“We Cannot Have Access To Abortion Care If We Don’t Have Providers”

In the wake of Dobbs, clinicians struggle to find abortion training, compounding a dangerous lack of healthcare for patients.

// Photo by Nenad Stojkovic

The national conversation around abortion typically centers on patients seeking abortions. Who will be forced to endure a pregnancy they don’t want? How far out of state will patients have to travel? What kind of disproportionate effect will there be on women of color?

These questions are dire, but they’re only half of the abortion story. After all, as Lynne Johnson, Executive Director of Midwest Access Project (MAP) said recently on a Public Rights Project panel, “We cannot have access to abortion care if we don’t have trained providers.”

MAP is a nonprofit that facilitates clinical reproductive health care and abortion training for providers, so few people understand the current dearth of medical training better than Johnson.

The only medical residency program that requires abortion training is the OB/GYN speciality, and even then, this training is “opt-out,” which means that residents who have “a religious or moral objection” do not need to receive training in induced abortions.

Meanwhile, other clinicians who frequently treat patients who could become pregnant — family medicine doctors, adolescent doctors, or advanced practice clinicians like nurse practitioners — are not guaranteed abortion training during their schooling.

In fact, they often have to find doctors to shadow and incur personal cost to gain education and instruction in abortion care.

On top of this strain, many clinicians are training in Catholic or other religiously restrictive hospitals where abortion training is not provided at all — a striking 13% of all hospitals in the US are Catholic.

All this adds up to a disturbingly low number of clinicians trained to provide abortions for the number of patients who need them: a 2011 study found that “among practicing ob-gyns, 97% encountered patients seeking abortions, whereas 14% performed them.”

Johnson explained MAP exists to fill this huge education and need-gap by “offering individualized clinical training to folks who don’t have access to it, who want it, and who have a passion for providing to underserved and unserved communities.”

MAP also trains clinicians on “how to provide culturally competent patient-centered care that is anti-racist, trauma-informed, and gender-affirming,” said Ramey Connelly, MAP’s Associate Director of Individual Clinical Training.

And in the wake of Roe being overturned, MAP’s work becomes more crucial each day as 13 states have outlawed abortion entirely.

Connelly shared that from 2021 to 2022 there was a 146% increase in the number of applications to MAP’s individual clinical training program (from 60 applications to 148).

Connelly said MAP has seen quite a few applications come in from people who applied to attend a specific residency program because they would get abortion training, but now that state has outlawed abortion “so they based the entire future of their medical career around training they no longer have access to.”

But the confounding thing is: those residents should still have access to that training. OB/GYN programs are required to continue providing this training — despite the new laws — and risk losing their accreditation if they fail to do so.

The Accreditation Council for Graduate Medical Education (ACGME) — the body that provides accreditation and curricular standards for medical residency programs throughout the US — revised its OB/GYN accreditation standards after the Dobbs decision and determined that clinical abortion provision training is still required for accreditation even in states where abortion is illegal.

“If a program is within a jurisdiction that legally restricts this clinical experience, the program must provide access to this clinical experience in a jurisdiction where no such legal restriction is present,” writes the ACGME.

While it’s crucial that the ACGME is trying to ensure the pre-Dobbs status quo of OB/GYN residency training, these new standards beg the question: have residency programs in states where abortion is now illegal actually been able to pivot and find out-of-state training for their residents?

These new standards would require residency programs to not only find training partners in non-hostile states who have the capacity to train their students (an already scarce resource), but they would also have to figure out how to fund that travel and how to house those students out-of-state for a lengthy period of time.

Based on the number of applications MAP has received, it seems as though many programs cannot pivot quickly enough, leaving a host of clinicians untrained.

The ACGME did not respond to questions on how programs across the country are abiding — or not — by these newfound accreditation requirements.

Susan White, the Vice President of Communications for ACGME did share that if the AGCME Review Committee determines a program is not compliant with a requirement (for example: providing abortion training), they can give that program a citation to force compliance.

But, White wrote me, “a single citation is unlikely to affect a program’s accreditation status provided the program demonstrates progress in addressing the issue.” She also shared that the ACGME “remains committed to supporting high quality, evidence-based care to maintain reproductive health for patients across the nation.”

What that means practically remains to be seen.

Given the on-again, off-again nature of many states’ abortion laws, it’s likely that the ACGME is giving programs a bit of wiggle room right now as they adjust to these news laws. But that wiggle room is the very thing leaving residents confused and untrained. Only time will tell how and if residency programs in hostile states will be able to remain accredited given state laws.

Meanwhile, MAP is doing all it can to provide abortion training to clinicians who want it, but it’s still a small organization with limited resources capable of training around 40 clinicians a year. And that’s simply not enough: a paper published by the journal Obstetrics & Gynecology found that once Roe was overturned, 2,638 residents were certain or likely to lose access to in-state abortion training.

Donate to MAP if you want to help them train more clinicians!

As a way to increase abortion care access beyond clinical training, MAP is bringing virtual self-managed abortion support and care training to the people throughout 2023.

“Even without the licensing, it is very important for anybody, not just providers, to know how to support somebody having a medication abortion. That does not require medical school,” explained Alyssa Stenson, MAP’s Provider & Community Education Manager who is running the virtual training program.

These trainings cover how to support someone having a medical abortion at home with the abortion pill as well as at-home miscarriage care. Stenson emphasized that “community knowledge” is important as a way to fill in the gaps of our medical systems.

And with the increased access to abortion pills, the opportunity for self-managed abortions has increased dramatically. The abortion pill can be taken up to 11 weeks of pregnancy and the average cost at Planned Parenthood is $580. (High, but still significantly less expensive than a surgical abortion).

“Everyone is going to know someone who needs to access an abortion or who has a miscarriage or who needs to advocate for themselves while they’re giving birth. And we just have to get that knowledge out so they can share their knowledge with their friends,” explained Stenson.

Connelly also highlighted the power of community when reflecting upon where we go from here, emphasizing the importance of advocacy on an institutional level and individual level.

“It’s important for everyone to have conversations with people in their everyday life about access to not just abortion, but to comprehensive sexual and reproductive healthcare also.”

The overturning of Roe compounded an already devastating lack of access to patient-centered reproductive healthcare training in this country. And as Connelly said, “this is a nationwide issue and it’s not something that can be solved quickly or easily.”

But, there are many organizations, including MAP, who are fighting the good fight on behalf of all patients seeking patient-centered care. And ensuring that those organizations work together is key to the fight for Connelly.

“Coalition building and collaboration amongst multiple organizations” is the only path forward.

Sign up for MAP’s public virtual workshop: Self Managed Abortion Support and Care on Feb 15, 2023 at 6:30pm CST.

During the workshop, host Larada Lee-Wallace, State Campaign Manager for Abortion Access, will discuss what self-managed abortion is, the various myths surrounding it, and how to increase access. Lee-Wallace will also cover the variety of ways that individuals self-manage and self-source medication abortion and how to support people accessing a self-managed abortion.

Follow MAP’s instagram for updates! @midwestaccessproject