Number 612 (Replaces Committee Opinion Number 424, January 2009)
Committee on Health Care for Underserved Women
This information should not be construed as dictating an exclusive course of treatment or procedure to be followed.
ABSTRACT: Access to safe abortion hinges upon the availability of trained abortion providers. The American College of Obstetricians and Gynecologists supports education for students in health care fields as well as clinical training for residents and advanced practice clinicians in abortion care in order to increase the availability of trained abortion providers. The American College of Obstetricians and Gynecologists supports the expansion of abortion education and an increase in the number and types of trained abortion providers in order to ensure women’s access to safe abortions. Integrated medical education and universal opt-out training policies help to lessen the stigma of abortion provision and improve access by increasing the number of abortion providers. This Committee Opinion reviews the current status of abortion education, describes initiatives to ensure the availability of appropriate and up-to-date abortion training, and recommends efforts for integrating and improving abortion education in medical schools, residency programs, and advanced practice clinician training programs.
The American College of Obstetricians and Gynecologists (the College) supports women’s access to safe abortion care, which hinges upon the availability of sufficient numbers of trained abortion providers. To increase the availability of trained abortion providers, the College makes the following recommendations:
Implement the Accreditation Council for Graduate Medical Education (ACGME) requirement that all obstetrics and gynecology residency programs provide training in comprehensive women’s reproductive health care, including opt-out abortion training, in which training is routinely integrated into residency but residents with religious or moral objections can opt out of participation.
Continue efforts to destigmatize and integrate abortion training into medical education as a critical element of women’s reproductive health care.
Include abortion education in the curricula of all medical schools.
Expand the trained pool of non-obstetrician–gynecologist abortion providers, such as family physicians and advanced practice clinicians (APCs), by
integrating first-trimester abortion training into family medicine and APC training programs
opposing restrictions that limit abortion provision to physicians only or obstetrician–gynecologists only
Support opposition to legislative restrictions that impede access to abortion and increase difficulty in abortion provision and training, including restrictions on public funding of abortion education and training.
Access to safe abortion services is a key component of women’s health care 1. Safe, accessible abortion care requires sufficient numbers of trained health care providers who offer the service. However, the number of abortion providers in the United States has not met the level of need 2. In the United States, 94% of abortions are provided in facilities outside of the traditional learning environment of the medical trainee, requiring concentrated efforts to integrate abortion training into medical school and residency curricula 2. Legal, regulatory, and other restrictions form barriers to education and training in abortion care Box 1. As a result, educators may encounter multiple obstacles to integrating appropriate training. The College supports the availability of high-quality comprehensive reproductive health care for all women and the integrated curricula with universal opt-out training required to achieve this goal.
Barriers to Education and Training in Abortion Care
Public funding or other restrictions on medical schools and teaching hospitals that limit abortion education and training for medical students and residents
Restrictions that limit abortion provision to physicians only or obstetrician–gynecologists only
Restrictions that burden access to abortion in other ways, thereby increasing difficulty in abortion provision and training (eg, mandatory delays and waiting periods for patients and hospital privileging requirements)
Hospital mergers with religious entities that prohibit reproductive health service provision and training
Scope of practice guidelines that limit abortion provision
Inadequate number of trained faculty at residency training programs and medical schools
Opt-in (instead of opt-out) abortion training creating a burden on the trainee to develop a clinical experience
Limited access to medications necessary for medical abortion
Medical Student Education
Studies indicate that medical education on abortion provision is not universally available, but it is highly valued by students who experience it. Approximately 32% of medical schools surveyed in one study offered at least one abortion-related lecture during the clinical years, and 45% of clerkship directors stated that they provided clinical exposure to abortion 3. Approximately one half of all medical schools that responded to the survey offered a fourth-year elective in family planning and abortion, and 17% of clerkship directors reported that their programs offered no formal abortion education for medical students in either preclinical or clinical years 3. Because participation often requires students to actively seek abortion experience, often at off-site facilities, students without a special interest in abortion may not have an opportunity to observe clinical abortion care.
Most students who participate in clinical abortion education find it valuable and recommend that it be an integrated part of training 4. However, even integrated experiences may be insufficient. At the end of their third year of clinical training at a program offering routine abortion experiences, 45% of students surveyed expressed dissatisfaction with the clinical opportunities available 5. Dissatisfaction probably is more common among students enrolled at religiously affiliated medical schools. In one survey at a religiously affiliated institution, most of the students surveyed described preclinical education on contraception, sterilization, and abortion as inadequate. Although education improved in the clinical years, approximately 70% of students still reported that their abortion training was inadequate during their third-year rotation 6.
This dissatisfaction with abortion training amongst medical students has had a significant effect on shaping abortion education. Student demand for abortion training led to the advent of Medical Students for Choice (MSFC) in 1993. Its mission is to increase abortion training opportunities for medical students and residents, ensuring a growing number of physicians committed to and trained in comprehensive abortion provision 7. Data demonstrate the success of MSFC in supporting medical students who wish to provide family planning and abortion care. Although only 14% of currently practicing obstetrician–gynecologists provide abortions 8, a survey of young MSFC alumni demonstrated that of the members who are obstetrician–gynecologists or family medicine providers, 31% currently are providing abortion care 9.
Since the legalization of abortion, medical school professors have understood the importance of training providers to care for women who require pregnancy terminations. In 1972, a published article signed by 100 professors of obstetrics and gynecology called for expanded abortion training to meet the need for services anticipated with the imminent legalization of abortion 10. Despite this call, the number of abortion providers has not met the level of need. In 2013, in the face of multiple social and legislative initiatives aimed at restricting women’s access to abortion, another 100 professors of obstetrics and gynecology affirmed their commitment to support training in and access to the full range of reproductive health services, including abortion 11.
Resident Training for Obstetrician–Gynecologists
Despite the importance of access to safe abortion, residency training in abortion care has been limited, even in obstetrics and gynecology residencies 12 13. There are three general approaches to abortion care training: “opt out,” in which training is routinely integrated into residency training but residents with religious or moral objections can opt out of participation; “opt in,” in which training is available but not routinely scheduled; and programs in which no training is provided. The nature of opt-in training places the burden to create a clinical experience on the residents and establishes a culture of marginalization for abortion provision and those who wish to obtain training.
Where training is routinely integrated (opt out), residents report a higher number of abortion procedures and higher self-assessed competence in procedural and counseling skills than those in programs with opt-in or no training 12. Residents in opt-in programs report similar clinical experience to those programs where abortion training is not available 12.
In 1996, the ACGME Obstetrics and Gynecology Program Requirement IV.A.2.d asserted that although no program or resident with a religious or moral objection shall be required to provide training in or to perform induced abortions, access to experience with induced abortion must be part of residency education 14. This requires programs to allow residents to opt out of, rather than opt into, abortion training 15. Military residency programs may have difficulty fulfilling these requirements because they are subject to additional restrictions.
A survey of residency program directors revealed that only 51% of obstetrics and gynecology residency programs offered routine abortion training 13. When compared with residents in programs with opt-in training, residents in programs with routine training were significantly more likely to receive instruction in all modalities of abortion provision and performed proportionally more first-trimester and second-trimester terminations 13. A more recent survey of obstetrics and gynecology residents found that 54% reported routine abortion training, 30% reported opt-in training, and 16% reported that training for elective abortion was unavailable 12.
Training in abortion includes many skills that are applicable to general obstetrics and gynecology practice, including counseling around topics such as pregnancy options, early gestational ultrasonography, pain management for gynecology-based office procedures, cervical dilation, and the use of manual vacuum aspiration for early pregnancy loss. Most residents who partially participate in abortion training affirm the value of a dedicated family planning rotation to these skills 16. Additionally, obstetrics and gynecology residents at one institution gave family planning rotations that included abortion training the highest rating among all third-year resident rotations 17.
In response to the need for organized resident education in abortion care, the Kenneth J. Ryan Residency Training Program was founded in 1999; currently, 67 U.S. and Canadian obstetrics and gynecology residency programs participate in the program 18. A recent survey of residents and residency directors demonstrated significant improvement in knowledge and skills related to family planning and abortion for residents involved in this program, even for those who opted out of some aspects of training 16.
Other Abortion Providers
Family Medicine Physicians
Although obstetrician–gynecologists perform most abortions in the United States, family medicine physicians play an important role in the provision of these services 19. Family medicine physicians are more likely than physicians in other specialties to provide primary care to underserved women, and specifically to women in rural communities 20. Providing training in first-trimester abortion care to family practice physicians may help reduce disparities in abortion access.
The American Academy of Family Physicians recognizes termination of pregnancy up to 10 weeks of gestation as an advanced core skill for family physicians 21. Studies have shown that first-trimester abortion training may be integrated safely and effectively into family medicine residency programs; however, most family medicine residencies have no abortion training available 22. In programs where abortion is an integrated part of the curriculum, residents generally report positive experiences 23 24. Residents who completed a required, opt-out abortion training program indicated that the curriculum enriched their educational experience and was consistent with the values of family medicine in providing continuity of care in a primary care setting 23. Another study evaluating resident experience and outcomes from a required, opt-out, comprehensive abortion training program showed interest among family medicine residents and general satisfaction with the program 24.
Currently, only 24 of the 461 accredited family medicine residency programs offer integrated abortion training, in part because it is not mandated by the ACGME as it is for obstetrician–gynecologists 23 25. The Reproductive Health Education In Family Medicine Program was established in 2004 to integrate high-quality, comprehensive abortion and contraception training into U.S. family medicine residency programs.
Advanced Practice Clinicians
Advanced practice clinicians, including nurse practitioners, physician assistants, and certified nurse–midwives, provide a large proportion of primary health care to reproductive-aged women, and their contribution is expected to increase with the implementation of the Affordable Care Act 26 27. Currently, five states allow APCs to provide first-trimester medical and aspiration abortions 28 29. Data suggest that abortion training is deficient in APC curricula 30. However, several reports show no difference in outcomes in first-trimester medical and aspiration abortion by provider type and indicate that trained APCs can provide abortion services safely 28 31 32.