ACOG Committee Opinion
Number 424, January 2009


Committee on Health Care for Underserved Women
The Committee on Health Care for Underserved Women would like to thank Eve Espey, MD, for her assistance in the development of this document.
This information should not be construed as dictating an exclusive course of treatment or procedure to be followed.


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Abortion Access and Training

ABSTRACT: Despite a decrease in abortion rates over the past decade, numerous political, social, and provider barriers limit access to abortion services. Barriers include state restrictions and mandates limiting access, lack of public funding for abortion services, and the decrease in abortion providers. Abortion education and training are limited in medical schools and in residency programs. The American College of Obstetricians and Gynecologists supports education in family planning and abortion for both medical students and residents and abortion training among residents. In addition, the American College of Obstetricians and Gynecologists supports availability of reproductive health services for all women, including strategies to reduce unintended pregnancy and to improve access to safe abortion services.


Abortion is one of the most common health services performed in the United States and is an integral component of women's reproductive health services. In 2005, 1.2 million abortions were performed (1). Approximately 50% of women in the United States will experience an unintended pregnancy by age 45 years, and based on current abortion rates, nearly one in three women will have an abortion by age 45 years (2). Since 1973 when the U.S. Supreme Court recognized the constitutional right to abortion in Roe v. Wade, morbidity and mortality from the performance of unsafe abortion have decreased dramatically. Abortion-related deaths decreased from 40 per million live births in 1970 to eight per million live births in 1976 (3). Although the majority of terminations are performed with aspiration, medication abortion has provided an alternative for women seeking first trimester termination (up to 63 days) of pregnancy since 2000, when the U.S. Food and Drug Administration approved mifepristone and misoprostol (4). In 2005, early medication abortion accounted for 13% of abortions.

Public health efforts have focused on reducing the frequency of unintended pregnancy, but the demand for abortion continues. The availability of abortion services is in jeopardy because of restricted access to the procedure and to limited training of physicians during residency.

Reducing the Need for Abortion

Reducing unintended pregnancy is the best way to reduce abortion. Abortion rates have decreased over the past decade. Obtaining accurate statistics about abortion prevalence is difficult given underreporting of abortion and lack of a national requirement for reporting abortion. Some states require reporting and others voluntarily report to the Centers for Disease Control and Prevention. Statistics from the Centers for Disease Control and Prevention indicate that the number of abortions in the United States has decreased during the 1990s and was at its lowest level in 2005 since 1974, at 19.4 abortions per 1,000 reproductive-aged women (1). The decrease in abortions directly reflects the decrease in unintended pregnancy over the same period (1). Three quarters of the decrease in unintended pregnancy is attributable to higher contraceptive prevalence and use of more effective contraceptive methods in reproductive-aged women (5). Strategies that may contribute to higher contraceptive prevalence include comprehensive sexuality education and improved access to contraceptive methods and emergency contraception.

Reduced Access to Abortion

Numerous barriers limit access to abortion. Federal funds may not be used for abortion except when the woman's life is endangered or in the case of rape or incest. Only 17 states allow state Medicaid funds to be used for medically necessary abortions (6). Private insurance varies in its coverage of abortion. Some states specifically prohibit private insurance from covering abortion except in cases where the woman's life would be endangered if she carried the pregnancy to term (7). Lack of health insurance and other financial concerns constitute a further barrier to access for the economically disadvantaged women who require abortion services.

State mandated restrictions on abortion reduce access. Thirty five states require some parental notification or consent or both for a minor seeking abortion (8). A minor can be exempted from a state's parental notification or consent requirement or both through a judicial bypass, by which a court grants approval instead of a parent. However, some evidence suggests that these procedures are frequently inadequate as well as medically and psychologically harmful to adolescents (9, 10). Twenty-four states require delays of up to 24 hours before an abortion may be performed as well as requiring the provision of information about abortion that may be misleading and sometimes not based on scientific evidence (11). Parental notification and consent laws and mandatory delays create obstacles for women, including family problems, increased expense, and travel difficulties. These restrictions may disproportionately affect low-income women, particularly those in rural settings.

The number of abortion providers has decreased over the past 2 decades. From 1996 to 2000, the number of abortion providers decreased from 2,042 to 1,819, a decrease of 11% (1). From 2000 to 2005, that number decreased from 1,819 to 1,787, a further decrease of 2% (1). Nearly 35% of women across 87% of U.S. counties had no abortion provider in 2005 (1). The lack of providers and the lack of integration of the procedure into routine practice may single out abortion as a reproductive health service that is much less accessible than others. One third of women live in counties without an abortion provider and more than 20% of women undergoing abortion in 2000 traveled more than 50 miles to obtain the procedure (12).

Abortion may take place in an atmosphere of controversy, harassment, and sometimes violence (13). The highly charged emotional and political debate stigmatizes the women who undergo abortion and the providers who offer abortion. In addition to creating a barrier for seeking care, this negative atmosphere may be a deterrent to training providers and offering reproductive health services.

Abortion Training

Despite the high demand for abortion procedures, education and training in abortion care are limited. Education in medical school about abortion is limited. In a recent survey of abortion education in medical school curriculum, 17% of educators reported no formal education about abortion either in the preclinical or clinical years for medical students (14). Only 32% of schools have at least one lecture specifically about abortion during the clinical years (14). Although 45% of schools offer a clinical experience in abortion care, participation is low (14). Unlike most clinical experiences that are integrated into the clerkship, clinical experience in abortion is often "opt in"—students must discuss their interest with the clerkship director and help arrange the clinical experience. Approximately one half of the schools offered a fourth-year elective in family planning and abortion, but few students participated (14).

Obstetrics and gynecology residency training in abortion care is similarly limited. Concerns about the lack of abortion training led the Accreditation Council for Graduate Medical Education (ACGME) to issue program requirements in 1996 that were specific to abortion training (15). These standards, supported by the American College of Obstetricians and Gynecologists, required that "experience with induced abortion must be part of residency training." Although residency programs may opt out of providing in-house training, they must provide their residents the opportunity for abortion training at an outside facility. Similarly, residents with religious or moral objections may opt out of receiving abortion training. However, residents must receive training in management of abortion complications.

Family Planning and Abortion Training Opportunities

The Fellowship in Family Planning–The objective of the program is to develop specialists focused on research, teaching, and clinical practice in contraception and abortion by receiving training in clinical and epidemiologic research, developing clinical and teaching skills, working internationally, and connecting to a rapidly expanding network of family planning experts. For more information, go to: http://familyplanningfellowship.org/whatis.html.

The Kenneth J. Ryan Residency Training Program in Abortion and Family Planning–A national program with the goal of formally integrating and enhancing family planning training for residents in obstetrics and gynecology. It strives to create academic settings for didactic education, clinical training, and research. For more information, go to: http://bixbycenter.ucsf.edu/training/training/
kenneth_j_ryan_training.html
.

For additional information, please go to www.acog.org/goto/underserved. Please note the American College of Obstetricians and Gynecologists (ACOG) does not necessarily endorse the views expressed or the facts presented on these web sites. Further, ACOG does not endorse any commercial products that may be advertised or available on these web sites.

Despite the institution of these standards, a survey performed by the National Abortion Federation in 1998 of the 261 accredited obstetrics and gynecology residencies revealed that although 81% of programs reported that they offered first-trimester abortion training, only 46% offered it routinely. In 34% of programs, abortion training was offered as an "elective," outside the standard curriculum (16). The nature of elective or opt in training places the burden to create a clinical experience on the residents, and prior data show that the majority of residents participate in training when it is integrated whereas a minority of residents participate when it is elective (17). Forty percent of programs responded that fewer than one half of their residents received training and 14% responded that no residents were trained. In a follow-up survey, conducted in 2004, 51% of responding obstetrics and gynecology residency program directors reported their programs offered routine abortion training, 39% offered elective training, and 10% did not offer training at all (18). Residents who attended programs where abortion training was integrated into the curriculum were more likely to undergo training in all abortion modalities and received more training.

A recent study supports high satisfaction with abortion training (19). Obstetrics and gynecology residents at the University of California at San Francisco were asked to evaluate their rotations and, specifically, to compare the value of their family planning rotation, which includes abortion training, with others. The family planning rotation received the highest rating of the third-year resident rotations and was comparable to a high volume surgical rotation. Training in abortion offers many skills which are applicable for the obstetrics and gynecology practice, including early gestational sizing through the use of examination and ultrasonography, pain management, and the use of manual vacuum aspiration for incomplete and missed abortions. Furthermore, evidence suggests that residents who receive more extensive abortion training are more likely to provide abortions after residency (20). Information on family planning and abortion training opportunities is listed in the box.

ACOG supports the availability of comprehensive reproductive health services for all women (21) and specifically supports:

  1. Strategies that may reduce unintended pregnancy, such as comprehensive sexuality education and improved access to effective contraceptive methods and emergency contraception for all women wishing to avoid pregnancy.
  2. Availability of safe, legal, and accessible abortion services.
  3. Education about family planning and abortion for all medical students as an integral part of reproductive health education.
  4. Education about family planning and abortion as an integrated component of the obstetrics and gynecology residency training.

References

  1. Jones RK, Zolna MR, Henshaw SK, Finer LB. Abortion in the United States: incidence and access to services, 2005. Perspect Sex Reprod Health 2008;40:6–16.
  2. Guttmacher Institute. In brief: facts on induced abortion in the United States. New York (NY): GI; 2008. Available at: http://www.guttmacher.org/pubs/fb_induced_abortion.html. Retrieved July 17, 2008.
  3. Cates W Jr, Grimes DA, Schulz KF. The public health impact of legal abortion: 30 years later. Perspect Sex Reprod Health 2003;35:25–8.
  4. Medical management of abortion. ACOG practice bulletin No. 67. American College of Obstetricians and Gynecologists. Obstet Gynecol 2005;106:871–82.
  5. Santelli JS, Lindberg LD, Finer LB, Singh S. Explaining recent declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use. Am J Public Health 2007;97:150–6.
  6. Guttmacher Institute. State funding of abortion under Medicaid. State Policies in Brief. New York (NY): GI; 2008. Available at: http://www.guttmacher.org/statecenter/spibs/spib_SFAM.pdf. Retrieved December 19, 2007.
  7. Guttmacher Institute. Restricting insurance coverage of abortion. State Policies in Brief. New York (NY): GI; 2008. Available at: http://www.guttmacher.org/statecenter/spibs/spib_RICA.pdff. Retrieved July 22, 2008.
  8. Guttmacher Institute. Parental involvement in minors' abortions. State Policies in Brief. New York (NY): GI; 2008. Available at: http://www.guttmacher.org/statecenter/spibs/spib_PIMA.pdf . Retrieved July 22, 2008.
  9. The adolescent's right to confidential care when considering abortion. American Academy of Pediatrics. Pediatrics 1996; 97:746–51.
  10. Dailard C, Richard CT. Teenagers' access to confidential reproductive health services. Guttmacher Rep Public Policy 2005;8(4):6–11.
  11. Guttmacher Institute. Counseling and waiting periods for abortion. State Policies in Brief. New York (NY): GI; 2008. Available at: http://www.guttmacher.org/statecenter/spibs/spib_MWPA.pdf. Retrieved July 16, 2008.
  12. Henshaw SK, Finer LB. The accessibility of abortion services in the United States, 2001. Perspect Sex Reprod Health 2003;35:16–24.
  13. Harper CC, Henderson JT, Darney PD. Abortion in the United States. Annu Rev Public Health 2005;26:501–12.
  14. Espey E, Ogburn T, Chavez A, Qualls C, Leyba M. Abortion education in medical schools: a national survey. Am J Obstet Gynecol 2005;192:640–3.
  15. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in obstetrics and gynecology. Chicago (IL): ACGME; 2007. Available at: http://www.acgme.org/acWebsite/downloads/RRC_progReq/220obstetricsandgynecology07012007.pdf. Retrieved December 19, 2007.
  16. Almeling R, Tews L, Dudley S. Abortion training in U.S. obstetrics and gynecology residency programs, 1998. Fam Plann Perspect 2000;32:268–71, 320.
  17. MacKay HT, MacKay AP. Abortion training in obstetrics and gynecology residency programs in the United States, 1991-1992. Fam Plann Perspect 1995;27:112–5.
  18. Eastwood KL, Kacmar JE, Steinauer J, Weitzen S, Boardman LA. Abortion training in United States obstetrics and gynecology residency programs. Obstet Gynecol 2006;108: 303–8.
  19. Steinauer J, Drey EA, Lewis R, Landy U, Learman LA. Obstetrics and gynecology resident satisfaction with an integrated, comprehensive abortion rotation. Obstet Gynecol 2005;105:1335–40.
  20. Steinauer JE, Landy U, Jackson RA, Darney PD. The effect of training on the provision of elective abortion: a survey of five residency programs. Am J Obstet Gynecol 2003; 188:1161–3.
  21. American College of Obstetricians and Gynecologists. Abortion policy. ACOG Statement of Policy. Washington, DC: ACOG; 2007.

Copyright © January 2009 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Requests for authorization to make photocopies should be directed to: Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400.

Abortion Access and Training. ACOG Committee Opinion No.424. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:247–50.