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To learn about that, and how to counsel patients about their options, Emma applied to an “away rotation” in Massachusetts. The elective course, at Brigham & Women’s Hospital, in Boston, lasted a month, and she paid for her housing and transportation out of her own pocket, about $2,500. Her school is one of a few in Texas in a consortium with Harvard Medical School, which offered the rotation, so she paid no tuition.
Emma puts what she learned into “three buckets.” How to do procedural and medication abortions and counseling is one, talking patients through the steps, what to expect. She also worked at a Planned Parenthood, where she realized that, bucket No. 2, “abortion is a really normal part of health care” and “faster than getting your teeth cleaned.”
She grew up in a conservative, Christian family in Houston. The most valuable thing she learned in Massachusetts she puts into the third bucket: “Reflecting on my own bias, that kind of internalized stigma that I didn’t realize I had about abortion,” from being in a community where the topic is “hushed.”
“And that was really powerful,” she said.
At least 10 percent of medical schools offer no formal training, clinical or classroom, in abortion care. In 2013, the last time The Chronicle wrote about abortion training, the number was a third.
Back then, we focused on Medical Students for Choice, an advocacy group that works to improve and expand abortion-care training for future physicians. Jody Steinauer, then an obstetrician-gynecologist and a professor at the University of California at San Francisco, had taken a year off med school to start MSFC in 1993.
Today, Steinauer directs the Bixby Center for Global Reproductive Health at UCSF, as well as the Kenneth J. Ryan Residency Training Program in Abortion & Family Planning, which trains ob-gyn residents, i.e., new doctors, in more than 100 programs at hospitals around the country and in Canada. Steinauer said that before June 2022, when the U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization overturned the constitutional right to abortion established by Roe v. Wade in 1973, abortion-care training was on the rise. About 64 percent of ob-gyn residencies had fully integrated the training, “so we were going up, compared to, if you use as your baseline, 1992,” when only 12 percent had such training. Complex family planning had recently become an accredited, board-certified part of obstetrics and gynecology. “It’s like finally medicine saw abortion and complex contraception care as critical,” said Steinauer. “And then Dobbs happened.”
A sweeping change in where people practice medicine is a “health issue facing campuses nationwide,” one that could affect where students decide to go to college.
But for all of that ruling’s effects — 15 states now ban abortion, with very limited exceptions, and six do so after six to 18 weeks’ gestation — Dobbs, coupled with Texas’ SB 8 (the “bounty” law that lets citizens sue anyone involved in an abortion), may have paradoxically opened pathways to better future access to abortion in some of the states where it is protected.
That’s because when SB 8 became law, the Ryan residency program went into high gear, matching medical residents at hospitals in abortion-restricted Texas with residencies in states with access — a process Steinauer’s team expanded to residents in other restricted states after Dobbs. With help from donors, Medical Students for Choice sent 20 students from restricted states to its annual Abortion Training Institutes, paying their room, board, and travel, and it moved more than 20 “externship” students, those with assistance awards or stipends for clinical abortion training, from Texas into states with abortion access. The medical profession also began to embrace the idea that physicians other than ob-gyns, including internal-medicine, family-medicine, emergency-room, and other doctors, should learn abortion care. And perhaps most surprising, the jettisoning of Roe v. Wade, which said abortion was a decision a woman should make in consultation with a “responsible physician,” has encouraged educators to train more nondoctors in abortion care. That means more nurse-practitioners, physician’s assistants, and certified nurse-midwives are now able to practice abortion in some states, a trend the American College of Obstetricians and Gynecologists has supported since 2014.
Dobbs is changing education in abortion care, making it more pervasive, with more states paying for that teaching.
Abortion “can feel like a niche topic that’s most relevant” to providers, said McNeilly, a third-year student at Albert Einstein College of Medicine, in New York, “largely ob-gyns and family-medicine physicians. But that’s actually not the case.” Their sample includes physicians and medical trainees who may never take part in an abortion or even reproductive health care but still “feel very personally impacted” by the restrictions, she said. “We thought that was very important for state legislators and leaders of academic medical centers, etc., to start thinking about.”
College leaders need to understand that a sweeping change in where people practice medicine is a “health issue facing campuses nationwide,” said Vineet M. Arora, another co-author, via email. A professor of medicine at the University of Chicago, Arora said that such a change in where doctors are located could affect not only faculty and staff members on campuses, but where students decide to go to college.
Today, the closure of clinics in the states that ban abortion means that people must cross state lines for abortion care. One in five people did so in the first half of 2023, compared with one in 10 in 2020, according to the Guttmacher Institute, a think tank that studies reproductive health. And the average number of abortions per month in the United States has increased since Dobbs, according to #WeCount, a project of the Society of Family Planning.
That has created much more demand for providers in the states that flank those where abortion is banned. “In Illinois,” said Pamela Merritt, executive director of Medical Students for Choice, patients are coming from “Kansas, Oklahoma, Kentucky, Indiana, Arkansas, and Missouri. And now even deeper South.” Doctors could not get a break, she said. It felt like “doing triage.”
The restrictions have put maternal health care at risk, too. Danna Ghafir, a medical- and business-school student in Texas, and the president-elect of Medical Students for Choice’s Board of Directors, said the concern in her state is that nearly “50 percent of counties don’t have active ob-gyns,” a statistic the March of Dimes dubs “maternity-care deserts.” In these largely rural jurisdictions — 46.5 percent of counties in the state — many low-income mothers have no access to obstetrician-gynecologists at all.
A study by the Commonwealth Fund found such deserts to be worse in states that limit abortion than in states that protect it. And a study published in November found that the post-Dobbs “reduction in obstetrics and gynecology work force could significantly exacerbate maternity-care deserts.”
“Abortion restrictions have a more profound impact on already-vulnerable populations,” said Emma, the Texas student who traveled to Massachusetts.
And alarmingly, last year the Association of American Medical Colleges found a drop of greater than 10 percent from the previous cycle in fourth-year med students’ applications for ob-gyn residencies in states with abortion bans. The year before that, the number of applications in that specialty went up.
That study might not yet reflect Dobbs. The match process, when med students start applying to residencies, begins in early June, and the justices’ ruling arrived on June 24, 2022. But a draft of the decision had been leaked in May of that year, and SB 8 went into place in Texas in September 2021. The wind that overturned Roe had been blowing for decades, and the study shows at least some ob-gyn residents appear to be voting with their feet. This year’s medical-school match, on March 15, will tell more.
“The best-case scenario is a regionalization of ob-gyn care,” Merritt said. “Worst-case scenario is that people are going to choose an area of medicine that won’t get them a felony conviction for saving somebody’s life.”
But Harvard has to give priority for that elective to Harvard students, so out-of-state med students attend only when a Harvard student unexpectedly can’t. Last year, just two others from beyond Massachusetts participated.
Medical Students for Choice’s reproductive-health externship, however, aims to provide 100 medical students and residents with a stipend in 26 states, and 50 more abroad, where students can spend two or four weeks working with physicians providing abortion care. The group also offers online classes and provides symposium speakers, and most of the medical students interviewed for this article, in Texas, Florida, Oklahoma, Missouri (all states where abortion is banned), and New York, had built chapters at their home institutions using those resources. From having 159 chapters in the United States and 12 other countries when The Chronicle last wrote about it, the group now has 287 in 29. And at 31 years old, MSFC has many ob-gyn alumni around the country who mentor current students.
‘Dobbs’ is changing education in abortion care, making it more pervasive, with more states paying for that teaching.
The American Medical Student Association also offers online abortion-care training via its Abortion Care & Reproductive Health Project, which started in 2019. It held one event, bringing medical students to lobby Congress for abortion education in their curricula, and then Covid put a stop to meeting in person. The pivot to virtual proved a boon, as new med students, whose education in 2020 was all online anyway, signed up, forcing the group to meet the demand for more programming in abortion and reproductive-health care. AMSA’s Reproductive Health Scholars Program, for example, comprises one-hour lectures every two weeks between mid-January and the end of April. Classes cover first- and second-trimester abortion procedures, the history of abortion in the United States, options counseling, and how to find clinical training in abortion if it isn’t offered at a med school.
The Ryan program now has 116 residencies, including 59 in states where abortion is restricted. When SB 8, which banned abortion at six weeks, became law, “we realized that all of these Texas residents, how were they going to be able to get trained in these skills?” Steinauer said. She and her staff of five had matched restricted-state residents with hospitals in access states, encountering hurdles — medical-malpractice insurance, vaccination requirements, licensing. A resident who had secured all that in Texas would now, thanks to the new law, have to set it all up again in another state.
Steinauer and her team decided that rather than connect people to programs, they could connect residencies at Texas hospitals with those in states that protect abortion. The arrangements took six months to set up, and residents started traveling to the two- or four-week rotations in March 2022, right up until Dobbs, in June, after which Texas banned all abortions, with rare exceptions. Then an anonymous donor stepped in, allowing the Ryan program to subsidize travel and housing. Since Dobbs, by the end of the 2023-24 academic year, the program will have sent 127 residents — most but not all from Ryan programs — to states where abortion is protected, said Kristin Simonson, director of programs and operations for Ryan.
“I came to medical school wanting to support communities that have the least access to care,” said Hanna Amanuel, current president of Medical Students for Choice’s board, and an M.D.-Ph.D. student at Harvard. “Black and brown communities, poor communities, people who are undocumented.” She had intended to apply for residencies in the South or Midwest. But “I won’t be applying to residency” there, she said. By the time she graduates, Amanuel wants to be able to provide the most comprehensive reproductive health care possible. “I wouldn’t be able to do that in those states.”
So will ob-gyn residencies in states that restrict abortion be easier for applicants to match into? Probably not. The field is competitive; last year, even with the drop in applications to ob-gyn spots in states with restrictions, every residency was filled.
Bethany, a fourth-year student at a medical school in Oklahoma, defies the research: She would like to stay in her state, which bans almost all abortions, for her residency, and eventually practice there. (Because of the sensitivity of abortion in Oklahoma, she prefers not to name herself or her school.)
She grew up in Oklahoma, and will very likely learn abortion care and counseling elsewhere, Bethany said, pointing to a “2023-2024 OBGYN Match” spreadsheet that enumerates, on a tab called “Roe,” a school-by-school and state-by-state “Plan for Abortion Training.” (“With new ban we are vigorously searching for place to send interested residents,” wrote one program manager in her state.)
“I can hope and pray that one day things will change” in Oklahoma, Bethany said. If they don’t, she wants patients to know their options. “I can at least not coerce my patients or gaslight them” with misinformation, she said.
Many of the states that have complete or partial bans are also states with physician shortages, she said. Before Dobbs, access to an abortion provider was through a person’s doctor, often an ob-gyn, but when restrictions drive ob-gyns away, “it could be your allergist,” she said.
To that end, the Midwest Access Project offers abortion-care training to doctors who are not reproductive specialists, to ob-gyn residents from restricted states, and to other health-care providers. In the fall of 2022, after Dobbs, MAP reached out to advanced-practice clinicians, the nurse-practitioners, physician’s assistants, and certified nurse-midwives who can legally provide procedural abortions in 20 states and medication abortion in 22. (“Advanced-practice clinician” is the term used in some parts of the country; elsewhere, they’re “advanced-practice providers,” and the term may include other practitioners in some states.)
Student trainees receive elective credit through their home programs, and the project aspires to offer continuing-education credit, which nurses need to keep their licenses current, in the future, said Latona Giwa, MAP’s executive director, via email.
More than half of its trainees go on to provide abortion care in their communities, according to a study by University of Chicago family-medicine researchers. MAP has trained 377 people in reproductive health since it started in 2007.
Nurses, including RNs and licensed vocational and practical nurses, “play a supporting role in helping the patient and clinic through the abortion procedure,” said Anna Brown via email. Brown is deputy director of programs at Nurses for Sexual and Reproductive Health, which, according to its website, offers “the nation’s only hands-on abortion-training residency for registered nurses.” While nurses cannot perform abortions, many residency participants are learning to be certified nurse-midwives or nurse-practitioners, and get continuing-education credit for NSRH courses through the California Board of Registered Nursing.
The organization’s Training in Abortion Care Residency provides clinical and online education to nurses in Maryland and Illinois, as well as from the restricted states Kentucky, Tennessee, and Missouri, supporting them with a $1,000 stipend, and teaching five or six nurses a year.
The group is part of California’s Reproductive Health Services Corps, funded by a state law signed by Gov. Gavin Newsom, a Democrat, in 2022. The corps gives stipends for training in reproductive health care, including abortion, especially to people underrepresented in the field, in exchange for service to the state. The law brought $20 million in state money to the project, which includes a program to train pharmacists in medication abortion.
The California corps was announced in November 2023. Maryland permitted the training of advanced-practice clinicians on July 1, 2022, a week after Dobbs, and this month Gov. Wesley Moore, a Democrat, announced an additional $15.6 million for abortion education. Washington and New Jersey have similar efforts underway, said Lina Buffington, executive director of NSRH. States that struggle with an influx of patients from other states, post-Dobbs, and hope to continue to offer abortion care, are “feeling the pressure.” As more state leaders think about how to ensure that their health-care work force is strong enough to meet the need, said Buffington, “one of the important things that’s happening, post-Roe, is an opening up of the field” and an understanding that “all disciplines need to be a part of the conversation.”
“I was given pretty explicit instructions” about how to avoid the protesters, said Mackenzie Lemieux, a medical student at Washington University in St. Louis, about crossing the state line to a clinic in Illinois so she could learn abortion care. The protesters were dressed in yellow like construction workers, pretending to give directions.
“Don’t stop. Just drive through,” clinic workers told her. “Put on sunglasses. Don’t look at anyone.” Lemieux was admitted through a back door. For the doctors, some of whom also crossed state lines, “people come and check the security of their house” in Missouri, she said, “because bad things happen to people that provide abortion in Missouri.”
That dichotomy — Lemieux’s view versus that of the protesters — reflects the division over abortion in the United States, one sharper than in many western nations. It is also why groups like the Ryan residency, Medical Students for Choice, Nurses for Sexual and Reproductive Health, the Midwest Access Project, and many other abortion-education programs are so important for students wanting to learn the full scope of reproductive health care.
“I came to medical school,” said Amanuel, the current Medical Students for Choice president, “to be in spaces where people are really talking about the politics that shape people’s health. That’s something that I found at MSFC.”
Said Ghafir, who will take over as president of the group this summer, “When the legislature implements these really harmful laws, it feels like, you know, what can I do as a med student in the face of these bans?”
Ghafir didn’t think she “could possibly effect change at a state level, at a national level.” But the group has been “key in linking students to the movement toward accessible reproductive health care for everyone.” Now she feels part of something larger.
