“Thing!” The familiar chime of a news alert sounds on our phones, as an anticipated New York Times headline appears: “Supreme Court to Hear Abortion Case Challenging Roe v. calf.” As third- and fourth-year medical students pursuing careers in obstetrics and gynecology, we fervently devour every line of the article. For each of us, 20 years of education have culminated in the excitement and anticipation of applying to residency programs. While our friends in other specialties weigh the relative academic merits of various programs, we must also navigate an uncertain and confusing political landscape. Our application process can be thrown into chaos by rapidly changing state and national policies that are far beyond our control. Sometimes, news alerts allow us to breathe a brief sigh of relief — if, for instance, a lower court temporarily blocks a restrictive abortion law. But when courts allow these laws to go into effect, our hearts sink as we reflect on the cataclysmic consequences for patients, as well as the potential effects on students like us who seek training in reproductive health care.
The US Supreme Court’s decision to hear Dobbs v. Jackson Women’s Health Organization, which challenges a Mississippi law banning abortion after 15 weeks of gestation, could dramatically change the landscape of abortion care in the United States. This case threatens the precedent set by the 1973 Roe v. calf decision, which prevents states from banning abortion before fetal viability, defined as the point at which a fetus can live outside the womb, typically around 23 to 24 weeks. If the Supreme Court overturns or ages this precedent, states will be free to ban or more extensively regulate abortion — possibly regardless of gestational age — which would devastate patients’ access to a common, safe medical procedure. States could also be allowed to impose new restrictions on various aspects of medical education and training related to reproductive health, from counseling to procedural skills. Such restrictions would create crucial gaps in the education of future Ob/Gyns, thereby affecting the quality of care that we and other trainees will be able to provide to our patients. Medical schools and residency programs could end up training generations of physicians who are unable to provide the comprehensive reproductive health care that patients need.
Even under current regulations, residency program directors report that only 22% of Ob/Gyn program graduates are competent in performing dilation and evacuation, the procedure that is used for the majority of second-trimester abortions.1 Only 71% of graduates are competent in performing first-trimester aspiration, 66% are competent in performing medication abortion, and 67% are competent in performing induction of labor for second- and third-trimester terminations.1 These figures are startlingly low, considering that one in four women in the United States will have an abortion.2
In medical school, we are taught “best practices” in areas throughout medicine, guidelines that are supported by extensive data. Yet in the clinical setting, we are confronted with hospital policies that stray from the appropriate and effective approaches that we have been taught. During one of our third-year clinical rotations, a patient presented with an early pregnancy failure. The patient was counseled on medical, surgical, and expectant management choices, and she opted for medical management. Medical management of early pregnancy loss can involve the use of two drugs: mifepristone and misoprostol. The preferred medical treatment is mifepristone and misoprostol together, which is effective in 84% of cases, as compared with misoprostol alone, which is effective 67% of the time.3 But in this hospital, like many others, mifepristone was not available because of an institutional policy restricting its use.
Unfortunately, this patient was among the 33% for whom misoprostol alone is not effective.3 Despite the patient’s desires, only less-effective medical treatment options were available because of political and social overreach. Since no physician who had been trained in performing in-clinic manual vacuum aspiration was available, the patient was scheduled for an aspiration with general anesthesia. This procedure carries significantly higher risks than either medical management or in-clinic manual vacuum aspiration. As medical students, we couldn’t help but consider the complications this patient could have faced, simply because of the stigma attached to a safe and effective drug.
Abortion provision and miscarriage management are essential components of Ob/Gyn training, but education in these areas isn’t always offered. The Ryan Residency Training Program provides resources to help residencies establish formal rotations in family planning, but just 34% of Ob/Gyn residencies have a Ryan Program.4 Institutions with these programs report that their residents rank family-planning rotations higher overall than other ambulatory or outpatient rotations.4 Although 19% of residents in these programs opt out of some aspects of family-planning training, they still benefit from increased exposure to training in contraception and management of early pregnancy loss.4 Eighty-one percent of directors of residencies with Ryan Programs report that providing this training has increased their program’s appeal to residency applicants.4 This finding indicates that trainees recognize the importance of abortion education and the positive effects it will have on accessibility of comprehensive reproductive care.
Even as the desire for abortion training increases, residents face barriers to receiving adequate education and training in abortion provision. In addition to federal and state-level abortion regulations, 57% of Ob/Gyn residency programs are subject to individual hospital policies that control abortion more strictly than state law does.5 Most of these institutions are in the southern and midwestern United States — areas that already have restrictive abortion laws.5 Many institutions with policies that limit abortion care regulate both medically indicated and nonmedically indicated procedures.5 The number of residency programs that are able to offer abortion education and training will inevitably decrease if the Supreme Court rules in favor of Dobbs and allows abortion laws in Mississippi and elsewhere to stand.
Many states have already passed “trigger laws” that would automatically implement complete bans on abortion if roe is overturned. In others, policymakers have passed legislation with the goal of evading judicial review, such as Texas Senate Bill (SB) 8, which recently went into effect. This bill not only bans abortion after detection of fetal cardiac activity, with no exceptions for cases of rape or incest, but also provides a $10,000 reward to private citizens who report anyone who “knowingly aids or abets” in the performance of a prohibited abortion. The lack of a rapid response by the Supreme Court to SB 8 may be an indicator of what’s to come in Dobbs.
Our top priority, as students and future residents, is receiving the education we need to provide exceptional care to our patients. We, along with most of our peers, strive to be educated at institutions that provide thorough training, including in dilation and evacuation, medical abortion, and medical management of miscarriage. Constantly changing state regulations — many of which could become more restrictive, depending on the Supreme Court’s decision in Dobbs — severely limit the number of institutions where we and other future Ob/Gyns will be able to acquire this training.
We are at a pivotal moment in our country’s history when it comes to reproductive health. As medical students, we should advocate for the inclusion of comprehensive training in reproductive health care in our medical education. Teaching these critical skills to future generations of clinicians will help ensure that such care remains safe and accessible for all patients.