Rachel is a third-year OB-GYN resident at a medical institute in Texas and last year, when the Dobbs vote overturned Roe v Wade, her education was derailed. For her safety, she declined to offer her last name or where she studies. In June 2022, the state’s “trigger law” went into effect and abortions became illegal – first after six weeks, now full stop.
“I was horrified and angry,” said Rachel, when Roe was reversed.
Following the ban, clinics in Texas have stopped providing abortion care to patients, as well as training to medical residents like Rachel.
Yet as a part of a national program requirement, under the Accreditation Council for Graduate Medical Education (ACGME), Rachel needs to have experience in abortion procedures to become an OB-GYN physician. In Texas, abortion training is now limited to miscarriage procedures, but not hands-on abortion care.
“I went into OB-GYN to help women understand the options they have surrounding their health,” continued Rachel. “I can’t think of another example in any other field of medicine where the law so clearly oversteps the boundaries of the patient-physician relationship by completely removing a safe, effective and well-studied healthcare option.”
Like Rachel, countless OB-GYN residents across the nation are finding their education at odds with recent abortion bans. One year after the Dobbs vote, 14 states have banned abortions outright, with several more imposing six- to 20-week bans. In some states, like Texas, Kentucky, Louisiana and Missouri, doctors could face felonies if they perform an abortion outside of saving a patient’s life. In this harsh new reality, OB-GYN programs nationwide are grappling with the logistical and legal challenges of how to graduate competent residents.
To meet her program requirement, last November, Rachel became the first out-of-state resident at Oregon Health & Science University (OHSU) in Portland. Sponsored by its Abortion Care and Training Fund, OHSU is now accepting OB-GYN residents from restrictive states for a month-long rotation in abortion procedures and surgeries, along with patient counseling.
“I had so little familiarity about what abortion care looked like that I really didn’t know what to expect at OHSU,” said Rachel, who called conversations around abortion there “more down-to-earth, practical, and straightforward than I would have assumed”.
“I was unsure how I would reconcile having sought out this training with my plans to return to a state where abortion is illegal,” she said. Back in Texas now, Rachel called it “frustrating” not being able to use her training. While she can advise patients to travel out of state for abortion care, “you have to be very careful and not document that you’ve had those discussions, because you put yourself at a lot of risk.”
Nationally, Oregon ranks as the state most protective of abortion.
“You really can’t separate out abortion from obstetrics and gynecology. It is basic essential healthcare,” said Alyssa Colwill, assistant professor of obstetrics and gynecology in the OHSU School of Medicine, who heads the new partnership. “And if you restrict a portion of it, it means that every other aspect of pregnancy is going to be a higher risk.” This includes long-term health complications and even a patient’s ability to get pregnant in the future.
OSHU’s new offering falls under the umbrella of its well-established Ryan Residency Training Program, a national initiative that directly works with more than 100 OB-GYN residency programs across the country to provide abortion training and contraception care.
“There are large ripple effects of these harmful policies that aren’t just limited to somebody trying to get an abortion,” said Colwill. “It is interrupting the obstetrics and gynecology field.”
Post-Dobbs, 19% of all OB-GYN residency programs across the nation – and over 1,100 residents – are located in states with the most restrictive bans. This includes eight Ryan Residency Training Programs.
To help cushion the blow, the Ryan Program at Cedars-Sinai in Los Angeles has created a partnership with its Planned Parenthood affiliate, where residents from a state in which abortion is banned can come to undertake their abortion training requirement. For the safety of its residents, Cedars-Sinai declined to identify the state.
Katrina Heyrana, director of Cedars-Sinai’s Ryan Program, is hoping that its partnership will have a farther reach than just medical training.
“One of the great things for [residents] coming over to California to train is that they can see how accessible and how normal abortion care is, and how truly low risk it is … which makes them more likely to become advocates,” she explained.
Still, while out-of-state rotations can help broaden perspectives, Heyrana said it was challenging “for programs in supportive states to be able to accommodate huge volumes of residents from restrictive states, because we also have the responsibility to train our own residents”.
In Oregon, the volume of applicants that OHSU received from abortion-restrictive states was so great that it had to launch its program nine months early, last autumn, to meet the demand. In its first formal application cycle, OHSU received 31 applicants from 21 different programs across 15 different states in which abortion training is limited or restricted.
To meet this demand in training, the national Ryan Residency Training Program, based at the University of California in San Francisco, is partnering with 15 of its programs in supportive states to host and train OB-GYN residents from states in which abortion is restricted.
Kristin Simonson, director of programs and operations at the national Ryan Residency Training Program, emphasized that abortion bans will hit rural areas the hardest, where gynecology often falls to family or general medicine. “It will be even harder now for family medicine residents to get abortion training because it’s not a specific requirement for their specialty,” she said. This creates a type of maternal care desert, where few general physicians are trained in pregnancy complications that might require termination.
Last month, the American College of Obstetricians and Gynecologists (ACOG) presented research that looked at how abortion bans are influencing medical students’ decisions about where to apply for residency, across all specialties. It found that over half (58.1%) of all respondents said they were unlikely to apply to a residency program in a state with abortion restrictions, potentially shifting the geographical distribution of healthcare.
In obstetrics and gynecology specifically, abortion bans also appear to be affecting the number of people entering the field. In April, the AAMC Research and Action Institute noted a 5% decrease in applicants for OB-GYN programs across all states, post-Dobbs. In states with abortion bans, there was a 10% decrease.
“They’re worried that they’re going to be criminally charged, they’re going to lose their license, they’re going to be put in prison for providing basic obstetric care,” said Colwill at OHSU.
Misha Pangasa is another out-of-state resident, from the University of Utah in Salt Lake City, who received her abortion training at OHSU last April. In Utah, abortion is banned after 18 weeks. Its statewide ban on abortion clinics is still tied up in the courts.
For her, being trained in the full scope of reproductive healthcare, including abortions, is wholly necessary – even if the law says she can’t provide them.
“At the end of the day, none of us were meant to be criminals,” said Pangasa, who does not speak for her university. “We are just trying to figure out what the best care is for our patients and how to give them that.”
Colwill said she had the greatest hopes that abortion rights will one day be restored. Until then, the institute will continue accepting out-of-state OB-GYN residents.
This article was amended on 20 June 2023 to correct the name of Oregon Health & Science University.
