US doctors struggle to get basic abortion training two years after fall of Roe

<span>A group of doctors join abortion rights supporters at a rally outside the supreme court in Washington DC on 24 April 2024.</span><span>Photograph: Andrew Harnik/Getty Images</span>
A group of doctors join abortion rights supporters at a rally outside the supreme court in Washington DC on 24 April 2024.Photograph: Andrew Harnik/Getty Images

The fall of Roe v Wade upended Dr Jasmine Chan’s career.

As a medical student, the Texas native wanted to provide abortions as an OB-GYN. But in 2022, as Chan prepared to apply for residency – a kind of years-long apprenticeship after medical school – she worried that the quirks of the residency placement process would keep her in Texas, which banned abortions after the US supreme court overturned Roe.

“I met with my advisers and I had very strong heart-to-heart conversations about how I couldn’t see myself practicing medicine if it didn’t include me getting to do abortions,” Chan said. Instead of becoming an OB-GYN, she decided to become a family medicine doctor – a less competitive specialty that increased her chances of finding a residency in a state that protects abortion access.

Now, two years into her residency program in New Jersey, Chan is preparing to finally get the training that she’s longed for her entire career. But, like many other doctors seeking abortion training after Roe’s demise, she will still have to overcome hurdles that didn’t exist just two years ago.

Over the next few months, Chan will pursue abortion training in two different clinics, the closest of which is three hours away, on top of her day job. In the fall, she’ll need to relocate entirely for training at a third clinic.

She’ll have to jump through all of those hoops because there just aren’t enough clinics left to train the US’s future doctors in a relatively quick, straightforward procedure that one in four women will undergo at some point in their lives.

Clinical training sites are overburdened just trying to meet patient need

Latona Giwa of the Midwest Access Project

When the US supreme court overturned Roe exactly two years ago, it paved the way for more than a dozen states to outlaw almost all abortions. It also plunged the American medical training system into chaos. Because many hospitals have long refused to perform most abortions, residents who want to learn the procedure have often received their training at abortion clinics. But now that bans have shuttered so many clinics, there are just not enough facilities to train all the residents.

“Clinical training sites are overburdened just trying to meet patient need, which makes it far less likely that they will accept as many trainees or for as many days as they used to,” said Latona Giwa, executive director of the Midwest Access Project, a non-profit that helps a range of healthcare professionals receive reproductive healthcare training, including abortion instruction.

But if they don’t, she said, “we will not have a next generation of abortion providers.”

Doctors across the country already say that abortion bans have forced them to delay care for pregnant women in medical emergencies. But as abortion training becomes more scarce, or accessible only to doctors such as Chan who have time and money to clear a logistical obstacle course, fewer doctors will have the skills to handle dangerous pregnancy complications, including miscarriages, which are often treated with the same procedures used in abortions.

Abortion training may soon become even harder to access. Project 2025, a playbook written by the influential thinktank the Heritage Foundation in anticipation of a second Donald Trump administration, recommends that the Department of Health and Human Services “ensure that training for medical professionals (doctors, nurses, etc) and doulas is not being used for abortion training”.

Project 2025 also recommends penalizing institutions that don’t make it easier for medical professionals to opt out of abortion training on conscience grounds.

Although the language is ambiguous, enforcing it could ultimately lead to the prohibition or even criminalization of abortion training, said Mary Ziegler, a professor at the University of California, Davis, who studies the legal history of reproduction.

“It sounds like, ideally, they want to defund or essentially have like a Hyde amendment for any kind of federal support, whether direct or indirect, for training,” said Ziegler, referring to a nationwide rule that bans the use of federal dollars for abortions. Residency programs and medical schools, like virtually all US educational institutions, take money from the federal government.

‘It is just so siloed’

It has never been exactly easy for American doctors to learn how to perform abortions. The hospital systems that run medical schools and residency programs are deeply hierarchical institutions that rely on public dollars – and so they tend to steer clear of issues as controversial as abortion. In 1992, two decades after the US supreme court first decided Roe, only 12% of OB-GYN residency programs routinely offered training in abortion. Three years later, the Accreditation Council for Graduate Medical Education decided, for the first time, to mandate that OB-GYN residency programs teach doctors how to perform abortions.

Still, as of 2018, just 64% OB-GYN residencies offered routine, dedicated abortion training. Meanwhile, hospitals provided just 3% of all abortions – and, usually, only in high-risk pregnancies or cases of fetal anomalies. That left the burden of training to abortion clinics.

To help close the gap, a national initiative called the Ryan Residency Training Program (RRTP) helps place OB-GYN residents with clinics for training.

In 2021, when Texas enacted a six-week abortion ban, the RRTP stepped up to help residents travel out of state for abortion training. But the process turned out to be a bureaucratic nightmare, as programs and clinics struggled to secure the right paperwork and legal clearances.

“Oh my God, it took six months before even the first resident could travel,” said Dr Jody Steinauer, who leads the RRTP. “That’s how hard it is to set these up.”

After Roe fell, the Accreditation Council for Graduate Medical Education announced that it would mandate OB-GYN programs to either offer residents training in abortion or send them to states where they can get it. However, a spokesperson for the council declined to say how many OB-GYN programs currently met that requirement. There are now nearly 1,300 OB-GYN residents living and working in states with near-total abortion bans – all of whom must travel out of state for hands-on training in abortion.

The RRTP has helped 16 programs in states with abortion bans set up partnerships to help residents travel out of state for training.

States with abortion bans, which tend to have among the highest rates of maternal mortality and morbidity in the nation, are now facing a worsening OB-GYN shortage. Fewer OB-GYNs are even applying to residency programs in those states. Louisiana, for example, saw a 17% drop; Alabama saw a 21% drop; Missouri, 25%.

Alongside OB-GYNs, family medicine doctors are the specialists most likely to learn how to perform abortions. But they aren’t required to complete that training – and the ones who want it, even in blue states, can’t necessarily acquire it.

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“There’s just a lot more competition for training spots,” said Erica Chong, executive director of the Reproductive Health Education in Family Medicine (Rhedi) program, the family medicine version of the RRTP.

Dr Amy Hoffman is a family medicine resident in Pennsylvania, a state that permits abortions. But although her institution supports her desire to learn to provide abortions, it does not have any faculty with the skills to teach her. At this point in her residency, she’s doubtful that she’ll get the training.

“I have to find a month where I can leave my residency and give myself months and months ahead of planning to get the medical agreements in place,” Hoffman said.

Her day job is already arduous enough. Residency programs are permitted to require residents to work up to 80 hours a week; they can also make them work 28-hour shifts.

“Every doctor in every specialty has seen a caesarean or seen an appendectomy or taken care of diabetes, but the majority of doctors have never seen abortion care and never seen the procedure performed,” Hoffman said. “It is just so siloed and inaccessible to patients and learners alike.”

A jump in interest

Advocates across the medical training field are thrilled that, since Roe fell, so many new providers want to get trained in abortion. A handful of new residency programs have already joined the Rhedi program. Steinauer said that there is now “a lot more collaboration, within states, within regions, nationally” between institutions looking to bulk up their abortion training.

The Midwest Access Project received nearly 50 applications in its first application cycle after Roe’s downfall. At the time, that was the most it had ever received.

Now the non-profit receives somewhere between 100 and 200 applications each cycle. It’s still only able to accept about 50 people each cycle, but it gives Giwa hope.

“That’s a huge number of great impact, because every time one abortion-trained provider is added to a community or region, a state, they can train tenfold providers and they can do it in a primary care setting, ideally,” Giwa said. She envisions a future in which “you can just go get your allergy medicine and your abortion pills from the same person, and it’s not this huge extra ordeal”.