What Happens When Doctors Don’t Learn How to Do Abortions?

The patient was hemorrhaging blood, recalled Dr. Alexandra Stiles, an OB-GYN resident. At first, there was very little the Ohio doctor could do for her. Before June, Stiles could have sedated the patient and performed a dilation and extraction, a surgical procedure commonly used in second-trimester abortions, to end the now-hopeless pregnancy. But soon after the Supreme Court overturned Roe v. Wade, Ohio banned abortion as soon as a doctor detects what the law calls a “fetal heartbeat.” And Stiles could still hear it. 

Now, the patient’s only choice was to grit her way through labor and deliver a stillborn.

Everybody felt awful, recalled Stiles, who was also working with another OB-GYN resident. 

“This whole situation was traumatizing for the patient,” she said. “This was a pregnancy that she had planned to keep and planned to carry, and her whole situation changed.”

As the patient’s labor stretched into the evening, the heartbeat disappeared, leaving Stiles free to perform the dilation and extraction. The resident working alongside Stiles should have known how to perform the procedure. But instead, the resident revealed, “I’ve never done this before.” Thanks to Ohio’s abortion ban, the resident had never had a chance to learn how to do perform a typical procedure—even in cases of medical emergencies.

In the months since Roe’s overturning, countless doctors have confronted abortion bans that, they say, have forced them to defy medical guidelines and their oath to do no harm. But amid that health care crisis, there’s another, burgeoning terror, one that’s set likely haunt medicine for years to come: Can doctors still learn how to do abortions?

The answer is worrying. At least 13 states have now banned almost all abortions, and hospitals in those states can no longer teach the next generation of doctors how to perform the procedure. Although Roe’s overturning has spurred more doctors to pursue abortion training, experts told VICE News, the few places that can provide that information are dwindling and overrun. Abortion providers’ ability to keep up what promises to be a decades-long fight over the future of abortion is now imperiled.

Twenty-six states are ultimately expected to ban abortion. In April, a study published in the medical journal Obstetrics & Gynecology estimated that, without Roe, roughly 44 percent of the 6,000-plus OB-GYN residents in the United States would lose access to in-state abortion training.

VICE News contacted dozens of OB-GYN residency programs in states with abortion bans about their plans for handling abortion training. (Ohio’s abortion ban was paused in September after a court challenge.) Just five programs responded; of those, two declined to speak. One program administrator talked only on the condition that VICE News not name their program. 

“I just literally do not want any additional attention on our residency, in case we are able to get people to go out of state,” they said. “The last thing I really want is the state legislature saying, ‘Oh, let’s hold up some funds or try to pass more legislation restricting the ability of our residents to get the training that they need.”

The administrator is even worried that people at the institution where they work may try to sabotage plans to train residents. Before the ban, when the program sent its residents to Planned Parenthood for training, an official initially refused to sign off on the agreement, the administrator said. 

Now, the administrator said, “We’re almost stuck cold-calling places to see if they’ll take residents.”

Patients are already paying the price.

“The ultimate concern is the trickle-down effect of this,” said Dr. Nicole Scott, director of the OB-GYN medical residency program at Indiana University. “In those 2 a.m. moments in the middle of the night, will you know what you need to do to save someone's life?” 

Dr. Doug Laube started performing abortions in Iowa in the ‘70s, after he said he watched a 17-year-old patient die from complications of illegal abortions. Back then, he never imagined that mainstream medical institutions would remain so resistant to providing the procedure. 

“I anticipated back then that, as time went on, that people who learned the technique during their residencies would just be doing them in their offices from time to time as they were needed,” Laube told VICE News in 2020. “That has not happened. It happens almost nowhere.”

As of 2017, 95 percent of all abortions were provided at clinics, according to data from the Guttmacher Institute, which tracks abortion restrictions. 

The physical separation between the hospital and the clinic reinforced the metaphorical distance: If it wasn’t done in hospitals, abortion seemed like an act outside of mainstream medical care. The separation endured and grew thanks to an array of forces: the complexity of paying for abortions using government funds such as Medicare; the (continuing) rise of Catholic hospitals, which largely refuse to perform abortions; the deeply hierarchical, traditional nature of the medical field itself, where institutions rely on donations and public dollars and are thus predictably allergic to controversy. 

The bulk of doctors’ practical training—and, in particular, training to do procedures like abortion—occurs in residency, a years-long kind of apprenticeship where recently graduated doctors hone their chosen specialties. For decades after Roe, residency training in abortion remained optional. In 1992, a study found that just 12 percent of OB-GYN residency programs offer training in first-trimester abortions. The National Coalition of Abortion Providers, which represented independent clinics, started issuing dire warnings about their inability to recruit well-trained physicians. Its executive director told the Washington Post in 1993, “It's not just a problem, it's the problem.”

Anti-abortion groups celebrated. “If there is no one willing to conduct abortions, there are no abortions,” one organization’s field director reminded the Post, in a comment that has new resonance in this post-Roe reality.

It was attacks against providers, ironically, that revitalized American abortion training. In 1993, a medical student at the University of California, San Francisco, named Jody Steinauer was mailed a brochure, as were many other medical students. The brochure read, “Q: What would you do if you found yourself in a room with Hitler, Mussolini, and an abortionist, and you had a gun with only two bullets? A: Shoot the abortionist twice.” Days later, an abortion provider named David Gunn was shot to death in Pensacola, Florida.

“Those two events together woke a whole group of medical students up,” Steinauer told VICE News in 2020. “We thought to ourselves, ‘Wait a second, this is part of healthcare.’”

After talking to students from medical schools across the country, Steinauer took a year off of medical school to dedicate herself to formally launching a group, Medical Students for Choice, to support aspiring abortion providers. Three years later, the Accreditation Council for Graduate Medical Education took action, decreeing for the first time that all OB-GYN programs must offer abortion training. 

It still didn’t quite take. A 2019 study from the University of California, San Francisco, found that, despite the council’s 25-year-old mandate, just 64 percent of 190 residencies truly include “routine training with dedicated time” for abortion. 

Dr. DeShawn Taylor, an OB-GYN who runs an Arizona clinic that offered abortions before the state banned them, told VICE News earlier this year that even before Roe’s fall, the stigma of the procedure has made doctors less able to diagnose and handle miscarriages and ectopic pregnancies.

“It already has started to be a situation where even miscarriage was starting to be marginalized and pushed out to let the abortion providers handle it,” Taylor said. 

Abortion hasn’t fared much better in medical schools. “Abortion is one of the most common medical procedures,” Stanford University researchers concluded in a 2020 study. “Yet abortion-related topics are glaringly absent from medical school curricula in the U.S.A. with half of medical schools including no formal training or only a single lecture.” 

When medical school ends, students aren’t free to simply pick where they go to residency. Instead, they spend the last year of school applying to a nationwide program called the Match, which will ultimately use an algorithm to sort out which residents go where. If students try to decline their match, they will likely have to wait another year to start residency—and run the risk of ruining their medical careers before they even really get started.

Even if a medical student desperately wants to learn how to perform abortions, even if they went to medical school to dedicate themselves to being abortion providers, they may have no choice but to live and work in a state where it’s now illegal.

In the United States, two kinds of doctors tend to perform abortions: OB-GYNs and family medicine doctors. University of Illinois, Chicago medical student Maria Valle Coto said she is applying to 80 different OB-GYN residency programs, including every single California residency program and most programs in New York. But if she still ends up in a state with an abortion ban, she may go anyway. She has $290,000 in medical school debt, she said, and just waiting for it to accumulate interest isn’t really an option.

“I’m not someone that comes from wealth or has family physicians, so this has been a huge investment in my future,” Valle Coto said. “And for it to be jeopardized because of policy is incredibly disappointing.”

Valle Cotto said officials at her medical school repeatedly advised to tone down her mentions of abortion in her residency applications. She refused.

“I’m not gonna tamp down who I am and what I believe just to try to match somewhere,” she said.

Jayaweera currently feels comfortable performing abortions up to 16 weeks of pregnancy, but she wants to learn how to provide it until at least 20 weeks. She had originally planned to do more training in Florida, Tennessee, or Kentucky, but thanks to abortion bans in those states, she won’t be able to go to sites there.

“Whichever ones will take me at this point, I will go. The need is just so high,” Jayaweera said. “My hope was that I could potentially get based in a place where I have a close friend or family member that would let me crash with them. But I imagine it would cost at least maybe $5,000 for lodging and transportation and everything.” 

Two major initiatives help residents get training in abortion: the California-based Ryan Residency Training Program, run by one Dr. Jody Steinauer, works with OB-GYN residencies, while the RHEDI program in New York does the same in family medicine. Programs that partner with these initiatives are committed to making sure residents have easy access to comprehensive abortion training; given that such a high volume of abortions are performed in clinics, they often help residencies iron out relationships with abortion clinics to teach doctors.

Out of the 107 active Ryan programs, the group has been trying to figure out what to do with 13 to 20 programs in states with abortion bans, Kirstin Simonson, director of programs and operations for Ryan, told VICE News in September. These residencies are in the midst of setting up partnerships with programs in more liberal states, figuring out paperwork, scheduling, and coordinating potential travel and lodging for residents fleeing bans. 

Residents will likely end up in cities like Chicago and New York City; Simonson has no idea how much relocating residents will cost programs or the residents themselves, who tend to make in the ballpark of $60,000 to $70,000 a year. 

“It is not most budget-neutral cities to be training in,” Simonson admitted. 

The earliest consistent travel will likely start in February or March 2023. Residency programs start nationwide on July 1, meaning that these residents are set to lose out on at least seven months of potential training time.

Simonson feels confident that the Ryan programs will be able to find ways for residents to still get abortion training. But only 36 percent of all accredited U.S. OB-GYN programs belong to Ryan. 

Before Roe’s overturning, the Accreditation Council for Graduate Medical Education—which sets standards for all residencies—didn’t have specific abortion requirements for family medicine doctors, but it did mandate that all OB-GYN residency programs “provide training or access to training in the provision of abortions, and this must be part of the planned curriculum.” 

As of mid-September, though, the council changed those rules. Now, according to the guidelines, “If a program is in a jurisdiction where resident access to this clinical experience is unlawful, the program must provide access to this clinical experience in a different jurisdiction where it is lawful.”

In other words: Send residents out of state. And if a residency program doesn’t pull that off—a costly, potentially legally hazardous maneuver—its accreditation could be threatened, at a time when OB-GYNs are already projected to be in short supply.

The Indiana University OB-GYN residency program, which Scott runs, is a Ryan program. Last May, when a Supreme Court draft opinion overturning Roe leaked, Scott scrambled to partner with an Illinois abortion clinic so residents could travel there to perform abortions for patients in the first-trimester of pregnancy. 

Scott declined to name the clinic or its exact location out of concern for residents’ safety.

“My greatest fear is that something would happen to our residents, whether it be a threat of violence or even just a car accident if they're driving 100 miles to a place to train,” Scott said. “Those are the things that keep me up at night.”

Under the new guidelines, OB-GYN programs must provide “support” for residents who need to travel out of state for training, although residents who leave the comfort of home may still find themselves paying out of pocket for expenses. When it proposed revising those guidelines, an Accreditation Council for Graduate Medical Education review committee also said that the changes aren’t expected to cost programs any “additional resources.” But that’s not true for Scott, who said that ferrying residents to Illinois is expected to cost her program more than $20,000 this year alone, as the program has to shoulder expenses like housing, lodging, and new Illinois medical licenses. Scott isn’t sure if she’ll be able to wrangle that kind of money next year.

If she can’t cover the costs, Scott’s program could be found to be out of compliance with accreditation requirements.

Those new rules about “support” don’t apply to family medicine residents. With 30 affiliated family medicine residencies, RHEDI is far smaller than Ryan. But two of its programs, in Idaho and Montana, are also facing the prospect of being unable to train doctors in-state. 

“They're trying to be creative and see if they can set up a satellite clinic across the border so people have been getting trained,” said Erica Chong, RHEDI’s executive director.

But part of the problem, she said, is that the abortion clinics who may normally teach residents are now seeing a surge in requests for training. “They're also receiving lots of requests from especially all of the OB-GYN residents who are now having a really challenging time. So it's a lot of people who are looking to get trained and not that many training slots.” 

The Midwest Access Project, a nonprofit that helps connect a range of health care professionals with reproductive health care training like abortion, received 49 applications for help in its first application cycle after Roe’s overturning. That’s the most applications the organization has ever received in a single cycle. But, Midwest Access Project Executive Director Lynne Johnson warned, “We’re going to start declining more people as a result of the decision.”

The fear is that, unless overworked doctors start taking extraordinary steps, there’s likely just not enough places for everybody—including doctors who have graduated from residency and are further along in their career—who wants to learn how to do abortions to do so. And with a new Match cycle now underway, residency programs in states with abortion bans will potentially get far fewer applicants, while programs in liberal regions will be flooded.

“I was hoping that the increased demand would lead to more days and then more training spots and everyone would jump in together to make sure that happens. But it's so much more complicated than that, than just saying, ‘Yes, everyone comes in and train,’” said Dr. Julia Eicher, a family medicine resident who works at a RHEDI-affiliated program in New York City. “What I've been seeing in my personal experience is, ultimately, there's maybe the same amount or maybe a little less training available now that all this is happening.”

This summer, North Carolina family medicine resident Dr. Chelsea Daniels had the rare chance to spend a few weeks working solely at a Planned Parenthood clinic. But when a more senior doctor, from Hawaii, had wanted to get training in abortion, there wasn’t enough room for both Daniels and that doctor to work at the clinic, Daniels said. Instead, Daniels ended up working at another Planned Parenthood in Chicago.

“I blew through my savings to do this,” Daniels said. “It could have been essentially free, had I been able to live in my apartment and just drive down the road.”

“If you're in a spot where you can't afford it, then you just lose out on the training, which is pretty unacceptable,” she continued.

All of these plans are built on one foundational premise: that doctors can safely cross across state lines. But that foundation is rickety at best, because the country is now pitted against itself in a kind of abortion arms race. Half the United States wants to protect the procedure, while the other is determined to eradicate it. And each side wants to undermine the other. 

Although abortion providers have spent years traveling into red states into perform abortions, rather than live permanently among hostile neighbors, abortion opponents have already started to push for laws to cut down on what they’re now calling “abortion tourism” for both patients and providers. In early June, the top anti-abortion groups who architected Roe’s toppling discussed strategies for attacking interstate travel for abortion. In July, Congressional Republicans blocked a bill meant to protect the practice. 

The governors of liberal states like Colorado and Washington, meanwhile, have vowed to ignore other states’ requests to investigate or extradite people for breaking abortion laws.

But come January, when many state legislatures go back to work, the legal landscape of abortion could shift again. While conservative states might not be able to restrict interstate travel this year, the campaign to chip away at and ultimately destroy Roe took decades. And it worked.

“It's likely only going to get worse, especially as all this stuff gets more siloed geographically,” said Eicher, the family medicine resident in New York. “There's going to be huge portions of the country where there's no one there who's ever done an abortion or known anyone to do an abortion.”