“If you don’t even have the experience, the competency[,] and the comfort of doing [abortions] in planned settings, when … it’s two o’clock in the morning and you have someone who’s hemorrhaging at 18 weeks? I think that the future generations of our physicians are just not going to feel comfortable managing that on their own, and that’s going to be a detriment to patients beyond those who are seeking and needing abortion care.”Footnote 1
I. Introduction
Medical training for obstetrics and gynecology (OB/GYN) has shifted in significant ways. Shortly after Dobbs v. Jackson Women’s Health Organization,Footnote 2 the United States Supreme Court decision that overturned Roe v. Wade Footnote 3 in 2022, news stories and medical and health journals documented the “brain drain” from OB/GYN residency programs in states with newly enacted or enforced abortion bans.Footnote 4 Less discussed, however, has been how residency programs’ abortion training, required for accredited OB/GYN residencies, has come under pressure. To receive core family-planning education and clinical experience, many residents in ban states now travel to out-of-state training sites where abortion is lawful.Footnote 5 But demand is great, travel for multiple weeks is expensive, and the clinical experiences at these sites can be limited by staff capacity.Footnote 6 Residency programs also offer simulation — training with models and without seeing an actual patient — for miscarriage and abortion care.Footnote 7
This shift suggests long-term effects for graduate medical education and the quality of patient care. For one, a cohort of the new generation of OB/GYNs will have limited experience treating patients with pregnancy loss or pregnancy complications that necessitate termination. As the number of OB/GYNs continues to decrease,Footnote 8 newly-trained providers will have different, and arguably diminished, skills in providing medically necessary and emergency abortion care. And as life and health exceptions increasingly determine access to complicated care in many states, there is no guarantee that physicians practicing under bans will feel comfortable or sufficiently supported in delivering that care. Doctors in states that ban abortion may not only hesitate to perform abortions, because of criminal and civil liability, but also be unprepared to do so.Footnote 9
This article focuses on changes to medical training in OB/GYN residency programs after Dobbs. In what follows, I demonstrate the relationship between the training provided today, providers’ navigation of abortion bans and exceptions, and what that might mean for patient care in the coming years. Part I surveys the landscape of abortion law after Dobbs; even the strictest abortion bans contemplate instances when abortion care is medically required and legally permitted. Part II summarizes the pre- and post-Dobbs expectations for training for OB/GYN residents, assessing how medical education has changed for residents in ban states. Part III contemplates shorter and longer-term effects of a system that relies on travel and simulation or is out of compliance with national accreditation standards. Part IV concludes with observations on potential paths forward that depend on state and national organizations supporting collaboration among the groups seeking to improve the current system.
II. The Legal Landscape for Abortion Care
Post-Dobbs abortion law in the United States is marked by division and, in many places, there is a lack of clarity about how abortion laws apply.Footnote 10 More than a dozen states enforce near-total bansFootnote 11 and several others impose early gestational limits (including six-week and twelve-week bans).Footnote 12 A number of states restrict abortion after viability.Footnote 13 In some jurisdictions, the scope of restrictions has shifted due to ongoing litigation.Footnote 14 Most state abortion bans impose both civil and criminal penalties for performing abortions, with some statutes authorizing severe sentences such as life imprisonment.Footnote 15
Abortion bans include exceptions for life-threatening conditions and medical emergencies,Footnote 16 and many are narrowly defined in physical terms only and expressly exclude psychological or emotional conditions.Footnote 17 For example, some states prohibit a medical emergency exception from applying when the pregnant person threatens self-harm and when “based on a claim or diagnosis that the woman will engage in conduct which she intends to result in her death or in substantial and irreversible physical impairment of a major bodily function.”Footnote 18
Fourteen state laws include exceptions for risks to health with language that varies,Footnote 19 such as “a serious risk of substantial and irreversible physical impairment of a major bodily function”Footnote 20 or “a condition that poses a serious risk of substantial and irreversible impairment of a major bodily function.”Footnote 21 Some laws’ health exceptions fall outside these broad categories. For instance, Indiana’s exception allows an abortion in circumstances when the pregnancy “would pose a great risk of death or substantial physical impairment of the patient.”Footnote 22 Mississippi’s ban permits for abortion if “a twenty-four-hour delay will create grave peril of immediate and irreversible loss of major bodily function.”Footnote 23
Providers experience uncertainty in applying this language and thus difficulty in gauging when and if an exception has been met.Footnote 24 News reports and court records document cases in which pregnant patients were denied abortion care despite significant medical need, resulting in severe injury and, in some cases, death.Footnote 25 Maxine Eichner and her co-authors conducted in-depth, qualitative interviews with maternal fetal medicine physicians and described,
recurring gaps between the ways that physicians make abortion decisions in standard medical practice and the language of medical exceptions[, which] create uncertainty regarding whether, among other issues, the level of risk to life or health experienced by the patient rises to the threshold required by state law, and whether and when the patient’s medical risk meets the exception’s requirements regarding timing of the abortion.Footnote 26
Health care professionals report misalignment between clinical judgment and statutory language, and a paucity of publicly available guidance from legislatures, courts, medical boards, and health departments.Footnote 27 When state entities have issued guidance, the results are mixed. Following a decision by the Texas Supreme Court, the Texas Medical Board approved guidelines to clarify when doctors can legally intervene in a medical emergency and what they must document, although the rule was criticized as incomplete.Footnote 28 Texas Senate Bill 31, enacted in August 2025, incorporates recent case law on the medical emergency exception and reasonable medical judgment, requiring one hour of continued medical education on Texas abortion law for physicians providing obstetric care.Footnote 29
Doctors are not alone in grappling with state laws. Nadia Sawicki notes that some hospital administrators may prioritize minimizing legal exposure, and recent studies suggest that hospital attorneys would rather settle a malpractice claim than risk criminal investigation or attract the attention of the state legislature.Footnote 30 The result is chill and confusion, or what one article deems “hesitant medicine” by institutions and lawyers.Footnote 31 Of course, liability aversion is not uniformly true of actors in ban states. Yvette Lindgren and Michelle Oberman recently wrote about hospital personnel in Indiana who issued guidance that, though somewhat heavy in process, facilitates medical judgment and centralizes the process for approving abortions under the state law’s exceptions.Footnote 32
The need for medically indicated abortions or urgent medical care continues regardless of state laws.Footnote 33 Abortion is a treatment for people with pre-eclampsia, risk of hemorrhage, or severe pulmonary hypertension.Footnote 34 The care for pregnancy loss and pregnancy complications is vital, no less so under the laws described here.Footnote 35 Part II surveys the current state of medical training for physicians who are expected to respond to patients’ needs under abortion bans.
III. Shifts in Medical Training for Abortion Care
Overturning Roe did not overturn the expectations of what physicians should learn. OB/GYNs are expected to provide comprehensive pregnancy options counseling and to competently manage early pregnancy loss and uterine evacuation, including abortion.Footnote 36 This Part reviews the national standards mandating abortion training, before and after Dobbs, and how residency programs for OB/GYNs have responded to abortion bans. Residents can opt out of abortion training, and resident education always has been limited in various regions and at religiously affiliated health care facilities.Footnote 37 But gaps in training availability are widening.
A. Pre- and Post-Dobbs Training
This section primarily focuses on residency programs for OB/GYNs to illustrate how abortion training has occurred and occurs in the United States. This article does not intend to suggest that OB/GYNs are the only health care providers who deliver abortion services. Training in abortion care occurs in other specialties, such as in family medicine as well as in emergency and internal medicine.Footnote 38 Twenty states permit advanced practice clinicians to provide abortion care.Footnote 39 As set out in Part III, more training for a greater diversity of health care professionals is needed. But this section focuses on OB/GYNs in part because the Accreditation Council for Graduate Medical Education (ACGME), which governs the accreditation of residency programs, explicitly requires that OB/GYN residency programs provide access to training in abortion care.Footnote 40 In addition, studies published before Dobbs reported that OB/GYNs provide over seventy percent of abortion care in the United States.Footnote 41
Following Dobbs, the ACGME clarified that programs in legally-restrictive locations must continue to arrange training access in states where abortion is lawful.Footnote 42 The ACGME mandates for all OB/GYN programs nationwide: (1) training, or access to training, in the provision of abortion; (2) an opt-out option for any resident with religious or moral objections; and (3) the provision of experience in managing complications of abortions and training in all forms of contraception.Footnote 43 This mandate covers all accredited institutions, including public, private, urban and rural programs.Footnote 44 However, federal law stipulates that health care entities cannot lose federal funding or accreditation status for failing to offer, provide, or make arrangements for training on induced abortion.Footnote 45
Family planning training, including abortion, is a standard component of an OB/GYN residency, often delivered via a dedicated rotation or integrated curriculum.Footnote 46 At Stanford Medicine, for example, family planning is integrated throughout the residency program.Footnote 47 Stanford residents should acquire competency in performing first- and second-trimester abortions as well as assessing and managing pregnancy complications.Footnote 48 Stanford offers third-year residents opportunities to train with community partners, including Planned Parenthood affiliates.Footnote 49 The Swedish Medical Center in Seattle requires residents to learn, among various skills, how to provide contraceptive counseling, perform both first- and second-trimester abortions, and triage any complications that arise from outpatient terminations.Footnote 50 This rotation additionally focuses on complicated counseling, office procedures, and the use of an operating room.Footnote 51
Residency programs incorporate clinical training in rotations beyond family planning. Clinical training includes the provision of pelvic exams, administration of anesthesia, and patient education. For instance, NYU Langone Health requires residents to “take ownership, develop surgical skills, and improve clinical decision making”Footnote 52 for “complex family planning” throughout all “research, clinical, and surgical” settings.Footnote 53 The Midwest’s Corewell Health (Corewell), located in Michigan, requires residents to complete multiple rotations in maternal fetal medicine, which the website describes as the study of “complicated and high-risk obstetric care, both inpatient and office based.”Footnote 54 Corewell emphasizes the use of models (or simulations) in procedural training for obstetrical emergencies and high-risk medical complications.Footnote 55
Shortly after Dobbs, in 2022, the ACGME informed residency programs that “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.”Footnote 56 ACGME requirements further stated that “[i]f for some reason a resident is unable to travel to another jurisdiction for clinical experience, the program must provide the resident with a combination of didactic activities, including simulation, and assessment on performing a uterine evacuation and communicating pregnancy options.”Footnote 57 Likewise, the American Board of Obstetrics and Gynecology (ABOG) mandates that graduates fulfill certain requirements in order to take specialty qualifying and certification examinations.Footnote 58 In response to the Dobbs decision, ABOG emphasized that “residents seeking ABOG certification [are] required to have satisfactorily completed a minimum of two months, two four-week blocks, or the equivalent of these experiences in family planning … .”Footnote 59
Thus, even in restrictive states, OB/GYN residency programs should incorporate training in abortion. At Morehouse School of Medicine in Georgia (which has a ban on abortion after six weeks),Footnote 60 first-year residents train in high risk obstetric care and family planning.Footnote 61 Before completion of the program, residents complete a rotation in the Emergency Care Center.Footnote 62 However, most programs do not advertise on their websites how they accommodate abortion training per the ACGME’s mandate, and many programs, for which information is not readily accessible, may be out of compliance.Footnote 63
Obstacles to abortion training, to be sure, preceded Dobbs. As one study concluded, “[i]nstitutional and programmatic barriers to incorporating training are common and may impose additional restrictions on abortion care provision than dictated by state laws.”Footnote 64 Estimates vary, but pre-Dobbs reports from residency directors suggest that only between sixty to sixty-four percent of OB/GYN residency programs offered routine, in-house clinical abortion training.Footnote 65 According to a 2021 study, sixty percent of OB/GYN residents reported routine abortion training, eighteen percent had a clear path to optional training, eleven percent had no clear path to training, and eight percent had no training at all.Footnote 66 Nevertheless, ninety-two percent of OB/GYN residents had access to some level of abortion training in their home programs pre-Dobbs, even in states where abortion was restricted.Footnote 67 After Dobbs, there has been a significant decrease in residency programs offering routine clinical training in abortion care. Early projections showed that “2,638 of the 6,007 current OB/GYN residents (43.9%) [were] likely or certain to lose access to abortion training in their states.”Footnote 68
ACGME does not require family medicine residency programs to offer abortion training; rather, residents must have clinical hours dedicated to gynecological issues. The American Academy of Family Physicians recommends residents have knowledge of family planning, options counseling, early pregnancy loss and post-abortion symptoms and complications.Footnote 69 As noted by one study, “there has been increasing appreciation of family physician’s [sic] role in abortion provision, especially because family physicians practice in communities where they may be the only health care clinician, and abortion care is well aligned with family medicine’s core values of continuity and whole person care.”Footnote 70 Dobbs has impacted medical education for those training in family medicine. In 2023,
although most (63.8%) family medicine residency programs were in states with at least some abortion restrictions, 251 programs (36.2%) were in states with laws protecting abortion. Of the 13,541 residents in accredited US family medicine programs, 3,930 (29%) were training in states that had banned abortion or where abortion was very restricted, and 5,020 residents (37.1%) were in states with protective policies.Footnote 71
Research reveals that residency programs operating in ban states have had decreased student applications and lower levels of participant satisfaction.Footnote 72 The next section briefly reviews those findings before turning to programmatic changes, including resident travel and increased reliance on simulation.
B. The Consequences of Abortion Bans for Training
Like gaps in training, problems in the availability of obstetric care have long plagued this country. Ban states already had a dearth of practicing OB/GYNs with regional care deserts in the South and Midwest:Footnote 73 “the American College of Obstetricians and Gynecologists (ACOG) estimated that, in 2020, there was a shortage of 8,800 practicing OB/GYNs nationwide, with more than half of all U.S. counties lacking any practicing OB/GYN at all.”Footnote 74 A decrease in applications to OB/GYN residency programs threatens to intensify that shortage.Footnote 75 One study conducted by the Association of American Medical Colleges on the 2022–2023 residency application cycle showed that states with total abortion bans saw the largest decrease in OB/GYN applicants, at 10.5%, or more than double the national average of 5.2%.Footnote 76
Dobbs, in addition to shaping where students apply for residency, effects where new OB/GYNs practice. In 2023, of the 349 surveyed residents graduating from abortion training programs, 17.6% indicated that Dobbs impacted their practice and fellowship plans.Footnote 77 Indeed, “[r]esidents who before the Dobbs decision intended to practice in abortion-restrictive states were eight times more likely to change their practice plans than those who planned to practice in protected states before the Dobbs decision.”Footnote 78 And current abortion bans have resulted in physicians moving their practices.Footnote 79 A 2023 survey found that forty percent of OB/GYNs practicing in Idaho, a state with a complete ban,Footnote 80 have left or are considering leaving the state.Footnote 81 Other providers have made the decision to cease providing abortion services and instead offer other types of sexual and reproductive health care.Footnote 82
Studies also demonstrate residents’ deep dissatisfaction with the current system, including moral distress and fears for personal safety.Footnote 83 As one recent report notes, “providers [in ban states] carry the tremendous emotional weight of being forced to limit access to essential patient care, or of risking their licensure or being criminalized. In addition, providers who stay in restrictive states may incur … increased security costs to counter harassment and threats of violence, and the expense of legal consultation or representation to address increased liability.”Footnote 84
To date, attention has focused on residency applications but less has been written about how residents in ban-state programs train. In ban states, there is a small patient population seeking in-state abortion services.Footnote 85 Residents rely on treating patients after pregnancy loss,Footnote 86 which typically falls outside of the definition of abortion, or patients with abortions covered by a legal exception,Footnote 87 which often lack clarity as noted in Part I. Said another way, there is an insufficient volume of patients to provide the clinical hours for ban-state training.Footnote 88 Travel for training has been one response to that challenge.
Thus, a core change to medical education has been increased resident travel to programs without restrictive laws, like California or Illinois, where there are more patients. Much of that resident travel has been facilitated by organizations like the Ryan Residency Training Program in Abortion and Family Planning (Ryan Residency Program),Footnote 89 which was established after ACGME first mandated abortion care training for all OB/GYNs. The Ryan Residency Program has helped match residents seeking abortion training with programs across the country.Footnote 90 This process has been and remains complicated: out-of-state rotations take several months to arrange, including completing agreements between programs and meeting in-state as well as institutional requirements for the resident’s placement.Footnote 91 As detailed below, just the paperwork to set up required licensing and insurance coverage is cumbersome, varying based on the home state and the training state.Footnote 92 Residents without the assistance of Ryan Residency Programs often “coordinate clinical opportunities with minimal assistance.”Footnote 93
Just before Dobbs, in 2021, eighty-nine Ryan Residency Programs populated sixty percent of residency programs in every region of the United States with one third in states considered hostile to abortion (and three at religiously affiliated hospitals).Footnote 94 After Dobbs, the Ryan Residency Program’s work became even more crucial, as now over 120 Ryan Residency Programs help accommodate residents in need of abortion training.Footnote 95
Yet, not everyone can travel for out-of-state training. Residents who cannot travel (as well as those who can) use simulation in order to build skills. Simulation, or using models to teach core procedures, “has been used for many years to augment clinical training in pregnancy termination. Several good models exist, including a papaya-based simulation and didactic scenarios for abortion related complications.”Footnote 96 Programs increasingly rely on simulation in restrictive jurisdictions when clinical experience is not available.Footnote 97 Although simulation and didactics are an important part of training, ACGME has emphasized that simulation cannot “fully replace real-life clinical experience”Footnote 98 — care performed in an office or in an operating room — and “cannot account for the entire context of a patient encounter, simulation is not a substitute for hands-on patient experience.”Footnote 99 Simulation also requires time and resources.Footnote 100
The next Part examines the consequences of post-Dobbs residency training for individual learners, for the institutions that host them, and for the future of patient care as well as physician competency. As Amirala S. Pasha and her colleagues wrote, “A gap between the training of clinicians and the needs of the community make care harder to access for all … lead[ing] to the same issues in training and clinical experience that existed prior to Roe.”Footnote 101
IV. The Burdens of the Current System
Of approximately 6000 OB/GYN residents in the United States, 2600 (forty-three percent) are in states with restrictive abortion laws;Footnote 102 over 1200 residents are in states that ban abortion at all stages of gestations.Footnote 103 As noted above, OB/GYNs and training opportunities were scarce in many places before Dobbs. Footnote 104 But more residents, after Dobbs, travel or rely on simulation to acquire foundational skills.Footnote 105 People who train to be OB/GYNs now find themselves in an even more fragmented system.
First, graduate education based in part on participant travel is burdensome. For residents in ban states, spending weeks away from their home programs in another state requires time and logistical flexibility. As is true for patients traveling out of ban states for abortion care, the ability to move across state lines depends on various forms of privilege, including resources to cover costs in two places and the ability to pause or delegate obligations at home.Footnote 106 Uprooting one’s life for weeks at a time can cause personal, social, and financial hardships that many residents cannot afford.Footnote 107 In addition, the clinics and hospitals that provide training are predominantly located on the coasts.Footnote 108 The distance between training centers and programs in ban states adds to both the logistical challenges for trainees and tracks “the ever-growing geographic disparities in the distribution of the abortion care workforce.”Footnote 109 Moreover, if residents travel to other programs, they may miss opportunities to hone skills while rotating in their home program and their home programs lose trainees’ labor.Footnote 110 Short-term rotations may not be as effective as learning skills over the course of an entire program.
Second, the post-Dobbs stress on institutions that train out-of-state residents is intense. Workforce competition and burnout increasingly characterize the field.Footnote 111 Residents’ demand for clinical hours can exceed the capacity of those programs to provide abortion training for both in-state and out-of-state residents.Footnote 112 As a result, there is increased competition between residents for time with patients.Footnote 113 Add to that logistical and administrative burdens, such as facilitating trainee licenses, that fall to overworked staff members at training institutions. High-volume sites already operate with stretched resources, serving more out-of-state patients and more patients who require complicated care after Dobbs. Without additional staff and resources,Footnote 114 cumulative pressures on health centers affect the ability or willingness to train residents.Footnote 115
Third, increased pressures on residency programs could affect the quality of training.Footnote 116 A study by Cara Grimes and her colleagues note the change in how residents now learn counseling skills:
From a nonprocedural perspective, participants identified ways abortion training teaches residents how to counsel patients in challenging situations…Multiple participants described the loss of opportunities to learn effective and compassionate communication skills in difficult encounters, counseling that frequently happens around abortion training.Footnote 117
Fewer educational opportunities could translate into decreased readiness to serve patients needing time-sensitive pregnancy care under restrictive frameworks. In a 2023 study, the research group, Advancing New Standards in Reproductive Health (ANSIRH), found that “post-[Dobbs] laws and their interpretations altered the standard of care across these scenarios in ways that contributed to delays, worsened health outcomes, and increased the cost and logistic complexity of care.”Footnote 118 While ANSIRH focused on care withheld due to legal constraints rather than training gaps, delays or denials — whether driven by law, institutional caution, or capacity — can produce adverse patient outcomes,Footnote 119 including increased risk of maternal and infant mortality.Footnote 120
Fourth, evidence suggests that the training some residents receive in ban states is focused on legal risk and overly cautious.Footnote 121 As Lindgren and Oberman have argued, the potential legal consequences of abortion bans, in combination with vague statutory language, have triggered a retreat from the prevailing standard of care when treating pregnant patients.Footnote 122 In the current context, doctors may practice “hesitant” medicine, providing less care than may be optimal because of the threat of civil liability and criminal punishment.Footnote 123 Patient injuries and deaths have been subject of headlines but have not resulted in provider punishment.Footnote 124
What do changes in residency education mean for the standard of care? It may be too early to say with any confidence. But the concern remains that residents trained today may not be equipped to perform essential procedures tomorrow. To help ensure a different trajectory, training across the country must be supported by resources and institutional infrastructure that can address the problems of the present system.
V. Potential Responses
This article has provided a snapshot of the changes that have emerged in OB/GYN residency programs post-Dobbs. The abortion laws that states have enacted in the last few years are unprecedented — total criminal bans, narrow exceptions, the absence of guidance — even as compared to laws that predated Roe. Footnote 125 And what residency programs have done under those laws is an experiment. Residents travel out of state in far greater numbers,Footnote 126 curricula have become piecemeal to a greater extent,Footnote 127 simulation is more prevalent,Footnote 128 and residents and institutions struggle to navigate new systems in the shadow of criminal and civil sanctions.Footnote 129
In this moment of change, responses to the gaps in medical education for OB/GYNs and other health care professionals depend on collaboration, innovation, and flexibility. In that vein, the following recommendations, offered by those working on the ground, seek to address the challenges raised in the previous parts of this article.
A. Resources for Trainers and Learners
Organizations central to post-Dobbs abortion training are translating lessons from their work into actionable best practices. A national summit of abortion providers, professional associations, and non-profit organizations gathered in 2024 to discuss the current landscape of abortion training and, specifically, the “availability, logistical support, legal restrictions, funding, and diversity of the abortion providing workforce.”Footnote 130 The group’s discussion focused on recommendations that could improve post-Dobbs resident and practitioner education.Footnote 131
The summit’s experts began by detailing the complications of setting up and coordinating a training program out of state. For example, credentialling standards and insurance requirements differ from place to place; residents’ services billed under supervising physicians can cause difficulties for billing practices.Footnote 132 As demand for training from clinicians and training sites continues to increase, a need has emerged for central databases that share information and training tools. A clearinghouse would be the place to track requests for training; assist institutions in accommodating residents without reinventing the wheel every year and for every program;Footnote 133 and offer training materials, forms, and guidance that could ease the burdens of administration.Footnote 134
Existing partnerships under a ‘hub’ model have developed sample program agreements or letters of affiliation, pre-travel curriculum, modules to accommodate out-of-state learners, and guides for residents. Creating agreements or educational plans and tracking state and professional requirements are time consuming tasks.Footnote 135 The nationwide initiative, the Abortion Training Nexus (ATN), provides these resources to “build a national infrastructure to sustain abortion training through out-of-state partnerships [and] tools.”Footnote 136 ATN seeks to ease the burdens on host sites so that more clinics and hospitals are willing to receive residents.Footnote 137
Funding is vital for groups like ATN, the Ryan Residency Program or the Midwest Access Project (now, Repro TLC), which was founded to coordinate training for family practice residents.Footnote 138 These groups depend on networks of professionals to facilitate training programs, which, as noted, can be expensive for all involved.Footnote 139 Training sites cover costs such as “paying a lawyer to assist with the creation of a training agreement, paying clinical staff overtime to stay later with learners, paying attendings for the time it takes to evaluate learners and provide feedback, hiring additional staff to support the learner experience, and loss of revenue due to longer visits resulting in fewer patients seen per day (lower productivity).”Footnote 140 Additional financial resources could help staff programs that manage the process of training out-of-state residents. The costs related to insurance, equipment, and staff salaries, for example, are often covered by private and state grants.Footnote 141 State funding in places that are supportive of abortion rights, such as in California, New York, Illinois, New Jersey, and Maryland, has supported the expansion of training opportunities.Footnote 142
State-funded programs have prioritized diversifying the pool of providers and better integrating abortion into primary care as well as hospital settings.Footnote 143 In addition to OB/GYNs, as mentioned in Part II, family medicine practitioners can offer obstetric servicesFootnote 144 and twenty states permit Advance Practice Clinicians (APCs) to provide abortion care.Footnote 145 States like California have invested in APC training at teaching hospitals and local clinics.Footnote 146 For instance, the Reproductive Health Services Corps (RHSC) is a statewide abortion training initiative that focuses on education for a team of professionals — APCs, RNs, MDs, midwives, EMTs, doulas, community health workers, and pharmacists working in a primary care setting.Footnote 147
Expanding educational opportunities also has incorporated training on medication abortion. Medication abortion typically consists of mifepristone followed by misoprostol and is FDA-approved through ten weeks of gestation.Footnote 148 Medication abortion accounts for over half of all abortions in the United States and is increasingly delivered through telehealth.Footnote 149 The growth of virtual clinics followed a 2020 federal district court decisionFootnote 150 that temporarily enjoined one of the FDA’s restrictions on mifepristone, which required patients pick up the drug in person.Footnote 151 In December 2021, the FDA lifted that rule,Footnote 152 clearing the way for certified prescribers to furnish mifepristone through mail-order subject to federal and state law.Footnote 153 The average number of abortions is higher now than before Dobbs, and mailed medication abortion helps account for that number. The #WeCount study, which has counted abortions since Roe was overturned, documents that providers mailed 12,000 packets of medication abortion per month in the last few months of 2024.Footnote 154 Of those, patients in states with total abortion bans or bans at six weeks of gestation received the majority of pills.Footnote 155
Organizations like the Reproductive Health Access ProjectFootnote 156 and Training in Early Abortion for Comprehensive HealthcareFootnote 157 seek to incorporate medication abortion through telehealth and at Federally Qualified Health Centers or other community-based settings.Footnote 158 The Whole Clinic Training Program at the University of Maryland, Baltimore, “brings expert, hands-on training directly to your site, empowering your entire team, including providers, nurses, administrative staff, and support personnel, with the skills, knowledge, and strategies needed to confidently and effectively integrate safe, high-quality medication abortion services into your practice.”Footnote 159
Having providers teach telehealth counseling, risk assessment, and provision of medication abortion at mobile clinics may increase the opportunities to provide care in states where procedural abortion is limited. In addition, health care professionals will continue to need training on follow-up or post-abortion care as patient travel, care through telehealth, and self-managed abortion increase.Footnote 160 Training programs rely on protocols and guidance to offer various services by a diversity professionals across locations. The next section addresses the role of institutions and professional organizations in assisting those programs.
B. Institutional Leadership
Institutional actors, such as professional associations, will shape the future of medical education in ban states. Lindgren and Oberman observe, “[t]o care for their patients, clinicians need to know the ‘least-worst best practices;’ [sic] they need the support of their profession to help them distinguish competent from incompetent care.”Footnote 161 ACOG and the American Medical Association came out strongly in support of comprehensive abortion training after Dobbs. Footnote 162 National organizations have since issued guidance on topics like emergency abortion care.Footnote 163 Indeed, the regulation of obstetric emergencies already has come before the Supreme Court.
Moyle v. United States Footnote 164 concerned whether Idaho’s abortion ban, which had no exceptions for medical emergencies, was preempted by the federal Emergency Medical Treatment and Labor Act or EMTALA,Footnote 165 which requires emergency departments to stabilize patients needing emergency care in Medicare-funded hospitals. The Supreme Court ruled that it improvidently granted certiorari and returned the EMTALA issue to lower courts to decide.Footnote 166 At the time of writing, providers are performing EMTALA‑required emergency abortions with protection from criminal sanction in Idaho.Footnote 167 In a separate case, however, the Fifth Circuit held that EMTALA does not authorize the federal government to compel health care providers to perform abortions, even in emergency situations, if abortion is prohibited by state law.Footnote 168
Although national medical organizations agree that abortion can be necessary to save the life or health of the pregnant person,Footnote 169 best practices for addressing both predictable and novel cases could help reduce patient harm. Oberman and her colleagues argue, “[ideally], the Joint Commission on the Accreditation of Hospitals and the National Committee on Quality Assurance (NCQA) would collaborate with professional organizations like ACOG to identify best practices, and adopt them into the relevant accreditation standards and protocols.”Footnote 170 Presently, doctors and their lawyers do not rely on “cross-institutional, multi-state professional networks to set community norms, which would, in turn, set guardrails around defensive medicine” based on consensus-based standards.Footnote 171 Groups with a national remit might be in the best position to gather data and evidence on the clinical care applicable to a range of cases, issuing guidance that could be applied with state laws in mind. Such guidance could inform the content of and the process by which residency education occurs, conferring legitimacy on the decisions of program administrators and participants. Moreover, national leadership might encourage partnerships among doctors and lawyers, who too often act in silos but could work together to train themselves and their colleagues.
Beyond national organizations, state health departments and medical boards also could provide leadership. State departments of health can allocate funding to groups that coordinate logistics for traveling residents, such as the Ryan Residency Program.Footnote 172 Investment in one state’s medical education system would have ripple effects for the entire country: the nature of travel means that states in non-abortion ban medical education systems can help ensure better education for residents who travel to these states and return to home.
State medical boards are the gatekeepers to the profession. One critique of state medical boards has been their historic reticence to wade into controversial topics.Footnote 173 But medical boards could intervene in order to protect their members’ professional interests by helping ensure physicians receive the best education possible. Boards have the power to reaffirm providers’ use of their reasonable medical judgment and doctors’ ethical duty to protect their patients as well as to help dismantle obstacles for out-of-state training through rules and advice.Footnote 174
On the latter, as residents increasingly leave their home states for training, trainee licensing has become a barrier: “[s]tate licensing times vary widely (three–twelve months) and can make cross-state training plans very difficult if not impossible to implement.”Footnote 175 Medical boards (or state entities with similar powers) can facilitate state training licenses for out-of-state learners.Footnote 176 Indeed, “[s]ome states have streamlined visiting-trainee licensure or permit supervised practice under specific training licenses.”Footnote 177 As a longer-term strategy, the Federation of State Medical Boards could advocate for a national system for and a national approach to OB/GYN trainee licensure as it does for licensure portability generally.Footnote 178
Finally, in response to changes in graduate medical education, the ACGME could increase transparency, building on its Resident/Fellow and Faculty Survey, and seek ways to hold non-compliant programs accountable with more publicly-available information.Footnote 179 This might entail developing additional monitoring tools for programs in ban states and asking different kinds of questions about residents’ experiences as well as the skills they have gained.
VI. Conclusion
Medical education for OB/GYNs has shifted in significant ways. Since Roe’s reversal, many states have strict laws that ban abortion. Although many bans contain life or emergency exceptions, they are often narrowly drawn, typically limited to physical conditions, and the health-related language is frequently complex or indeterminate. Doctors and lawyers’ inability to gauge when an exception is met has resulted in delayed and denied care for fear of criminal or civil liability. Under these pressures, perhaps it is not surprising that there has been a drop in applications to OB/GYN residency programs in states with abortion bans.
This article, however, focuses on another concern. Although the availability of abortion training was a problem preceding Dobbs, statistics showed most OB/GYN residents had access to some level of training in their home programs. But, since Dobbs, the number of residency programs offering routine clinical training in abortion care has decreased. To get the basic education that health care professionals need, many residents in ban states travel for an intensive out-of-state program. While ACGME requires programs to provide access to training, demand is high, multi-week travel is costly and logistically complex, and training-site capacity is limited. This current arrangement cannot serve all users.
Until states no longer ban abortion, the future of abortion training is unclear and what could shift most immediately is the willingness of professionals to work within the present system. OB/GYN residents living in ban states might be increasingly deterred from travel given all the burdens described above. Yet, those residents, who will not or cannot travel, nevertheless are likely to see patients that require abortion care over the course of their careers.
This article has described critical efforts underway to stabilize and to improve graduate medical education for OB/GYN residents post-Dobbs. Funding and infrastructure support has helped hospitals and clinics coordinate the burdens of travel. Collaboration among abortion-supportive legislatures, professional organizations, and state boards and health departments has secured resources for cross-state training, both in procedural abortion as well as for medication abortion. But there is more that can be done. Without sustained and increased investment, patients ultimately will pay the price if the number of providers willing and able to offer abortion care continues to decline.
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