Pro-choice timidity in fighting shortage of abortion providers

Original Reporting | By Heather Rogers |

Major gaps remain in medical school training

If most ob-gyns already in practice are not being reached, what about medical students? Dr. Jody Steinauer, an associate clinical professor in the Obstetrics and Gynecology and Reproductive Sciences Department at UCSF, and a founder of Medical Students for Choice (MSFC) when she was in medical school 20 years ago, says that a student’s intention to include abortion services in her practice upon graduating from medical school has been a significant predictor of who ultimately becomes an abortion provider. Steinauer was the lead author of a 2008 study that found that of practicing abortion providers, 77 percent had gone into residency intending to perform abortions.

Nevertheless, major barriers remain to giving all medical students initial experience with the field. Lois V. Backus, MSFC’s executive director, said the lack of abortion education in many medical schools is a “huge problem.” According to MSFC, even those medical schools that do offer abortion education in the first two years dedicate less than 30 minutes to the topic. The group claims that most of this instruction is limited to ethics discussions, and not education and training.

Medical schools that do offer abortion education in a student’s first two years dedicate less than 30 minutes to the topic, according to Medical Students for Choice.

And during the final two years, when medical schools focus on clinical training, less than a third of all medical schools have at least one lecture specifically about abortion, as reported in a 2005 article in the American Journal of Obstetrics and Gynecology, an academic journal.

Backus said that many medical schools are reluctant to teach abortion out of fear of losing public and private funding. She also said that there were instances of students threatening to sue medical schools if they were made to study abortion. Noting that there were subjects other than abortion that some students did not wish to learn, Backus she would like medical schools to take the position of saying, in effect, “Too bad, you’re a medical student!’” Instead, she said, medical schools typically accommodate themselves to student resistance rather than incorporating abortion education into the required curriculum.

When MSFC members have been successful in getting a school to include abortion instruction, such progress is often transient. Sometimes MSFC chapters convince their institutions to incorporate abortion instruction into the overall curriculum, but more often they are only able to convince individual faculty members to give lectures on abortion in class. The MSFC chapter at George Washington University worked for three years to get an instructor to include a one-hour lecture on abortion. When he left, three or four years later, a new teacher came in and cut the lecture. “So the chapter had to reengage,” Backus said, “and spend another two years convincing the new teacher that they really did want that one-hour lecture on abortion.”


Failed promise in residency programs

Residency programs come under the aegis of the American Council of Graduate Medical Education (ACGME), which is the sole accreditation body. In 1996, the ACGME enacted a rule establishing that “experience with induced abortion must be part of residency training.” The rule had an impact: whereas only a small fraction of residency programs routinely integrated the training into their curricula prior to the rule, 50 percent of residency programs do so today (residents retain the ability to opt out).

Why does initial interest in providing services often not translate into practice?

As noted above, the universe of doctors who do provide abortion services is primarily made up of those who went into residency with the intention of offering pregnancy termination as practicing doctors. But it is still the case that a significant percentage of doctors who do receive abortion training don’t go on to offer the service once they begin taking patients.

Lori Freedman is a sociologist and assistant researcher at the Department of Obstetrics, Gynecology and Reproductive Sciences at UCSF, and the author of the book “Willing and Unable: Doctors’ Constraints in Abortion Care.” She was the lead author of a 2010 study that found that 60 percent of those surveyed had wanted to offer elective abortions after their residencies. Ultimately, however, just 10 percent were doing so.

“There are a lot of problems with integrating abortion into practices,” Freedman told Remapping Debate. “The reasons for policies barring abortions are stigma, fear of lost business through controversy, or people protesting. And sometimes it’s just logistics.” The barriers can range from highly charged political and religious objections to the more mundane. For example, if a group practice or clinic starts offering abortions, this may slow down the number of patients its doctors can see in any given week. “They may not have a huge opposition to it, but it would create a disruption to the flow of the clinic,” Freedman said. “If it’s not a priority and if it’s very easy to send them to Planned Parenthood, why bother?”

In more extreme cases doctors are contractually barred from offering abortions by their employers. Dr. Rebecca Mercier, an ob-gyn based in North Carolina, described the situation faced by a colleague from residency who accepted a position with a large health care employer in the Midwest. Once she arrived, she found out that her employer didn’t offer abortions at its facility, and was surprised to discover that her contract stipulated that she could not perform abortions in her spare time anywhere else. This predicament is not uncommon, leading Dr. Debra Stulberg of the Midwest Access Project to say that, as part of standard abortion training, residents should be taught contract negotiation techniques to ensure they don’t inadvertently or unwillingly sign an agreement that prevents them from providing pregnancy terminations.

Being able to give abortions is “so much harder than people realize because you have to have an entire staff on board with you too,” added Freedman. “You’re kind of swimming upstream if your practice isn’t already doing it, and the entire structure of the clinic and all the assistance you’d need isn’t there yet.” Whether a doctor is working at a group practice that doesn’t offer abortions, or is on staff at a large hospital that bars it, if she can’t provide abortions and she wants to, she’s going to need support in creating that option.

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