Implications of Overturning Roe v Wade on Abortion Training in US Family Medicine Residency Programs

INTRODUCTION

On June 24, 2022, the US Supreme Court overturned Roe v Wade (Roe), and in doing so eliminated the constitutional right to abortion in Dobbs v Jackson Women’s Health Organization (Dobbs). As of August 2, 2023, abortion had been banned or severely restricted in 17 states (14 states with complete bans, 3 with early gestational age bans), and several states had bans that were pending or temporarily suspended.¹

These bans have raised concerns about the availability of comprehensive reproductive health training for clinicians in abortion-restrictive states. For medical residencies in obstetrics and gynecology (OB/GYN), Vinekar et al conducted an analysis on the projected impact of Dobbs before the decision and found 45% of accredited OB/GYN residency programs were in states anticipated to ban abortion if Roe was overturned.²

Although family medicine residency training, unlike OB/GYN training, does not require abortion training for accreditation, the Accredited Council for Graduate Medical Education (ACGME) does require residents have hours dedicated to gynecologic issues, and the American Academy of Family Physicians recommends residents have knowledge of early pregnancy loss (EPL) and post-abortion symptoms and complications.^3,4 There is substantial evidence that abortion training in family medicine residency is safe, appropriate, and supported by patients and residents.^5-7 Additionally, there has been increasing appreciation of family physician’s role in abortion provision,⁸ especially because family physicians practice in communities where they may be the only health care clinician,⁹ and abortion care is well aligned with family medicine’s core values of continuity and whole person care.¹⁰

Though state-level abortion restrictions likely impact family medicine residency training in abortion, post-abortion care, pregnancy options counseling, and EPL management, the extent of this impact remains unknown. We sought to understand the implications of overturning Roe on family medicine residency programs.

METHODS

To assess the number and proportion of family medicine residency programs and trainees in states with abortion bans, we used a publicly available American Medical Association database of all accredited family medicine residency programs in the United States and abstracted the number of residents per year.¹¹ When information was unavailable in this database, we searched residency program websites and contacted programs by e-mail or telephone.

We used a Guttmacher Institute policy analysis from August 2, 2023, to identify state abortion policies categorized from “most restrictive,” states with total abortion bans, to “most protective,” states with protections for abortion patients and clinic staff.¹ We included active accredited family medicine programs in all 50 states and Washington, DC. Additionally, we used a publicly available list of family medicine programs that provide abortion training from Reproductive Health Education in Family Medicine (RHEDI) to assess the state policy environment of programs with abortion training.¹²

We geocoded (obtained latitude and longitude coordinates) and mapped all US family medicine residency sites. All geospatial mapping was performed in QGIS (version 3.4) and program and resident quantifications were performed in Microsoft Excel 2302 (Microsoft Corp).

The study protocol was reviewed by the Institutional Review Board at the University of California, San Francisco, which determined this study did not meet the definition of human subjects research and did not require formal exemption or approval.

RESULTS

Of 693 accredited family medicine residency programs in the United States, 201 programs (29%) were in states where abortion was banned or very restricted as of August 2, 2023. Fourteen of the 17 states in this category had full abortion bans, Georgia had a 6-week ban, and Nebraska and North Carolina had 12-week bans (Figure 1).

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Figure 1.

Family medicine residency programs in the United States by state abortion designation.

Note: State policy designation is based on a Guttmacher Institute analysis from August 2, 2023.¹ Green indicates states where abortion is banned (n = 14) or very restricted (n = 3), which includes Georgia (6-week ban), Nebraska (12-week ban), and North Carolina (12-week ban).¹²

Although most (63.8%) family medicine residency programs were in states with at least some abortion restrictions, 251 programs (36.2%) were in states with laws protecting abortion. Of the 13,541 residents in accredited US family medicine programs, 3,930 (29%) were training in states that had banned abortion or where abortion was very restricted, and 5,020 residents (37.1%) were in states with protective policies.

Of 40 programs known to offer abortion training, 1 was in a state that had banned abortion. Most residency programs with abortion training (85%) were in states with protective abortion policies (Figure 2).

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Figure 2.

Family medicine residency programs with abortion training in the United States by state abortion designation.

RHEDI = Reproductive Health Education In Family Medicine.

Note: The state policy designation is based on a Guttmacher Institute analysis from August 2, 2023.¹ Family medicine residency programs with abortion training include RHEDI programs (n = 34) and RHEDI-affiliated programs with integrated abortion training (n = 6).

DISCUSSION

We found 29% of family medicine residents trained in states where abortion was banned or very restricted, impacting residents’ knowledge of and clinical experience with comprehensive reproductive health care. Family physicians, regardless of the political environment in which they practice, need to be able to care for patients seeking abortions or follow-up care. An analysis by Aiken et al, showed request rates for self-managed medication abortion increased in all states since Dobbs, with the largest increases in states with total abortion bans.¹³ Although self-managed abortion with mifepristone and misoprostol or misoprostol alone is very safe,^14,15 some patients will seek or require follow-up care from their family physicians.

The impact of state bans extends beyond abortion training and care. A 2023 study found institutions with state or institutional abortion restrictions are less likely to follow evidence-based treatment for EPL, offer the full range of EPL treatment options, and take patient preferences for EPL management into account.¹⁶ Consistent with the recognized phenomenon of educational imprinting,¹⁷ in which physicians are more likely to provide services for which they were trained, residents who receive abortion training are more likely after residency to provide abortion care as well as EPL care, pregnancy options counseling, and long-acting reversible contraceptives.¹⁸ Family medicine residency programs in states where abortion remains legal can prepare physicians to provide comprehensive reproductive health care by expanding abortion training opportunities.

Residency programs in restrictive states should consider how they will provide training in pregnancy options counseling, abortion referrals, post-abortion care, and EPL. Programs in these states may experience a reduction in qualified applicants who instead want to train in states where they can receive comprehensive training. This is supported by the recent finding that OB/GYN residency programs in states with total abortion bans saw the largest decrease in applicants last cycle, 10.5%, more than double the national average.¹⁹ Residency training should also address the fact that abortion restrictions potentiate systemic racism, disproportionately harming communities of color and other marginalized communities.²⁰ Moreover, forced birth has been associated with worsened physical and mental health, and increased incidence of adverse pregnancy outcomes²¹ that family medicine residents in these states should be prepared to address.

Our finding that 29% of family medicine programs were in states with abortion bans or very restrictive laws is lower than the 45% of OB/GYN residency programs that Vinekar et al predicted to be affected by abortion bans.² This discrepancy is due to their study’s use of an earlier Guttmacher analysis that predicted 26 states would ban abortion if Roe were overturned,²² compared with the 17 states that had enacted such bans at the time of this analysis. Of note, family medicine programs have substantially more residents compared with OB/GYN, including more residents in banned/very restricted states. Our analysis revealed 3,930 family medicine residents are in states where abortion is banned or very restricted compared with the 2,638 OB/GYN residents projected in the Vinekar et al analysis.

Given the evolving policy environment, this analysis will require intermittent updates for accuracy as more states are expected to pass restrictive and protective laws. The Guttmacher analysis used for this study only includes restrictions currently in effect and does not factor in bans that are temporarily blocked. Additionally, there may be family medicine programs that offer but do not publicize abortion training, including programs in states that have recent bans. For these reasons, the implications of overturning Roe on family medicine training are likely more severe and far reaching than this analysis describes.

The overturning of Roe will impact family medicine residency training and have long-term effects on family physicians’ ability to provide abortion and follow-up care, manage EPL, and care for patient and community reproductive health needs. The ACGME can mitigate this effect by establishing explicit family medicine requirements for developing skills in comprehensive reproductive health care, regardless of policy environment. Further, individual residency program leadership teams, as well as family medicine organizations, must work to optimize training in restrictive states and expand abortion training where possible to promote high-quality, equitable reproductive health care in the context of abortion restrictions.