In the wake of the Supreme Court decision last week eliminating a constitutional right to an abortion, dozens of states are moving to either restrict abortions or ban the procedure outright.
Almost all of those restrictions leave pregnant patients out of the picture when it comes to levying potential fines and/or prison time. Instead, the laws target health care providers, the ones carrying out procedures to terminate a pregnancy.
That not only could have a chilling effect on reproductive health care providers, but it could also create a whole new landscape for how OB-GYNs and other health care providers are trained in medical schools and nursing programs.
Educators are now worried how abortion bans could create impediments to learning about the management of miscarriages, fertility treatment and other aspects of reproductive health care that could have an impact on how they care for patients.
The Supreme Court’s ruling has created an uneven landscape in states with abortion bans and those that will become safe harbors for people seeking to end their pregnancies.
Right now, abortion remains legal in North Carolina. Despite Republican majorities in both chambers of the legislature, Democratic governor Roy Cooper has said he would veto any attempts to outlaw the procedure. If the mid-term elections this fall result in veto-proof Republican majorities at the General Assembly, North Carolina could join the ranks of dozens of other states that are severely limiting abortion or banning it outright.
The Accreditation Council for Graduate Medical Education requires access to abortion training for obstetrics and gynecology residency programs to become accredited. Specialty boards, such as the American Board of Obstetrics and Gynecology require newly minted obstetrician-gynecologists to learn the management of incomplete abortions as part of their education and to become board certified. Being board certified, a voluntary process, is seen as a mark of quality and excellence in practice.
In an opinion piece in April in Obstetrics and Gynecology, Kavita Vinekar, an OB-GYN from the UCLA David Geffen School of Medicine, and other authors found that 286 accredited obstetrics and gynecology residency programs are in states that are either certain or likely to ban abortion, meaning that 2,638 residents either certainly or likely would lack access to in-state abortion training.
Abortion policies currently in effect in North Carolina
- Abortion is banned at fetal viability, generally 24–26 weeks of pregnancy
- Patients are forced to wait 72 hours after counseling (not required to be in person) to obtain an abortion
- State Medicaid coverage of abortion care is banned except in very limited circumstances
- Medication abortion must be provided in person because state bans the use of telehealth or mailing pills or requires in-person visit
- Parental consent or notice is required for a minor’s abortion
- Only physicians can provide abortions and not other qualified health care professionals
- Required counseling of patients by the physician, using a pre-approved script
- Unnecessary regulations are in force that are designed to shutter abortion clinics without basis in medical standards
- Protections for patients and abortion clinic staff
Synopsis courtesy: Guttmacher Institute
State limitations around abortion procedures mean that these students and medical residents will be learning in a highly charged atmosphere. They may get only limited experience managing these patients, they may have to travel out of state to receive instruction, and they may choose to avoid learning and practicing in states where these limitations exist.
These physicians also worry that more people will die from postpartum complications.
Headed out of state
In states that have had restrictions in place, this is already an issue at medical schools. Ashley Navarro, who now practices in North Carolina, spent her first year of residency (called the intern year) at the main UCLA hospital in Los Angeles.
There, she often saw patients from the Southeast who had traveled to California to get abortions because it was less cumbersome than getting one in their home states.
“They tended to be white, well-educated and definitely had the financial resources and the family support to be able to, you know, take care of their other children while they were traveling across the country trying to find a doctor,” Navarro told North Carolina Health News recently.
Navarro was determined to return to the Southeast, her home region, to complete residency and ended up at the Medical University of South Carolina in Charleston. There, a state restriction stating that full-time state employees cannot provide abortions meant that any abortion providers at MUSC needed to only work part-time.
The medical school in Charleston didn’t provide abortions, only care after incomplete miscarriages and care for patients who faced life-threatening conditions such as preeclampsia or hemorrhaging.
So Navarro sought out extra training in Boston. Doing that was expensive. She had to continue paying rent in Charleston while picking up room and board in Boston for almost a month. She also had to pay to become licensed in Massachusetts, which was a months-long process in itself.
“It’s just a huge undertaking,” she said.
Of Navarro’s 24 fellow OB-GYN residents at MUSC, none of the others took these steps. In states such as Texas, which has restricted abortion to those occuring only before six weeks of pregnancy, residents have headed to states such as California and Illinois to get similar training.
“These are important skills. It’s always safer to learn how to do a skill in a low risk environment, rather than having someone show up on labor and delivery, you know, hemorrhaging and not know what to do or how to do it,” Navarro said.
“It’s second trimester surgical care that’s often when you face very emergent situations where you need to have the skill set,” said Beverly Gray, an OB-GYN at Duke University who is the director of the program for OB-GYN residents. “For people that are learning in a state where you’d have abortion restrictions, you just don’t have the adequate skill set to provide that care.”
Providing that care in a high-volume environment is a good way to practice. A physician’s chances of encountering someone who’s coming in with complications rise as the number of patients increases for a procedure considered safe. Research shows that the death rate for abortion in the U.S. is far less than 1 woman per 100,000 procedures.
Maternal mortality in the U.S. is the highest of any westernized country, at about 20.1 deaths per 100,000 live births. In North Carolina, the maternal mortality rate is 21.9 per 100,000 live births according to the most recent America’s Health Rankings report.
Gray said Duke is where many patients who need emergency treatment for pregnancy complications past the 20th week get sent. There’s only one or two of those patients each month, she added. Gray worries that further restrictions in the state could cause providers encountering these patients to hesitate as they start to provide care for them, wondering if they’d be open to prosecution. That’s what she’s hearing from colleagues in Texas.
Navarro is now doing a fellowship in North Carolina where she’s been able to practice more and see complicated cases she didn’t see in South Carolina.
“The more cases that you do, the higher the odds that you’ll see a complication or two in your career and you’ll know how to handle those,” Navarro said. “Abortion care is safe. And so the likelihood of a complication happening as a resident and training in the Southeast is pretty low.
“I wanted to have that high volume of cases.”
‘Worrying that they’re not breaking the law’
“There’s a minimum number of first- and second-trimester procedures that you are supposed to perform based on recommendations from the [American College of Graduate Medical Education],” Gray said.
She noted that residents can fulfill their training obligations treating patients with miscarriages. That’s how these new doctors who object to abortion and who opt out of doing them fulfull their requirements now.
The problem, Gray explained, is volume. Because managing an abortion is almost identical to managing a miscarriage, you can see the situation more frequently if you perform abortions. Women with miscarriages don’t walk into clinics as often as women seeking abortions.
Providers use the same medications and the same procedures to treat abortion, miscarriage and incomplete abortions, the management is the same for all of them. It could be further medication to induce uterine contractions to expel that retained tissue, or it could be the use of an aspiration device — either using a syringe or a suction machine — to empty the uterus. In some advanced cases, a dilation or curettage procedure or even surgery might be in order.
Abortions versus miscarriages
In the U.S. about 80 percent of abortions occur before the 12-week mark. Now doctors are able to use pills to induce the procedure, a development that has increased the safety of abortion.
In medical terms, a miscarriage is called a “spontaneous abortion” when the pregnancy failed and the patient’s body starts expelling the fetal tissue seemingly without rhyme or reason. Estimates are that 10 to 15 percent of all recognized pregnancies end in such spontaneous abortions, and a “significant proportion” of pregnancies are lost even before someone notices they’ve missed their monthly menstrual period, so that number could be even higher.
Whether induced or occurring spontaneously, sometimes fetal tissue remains in the uterus, which is known as an “incomplete abortion.” There are also “missed abortions” when a pregnancy failure has occurred but the gestational sac has not passed.
Having tissue remaining in the uterus puts someone at risk for an infection that could be life-threatening, and the tissue must be completely expelled or removed.
The physicians contacted for this story all said the same thing: in treating a patient who walks into a doctor’s office in this situation it’s almost impossible to tell if a patient experiencing an incomplete or missed abortion took pills or if their pregnancy ended naturally.
“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,” wrote Janis Orlowski, the AAMC’s chief health care officer.
“All medical schools currently require students to complete a clerkship in obstetrics and gynecology and obstetrics-gynecology residencies are required to provide training or access to training on the provision of abortions, though residents with objections may opt out of performing induced abortions,” she wrote.
Iffath Abbasi Hoskins, president of the American College of Obstetrics and Gynecology, spoke to the ambiguity about what will happen at medical schools in affected states during a webcast last week in the wake of the Supreme Court announcement. Once all of the abortion trigger laws and bans take effect in the coming weeks, ACOG estimates that some 44 percent of all OB-GYN residents will be doing their training in a state with restrictions.
“I think of the clinicians who will have to pause in providing the critical care that is needed, but will be distracted, that they are worrying that they’re not breaking the law,’ Hoskins said.
That sentiment was echoed by Gray, who said that to be an OB-GYN these days requires physicians to also understand the law in order to advocate for their patients.
“There’s some days I wish I could just go to work and do the right thing for people and not have to also have a mini law degree to be able to practice medicine the way it should be practiced,” Gray said.
Meeting standards
“It is crucial that physicians have comprehensive training in the full spectrum of reproductive health care, since similar medical procedures address many health conditions,” according to a statement on the website of the Association of American Medical Colleges in response to the Supreme Court ruling. “All medical schools currently require students to complete a clerkship in obstetrics and gynecology, and OB-GYN residencies are required to provide training or access to training on the provision of abortions, though residents with objections may opt out of performing induced abortions.”
The statement went on to say the association was examining the decision and its implications for medical education.
The American Board of Obstetrics and Gynecology, which provides board certification for OB-GYNs, said in a statement on its website that it “will continue to include comprehensive family planning and abortion topics in certification standards and assessments based on data reflecting the scope of practice of OB GYNs across the nation.
“ABOG certification standards require that physicians have the knowledge and ability to perform and care for patients who have had an abortion, regardless of if a physician chooses to perform one or practices in a state with restrictions.”
It’s still unclear what will happen to OB-GYN programs located in the 26 states expected to have bans or severe restrictions in place by mid-summer.
“It is up to the program to fulfill requirements, how is that going to look when we have so many residents who are going to need to seek that training?” asked Navarro. “Those programs have their own residents they need to teach.”
Right now, North Carolina has five medical schools, with a sixth planned for Charlotte (there’s currently a residency program at the Carolinas Medical Center Program in Charlotte). Four of those locations participate in the Kenneth J. Ryan residency training program, which helps new physicians learn the skill sets required for managing abortions.
Research on the health care workforce shows that medical residents are more likely to remain in the places where they completed their training. That’s why so many programs in rural North Carolina have been working to provide residency opportunities for new physicians.
If the state were to impose new restrictions, finding people willing to fill those slots and come to underserved areas could become even harder. Navarro said that her fellow residents routinely tell their department chairs that they need more abortion training. Already, Navarrro said she’s been contacted by medical schools in Tennessee about whether her program will be able to accommodate residents from that state who need help fulfilling their ACGME requirements on abortion training.
“Some people may be afraid of what the landscape in OB-GYN is gonna look like in the next 20, 30, 40 years,” Gray said. “[New physicians] might be hesitant to enter a field, where they could be prosecuted for doing their job.
“I am 100 percent positive that residents or medical students making decisions for residency are looking to states that still allow care to be provided. And so I think that is part of the calculation that students are making when they’re deciding which programs to apply to,” Gray said.
As North Carolina faces a physician shortage, it’s important to get physicians in training to come to this state and stay.
“I just fear that when we put these bans into effect, that we’re not going to have residents stay in our state or trainees stay in our state,” Navarro said. “Because why would they when they can go to California, or they can go to Colorado or New York and become comprehensive OB-GYNs.”
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