Abstract
Many counties in the US do not have an abortion provider despite abortion being one of the most common medical procedures among reproductive aged women. Increasing the number of abortion providers in the country is a multi-faceted endeavor. Understanding the factors that influence obstetrics and gynecology residents to include abortion in their future practice is an essential component. This study sought to determine the relationship between knowledge and attitudes about abortion during residency training and the intention to provide abortion care after residency training completion. An anonymous online survey was distributed to obstetrics and gynecology residents via an invitation to program directors at accredited obstetrics and gynecology residency programs in the US. Eligible participants were obstetrics and gynecology residents enrolled at accredited residency programs in the US at the time of distribution. Survey data were collected from August 2019–February 2020 and were compiled online. Our multivariable analysis found that participation or planned participation in abortion training during residency positively influenced residents’ intention to provide abortion care post-residency which supports the importance of abortion training during residency thereby improving access to abortion care. As comprehensive abortion training for obstetrics and gynecology residents is threatened with the overturn of Roe v Wade by the US Supreme Court in 2022, this research demonstrates the value of hands-on abortion experience in ensuring that this skill remains a core component of obstetrics and gynecology practice.
Keywords: residency education, abortion care, survey and questionnaires, United States residency training
Introduction
Despite abortion being one of the most common medical procedures among women of reproductive age, it is estimated that 89% of US counties do not have an abortion provider, and nearly 40% of reproductive-aged women live in these counties.1–3 A 2011 study found that 97% of US obstetrician-gynecologists encountered patients seeking abortion care, yet only 14% provide that care.4 Geographical disparities in abortion provision influence the type of abortion that patients can access. Patients who live 50 miles or more from an abortion provider are more likely to have second trimester abortions compared to patients who live within 25 miles or less from a provider.5
Abortion training during residency is one of the biggest predictors of future abortion provision.6 In 1996, the Accreditation Council for Graduate Medical Education (ACGME) required that obstetrics and gynecology (OB-GYN) residency programs offer induced abortion training to residents, allowing residents to opt out for religious or moral objections.7 Abortion training during residency has also increased due to the support of the Ryan Residency Training Program, an initiative to increase family planning training within OB-GYN residency programs, resulting in nearly 7000 OB-GYN residents participating in abortion training since its inception in 1999.6,8 The 2022 Supreme Court decision in Dobbs vs Jackson Women’s Health Organization has put these requirements for training in jeopardy. A 2022 analysis determined that nearly half of the US OB-GYN residency programs are located in states that were likely or certain to ban abortion in a post-Roe environment.9 All of these states have since instituted an abortion ban or attempted to institute a ban.
Across medical specialties and training environments, it is evident that abortion training and education increases medical professionals’ interest in providing abortion care.8 Medical students’ participation in Reproductive Health Externships through Medical Students for Choice increases their intention to provide abortion care, while pharmacists’ knowledge of medication abortion was positively correlated with their willingness to dispense mifepristone when given the opportunity.10,11 Reproductive Health Externships provide medical students an opportunity to observe reproductive health services, such as abortion care, in a clinical setting. They can be particularly beneficial for medical students attending medical school in geographical locations with abortion bans or where observation experiences can be limited. A recent study found that the majority of physicians, across specialties, at an academic medical center in Wisconsin were willing to consult on abortion care, however the strongest willingness was found among those who perceived that their professional peers were also supportive of abortion care.12
This study seeks to more comprehensively ascertain if there are personal characteristics or experiences that influence a resident’s intent to provide abortions in their practices after completing their residency training. While training environments and exposure to abortion among trainees can increase their intention to provide care, it is also important to understand how the clinical knowledge and perspective of obstetrics and gynecology residents impact their intention to provide abortion after residency. A national survey of OB-GYN residents was completed to evaluate whether there is a correlation between knowledge about abortion and attitudes toward abortion, and whether either knowledge or attitude affect intention to provide abortions after residency. The authors hypothesized that knowledge levels differ among those with supportive and unsupportive attitudes toward abortion. It was also hypothesized that higher knowledge and supportive attitude scores positively correlate with intention to provide abortion care after residency graduation.
Methods
Study Design
Eligible survey participants were current obstetrics and gynecology residents at accredited residency programs in the US at the time of survey distribution. Between August 2019–February 2020, the resident researcher contacted via e-mail either the residency program coordinator, or, if information was not available for a coordinator, contacted the residency program director for all ACGME accredited obstetrics and gynecology programs in the US. The email requested their assistance in disseminating the anonymous survey (Appendix 1) to current residents. The first 100 residents who responded were offered a monetary incentive for participation. Programs who did not initially respond were contacted at least 2 more times to request their assistance with dissemination.
The primary outcome of this study was to better understand the relationship between different predictors of the intent to provide abortion care after residency training. The survey collected demographic information about participants’ age, gender, religion, religiousness (self-defined through a Likert scale response to the question “how important is religion in your life?”), marital status, number of children, year in residency, type of abortion training in their residency program, and experience or planned experience with procedural abortions. It included 7 knowledgebased multiple-choice questions about abortion in the US, each scored with 1 point for correct and 0 points for incorrect (a total of 7 possible points). Participants rated the moral acceptability of 8 scenarios in which an individual might seek an abortion using a 5-point Likert scale. Finally, participants were asked if they planned to offer abortion services once they completed residency training.
Surveys were sent to every residency program in the US resulting in an estimated 5400 potential respondents. The goal was to collect 1545 completed surveys, or a 30% response rate, based on response rates from previously published studies of surgical residents.13,14
Data Analysis
The surveys were collected via REDCap [(Research Electronic Data Capture) Vanderbilt University, Nashville, TN], a secure, Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant data collection tool. Survey participants’ characteristics were summarized using descriptive statistics. Bivariate association between intention to provide abortion services after graduation and other characteristics was tested using 2-sample t-test or Wilcoxon rank sum test for continuous variables, and Chi-squared test or Fisher’s exact test for categorical variables. A multivariable logistic regression model was fitted for intention to provide abortion services after residency adjusting for age, gender, religion, religiousness, marital status, having children, year in residency, abortion training types provided, participation in abortions during residency, knowledge score, and moral acceptability score.
The University of Hawai‘i IRB approved this study, protocol number 2018-00835.
Results
A total of 5400 eligible subjects were targeted for the sample however this number cannot be verified due to lack of response from some programs. A total of 547 responses were collected. Of those, 46 were excluded due to incomplete responses, resulting in final analysis of 501 responses. The demographic characteristics of respondents are presented in Table 1. Most respondents identified as female (86.8%), and nearly half (45.5%) were married. Ages ranged from 24 to 47 years (mean age 29) and respondents were nearly evenly distributed among the 4 years of residency.
Table 1.
Summary of Demographic Data of OB-GYN Resident Respondents, August 2019–February 2020 (n=501)
| Variable | Mean ± SD or n (%) |
|---|---|
| Age (2 missing) | 29.3 ± 2.5 (min=24, max=47) |
| Gender | |
| Female | 435 (86.8%) |
| Male | 61 (12.2%) |
| Gender diverse | 3 (0.6%) |
| Missing | 2 (0.4%) |
| Religion | |
| Atheist | 129 (25.7%) |
| Non-Catholic Christian | 129 (25.7%) |
| Catholic | 92 (18.4%) |
| Jewish | 42 (8.4%) |
| Muslim | 10 (2.0%) |
| Buddhist | 4 (0.8%) |
| Hindu | 17 (3.4%) |
| Other | 64 (12.8%) |
| Missing | 14 (2.8%) |
| Religiousnessa | |
| Not important | 206 (41.1%) |
| Slightly important | 86 (17.2%) |
| Neutral | 55 (11.0%) |
| Moderately important | 90 (18.0%) |
| Extremely important | 61 (12.2%) |
| Missing | 3 (0.6%) |
| Relationship Status | |
| Single | 113 (22.6%) |
| In a relationship | 93 (18.6%) |
| Co-habiting | 65 (13.0%) |
| Married | 228 (45.5%) |
| Missing | 2 (0.4%) |
| Have Children (2 missing) | 64 (12.8%) |
| Year in Residency | |
| First | 144 (28.7%) |
| Second | 131 (26.1%) |
| Third | 126 (25.1%) |
| Fourth | 96 (19.2%) |
| Missing | 4 (0.8%) |
| Abortion Training Availabilityb | |
| No training available through my program | 44 (8.8%) |
| Opt-in training available | 104 (20.8%) |
| Opt-out training available | 331 (66.1%) |
| Mandatory training | 19 (3.8%) |
| Missing | 3 (0.6%) |
| Participated or plan to participate in procedural abortions during residency (2 missing) | 426 (85.0%) |
| Knowledge Score [possible range 0–7] a | 3.6 ± 1.4 (min=0, max=7) |
| Attitude Score [possible range 0–32]b | 28.1 ± 7.8 (min=0, max=32) |
| Plan to offer abortion services after graduation | |
| Yes | 280 (55.9%) |
| No | 109 (21.8%) |
| Undecided | 109 (21.8%) |
| Missing | 3 (0.6%) |
Complete answers only; 7 missing
Complete answers only; 18 missing
Over half of the respondents (66.1%) had an opt-out abortion training rotation in their residency, a form of training where training is routinely integrated into the residency but residents with objections can opt out of participation, and 85.0% participated in or planned to participate in procedural abortion procedures during residency. More than half of the respondents (55.9%) reported planning to offer abortion services after graduation, while 21.8% indicated they would not offer services and 21.8% were undecided. The mean score for the 7 abortion knowledge questions was 3.6 (SD = 1.4), with a range from 0 to 7. Distribution of knowledge scores over years of residency are shown in Figure 1. Supportive attitude toward abortion scores ranged from 0 to 32, with the average score of 28.1 (SD = 7.8).
Figure 1.
Distribution of Knowledge Score on Abortion by Year in Residency from OB-GYN Survey Respondents February 2019–August 2020
Bivariate analyseses revealed that residents who planned to provide abortion had higher knowledge and moral acceptability scores on average compared to those who did not intend to participate or are undecided (Table 2). Other factors shown to have associations with intent to provide abortion were religion, religiousness, marital status, having children, offered abortion training types, and participation in procedural abortions during residency. The majority of respondents (n = 205, 73.0%) who reported religion as not or slightly important planned to provide abortion after graduation, compared with 15.0% (n= 42, P<.001) of residents who reported religion as moderately or extremely important. Almost all (99.0%, n=276) residents who planned to provide abortion care after graduation participated or planned to participate in procedural abortions during residency, compared to 68.0% (n=149, P <.001) of providers who did not plan to provide abortion care upon graduation.
Table 2.
Intention to Provide Abortion Care by Demographic Characteristics, Abortion Training, Abortion Knowledge Scores, and Moral Acceptability Scores
| Variable | Mean ± SD or n (%) | P-valuea | |
|---|---|---|---|
| No/Undecided on providing abortion care (n=218) |
Yes, intending to provide abortion care (n=280) |
||
| Age | 29.1±2.4 min=24; max=39; median=29 |
29.5±2.6 min=24; max=47; median=29 |
.091 |
| Knowledge Score | 3.3±1.4 min=0; max=7; median=3 |
3.8±1.3 min=0; max=7; median=4 |
<.001 |
| Moral Acceptability Score | 24.7±9.2 min=0; max=32; median=29 |
30.8±5.2 min=0; max=32; median=32 |
<.001 |
| Gender | .42 | ||
| Female | 192 (88.1%) | 243 (86.8%) | |
| Male | 26 (11.9%) | 34 (12.1%) | |
| Gender diverse | 0 (0.0%) | 3 (1.1%) | |
| Religion | <.001 | ||
| Atheist | 30 (13.8%) | 99 (35.4%) | |
| Non-Catholic Christian | 84 (38.5%) | 44 (15.7%) | |
| Catholic | 49 (22.5%) | 43 (15.4%) | |
| Jewish | 7 (3.2%) | 35 (12.5%) | |
| Muslim | 9 (4.1%) | 1 (0.4%) | |
| Buddhist | 0 (0.0%) | 4 (1.4%) | |
| Hindu | 10 (4.6%) | 7 (2.5%) | |
| Other | 23 (10.6%) | 41 (14.6%) | |
| Missingb | 6 (2.8%) | 6 (2.1%) | |
| Religiousness | <.001 | ||
| Not important | 57 (26.1%) | 149 (53.2%) | |
| Slightly important | 30 (13.8%) | 56 (20.0%) | |
| Neutral | 22 (10.1%) | 33 (11.8%) | |
| Moderately important | 54 (24.8%) | 35 (12.5%) | |
| Extremely important | 54 (24.8%) | 7 (2.5%) | |
| Missing | 1 (0.5%) | 0 (0.0%) | |
| Marital Status | <.001 | ||
| Single | 37 (17.0%) | 76 (27.1%) | |
| In a relationship | 37 (17.0%) | 56 (20.0%) | |
| Co-habiting | 18 (8.3%) | 47 (16.8%) | |
| Married | 126 (57.8%) | 101 (36.1%) | |
| Have Children | 41 (18.8%) | 22 (7.9%) | <.001 |
| Year in Residency | .21 | ||
| First | 68 (31.2%) | 76 (27.1%) | |
| Second | 51 (23.4%) | 79 (28.2%) | |
| Third | 49 (22.5%) | 77 (27.5%) | |
| Fourth | 48 (22.0%) | 48 (17.1%) | |
| Missing | 2 (0.9%) | 0 (0.0%) | |
| Abortion Training Availability | <.001 | ||
| No training available through my program | 30 (13.8%) | 14 (5.0%) | |
| Opt-in training available | 66 (30.3%) | 38 (13.6%) | |
| Opt-out training available | 115 (52.8%) | 215 (76.8%) | |
| Mandatory training | 6 (2.8%) | 13 (4.6%) | |
| Missing | 1 (0.5%) | 0 (0.0%) | |
| Participated or plan to participate in procedural abortions during residency | 149 (68.3%) | 276 (98.6%) | <.001 |
Two-sample t-test or Wilcoxon rank sum tests were used for continuous variables and Chi-squared or Fisher’s exact test were used for categorical variables.
Missing responses are not included in the statistical tests.
Multivariable logistic regression with all variables showed that participation or planning to participate in abortion training during residency had a significant and large positive effect on intention to provide abortion care after residency (adjusted odds ratio [AOR] 19.29, 95% CI 5.86–84.48), while greater religiousness was negatively associated with intention to provide abortions after residency (AOR 0.24, 95% CI 0.07–0.74). Age also produced a small positive, significant association. The full analysis is shown in Table 3.
Table 3.
Characteristics of Residents Who Plan to Offer Abortion Care Post Residency
| Variable | Plan to offer abortion compared to no and undecideda | |
|---|---|---|
| Adjusted Odds Ratio (95% C.I) | P-valueb | |
| Age | 1.15 (1.03,1.31) | .019 |
| Male (ref: Female) | 1.52 (0.71,3.37) | .29 |
| Religion (ref: Atheist) | ||
| Non-Catholic Christian | 0.46 (0.20,1.06) | .067 |
| Catholic | 0.76 (0.34,1.73) | .52 |
| Jewish | 2.67 (0.89,8.80) | .091 |
| Other | 0.52 (0.25,1.12) | .093 |
| Religiousness (ref: Not important) | ||
| Slightly important | 0.84 (0.40,1.77) | .65 |
| Neutral | 0.91 (0.40,2.11) | .83 |
| Moderately important | 0.36 (0.16,0.78) | .011 |
| Extremely important | 0.24 (0.07,0.74) | .015 |
| Marital (ref: Single) | ||
| In a relationship | 0.68 (0.33,1.42) | .30 |
| Co-habiting | 0.96 (0.41,2.32) | .93 |
| Married | 0.43 (0.22,0.82) | .012 |
| Have Children | 0.59 (0.25,1.37) | .22 |
| Year in Residency (ref: First) | ||
| Second | 1.23 (0.63,2.41) | .54 |
| Third | 1.45 (0.74,2.88) | .28 |
| Fourth | 0.72 (0.33,1.56) | .40 |
| Training (ref: Opt-out training available) | ||
| No training available through my program | 1.14 (0.42,3.20) | .80 |
| Opt-in training available | 0.59 (0.32,1.09) | .089 |
| Mandatory training | 1.92 (0.51,8.64) | .36 |
| Participated or plan to participate in procedural abortions during residency | 19.29 (5.86,84.58) | <.001 |
| Knowledge Score | 1.16 (0.97,1.40) | .115 |
| Moral Acceptability Score | 1.07 (1.03,1.12) | .001 |
No/Undecided combined as reference category
Multivariable logistic regression analysis was used.
Discussion
The greatest predictor of the intention to provide abortion care post-OB-GYN residency was experience or planned experience in abortion education and care during residency. This relationship was stronger than any other association in the data and underlines the critical impact of abortion training in residency shown in previous research. While other factors, such as religiousness, marital status, and age were associated with intention to provide abortions, these associations were not as strong as the association between exposure/planned exposure to abortion care during residency training. It is also important to note that the number of residents who were undecided about providing abortions after residency was equivalent to the number who did not plan to provide abortions; there is an important opportunity to increase the number of individuals committed to providing abortion care by addressing this indecision through exposure to hands-on training.
The impact of real-life, hands-on training in developing OB-GYNs with commitment to providing abortion care must be understood in the context of how the landscape of abortion access is shifting after the Dobbs decision. It is reassuring that the data confirm the prior evidence that training significantly impacts intent to provide abortions. It is, however, troubling that access to hands-on training will likely diminish as more states ban abortion.15–17 Little has been published to comprehensively capture the landscape of abortion training in the US since the overturn of Roe; however, a study that analyzed abortion training practices among residencies with Ryan Programs found that following the Dobbs decision, 14% of residency programs lost in-state abortion training.18 Medical students are aware of these changes in abortion access and the threat that it provides to their training. One study showed that medical students expressed that changes in abortion access at potential training programs would likely or very likely influence their decision regarding location of considered residency program.19 As hands-on training becomes scarce as more states ban abortion, it is critical for programs to find avenues for their students to access training through travel rotations, simulations, or increased training in miscarriage management. However, these workarounds are not equal to having integrated, routine abortion training as part of a residency program, and they fail to overcome the gaps left by abortion bans.
Hawai‘i has a long history of protecting abortion access and providing reproductive health education to medical students and residents. In anticipation of the volatile legal landscape in other states, Hawai‘i signed in a new bill in 2023 that protects local health care providers from prosecution by out of state authorities. This bill proactively protects abortion training, care, and education within the state of Hawai‘i so that training programs within the state can continue to be a resource for training future abortion providers. As abortion training and education declines nationally, the authors hope Hawai‘i can be a resource and a partner for colleagues across the country.
This study has limitations. A true response rate cannot be calculated given the lack of the total number of email invitations received by residents. In 2020, there were ∼5400 active OB-GYN residents according to the Association of American Medical Colleges which suggests this study data captured roughly 10% of all residents.20 This 10% response rate may significantly reduce the generalizability of these findings. In addition, because our study relied on program coordinators or directors to disseminate the survey to their residents, the programs that did not respond to our email may not have disseminated the survey. It is likely that not all 5400 of the active OB-GYN residents received the survey. We do not have information on which programs did not respond and whether they did or did not disseminate the survey. Additionally, to limit question fatigue for respondents, the survey did not ask respondents to report race and ethnicity or the geographic locations of respondents or their institution. Additional information about the residency program that could have been illuminating but were not collected included presence of a complex family planning fellowship, or complex family planning fellowship trained faculty and program type (university, community, etc). These factors could have significant influence on an individual’s training and intention to provide abortion care. Finally, selection bias may be informing these results, as individuals with particularly strong feelings about providing abortion care may have been most motivated to participate in the survey, thus skewing the findings.
Conclusion
Today’s physician residents are graduating into a health care and legislative landscape that is increasingly stratifying access to abortion care, which subsequently restricts the abortion training available to residents. This study found that exposure to abortion care during training is the most powerful tool for ensuring ongoing commitment to provide abortion care among obstetrician-gynecologists.8, 21 Thus it is imperative that medical education infrastructure ensures this training remains accessible for all residents. Didactic sessions about abortion will not have the same impact on future generations of providers that hands-on patient experience has repeatedly demonstrated to provide. Abortion training is critical for creating future abortion providers and thereby ensuring and sustaining access to this essential and fundamental component of reproductive health care.
Acknowledgments
Authors have no conflicts of interest to report. The study was funded by the Lakshmi Devi and Devraj Sharma Endowment. So Yung Choi is partially supported by the National Institutes of Health grant U54MD00760131. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Glossary
Abbreviations
- ACGME
Accreditation Council for Graduate Medical Education
- HIPAA
Health Insurance Portability and Accountability Act of 1996
- OB-GYN
Obstetrics and Gynecology
Appendix 1
Conflict of Interest and Disclosures
Authors have no conflicts of interest to disclose.
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