 2018. The proportions were as follows: 64.9% white, 8.5% black, 4.1% Hispanic/Latino, 18.8% Asian, and 3.8% as other. Overall, 56.9% intended to provide abortion for all indications and 82.4% for pregnancy complications. In a univariate analysis, Asian residents were significantly more likely to intend to provide abortions for all indications compared with white residents (68.4% vs 56.0%, odds ratio, 1.69, confidence interval, 1.13-2.53). This difference was not significant when controlling for religiosity and abortion attitudes. Religiosity (odds ratio, 0.60, confidence interval, 0.47-0.77) and abortion attitude (odds ratio, 3.32, confidence interval, 2.48-4.44) were significantly correlated with intention to provide abortion for nonmedical indications after residency. In a modified mediation analysis, the relationship between race and intention to provide was mediated by religiosity for black residents and abortion attitude for Asian residents. There was no difference in participation in abortion training by race/ethnicity. CONCLUSION: Racial differences in intention to provide abortion in postresidency practice are mediated by religiosity and abortion attitude. Better understanding the intricate relationships between race, religiosity, participation in training, and future practice will allow us to improve abortion training while paving the way to support a more diverse abortion provider workforce.

Sources of support for and resistance to abortion training in obstetrics and gynecology residency programs.

BACKGROUND: Only 64% of obstetrics and gynecology program directors report routine, scheduled training in abortion, despite the Accreditation Council for Graduate Medical Education's requirements for routine training. Most report that exposure to training is limited to specific clinical circumstances. OBJECTIVE: We sought to describe residency program directors' perspectives of support for and resistance to abortion training in residency training programs in the United States. MATERIALS AND METHODS: A national survey of directors explored the availability of abortion training as well as support for and resistance to abortion training within their departments and institutions. In addition, directors who indicated that training was not available at all, available only as an elective, or as routine but limited to specific clinical circumstances, were also asked which procedures were limited, in what ways, and by whom. Descriptive and bivariate analyses were performed. RESULTS: A total of 190 residency program directors (79%) responded from throughout the United States (30% in the Northeast, 30% in the South, 23% in the Midwest, and 16% in the West), and 14% described their program as religiously affiliated. Most directors (73%) reported at least some institutional or government restrictions to training, and reported an average of 3 types of restrictions. Hospital policy was the most commonly reported restriction, followed by state law. Programs with routine abortion training reported an average of 2 restrictions, compared with 4 restrictions in programs with optional training, and 5 restrictions in programs with no abortion training. CONCLUSION: Significant barriers to integrating abortion training into residents' schedules continue to exist decades after the Accreditation Council for Graduate Medical Education training mandate. We should use these data to develop better support and targeted strategies for increasing the number of trained abortion providers in the United States.

The importance of access to comprehensive reproductive health care, including abortion: a statement from women's health professional organizations.

Barriers to women's reproductive health care access, particularly for termination of pregnancy, are increasing at the local, regional, and national levels through numerous institutional, legislative, and regulatory restrictions. Lack of access to reproductive health care has negative consequences for women's health. Twelve women's health care organizations affirm their support for access to comprehensive reproductive health care, including abortion.

Abortion training in US obstetrics and gynecology residency programs.

BACKGROUND: Nearly 15 years ago, 51% of US obstetrics and gynecology residency training program directors reported that abortion training was routine, 39% reported training was optional, and 10% did not have training. The status of abortion training now is unknown. OBJECTIVE: We sought to determine the current status of abortion training in obstetrics and gynecology residency programs. STUDY DESIGN: Through surveying program directors of US obstetrics and gynecology residency training programs, we conducted a cross-sectional study on the availability and characteristics of abortion training. Training was defined as routine if included in residents' schedules with individuals permitted to opt out, optional as not in the residents' schedules but available for individuals to arrange, and not available. Findings were compared between types of programs using bivariate analyses. RESULTS: In all, 190 residency program directors (79%) responded. A total of 64% reported routine training with dedicated time, 31% optional, and 5% not available. Routine, scheduled training was correlated with higher median numbers of uterine evacuation procedures. While the majority believed their graduates to be competent in first-trimester aspiration (71%), medication abortion (66%), and induction termination (67%), only 22% thought graduates were competent in dilation and evacuation. Abortion procedures varied by clinical indication, with some programs limiting cases to pregnancy complication, fetal anomaly, or demise. CONCLUSION: Abortion training in obstetrics and gynecology residency training programs has increased since 2004, yet many programs graduate residents without sufficient training to provide abortions for any indication, as well as dilation and evacuation. Professional training standards and support for family planning training have coincided with improved training, but there are still barriers to understand and overcome.

Exploring How Residents Who Partially Participate in Family Planning Training Determine Their Level of Participation.

OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) requires that obstetrics and gynecology residency programs provide access to abortion training, though residents may elect to opt out of participating due to religious or moral objections. While clinical benefits of partial participation have previously been explored, our study aimed to explore how residents navigate partial participation in abortion training and determine their limits. STUDY DESIGN: This study was qualitative in nature. Between June 2010 and June 2011, we conducted 26 semi-structured phone interviews with residents who opted out of some or all of the family planning rotation at 19 programs affiliated with The Ryan Residency Training Program. Faculty directors identified eligible residents, or residents self-reported in routine program evaluation. We analyzed data using the conventional content analysis method. RESULTS: We interviewed all 26 (46%) of 56 eligible residents willing to be interviewed. Three main categories constituted the general concepts concerning resident decision-making in training participation: (1) variation in timing of when residents determined the extent of participation, (2) a diversity of influences on the residents' level of participation, and (3) the perception of support or pressure related to their participation decision. CONCLUSIONS: The findings indicated that residents who partially participate in abortion training at programs with specialized opt-out family planning training weigh many factors when deciding under what circumstances, if any, they will provide abortions and participate in training.

Impact of partial participation in integrated family planning training on medical knowledge, patient communication and professionalism.

INTRODUCTION: Obstetrics and gynecology residency programs are required to provide access to abortion training, but residents can opt out of participating for religious or moral reasons. Quantitative data suggest that most residents who opt out of doing abortions participate and gain skills in other aspects of the family planning training. However, little is known about their experience and perspective. METHODS: Between June 2010 and June 2011, we conducted semistructured interviews with current and former residents who opted out of some or all of the family planning training at ob-gyn residency programs affiliated with the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning. Residents were either self-identified or were identified by their Ryan Program directors as having opted out of some training. The interviews were transcribed and coded using modified grounded theory. RESULTS: Twenty-six physicians were interviewed by telephone. Interviewees were from geographically diverse programs (35% Midwest, 31% West, 19% South/Southeast and 15% North/Northeast). We identified four dominant themes about their experience: (a) skills valued in the family planning training, (b) improved patient-centered care, (c) changes in attitudes about abortion and (d) miscommunication as a source of negative feelings. DISCUSSION: Respondents valued the ability to partially participate in the family planning training and identified specific aspects of their training which will impact future patient care. Many of the effects described in the interviews address core competencies in medical knowledge, patient care, communication and professionalism. We recommend that programs offer a spectrum of partial participation in family planning training to all residents, including residents who choose to opt out of doing some or all abortions. IMPLICATIONS: Learners who morally object to abortion but participate in training in family planning and abortion, up to their level of comfort, gain clinical and professional skills. We recommend that trainers should offer a range of participation levels to maximize the educational opportunities for these learners.

Availability and characteristics of abortion training in US ob-gyn residency programs: a national survey.

OBJECTIVE: To assess the availability and characteristics of abortion training in US ob-gyn residency programs. METHODS: We surveyed fourth-year residents at US residency programs by email regarding availability and type of abortion training, procedural experience and self-assessed competence in abortion skills. We conducted multivariable, ordinal logistic regression with general estimating equations to determine individual-level and resident-reported, program-level correlates of quantity of uterine evacuation procedures done during residency. RESULTS: Three hundred sixty-two residents provided data, representing 161 of the 240 residency programs contacted. Access to training in elective abortion was available to most respondents: 54% reported routine training--where abortion training was routinely scheduled; 30% reported opt-in training--where training was available but not routinely integrated; and 16% reported that elective abortion training was not available. Residents in programs with routine elective abortion training and those who intended to do abortions before residency did a greater number of first-trimester manual uterine aspiration and second-trimester dilation and evacuation procedures than those without routine training. Similarly, routine, integrated training, even for indications other than elective abortion, correlated with more clinical experience (all p<.01, odds ratio and confidence interval shown below). CONCLUSION: There is a strong independent relationship between routine training and greater clinical experience with uterine aspiration procedures.

Barriers to D&E practice among family planning subspecialists.

OBJECTIVE: Over 95% of all second-trimester abortions are managed by dilation and evacuation procedures (D&E) and account for nearly 9% of all abortions in the United States annually. The Fellowship in Family Planning (FFP) offers subspecialty training in abortion and contraception to obstetrician-gynecologists and family medicine physicians. Twenty years after the FFP founding, we report on the abortion practice characteristics and specific barriers these subspecialists face. STUDY DESIGN: We surveyed obstetrician-gynecologist family planning (FP) subspecialists by email regarding second-trimester abortion training and practice barriers with a focus on D&E. RESULTS: Our response rate was 62% (105/169) of all fellowship-affiliated physicians. Respondents were composed primarily of young women working in academic settings in the West and Northeast regions. Nearly all FP subspecialists have been trained to 24 weeks' gestation and currently provide D&Es, with an average of nearly 200 per year. D&E practice barriers vary by geographical location and degree of "regional restrictiveness." FP subspecialists practicing in more abortion-restrictive regions were four times more likely to report a personal main barrier (such as concern for safety) than other types of main barriers (p=.05). Providing D&Es in a hospital operating room was associated with 2.8 times higher odds of reporting an institutional or coworker main barrier (p=.02). High-volume D&E practice was associated with three times lower odds of reporting an institutional/coworker main barrier (p=.02). CONCLUSIONS: By identifying the barriers to D&E practice experienced by FP subspecialists, we can begin to develop a coordinated approach to eradicating modifiable barriers and, ultimately, improve access for women seeking D&E services.

The benefits of family planning training: a 10-year review of the Ryan Residency Training Program.

OBJECTIVE: The objective was to determine the effect of routine, opt-out abortion and family planning training on clinical exposure to uterine evacuation, contraception and other gynecologic skills. METHODS: Data from the first 10 years of the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning were analyzed. Pre- and postrotation surveys assessed residents' experience with abortion, contraception and other gynecologic skills. Thirty-nine residency program director surveys were analyzed to assess benefits of the training from the educators' perspective. RESULTS: A total of 491 residents completed both pre- and postrotation surveys. During the rotation, residents, including those who partially participated, gained significant exposure to all methods of first- and second-trimester termination and contraception care. Ninety-seven percent of Residency Program Directors reported that training improved resident competence in abortion and contraception care. CONCLUSION: Routine, opt-out training in abortion and family planning gives OB-GYN residents an opportunity to increase proficiency in patient counseling, contraception care, ultrasound and all aspects of uterine evacuation, regardless of level of participation.

Medical education and family planning: developing future leaders and improving global health.

Well-trained medical professionals are key to improving global reproductive health and reducing rates of unsafe abortion, but medical training often fails to prepare practitioners to provide essential family planning services. The field of medical education is currently undergoing reformation to better meet the needs of a global population, and comprehensive, integrated family planning training will be an important part of those reforms. Family planning training is not only vital to address global reproductive healthcare demand, but integrates effectively with cornerstones of current medical education reform: competency-based education, leadership development, collaboration with practitioners of all levels, and global health context. Examples of successful integration of family planning education are outlined, and recommendations for integrating family planning into medical education detailed at the 2012 FIGO World Congress are discussed.

Opting out of abortion training: benefits of partial participation in a dedicated family planning rotation for ob-gyn residents.

BACKGROUND: This study was conducted to describe the experiences of residents who opt out of some components of a dedicated abortion rotation. STUDY DESIGN: Eligible residents at programs receiving funding from the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning were invited to complete a cross-sectional, online survey. RESULTS: The majority of residents who opted out of some portion of the family planning training reported that the rotation positively affected skills in pregnancy options counseling, cervical dilation, first-trimester ultrasound, techniques of first-trimester uterine evacuation and other skills. Twenty-one of the 65 (31%) did an elective abortion, and 56 (84%) completed aspirations for at least one non-elective indication including therapeutic abortion and miscarriage. While no resident desired additional elective abortion training, 11 (16%) wanted additional uterine aspiration and 14 (21%) wanted additional second-trimester uterine aspiration training for non-elective indications. CONCLUSION: Providing access to an abortion rotation for residents who do not plan to do elective abortions gives them the opportunity to improve their skills in family planning, therapeutic abortion and miscarriage management.