Ghazaleh Moayedi credits many of her strengths as a Texas-based obstetrician-gynecologist to training related to abortion. Outpatient abortion training builds bedside manner and teaches practical technical skills outside of a hospital, she says.
"Having so much experience in abortion care has actually really trained me and prepared me in handling other situations," said Moayedi, a fellow with Physicians for Reproductive Health and a mentor to many residents.
She pointed to her adeptness with early ultrasonography, used to identify complications in early pregnancy.
But since the Supreme Court's Dobbs v. Jackson Women's Health Organization decision in June overturned the constitutional right to an abortion, broad bans on most abortions in Texas and other states could hamper training for future medical providers.
"I had a medical student that messaged me and said they were on their obstetrics rotation and were saying, like, 'People are coming in, and we're having to tell them, like, their bag of water broke, but we can't do anything until they have a fever.' That's not how we should be training people," Moayedi said.
More than a dozen medical groups, providers, residents and students expressed concern that changing laws will harm medical training in areas including miscarriage management counseling and reduce experience with emergency complications.
Experts say Dobbs' impact will vary based on local policies and resources, as will the effect on students, educators and practitioners navigating what is legal to practice, observe, refer, teach or prepare for. They also said the legal confusion may add to burnout among health care workers.
One option for students and educators in states where abortion is restricted is to work with institutions in places where it isn't.
The logistics of partnering with other institutions to get licensure agreements in place is difficult, said Jody Steinauer, who leads the Kenneth J. Ryan Residency Training Program in abortion and family planning at the University of California, San Francisco.
"When you're in a place where not many abortions are provided, and you're only learning for miscarriage patients, you just don't necessarily have enough volume," said Steinauer. "We're going to start having more and more programs that are going to have a hard time training residents to competence in the skills of emptying the uterus."
The nuances of restrictions could also amplify maternal care shortages, especially in rural areas with high maternal mortality rates. Providers say it could limit the ability to increase and even retain practitioners.
"We are already dealing with a doctor shortage in this state," said Rep. Susie Lee, D-Nev., during a July 15 press call organized by Nevada Democratic Victory. "We're going to see less residents choose to go into OB-GYN because they're not going to be able to practice health care that keeps their patients safe."
The Health Resources and Services Administration's Bureau of Health Workforce projected last year that the number of OB-GYNs will fall almost 7 percent, from 50,850 in 2018 to 47,490 in 2030, leaving a gap of 5,170 between supply and demand even as the population of women increases.
Erica Chong, executive director for Reproductive Health Education in Family Medicine, based in New York, said training could also suffer because out-of-state patients are pushing up the workload at clinics in states where abortion is still legal.
"I think training sort of falls off their priority because they're just trying to get patients the care they need," she said. "In general, I think there's just a lot more people trying to get trained at fewer spots that are available."
The questions arise just as medical school applications roll in and as medical school graduates plan for the next matching of residency programs in March 2023.
CQ Roll Call's analysis of the Association of American Medical Colleges found that 64 of its member schools, or 42 percent, are in states or territories enforcing or litigating pre-viability bans on abortion. About 23 schools, or 54 percent, belonging to the American Association of Colleges of Osteopathic Medicine could also feel the impact.
As of Monday, 20 states are implementing or in the midst of litigation over pre-viability bans.
States require different medical credentials to practice. Training also varies, by specialty, discipline, geography and individual interests.
Alison Whelan, AAMC's chief academic officer, said all medical schools require students to complete an obstetrics and gynecology clerkship, and obstetrics-gynecology residency programs must provide training or access to training on abortion — though residents who object may opt out of this part.
"It is important for physicians to have comprehensive training in women's reproductive health care, especially since the technical procedure for providing an abortion — dilation and curettage — is the same procedure that is performed after a miscarriage, or in some cases, to treat excessive bleeding or take a biopsy from the uterus," said Whelan.
David Forstein, president of Rocky Vista University College of Osteopathic Medicine and an OB-GYN in Colorado, said knowledge gaps are "a potential tragedy waiting to happen."
Rebecca Henderson, a third-year medical student at the University of Florida, said her calling to become an abortion provider was one reason she went to medical school, and she faced training roadblocks even before Dobbs, relying on opportunities through outside groups.
"I watched some of my peers who go through medical school with me go and do residency programs in places where they don't get that training. And it's like, they don't even recognize how much is missing," said Henderson, who is in an MD-Ph.D program. "You have to really seek it out."
The Accreditation Council for Graduate Medical Education is proposing to revise requirements for obstetrics and gynecology residents. Programs in states with bans would have to coordinate access at a program without legal barriers. If the resident can't travel, the program would have to provide simulations and assessments on uterine evacuation and pregnancy option counseling or other experience.
Abortion training is not limited to OB-GYN residents, and bans and restrictions also affect family medicine, emergency medicine and other specialties.
Religiously affiliated schools and hospitals already limit training related to abortion and long-acting contraceptives.
Not all providers think abortion bans will limit medical experience.
Christina Francis, CEO-elect of the American Association of Pro-life Obstetricians and Gynecologists, said her training at a Catholic hospital didn't affect her becoming board certified.
"We did not do any elective abortions at that hospital, and yet I was able to be trained in the full spectrum of OB-GYN and women's health care," she said, adding that hasn't affected her ability to treat ectopic pregnancies or miscarriages.
Francis said state bans won't prevent anyone from training at a school where abortion remains legal and will limit pressure on medical students to violate moral beliefs.
"I would just encourage legislators to, you know, ensure that they provide appropriate exceptions in their laws, so that it's very clear to physicians and to patients that emergency medical services, life-saving treatments for women can still be provided," she said.
Most medical groups, however, said they are worried that these bans will limit residents', students' and fellows' chance to gain experience in various procedures.
"Every OB-GYN program across the country, you're going to learn how to do a uterine aspiration, and dilation and curettage," said Moayedi. But she noted that it would be in the setting of miscarriage care, making it very different than the setting of abortion care. She added that few OB-GYN programs in Texas get integrated outpatient abortion care as part of the training.
Rebecca D. Lewis, a family physician in Oklahoma whose scope includes obstetrics, said her state's ban means she can't even discuss pregnancy termination with residents. She cited a case of several high school girls becoming pregnant and using an abortifacient meant for cattle because of the lack of options.
"Any of our residents who are in Oklahoma, whether they plan to stay here or practice in a state where they have that potential to do pregnancy terminations, they would not have the ability to train in that in our state," she said. "It really affects the dynamic of how we are going to train our new physicians."
Policy and travel
The medical groups, providers and student groups couldn't point to a solution or legislation that could ease training concerns.
The congressional committees of jurisdiction on graduate medical education didn't identify any activity on federal bills related to post-Roe training. The Hyde amendment in the Labor-HHS-Education spending bill has blocked federal funding for most abortions.
Publicly funded institutions could face another challenge that private schools don't. Some states limit tuition or resources related to abortion training.
Pamela Merritt, executive director at Medical Students for Choice, said the group's University of Wisconsin-Madison chapter faces an administration that won't give credit for training or education in states where abortion is legal or liability insurance to medical students who receive training or field work in these other states.
Kavita Vinekar, assistant clinical professor at the David Geffen School of Medicine at UCLA and a PRH fellow, projected in April that 44.8 percent of accredited obstetrics and gynecology residency programs were in states likely to ban abortion, or 128 programs.
"I think that it's going to be really hard to sustain a career in OB-GYN if we're practicing in environments where fear and confusion prevail," she said.
The U.S. already faces the highest rates of maternal mortality and morbidity among developed nations. Many states with the highest per capita maternal death rates also have some of the strictest abortion laws.
Some states limit abortion care only to physicians, while others permit advance practice providers — including physician assistants, advanced nurse practitioners or certified midwives — to perform abortions, provide post-abortion care or help patients with pregnancy loss.
Nineteen states and Washington, D.C., either permit or don't ban abortion by some advance practice providers, according to data from the Guttmacher Institute.
But the varying abortion bans could affect 37.5 percent of accredited midwifery schools.
Regional gaps in health care workers could be worsened if practitioners get their training where abortion is illegal. The choice of where to train could have a long-term effect. AAMC data shows most doctors — 57.1 percent — who completed a residency between 2011 and 2021 went on to practice in the same state.
Henderson, the medical student, says constantly changing legislation factors into considering where and if people will move.
"If you have started a family and gotten married to somebody, you have to face the decision of, do you want to go where there's a need or do you want to go, like, where you have been living for the past four years," she said. "I'm hopeful that in, what, seven, six or seven years, maybe this won't be the landscape that I'm faced with."
Niels Lesniewski contributed to this report.