As a first-year medical student, I am interested in a career in obstetrics and gynecology. Yet, even in this early stage of my education, I am hesitant to consider applying for residency in states with abortion restrictions. I grew up in San Francisco, and when I became a woman of childbearing age, my abortion rights were protected by state law. As I consider my future training, I am confronted with the reality that this might not always be the case in a post-Dobbs U.S.
Currently, 21 states ban abortion or restrict the procedure to earlier pregnancy timelines than the standard set in Roe v. Wade. In 14 of those states, abortion is banned in almost all circumstances, including rape or incest in some places.
Regardless of your stance on abortion, it is important to understand the effects of the Dobbs ruling on ob/gyn residency programs, trainees’ access to comprehensive training, and the subsequent impact on access to maternal care, particularly in states with restrictive abortion laws.
What Does This Mean for Patients?
Even before the Dobbs decision, states with the most restrictive abortion laws had the weakest maternal support, leading to worse maternal/child health outcomes compared to the rest of the nation. In a global context, the U.S. has a maternal death rate 10 times higher than the estimated rate of some other high-income nations. This is unsurprising considering that 36% of U.S. counties, particularly in the Midwest and South where abortion laws tend to be stricter, are maternity care deserts and lack ob/gyn providers and birth centers.
After the Dobbs decision, this shortage will likely increase, both due to current ob/gyn physicians leaving states that restrict abortion, and the decreased application of medical graduates to residency programs in these states. According to the Association of American Medical Colleges, ob/gyn residency applications from MD-granting schools dropped 10% in states with total abortion bans and 6.4% in states with gestational limits on abortion.
Considering that the majority of physicians end up working in the state in which they complete training, lower application rates will likely further exacerbate the issue of women’s health access in restricted states. In Idaho, almost a quarter (22%) of practicing ob/gyn doctors have left since the abortion ban. With no ob/gyn residency or fellowship programs in-state and a drastic decrease in out-of-state applicants, Idaho is experiencing obstetric care deserts. Other states are seeing similar patterns.
As a first-year medical student, I am not the only one who feels this hesitancy to apply to programs in states with abortion bans. In a national survey of third- and fourth-year medical students, 58% reported that they were unlikely to apply to programs in restricted states, many attributing their decision to a desire to receive comprehensive ob/gyn training. This points toward a need to support complete ob/gyn training — including abortion procedures — in all states.
Maintaining Access to Comprehensive Training
Despite changes to federal law, the American College of Graduate Medical Education (ACGME), which accredits residencies, has upheld its requirement for ob/gyn residency programs to offer training in abortion care, including spontaneous abortion and pregnancy loss. The curricula in restricted states varies with some offering out-of-state partnership. Meanwhile, the American College of Obstetrics and Gynecology (ACOG) created an online abortion care training module to be available in all states. This is essential.
A qualitative analysis of interviews conducted with leaders in the field has revealed concerns that decreased abortion training could lead to worse outcomes in other common procedures that use similar technical skills such as uterine manipulation or hysteroscopy. They also expressed concerns over the ability of ob/gyn programs in restricted states to recruit strong residency candidates, over time creating two tiers of training, with more qualified students only applying to states with protected abortion.
All ob/gyn residency programs must be able to offer abortion care training, both to recruit applicants and to maintain physician proficiency. Many programs in restricted states have partnered with clinics in nonrestrictive states to provide residents with the required training. However, some of these institutions have encountered obstacles, including difficulty organizing travel, delays in obtaining licenses in different states, and added expenses. For example, Indiana University’s ob/gyn residency program offers abortion training through a partner clinic in Illinois. Certain aspects of the residents’ lodging and food are funded, but Indiana University has to foot the unforeseen additional cost of $20,000/year.
How to Prevent a Widening Gap in U.S. Women’s Health
Following the call to action from ACOG, medical societies and individuals must push for more federal funding to support ob/gyn programs in restricted states that are struggling to offer their residents comprehensive education. The Congressional Research Service has suggested using existing federal grant programs that support geriatrics and primary care as models for federal funding in ob/gyn training. Additionally, graduate medical education funding could be appropriated to fund visiting rotations for residents from restrictive states.
Ensuring that all institutions have adequate ob/gyn training can help decrease the hesitancy of medical school graduates to apply to programs in restricted states. Because these states are often the same regions with worse access to women’s healthcare and poorer maternal/fetal outcomes, this is a crucial measure to prevent further provider shortages and improve maternal health outcomes.
Regardless of your stance on abortion, it doesn’t appear Dobbs is going away, and it is imperative that we preserve training for future generations of physicians.
Samantha Kwock is a medical student at the University of Chicago, and a board member for the Bridgeport Free Clinic. She conducts qualitative research on the experiences of transgender and gender-diverse individuals who are pregnant.
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