Satisfaction With Abortion Training in an Abortion-Restrictive State

As obstetrician-gynecologists (OB/GYNs) are the primary providers of reproductive health care in the United States and often the first point of contact for patients experiencing unintended pregnancies, abortion training is a required competency in an OB/GYN residency.¹  The Accreditation Council for Graduate Medical Education (ACGME) requires that OB/GYN residency curricula include abortion training.

Despite these clear training guidelines, barriers such as hospital policies or state-level restrictions can hinder the routine integration of abortion training into OB/GYN residency programs.²  Since the Dobbs v Jackson Women’s Health Organization decision in June 2022 and the subsequent loss of federal protections for abortion, barriers to integrating abortion care into training have only increased. One national study projected that, following the Dobbs decision, the proportion of residents having access to abortion training will decrease from 92% to 56%, as 45% of OB/GYN programs are located in states now certain or likely to ban abortion.³ 

Despite an unprecedented increase in state-level abortion restrictions over the last 10 years,⁴  the number of OB/GYN residency programs offering abortion training has increased in politically restrictive environments.⁵  Ohio is a state considered hostile to abortion due to the number of restrictive abortion policies.^6,7  At the time this study was conducted, examples of restrictions in Ohio included a ban on dilation and evacuation (D&E) procedures, required in-person abortion counseling followed by a waiting period, restricted insurance coverage for abortion, and limited abortion access for minors.

Prior research has established a negative association between training in a faith-based institution and satisfaction with family planning training.⁸  Like states with abortion restrictions, faith-based institutions similarly restrict abortion training due to religious directives. Residents training in restrictive states may similarly feel dissatisfaction. As availability of abortion training is positively correlated with providing abortion in future practice,⁹  a lack of training may also have an adverse effect on a resident’s intent to provide abortions in the future. To our knowledge, no study has assessed how state-level abortion restrictions affect resident training experiences and satisfaction. This survey-based study aims to characterize how resident perceptions of abortion restrictions impact satisfaction with training and intent to provide abortion post-training. We hypothesized that residents who considered the legal environment in Ohio restrictive to abortion would have lower satisfaction with their training. Secondarily, we hypothesized that residents who considered the legal environment in Ohio restrictive would be less likely to provide abortions in their future careers.

During the 2019-2020 academic year, we recruited all residents enrolled in the 15 ACGME-accredited OB/GYN residency programs in Ohio to participate in a survey via email. We accessed residents’ email addresses, either through publicly available information or by emailing residency program coordinators. The email included a description of the study and a link to an electronic consent detailing study requirements and privacy protections.

All consenting participants then anonymously completed a survey housed through the Research Electronic Data Capture (REDCap).^10,11  Reminder emails were sent 1 month and 2 months following the initial email. The survey was closed after 6 months.

The 43-item survey (provided as online supplementary data) queried participant demographics, residency program characteristics, and training experiences. We modeled our survey on previously published surveys of resident abortion training experiences.^8,9,12,13  We added questions related to training in a legally restrictive environment. Respondents reported personal characteristics, including postgraduate year, age, gender identity, level of religiosity, and personal beliefs around abortion. Respondents ranked their personal beliefs around abortion on a continuous scale from 0 to 100, with 0 representing “oppose in all circumstances” and 100 representing “support in all circumstances.” Given the nuanced nature of abortion attitudes, which often do not fall into binary categories, this numerical scale has been used to measure abortion beliefs in prior studies.¹⁴ 

We collected program characteristics through program websites, including program type (community or university), presence of a dedicated family planning rotation (Ryan Program), and hospital faith affiliation. A Ryan Program refers to a formal family planning curriculum with support from the national Ryan Program initiative designed to integrate family planning training into OB/GYN residencies.¹⁵ 

Respondents reported whether they participated in all, some, or none of the available abortion training experiences offered, as residents with religious or moral objections are always permitted to opt out of participation. They also reported their intent to provide abortions after graduation. To provide more context to survey responses, respondents completed open-ended questionnaires about satisfaction with training and the effect of the legal environment on training. Open-ended questions included, “If somewhat satisfied or unsatisfied [with the family planning training], why?” and “[In what way] do you feel as if the legal climate in Ohio affected your training?” Participants free texted their responses and had no restrictions on their response length.

Categorical demographic data were compared across outcomes of interest using frequencies and percentages, while continuous data were described using means and standard deviations. Unadjusted logistic regression models were used to assess associations between the perceived effect of the legal climate in Ohio on abortion training and the outcomes of satisfaction with training and intent to provide any abortion procedure, as well as intent to provide each type of abortion procedure. An adjusted logistic regression model was subsequently fit for each of the outcomes; each model was adjusted for Ryan Program status and respondents’ personal abortion beliefs, because these 2 characteristics could influence respondents’ views on how Ohio’s legal climate affected their training and each outcome of interest. All analyses were conducted in SAS/STAT software, Version 9.4 of the SAS System for Windows (SAS Institute Inc, Cary, NC).

To provide additional context to our survey responses, we reviewed open-ended responses to questions about satisfaction with training and the role of the legal environment on training. We have presented representative quotations to illustrate salient topics.

This study was reviewed and approved by our institution’s Biomedical Institutional Review Board (#2020E0779).

We attempted to email the 343 OB/GYN residents training in Ohio, either directly or through a program coordinator. We do not know whether all program coordinators forwarded the email to their residents. Of these, 29% (100 of 343) of residents completed the informed consent, and 88% (88 of 100) of residents subsequently completed the survey, amounting to a 26% individual response rate (study flow diagram provided as online supplementary data). Of the 15 OB/GYN programs in Ohio, we received at least one resident response from 13 of the programs, amounting to an 87% (13 of 15) program response rate.⁸ Table 1 includes respondent characteristics, and Table 2 includes program characteristics.

Most (73%, 64 of 88) respondents answered “yes” that the legal climate in Ohio affected their abortion training. Almost all (90%, 79 of 88) residents were satisfied or somewhat satisfied with their abortion training, and only 5% (4 of 88) were unsatisfied; the remaining 5% (4 of 88) reported “not applicable.”

More than 40% of all respondents indicated they intend to provide most abortion procedures after graduation, except for D&E. Only 29% (25 of 88) of respondents intended to provide D&E (Figure). Among the 41 respondents who did not intend to provide abortions after graduation, 44% (18 of 41) attributed this to an inability to provide abortions in the environment in which they plan to practice, 41% (17 of 41) did not feel comfortable morally, and 15% (6 of 41) did not feel comfortable medically.

In unadjusted logistic regression models, respondents who reported that the legal climate in Ohio affected their abortion training experience had 6.13 times the odds of being unsatisfied with their training compared to those who did not think the legal climate affected their training (odds ratio [OR] 6.13; 95% confidence interval [CI] 1.64-22.88; Table 3). This association was strengthened after adjusting for Ryan Program status and personal beliefs around abortion (adjusted odds ratio [aOR] 16.6; 95% CI 2.83-97.22).

There was no association between respondents who felt that the legal climate affected training and an intention to provide any type of abortion in future practice, compared to respondents who did not feel that the legal climate affected training (OR 1.52; 95% CI 0.59-3.90). This remained true when looking at intent to provide each individual type of abortion procedure separately. After adjusting for Ryan Program status and personal beliefs around abortion, this lack of association was unchanged (aOR 0.81; 95% CI 0.24-2.69).

Many respondents (57%, 50 of 88) provided a response to open-ended questions about satisfaction with abortion training and the effect of the legal environment in Ohio on training, with the responses ranging from 1 to 4 sentences in length. Their responses have been grouped into the following topical categories: (1) desire for more abortion training experiences; (2) barriers to providing abortion care; and (3) positive aspects of training in a restrictive environment. Illustrative quotes are followed by year of training and Ryan Program status.

Many respondents expressed that they wished they had more experience with abortion procedures, particularly D&E. One respondent described how state-level restrictions on hospital-based abortion impacted the number of D&Es she had performed, as she was “unable to provide abortions at major medical centers, [and] unable to provide abortions to a higher gestational age and become more comfortable with dilation and evacuations” (first-year resident, Ryan Program). Because most respondents wanted more experience, many described feeling frustrated by legal restrictions. A respondent stated, “Ohio laws are becoming more and more strict and [are] closing down clinics and creating situations where we can’t learn the full spectrum of abortion care” (second-year resident, non-Ryan Program).

Respondents described significant obstacles to providing abortion care. These obstacles impeded abortion access for patients and resulted in fewer training opportunities and fewer trained attendings. One respondent stated, “Restrictions make it nearly impossible for patients to access abortion clinics, and it is a topic that is not openly discussed within our residency program or offered often enough due to the culture of Ohio” (second-year resident, non-Ryan Program). Another respondent stated that “Ohio politically creates a very negative environment surrounding abortions. Many of my attendings who do not perform them are uncomfortable with counseling” (second-year resident, non-Ryan Program).

Some residents highlighted the positives of training in a restrictive environment and felt that a restrictive environment allowed them to better understand barriers to care, the importance of abortion access, and the skills needed to advocate for patients. One respondent stated that the legal environment was “positive” as it allowed her to “understand barriers women face” (fourth-year resident, Ryan Program). Another stated the legal restriction “made it obvious why this work is so important” (third-year resident, Ryan Program). Another stated, “It taught me advocacy, a skill I wouldn’t have needed to learn in a state not hostile to reproductive rights” (fourth-year resident, Ryan Program).

This study provides insights into the abortion training experience of a cohort of OB/GYN residents training in a state considered hostile to abortion. Most residents (73%) in our study felt that the restrictive legal environment in Ohio impacted their training. This belief was 6 times more common in residents who had less satisfaction with training, an association that was strengthened when we adjusted for abortion belief and Ryan Program status.

These findings mirror those of a previous study that found a negative association between training in a faith-based institution and satisfaction with family planning training.⁸  Though our small sample size contributed to a large confidence interval for this estimate, it supports the association between a restrictive training environment and decreased satisfaction with training. Like faith-based institutions, a restrictive legal environment poses limitations to residents’ exposure and access to abortion procedures.

While we did not see an association between the belief that Ohio’s legal climate affected training and intent to provide abortions in future practice, less than half of respondents stated that they intend to provide abortions after graduation, with respondents most commonly citing that they cannot provide abortions in the environment in which they plan to practice. This low percentage of participants who intended to provide abortion is consistent with a prior national survey of OB/GYNs which found that working in a restrictive practice or hospital was negatively associated with abortion provision.⁹  In that survey, only 23% of recently board-certified OB/GYNs reported that they provide abortions in situations other than for “medical necessity.”

In our review of open-ended questions, we gained additional context to resident survey responses. Residents described frustrations related to legal restrictions. These frustrations are not surprising given the high number of abortion restrictions in Ohio.⁶  Yet some respondents valued the insights they gained from training in a restrictive environment. Witnessing patient barriers to abortion care inspired some to engage in advocacy. These findings mirror the responses of medical students participating in abortion care in Ohio, who also highlighted the value of learning advocacy skills in a restrictive learning environment.¹⁶  This reveals a unique perspective that residents and students may obtain by training in a state hostile to abortion, though we did not survey residents in more abortion-permissive states for comparison.

Though we had a high program response rate (87%), our low individual response rate introduces the risk of selection bias. Residents with a strong interest in learning about and providing abortion care may have been more likely to complete the survey, thus overestimating participation in abortion training, positive attitudes toward abortion, and intent to provide abortion. Our response rate is not surprising given the generally low and declining response rate among physicians to surveys in recent years.¹⁷  A study on the physician response rate to web-based surveys found an overall response rate of 35%.¹⁸ 

In addition, our survey findings lack generalizability beyond Ohio, and our findings may not apply to residents training in other states, particularly more permissive states. Future studies should explore how resident experiences are shaped nationwide following the Dobbs decision.

Though this study was conducted prior to Dobbs, our findings have become even more relevant post Dobbs, as access to abortion care and to abortion training become increasingly disparate across state lines. Indeed, the Association of American Medical Colleges recently reported a 10.5% drop in OB/GYN residency applications to programs in states with abortion bans.¹⁹  Our study provides insights into these trends in OB/GYN training.

Recognizing how a restrictive legal environment affects abortion training can help educators identify disparities in abortion education, depending on state of training, and advocate for more comprehensive abortion training for OB/GYN residents, particularly in restrictive states. In addition, gaining a better understanding of the factors that influence a resident’s intent to provide abortions in future practice is crucial to improving the availability of abortion care, particularly in states with few abortion providers.

Many residents felt that the legal climate in Ohio affected their abortion training, a perception that was associated with decreased satisfaction with training.

The online version of this article contains the survey used in the study and the study flow diagram.

Funding: The authors report no external funding source for this study.

Conflict of interest: The authors declare they have no competing interests.

This work was previously presented at the virtual Society for Academic Specialists in General Obstetrics and Gynecology Annual Meeting, April 9, 2021.