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.

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.

Dilation and evacuation training in maternal-fetal medicine fellowships.

OBJECTIVE: Many maternal-fetal medicine (MFM) specialists provide dilation and evacuation (D&E) procedures for their patients with fetal or obstetric complications. Our study describes the D&E training opportunities that are available to MFM trainees during their fellowship. STUDY DESIGN: National surveys of MFM fellows and fellowship program directors assessed the availability of D&E training in fellowship. Univariate and multivariate comparisons of correlates of D&E training and provision were performed. RESULTS: Of the 270 MFM fellows and 79 fellowship directors who were contacted, 92 (34%) and 44 (56%) responded, respectively. More than one-half of fellows (60/92) and almost one-half of fellowship programs (20/44) report organized training opportunities for D&E. Three-quarters of fellows who were surveyed believe that D&E training should be part of MFM fellowship, and one-third of fellows who have not yet been trained would like training opportunities. Being at a fellowship that offers D&E training is associated with 7.5 times higher odds of intending to provide D&E after graduation (P = .005; 95% confidence interval, 1.8-30). CONCLUSION: MFM physicians are in a unique position to provide termination services for their patients with pregnancy complications. Many MFM subspecialists provide D&E services during fellowship and plan to continue after graduation. MFM fellows express a strong interest in D&E training; therefore, D&E training opportunities should be offered as a part of MFM fellowship.

"I Went Into This Field to Empower Other People, and I Feel Like I Failed": Residents Experience Moral Distress Post-Dobbs.

Background The 2022 Supreme Court ruling in Dobbs v Jackson Women's Health Organization nullified the constitutional right to abortion, which led to effective bans in at least 14 US states and placed obstetrics and gynecology (OB/GYN) residents in dilemmas where they may have to withhold care, potentially causing moral distress-a health care workforce phenomenon less understood among resident physicians. Objective To identify and explore moral distress experienced by OB/GYN residents due to care restrictions post-Dobbs. Methods In 2023, we invited OB/GYN residents, identified by their program directors, training in states with restricted abortion access, to participate in one-on-one, semi-structured interviews via Zoom about their experiences caring for patients post-Dobbs. We used thematic analysis to analyze interview data. Results Twenty-one residents described their experiences of moral distress due to restrictions. We report on 3 themes in their accounts related to moral distress (and 4 subthemes): (1) challenges to their physician identity (inability to do the job, internalized distress, and reconsidering career choices); (2) participating in care that exacerbates inequities (and erodes patient trust); and (3) determination to advocate for and provide abortion care in the future. Conclusions OB/GYN residents grappled with moral distress and identified challenges from abortion restrictions.

The association between abortion training and obstetrics and gynecology resident competence and intention to provide abortion care before Dobbs.

OBJECTIVE: To assess the role of abortion training in fourth-year obstetrics and gynecology (OBGYN) residents' abortion care competence and practice intentions before the Dobbs decision. STUDY DESIGN: This is a planned secondary analysis of survey data of fourth-year U.S. OBGYN residents. Abortion training was defined as 'routine' if automatically included in schedules, ''optional'' if not scheduled but available, and ''not available''. Self-assessed competence was defined as feeling prepared to independently provide care. Participants were asked about their competence and post-residency intentions to provide specific aspects of pregnancy loss and induced abortion care. RESULTS: Of 1241 fourth-year residents, 885 (71%) completed the questions of interest. For each skill, more residents with routine training reported competence compared to those with less comprehensive training. More residents with routine training reported intentions to include abortion care in practice (422, 79%) compared to residents with optional (171, 66%) or no training (51, 55%), p < 0.001). Residents with routine training were nearly six times more likely to intend to provide medication abortion post-residency compared to residents without training; more residents in all groups reported intentions to provide care for pregnancy loss compared to abortion. CONCLUSIONS: Pre-Dobbs, residents with routine abortion training had greater self-assessed competence in abortion care than those with optional or no training and were more likely to intend to provide this after residency. Given the evolving impacts of the 2022 reversal of Roe v Wade, residency training programs must work to ensure routine access to legally permissible abortion training as routine training is associated with intention to provide fundamental, reproductive healthcare. IMPLICATIONS: Routine training in abortion care during OBGYN residency is associated with higher competence and intention to provide post-residency - availability of this training Is severely compromised in restricted states post-Dobbs.

Abortion training in U.S. obstetrics and gynecology residency programs in a post-Dobbs era.

OBJECTIVES: The Accreditation Council for Graduate Medical Education requires all obstetrics and gynecology residents have access to abortion training. The impact of Dobbs on training remains unknown. We aimed to describe residency programs affected by abortion bans and those lacking abortion training despite permissive state policies. We considered demographic data to understand the impacts on residents under-represented in medicine. STUDY DESIGN: We used residency databases and websites to abstract data. We identified programs offering routine abortion training as either those with Ryan Programs or those with website or email acknowledgment of training. We defined states with abortion bans as those with either complete or 6-week bans as of December 2022. We used χ2 and Student's t tests in descriptive analyses and performed a logistic regression to adjust for demographic and program-specific variables. RESULTS: Of 286 residency programs included, 140 (49%) offered routine abortion training prior to Dobbs. As of December 2022, 19 of these (14%) had lost the ability to provide routine in-state abortion training. Of 223 residency programs in states with legal abortion, 102 (46%) programs lacked routine abortion training. These sites were more likely to be community or community-university programs, with graduates more likely to practice as generalists. Resident race/ethnicity did not differ between residents in states with legal abortion vs abortion bans. CONCLUSIONS: Nearly half of obstetrics and gynecology residency programs in states with legal abortion do not appear to provide routine abortion training. Further work is needed to understand this paucity of training and maximize access in legislatively permissible environments. IMPLICATIONS: Following Dobbs, 14% of residency programs lost in-state abortion training. Notably, in states with legal abortion, 46% of programs lack routine abortion training despite permissive legislation. This presents a window of opportunity for expansion of abortion training, particularly at community and community-university hybrid residency sites.

Trainee Perspectives Regarding the Effect of the Dobbs v. Jackson Women's Health Organization Supreme Court Decision on Obstetrics and Gynecology Training.

Objectives: We aimed to describe obstetrics and gynecology (OBGYN) trainees' anticipation of how the Dobbs v. Jackson Women's Health Organization (Dobbs) U.S. Supreme Court decision may affect their training. Methods: A REDCap survey of OBGYN residents and fellows in the United States from September 19, 2022, to December 1, 2022, queried trainees' anticipated achievement of relevant Accreditation Council for Graduate Medical Education (ACGME) training milestones, their concerns about the ability to provide care and concern about legal repercussions during training, and the importance of OBGYN competence in managing certain clinical situations for residency graduates. The primary outcome was an ACGME program trainee feeling uncertain or unable to obtain the highest level queried for a relevant ACGME milestone, including experiencing 20 abortion procedures in residency. Results: We received 469 eligible responses; the primary outcome was endorsed by 157 respondents (33.5%). After correction for confounders, significant predictors of the primary outcome were state environment (aOR = 3.94 for pending abortion restrictions; aOR = 2.71 for current abortion restrictions), trainee type (aOR = 0.21 for fellow vs. resident), and a present or past Ryan Training Program in residency (aOR = 0.55). Although the vast majority of trainees believed managing relevant clinical situations are key to OBGYN competence, 10%-30% of trainees believed they would have to stop providing the standard of care in clinical situations during training. Conclusions: This survey of OBGYN trainees indicates higher uncertainty about achieving ACGME milestones and procedural competency in clinical situations potentially affected by the Dobbs decision in states with legal restrictions on abortion.

An educational workshop and student competency in pregnancy options counseling: a randomized controlled trial.

OBJECTIVE: We sought to determine the effect of a pregnancy options counseling workshop focusing on communication skills and ethics on medical student competency. STUDY DESIGN: This educational trial randomized 105 third-year students to performance of an objective structured clinical examination before or after participation in the workshop assessed by a blinded reviewer. The primary outcome variable was student-level global competency in options counseling; secondary outcomes included competency components of general communication. RESULTS: Global competency was achieved by 36% of students in the preworkshop group and 50% in the postworkshop group (P = .16). Students who participated in the workshop demonstrated higher communication skills. Student ratings of objective structured clinical examination quality were 96-100% positive, with 80% reporting an increase in comfort with options counseling and 88% reporting increased comfort with communication skills. CONCLUSION: Participation in a workshop focusing on conscientious refusal positively improved communication skills, but did not significantly impact students' competency in pregnancy options counseling.

Maternal-fetal medicine subspecialists' provision of second-trimester termination services.

OBJECTIVE: Most abortions for pregnancy complications occur in the second trimester. Little is known about whether maternal-fetal medicine subspecialists (MFMs) perform terminations for these women. STUDY DESIGN: We surveyed all members of Society of Maternal Fetal Medicine by e-mail or mail regarding second-trimester abortion provision. We conducted analyses of whether MFMs perform abortions, by what method, and how frequently. RESULTS: Our response rate was 32.4% (689/2,125). Over two-thirds of respondents perform either dilation and evacuation (D&E) or induction; 31% perform D&Es. Male gender, frequent chorionic villus sampling provision, and being trained in D&E during fellowship are associated with performing D&Es. Nonprovision of any second-trimester abortion is significantly associated with age over 50, nonacademic practice setting, and less supportive abortion attitudes (p < 0.001). A nonsignificant trend toward association between south/southeast region and nonprovision of any second-trimester abortion is seen (p = 0.09). CONCLUSION: Many MFMs include D&E and induction termination services in their practice. Supporting current D&E providers and expanding training options for MFMs may optimize care for women diagnosed with serious pregnancy complications.

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

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.

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.

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.

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.

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.

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.