This article reviews the challenges facing family planning education in the setting of abortion care, legal restrictions, and institutional policies. It discusses the impact of incomplete residency training on the health care workforce and implications for the future of patient care. We specifically discuss resident satisfaction, competence, and intentions to provide full scope family planning services, including abortion and early pregnancy loss care.
Key points
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Comprehensive family planning residency training is associated with higher levels of resident satisfaction, skills acquisition, and intention to provide full scope patient care.
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Training models for abortion care are highly variable.
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Family planning training may be limited by state and institutional policies, especially after the Dobbs Supreme Court decision removed federal protections for abortion care.
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Medical students preferentially apply to residency programs with comprehensive training.
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Training impacts the obstetrics and gynecology workforce and future patient care.
| ABOG | American Board of Obstetrics and Gynecology |
| ACGME | Accreditation Council for Graduate Medical Education |
| ACOG | American College of Obstetricians and Gynecologists |
| CREOG | Council on Resident Education in Obstetrics and Gynecology |
| MSFC | Medical Students for Choice |
| PACE | Patient-Centered Abortion Care Education |
Introduction
In September of 2018 The Council on Resident Education in Obstetrics and Gynecology (CREOG), American College of Obstetricians and Gynecologists (ACOG), and 10 other women’s health organizations published that “access to safe abortion hinges on the availability of sufficient number of trained physicians and providers willing and able to offer abortion care.” In 2022, federal protections for abortion care were removed by the Supreme Court decision in Jackson Womens’ Health Organization v Dobbs , thereby allowing individual states to ban abortion care at any gestational age. At the time of this writing (December 2024), 13 states had complete bans and an additional 8 states had bans at 6 to 18 weeks gestation. The impacts of these state-level policy changes on patient outcomes, resident training, and medical education are only now beginning to be documented and will be incorporated into this article, but we anticipate more data in coming years. Importantly, it had been shown prior to Dobbs that residents with routine exposure to training in induced abortion are more likely to provide this care after residency. , This training expands patient’s access to other care as well. Studies have shown that residents who receive more comprehensive training will go on to provide more expansive options for management of miscarriage , and more patient-centered care for abnormal pregnancies. Treatment options for early pregnancy loss are fast evolving, with the recent addition of mifepristone and increasing use of outpatient manual vacuum aspiration. , Basic care for early pregnancy loss, abortion, and contraception is referred to collectively as Family Planning and is considered foundational for all obstetricians and gynecologists. More nuanced and complicated care in these areas is referred to as Complex Family Planning, and some skills may be acquired most efficiently through subspecialty training after residency.
History of residency training requirements in family planning
In 1996, the Accreditation Council for Graduate Medical Education (ACGME) began requiring residency programs to provide access to abortion training for all residents. They allowed that “residents who have a religious or moral objection may opt-out and must not be required to participate in training in or performing induced abortions”, but the training must be made available. The requirement allows for treatment methods and procedural skills to be acquired through induced abortion, or obtained in other settings, such as the management of early pregnancy loss. The ACGME requirement goes on to state that “residents must have experience in managing complications of abortions…”
In 2022, CREOG affirmed this requirement and specifically delineated that residents become competent in options counseling, referral, and management of complications related to induced abortion. Similar to the ACGME, CREOG allowed that skills may be acquired through early pregnancy loss and management of other diagnoses, so long as adequate exposure occurs to ensure competence. Regarding care for early pregnancy loss, CREOG separately delineates the requirements for competence in expectant, medication, and procedural management. Contraceptive mechanisms of action, risks and benefits, individual options counseling, and impacts on population health are also basic requirements. In addition to the science and clinical learning required for all competencies, CREOG milestones also include that obstetrics and gynecology residents should “understand national, local, and institutional policies and state laws” regarding the provision of contraception and abortion care.
In September of 2022, in the wake of the Dobbs decision, the American Board of Obstetrics and Gynecology (ABOG) reiterated their standards for certification. “During the 48 months of residency training, residents seeking ABOG certification will be required to have satisfactorily completed a minimum of 2 months, as two 4-week blocks or the equivalent of these experiences in family planning (also called comprehensive reproductive health care). This includes abortion-related health care. This represents approximately 4% of the time in residency and correlates with the proportion of these areas in the testing blueprints for obstetrics and gynecology certification.” In the same year, ABOG began offering subspecialty certification in complex family planning.
Models for family planning residency training
The implementation of family planning training requirements is highly variable. Rotations may be routine, optional, or unavailable (in violation of the ACGME requirement). “Routine” training is scheduled automatically for all residents. Optional training is available to interested residents, but not required. Recent national data has shown that resident satisfaction with training, self-assessed competence, and intention to provide comprehensive care for both abortion and early pregnancy loss are highest when abortion care training is routinely provided within the residency rotation schedule. , , When “optional” training is further subdivided into “optional with a clear process” for receiving training, and “optional without a clear process,” it is clear that the former tracks more closely with routine training responses, and the latter more closely with no training. , Results from a corresponding survey of residency program directors mirror the residents’ responses.
In a survey of 5427 obstetrics and gynecology residents taking the CREOG inservice training examination in 2020, 60% reported receiving routine training, 18% optional training with a clear process, 11% optional training without a clear process, and 8% no training. There are many ways to implement family planning training. Training may occur onsite at the home institution, offsite through a partner institution, or a hybrid. Many residency programs that provide abortion care training do so through partnerships with Planned Parenthood or other specialized family planning clinics. These partnerships can provide a real-world perspective on the myriad ways health care is delivered in the United States, thus giving a systems-level education in addition to concentrated clinical training.
Access to training
Religiously affiliated residency programs report statistically similar rates of routine, optional, and no training as secular hospitals, but face unique barriers to fulfilling training requirements and more often struggle to do so. In a study including 25 religiously affiliated obstetrics and gynecology residency programs, 5/19 (26%) Catholic programs stated that their residents did not meet the minimum ACGME requirements for dilation and curettage (D&C), a foundational family planning skill. In the same study, the majority of Catholic programs stated that they had concerns about their residents receiving adequate training in postpartum tubal ligations, and 84% relied on outside institutions to provide adequate exposure in both contraception and abortion care.
Many secular hospitals and health systems also restrict access to abortion care more stringently than state laws, despite the Society for Maternal Fetal Medicine (SMFM), ACOG, and the Society of Family Planning (SFP) recommending against such restrictions. Prior to the Dobbs decision, only 140/286 (49%) programs in the United States had integrated routine abortion care training; 6 months after the decision, 19/140 (14%) lost routine in-state training due to prohibitions on care. Residents may have specifically chosen those programs because they provided comprehensive training in early pregnancy loss, abortion, and contraception. When state laws changed in the wake of the Dobbs decision, they also lost opportunities to train in the standard of care for early pregnancy loss. A pre- Dobbs study of residency institutions found that those restricting induced abortion by indication were less likely to provide the most effective treatments for early pregnancy loss, and were less likely to incorporate patient-centered principles into management decisions. Residency training is time limited, and there may be some trainees during this period of legislative transition who neither meet requirements, nor become trained to competency. As the federal, state, and local laws regarding abortion care and training continue to change, more residency programs may face challenges meeting basic educational requirements, which have not changed.
Some residency programs in states that lost training have begun to arrange for out-of-state rotations through pilot programs. Although generally successful in training residents, these programs are logistically complicated due to licensure, scheduling, allocation of learning opportunities, and cost. It took an average of 5 months for each of the 13 programs to establish a partnership, with 60 total residents traveling. Some states also interpret prohibitions on state funding for abortion care to extend to resident salaries, benefits, and/or malpractice insurance, compounding the costs for out-of-state training. Even in the best of circumstances, trainees must leave their home institutions, families, and programs for an extended period. It also puts strain on the call schedule at their home programs, requiring the non-rotating residents to cover gaps. Traveling for training may be emotionally difficult or logistically impossible for some individuals who will have incomplete training as a result.
Implications for residency programs
Medical students pursuing residency in obstetrics and gynecology understand that routine training in abortion care will improve their training in comprehensive family planning skills for early pregnancy loss. Most believe that this training is important. In a study of 313 residency applicants from 38 states applying to a residency program in a very restrictive state, a program in a very permissive state or both, 33% said that abortion training was “essential” and 33% selected “very important.” These 2/3 of applicants were less likely to be applying to residency programs in states that banned or heavily restricted care, but 82% of them still did (vs 98% of those for whom abortion training was less important). There are other competing priorities, such as program culture, geography, quality, reputation, and commitment to diversity, equity and inclusion.
National data reflect these findings. The Association of American Medical Colleges (AAMC) published residency application data for 2022-23, the first year after the Dobbs decision was announced. Across all states, applications to obstetrics and gynecology residency programs decreased by 5.2%, with applications to ban states down by 11.7%, more than twice the national decrease. The differences were even more stark the following year. In the 2023-24 application cycle, overall applications to obstetrics and gynecology residency programs reversed direction and increased by 0.6%, while applications to ban states continued to decrease by a further 6.7% compared with the prior year cycle. Interestingly, the AAMC data shows that this trend persists for all specialties. Thus, state-level abortion care bans are impacting where the future physicians and surgeons across the spectrum of care apply to residency preferentially.
Obstetrics and gynecology is a competitive specialty and most residency positions fill each year. However, programs in ban states may struggle to attract the most dedicated and brightest medical students if they have not made accommodations to ensure comprehensive family planning training. This will, in turn, impact the local workforce and may have implications for patients for years to come.
Implications for future patient care and the workforce
According to the AAMC, 58.6% of graduating residents practice in the states where they completed residency. This means that those training in states with limited access to comprehensive family planning training are likely to practice in those same states. Thus, patients living in those states are more likely to be treated by physicians who do not feel competent in all skills necessary for comprehensive treatment of early pregnancy loss and abortion care. When emergent cases rise to the local legal standard for treatment, they may find themselves without a physician capable of providing the skilled care they need, such as second trimester dilation and evacuation. Moreover, trainees may experience moral distress by being forced to provide substandard or unethical care (or denials of care) that will harm patients, and this moral distress may affect their identity as physicians and career longevity. Moral distress is the emotional state that occurs when an individual believes they know the ethically appropriate course of action but cannot carry it out, often due to external circumstances. Trainees are particularly susceptible, given their relative lack of agency in the health care provider hierarchy. The lack of training will be perpetuated as new residents graduate without comprehensive training in essential family planning skills, practice locally, and train the next generation. Thus, patient care will be highly geographically dependent.
Medical student education
Most physicians will care for patients capable of pregnancy at some point in their careers, regardless of chosen specialty. It is essential that they understand the impacts of pregnancy on comorbidities, and vice versa, to completely counsel their patients on the risks and benefits of being pregnant. Although recommended by ACOG since 2014, the AAMC reported that even prior to the Dobbs decision, 1 in 5 medical schools did not provide any formal education in abortion care. Those that do provide education are highly variable in their scope and content. Medical students themselves are often of reproductive age and may have an unintended pregnancy during training, with limited options and implications for their future careers. Without formal education, they are susceptible to the same misrepresentations of reproductive health care in media and politics as non-clinicians. They may be unaware that safe, legal abortion care services exist and should be offered as standard of care through patient-centered options counseling. Their education may be skewed by the highly restrictive environments in which they are training. Similarly, they may be unaware that residency programs are highly variable by state and that their access to comprehensive training in counseling and skills related to induced abortion and early pregnancy loss care could be impacted by location.
Tools to improve training
Tools exist to improve training in medical school and residency ( Table 1 and Fig. 1 ). The Association of Professors of Gynecology and Obstetrics includes pregnancy termination as topic 34 in the 11th edition of their Medical Student Educational Objectives . This tool can help to streamline introduction to proper terminology and concepts at the undergraduate medical education level, even in states or institutions that severely restrict or ban care. Medical Students for Choice (MSFC) is a medical student led advocacy organization dedicated to improving comprehensive reproductive health care education. MSFC was founded in 1993, when abortion care training was virtually absent from all medical student education.
