The double-edged sword of abortion regulations: Decreasing training opportunities while increasing knowledge requirements

ABSTRACT Purpose The authors explore how abortion regulations in Ohio, an abortion-restrictive state in the USA, impact obstetrician-gynecologists’ (OB/GYNs) training in reproductive healthcare and describe what OB/GYNs believe to be the broader impact of Ohio’s regulations on skill-building, skills maintenance, and professional retention of reproductive healthcare providers in the state. Authors discuss how their findings foreshadow abortion training limitations in Ohio and other abortion-restrictive states now that abortion regulations have returned to the states. Methods The authors conducted four semi-structured focus groups and five in-depth interviews between April 2019 and March 2020. Participants included OB/GYNs practicing obstetrics and gynecology in Ohio between 2010 and 2020. Thematic analysis was conducted using Atlas.ti. Results Twenty attending physicians and 15 fellows and residents participated in the study. Participants discussed the impact of Ohio’s written transfer agreement, gestational-limit, and abortion method and facility bans on training and skill-building opportunities. Participants felt that Ohio’s strict abortion regulations 1) limit opportunities to observe and perform abortion procedures during training; 2) require learning the ever-changing legality of abortion provision; 3) limit the number of abortions OB/GYNs can provide, leading to the atrophy of their skills over time; and 4) may prevent prospective medical students and residents from choosing to study in Ohio and may lead to physician attrition from the state. Conclusion Prior to the reversal of federal protections for abortion in 2022, OB/GYNs in Ohio and other abortion-hostile states experienced barriers to training in abortion care. In returning abortion regulation to the states, access to training is likely to be increasingly restricted. This research demonstrates how abortion-restrictions hamper physicians’ skills needed to care for patients, particularly in emergent situations. This puts patients at risk and places physicians in precarious ethical positions. Expanding protections and reducing restrictions on abortion will ensure OB/GYNs and trainees have the skills necessary to care for patients presenting for reproductive healthcare.


Introduction
On 24 June 2022, the Supreme Court of the USA (U. S). upended decades of legal precedent when it overturned Roe v Wade and Planned Parenthood v Casey. The Justices' decision in Dobbs v Jackson Women's Health Organization returned the right to regulate abortion back to individual states [1]. Although abortion restrictions have proliferated in the U.S. since 2011, 26 states were expected to completely outlaw abortion after the decision [2]. Many of these states have indeed taken steps to outlaw or severely restrict abortion; while some have been successful, others have been met with legal challenges [3,4].
Prior to the decision, experts anticipated that access to abortion training for obstetricians and gynecologists (OB/GYNs) would diminish significantly if Roe and Casey were overturned [5][6][7][8]. While the Association for Professors of Gynecology and Obstetrics (APGO) recommends including pregnancy termination in medical school curricula and the Accreditation Council for Graduate Medical Education (ACGME) requires that OB/GYN residents have access to training in abortion provision, such training in the U.S. has historically been variablewith a plethora of studies highlighting differences in training accessibility based on one's region of work or study and institutional religious affiliation [9,10].
For example, studies published in 2011 showed that medical students, especially those attending religiously-affiliated schools, reported dissatisfaction with the training they received on family planning topics including abortion, sterilization, and contraception [11,12]. As such, many medical students have relied upon family planning electives to learn about these topics [13].
A 2008-2009 survey of residents in several midwestern states found that those in faith-based programs were less likely to be satisfied with their family planning training than their peers in non-faith-based programs [14].
In addition, residents in the southern region of the U.S. had less training on dilation and evacuation (D&E) procedures, the most common secondtrimester abortion method, than residents in other regions of the U.S., especially those in northeastern states [15]. In more recent studies, nearly half of residency program directors in Catholic schools reported access to abortion training was 'poor' when surveyed; more than one-quarter additionally reported that their programs did not meet specific ACGME requirements [16].
Despite these findings, research shows improved access to abortion training for residents -even in the South and Midwest -since the Kenneth J. Ryan Residency Training Program was established in 1999 [17][18][19]. Nearly 7,000 OB/GYN residents have trained with the program that ensures they have access to family planning rotations, and Ryan residency program directors have reported that their residents were competent in abortion and contraceptive care and that their programs were more desirable to applicants [19]. Importantly, residents with access to abortion training reported feeling more prepared to manage pregnancy loss and complications [20]. Still, additional surveys of residency program directors indicate hospital policies (both informal and formal), state laws, and a lack of faculty able to provide training continue to create barriers to abortion education [21,22].
Regardless of constraints on training, skills applicable in abortion provision are widely used across obstetric and gynecological practice. They are utilized for management of miscarriage, ectopic pregnancies, fetal demise, and other cases wherein a pregnancy may harm the health of a pregnant patient. Moreover, abortion is common, and hundreds of thousands of people seek abortion care per year. For example, Guttmacher reports there were 930,160 abortions in the U.S. in 2020 -up eight percent from 2017 [23].
In this paper, we examine how OB/GYNs in one abortion hostile state, Ohio, experienced abortion restrictions in the years prior to the Dobbs decision. While we have previously reported on how state abortion laws hinder physicians from exercising clinical judgment and cause ethical dilemmas [24], here we consider what broader consequences these regulations and subsequently limited training opportunities have had on physicians. The two main objectives of this paper are to describe 1.) how Ohio's abortion regulations affect OB/GYNs' training in reproductive healthcare; and 2.) what OB/GYNs believe to be the impact of Ohio's regulations on skills building, skills maintenance, and professional retention of OB/GYNs in the state. We then explore the expected impact of these regulations and training limitations in Ohio and other abortion-hostile states in the post-Dobbs era.

Methods
We conducted semi-structured focus groups and interviews with OB/GYNs from across Ohio. We recruited study participants with at least six months of experience practicing obstetrics and gynecology in Ohio between 2010 and 2020, from hospitals affiliated with Ohio universities, medical specialty professional societies, and advocacy groups via direct email and snowball sampling. Because most research that involves abortion providers is focused on physicians at abortion clinics, we were interested in the experiences of OB/GYNs working at abortion clinicadjacent facilities. Consequently, OB/GYNs who worked in free-standing abortion clinics at the time of the study, including Planned Parenthood clinics, were ineligible to participate.
We conducted four semi-structured focus groups with a total of 30 participants and in-depth interviews with five participants between April 2019 and March 2020. Focus group discussions lasted 90 minutes. Participants who were unable to attend scheduled focus groups were offered individual interviews, each of which lasted 45-60 minutes. Focus groups and interviews utilized the same moderator guide (Appendix 1).
Participants included 20 attending physicians and 15 fellows and residents who were based in Ohio's most populous regions. While a small number practiced privately, most of the 35 study participants worked in public, not-for-profit community hospitals, and academic medical centers. Most participants volunteered that they had current or previous experience providing abortion care in hospital settings, and some had previously worked in abortion clinics.
Because little is known about the extent to which abortion-clinic adjacent healthcare professionals experience abortion regulations, and to generate conversation about the specific pieces of legislation that impacted their work, the study moderator gave participants a legislative timeline describing state abortion laws that were enacted, enjoined, or proposed in Ohio between 2011 and 2019 [25]. After acquiring verbal consent to participate in the study, we asked participants to review the timeline and discuss which pieces of legislation had impact on their professional practice. We audio-recorded each focus group and interview and transcribed the recordings. Each transcript was deidentified and participants were assigned pseudonyms. Two members of the research team (HG and MF) conducted a thematic analysis of transcripts using ATLAS.ti, and then met to review themes and reach consensus [26]. We collected data until we reached theoretical saturation.

Results
Participants discussed a range of Ohio's laws but focused on three pieces of enacted and two pieces of enjoined legislation that had or could impact training and skill-building opportunities (Table 1). Our participants discussed four key ways that Ohio's abortion regulations and institutional interpretations of these regulations affect medical students and OB/GYN trainees. First, Ohio's abortion regulations limit the availability of opportunities for trainees to observe and perform abortion procedures. Second, regulations require trainees to track the ever-changing legality of abortion provision. Third, participants felt Ohio's abortion regulations led to the atrophy of their skills over time as they were, by law, severely limited in their ability to provide abortion care within their institutions. Finally, participants agreed that the state's strict regulations would discourage medical students and residents from choosing to study in the state and may also prompt physicians already practicing in Ohio to leave in order to practice in less restrictive environments.

Ohio abortion regulations limit training opportunities
Throughout our study, participants emphasized the importance of being trained to provide abortion care as a component of comprehensive reproductive healthcare. Dylan, a resident in central Ohio, said: Dylan's comment is illustrative of how participants valued access to abortion training and viewed abortion provision as a skill necessary for comprehensive patient care.
Ohio's OB/GYN trainees must decide whether to accept the limited exposure they will receive in their programs or supplement it through extra clinical rotations or post-residency fellowships. Some participants discussed seeking extra clinical rotations outside of their programs. A resident in central Ohio, Carol, discussed her previous experience as a medical student in Ohio: I, as a third-year med student, was able to rotate at Planned Parenthood. It was like an optional rotation, and I elected to go, and so I got . . . better information than certain people, because I went there and talked with the providers who actually are providing the services. . . . I think you kind of had to seek that information out though. It wasn't something that in medical school, you really were taught.
Another participant, Carla, said that even though her residency program in northeastern Ohio included a family planning rotation, there were too few abortions performed at her home institution to provide adequate training. She explained: These quotes demonstrate how seeking additional training opportunities may be beneficial but inadequate to fully prepare trainees for patient care.
Tamara, a resident in northwestern Ohio, illustrates how trainees experience different challenges accessing abortion training -in some cases, precluding training on certain types of abortion entirelybased on the region in which they train. Tamara's residency program partners with an independent abortion clinic that ceased providing procedural abortions after it was unable to comply with the state's written transfer agreement law ( § 3702.3010) [27]. While she was happy that she had the opportunity to rotate at the clinic, she felt disappointed that she would not get experience with procedural abortions. She explained, ' . . . it was better when . . . they did surgical abortions. . . . it'll be good to see [medication abortions], but I'm not really going to learn that much that I don't know.' Thus, limited clinic operations and exposure to a small number of procedural abortions within her residency program at a public institution barred from providing nontherapeutic abortion care conspire to further limit Tamara's training on a broad spectrum of abortion care. Other medical students and residents in the region who rely upon this clinic for their abortion education will similarly receive limited training.
Participants repeatedly discussed Ohio's public facilities ban ( § 5101.57) and dilation and evacuation (D&E) ban ( § 2919. 15 Mary highlights how, in banning public facilities from performing 'nontherapeutic' abortions, policymakers are risking the lives of patients, because many OB/GYNs cannot get adequate training, and consequently, cannot perform D&Es in emergency situations. Several participants stated that only one or two attendings in their institutions were skilled enough to perform D&Es in any situation.

Ohio abortion regulations require learning the ever-changing legality of abortion provision
Another theme that emerged was that Ohio abortion regulations increase the amount of regulatory knowledge that OB/GYNs should have when they complete their training. Every new abortion regulation, and any change to the legal status of an existing one, represents additional information that OB/GYNs must learn. Furthermore, they must understand both how their institution interprets the regulation and what policy the institution implements (or not) as a result.
The majority of participants agreed that their training programs educated them about neither abortion regulations nor institutional interpretations of regulations. Consequently, trainees must identify alternate sources of clear and unbiased information about regulations. Individual trainees accomplish this to varying degrees, leaving some worried about the possibility of unknowingly breaking the law. Discussing their experience as a medical student, Anna, who completed both medical school and a fellowship in Ohio, said: Without their programs providing education in medical law, participants sought other sources of information, often news outlets or public advocacy groups. Carla, a resident in northern Ohio, relayed sources of information upon which they relied: 'It's hard in residency. I try to watch the news as much as I can. A lot of my friends are . . . also involved in that kind of stuff . . . it does come up on social media, so I do get a lot from there too . . . ' Some residents noted that they relied upon their attendings' understanding of abortion laws. Unfortunately, participants who were attendings also expressed confusion and struggled to keep up with the ever-changing laws. Thus, both residents and attendings felt that they The absence of widespread reliable information left individual OB/GYNs of all levels of experience feeling responsible for deciphering healthcare policy, unsure that what was clinically indicated was legally permissible, and vulnerable to unknowingly breaking the law.

Ohio abortion regulations lead to the atrophy of clinical skills over time
Participants also revealed that their procedural abortion skills atrophied over time because state law prevented them from performing a sufficient number of abortions to maintain them after residency. Pamela, an attending physician in a public institution in northeast Ohio, said: The lack of case volume and access to training reduced the number of physicians qualified to perform D&Es within the participants' institutions of employment. In one focus group, Crystal, a resident, expressed concern that only one attending at her hospital is trained in providing D&Es. In response, Tammy, an attending, shared that she is the person within her institution who is called upon to perform D&Es in emergent situations. Consequently, finding a skilled physician to perform a procedure delays patient care in emergent situations, which participants reported puts their patients at risk. For example, Erin, an attending in southwest Ohio, noted, 'when we have someone that is hemorrhaging, and she needs a D&E, it's like we have to find the two or three people that know how to do it, and if they're out of town or they're not there . . . we're in trouble.' Tammy and Erin's stories elucidate both the stress placed upon the few physicians capable of providing D&Es in emergent situations as well as the risk to patients' health.

Ohio abortion regulations may prevent trainees from studying in Ohio and lead to physician attrition from the state
In all, participants reported that Ohio's abortion restrictions could lead to an exodus of OB/GYNs who provide abortions and that some trainees who recognize that regulations limit access to abortion training would avoid applying to medical schools or residency programs in states with more restrictions. Heather, a fellow in northeastern Ohio, recalled: I was at the [medical school's] medical student resident fellow meeting, and the medical students were talking about it. People who were planning to go into OB, and saying they're not ranking [university in Ohio], Ohio schools or Ohio programs, or ranking them really low, because they wouldn't get adequately trained in the full spectrum of OB/GYN care.
Heather's quote highlights the perceived role of abortion restrictions in deterring future OB/GYNs from training and working in Ohio.
Similarly, Tamara, a resident in northwest Ohio said, ' . . . I'm glad I'm training in Ohio, but . . . most of me wants to leave Ohio if it keeps going like this . . . I hate that . . . everyone who would provide good care to these patients is going to leave because they're annoyed about the laws.' Participants stated that they do not want to work in a state where their professional community is under attack and comprehensive reproductive healthcare practice is constrained.
Anna attended medical school in Ohio but completed residency outside of the state. In our interview, she estimated that she performed hundreds of abortions during residency. When she returned to Ohio for fellowship, she was prohibited from providing abortion care. She recalled: Anna was not able to use her expertise to provide this care for patients in Ohio nor share it with other physicians who lacked similar training. Ultimately, she left to practice in another state after fellowshiptaking her skills and expertise along with her.

Discussion
Our findings echo previous research on the availability of abortion education in medical schools and residency programs [11][12][13][14][15]. Our participants similarly felt that their programs did not provide adequate information on abortion or abortion laws, that expanding their knowledge base and skillset pertaining to abortion necessitated electives or supplemental trainings, and that they were inadequately trained to provide D&Es [11][12][13][14][15]. In addition, our participants drew clear connections between the deficiencies in their training and Ohio's abortion regulations.
Participants felt that Ohio's strict regulations limited the number and types of procedures they were able to observe and perform because the law limits abortions in public academic settings. While some participants sought out electives in order to learn more about abortion care, they felt this process was inefficient and burdensome. Our participants also noted that even after receiving adequate training, abortion restrictions led to an atrophy of their skills and left their patients underserved by limiting the number of OB/GYNs able to provide care in emergent situations. Finally, our participants expressed concern, and provided anecdotal evidence, that some prospective medical students and residents would choose not to train in Ohio, because the hostile regulatory environment would prevent them from receiving comprehensive training in abortion care. At the same time, they anticipated that some individuals who did train in Ohio would ultimately leave to practice in other states where they would not be as restricted by abortion laws.
Our data suggest the state should create a more hospitable regulatory climate for physicians: one that does not include laws that are restrictive, confusing, and threaten physicians with legal penalties for providing abortions. Yet, in the wake of the Dobbs decision, Ohio successfully banned abortions after the presence of embryonic cardiac activity on ultrasound for nearly three months and is working to implement further restrictions [3,4]. Our data foreshadow that this will burden Ohio's trainees by demanding they keep up with ever-changing regulations and further curtailing their training opportunities. OB/GYNs and OB/GYN trainees in similarly restrictive states will face comparable challenges.
While all OB/GYNs seeking to provide comprehensive care are affected by restrictions on abortion, trainees -and by extension, the broader health system they will staff -are disadvantaged by the inhospitable legal context of Ohio. Whether trainees stay in state without learning necessary skills or depart for practice settings where they can practice in accordance with their professional judgment, abortion restrictions are likely to exacerbate shortages of OB/ GYNs in rural and medically underserved communities across vast geographic areas of the U.S. Moreover, those that stay in restrictive states will face ethical dilemmas as their ability to exercise clinical judgment is increasingly constrained [24]. Our findings, and previous research, suggest that this would put patients at risk -especially as healthcare professionals and researchers also anticipate an increase in injuries associated with less safe abortion practices and higher risk pregnancies in the absence of legal options for abortion care. [6][7][8] State laws may not be the sole reason for deficient training in abortion care. Our findings suggest that medical schools and residency programs ought to consider their responsibilities in sufficiently preparing their trainees to practice medicine and provide comprehensive reproductive care for their patients in abortion-restrictive states. Moreover, employing institutions must also contemplate their role in ensuring physicians remain competent to provide a full spectrum of OB/GYN care. This might mean providing continuing education opportunities that enable physicians to practice their skillsets or advocating to state legislators about the impact of laws that limit abortion provision in their facilities in order to support both physician and patient well-being.
The landscape of reproductive healthcare in the U.S. is complex, and simply increasing the number of OB/GYNs trained in abortion care is insufficient to redress all its shortcomings. There remains a great need to address abortion stigma, systemic racism, and poverty -all issues that impact reproductive wellbeing. Still, the need for comprehensive reproductive healthcare will persist, and it would behoove the medical community to be well positioned to meet those needs.

Limitations
This study has several limitations. Study participants were predominately white women who practiced OB/ GYN in metropolitan areas. Additionally, it is possible that physicians who support abortion rights were more likely to participate in the study. Thus, the study topic and participant demographics possibly limited the number of study participants and range of perspectives shared in focus groups and interviews. Future research that includes a more diverse group of participants may reveal additional perspectives on and experiences with Ohio's abortion laws. Moreover, the voices of current medical students would help to further elucidate the link between Ohio's abortion laws, what Ohio's medical students learn about abortion, and what role medical schools might play in expanding educational opportunities about abortion.

Conclusion
Prior to the reversal of Roe v Wade and Planned Parenthood v Casey, OB/GYNs in Ohio and other abortion hostile states already experienced barriers to training in abortion care. In the post-Dobbs era wherein abortion laws in roughly half of U.S. states severely restrict, completely outlaw, or leave abortion legality in flux as court cases play out, abortion training will become increasingly difficult to access. Based on the previous experiences of OB/GYNs in hostile states, this is likely to leave a large swath of physicians without the skills needed to provide care for their patients -especially in emergent situations. This puts the lives, health, and autonomy of patients at risk and places physicians who wish to care for their patients in precarious ethical positions. Reducing abortion restrictions and expanding protections for abortion access will ensure OB/GYNs have the opportunity to learn and keep skills necessary for the provision of critical reproductive healthcare services; moreover, it will ensure that patients have access to the care they want, need, and deserve.