A pilot online, video-based abortion care curriculum nationally positively affected obstetrics-gynecology residents' clinical knowledge, providing residency programs with a useful, centralized educational resource.

Objective: To develop and evaluate the acceptability and effectiveness of an extended reality (XR) avatar-based menopause education simulation module for the clinical training of OB/GYN residents. Methods: This menopause education pilot recruited 57 OB/GYN residents from nine institutions via listservs and snowball sampling. Participants completed a menopause-focused XR avatar simulation module developed using Kern’s curriculum design framework and guided by APGO/CREOG objectives and national guidelines. Learners completed an 11-item preintervention and postintervention assessment measuring usability and satisfaction (Kirkpatrick Level 1: reaction outcomes) and knowledge and self-reported confidence (Level 2: learning outcomes). Descriptive statistics summarized additional outcomes, and paired t tests were used to evaluate changes in knowledge. We also conducted a brief descriptive review of voluntary free-text comments. Results: From preintervention to postintervention, mean knowledge scores improved from 79.8% to 82.8% ( P =0.028). Participants reported improved preparedness and confidence across multiple domains: 59% improvement in overall readiness to manage menopause, 50% in comfort managing hormone therapy, and 39% in managing nonhormone therapy. No learners reported feeling “not at all prepared” postintervention. Most rated the module as effective (63%) and more engaging than lectures (60%); 96% would recommend it. Narrative feedback endorsed the module as valuable while suggesting improvements in interactivity, content depth, and avatar responsiveness. Conclusions: The XR simulation module demonstrated acceptability and effectiveness in enhancing clinical menopause training. Results support its potential as a scalable educational tool to address gaps in clinical menopause education.

BACKGROUND:In the United States, the Dobbs v. Jackson Women's Health Organization (Dobbs) decision has implications not just for patient care, but for abortion training. Consequently, training programs in states with abortion bans are developing out-of-state training rotations by partnering with programs in abortion-accessible states. It is unclear what barriers exist for trainees, sending and receiving site faculty as they develop and manage out-of-state training rotations. OBJECTIVE:This study aims to understand the perspectives of trainees and faculty as they navigate the post-Dobbs landscape and develop out-of-state training relationships. STUDY DESIGN:This qualitative study interviewed trainees, faculty from states with abortion bans considering sending trainees for abortion training ("Sending Sites") and faculty from states supportive of abortion that are receiving trainees ("Receiving Sites"). Interviews were conducted over Zoom, transcribed, and interview transcripts were analyzed utilizing Nvivo software for thematic qualitative analysis. RESULTS:We interviewed 9 trainees, 8 sending sites faculty and 5 receiving sites faculty across the country. Faculty in states with abortion bans noted many barriers to establishing an out-of-state rotation including funding and legal support. Receiving sites were worried about integrating outside trainees and making sure they got enough experience without negatively impacting their home trainees' training. Regardless of rotation length and level of participation, all trainees reported positive experiences with out-of-state training. CONCLUSION:Despite barriers to developing out-of-state training rotations, trainees value the opportunity to obtain abortion training. Efforts should be made to improve facilitation of out-of-state training opportunities in the post-Dobbs medical landscape.

Background The evolution of medical standards in stigmatized areas like abortion is influenced by medical, political, and social factors. Self-sourcing and managing medication abortion (SSMA) is on the rise in the United States, where individuals obtain medications to end their pregnancies outside traditional medical settings. Physician attitudes towards SSMA are not well understood, despite physicians’ role in setting care standards, providing medical oversight, and de-stigmatizing healthcare both within and outside clinical environments. Materials and Methods We interviewed 40 physicians (MD/DOs) who perform abortions about their views on SSMA. We used inductive-deductive coding for transcript analysis and qualitatively assessed how attitudes shifted before and during the interviews. Results Most participants were aged 31-35 years (n=16, 40%), non-Hispanic White (n=29, 72.5%), and female (n=33, 82.5%). We oversampled family medicine-trained physicians (n=31, 78%) compared to OB/GYNs (n=9, 22.5%). Participants were from 24 states, with half from states supporting abortion rights and the other half from states with hostile or neutral stances. Half of the cohort supported SSMA, while the other half was ambivalent. Medical evidence alone did not sway physician views on SSMA; instead, participants adjusted their attitudes by clarifying their professional values, evaluating SSMA’s alignment with these values, and considering values-based frameworks as alternatives to medicalization. Discussion Although medical care is typically seen as objective and standardized, physicians’ ethics to ensure safe access to care often clash with political restrictions in this stigmatized field. Physicians are more worried about the broader structural issues related to SSMA, such as how political and social vulnerabilities could harm the most vulnerable patients, rather than the medical care itself, which they see as safe and effective, with or without physician oversight. Positive attitudes toward SSMA were strengthened by exposure to values-based frameworks that offer alternatives to strict medicalization.

Objective: This study aimed to assess the perceived impact of state and institutional policies on managing pregnancies of unknown location (PULs) at US Ryan residency programs. Study design: We conducted a cross-sectional electronic survey of US Ryan residency programs (n = 113) from March to April 2024. We compared the perceived influence of institutional and state policies on PUL management among Ryan Programs in restrictive vs nonrestrictive abortion climates. Provision of diagnostic uterine aspiration in the workup of PUL was a secondary outcome. We compared proportion of responses between restrictive and nonrestrictive climates with Fisher exact tests. Results: We obtained responses from 75 Ryan Programs in 32 states (66.4% response rate). 29 (38.7%) were from states with restrictive abortion policies. Eight programs (10.7%) changed PUL management after the Dobbs decision. Compared to programs in nonrestrictive states, programs in restrictive states were more likely to report that state policy inhibits their ability to care for patients with PUL (34.5% vs 2.17%, p < 0.001), rarely or never offer diagnostic uterine aspiration (34.5% vs 8.7%, p = 0.01), and identify institutional leadership as a barrier to offering diagnostic uterine aspirations (20.7% vs 2.2 %, p = 0.01). The most common institutional barriers to providing diagnostic uterine aspiration were staffing and faculty comfort/willingness, which did not differ by state abortion climate. Conclusions: State abortion policy and institutional policy may impact the options available to patients with PULs. Implications: Programs in all legislative climates should address institutional barriers to providing diagnostic uterine aspiration. Legislative advocacy in restrictive states is needed to ensure access to expedient PUL management. (c) 2025 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

BACKGROUND:Reproductive health, including abortion care, is a critical component of undergraduate medical education (UME) that is inconsistently included in UME. OBJECTIVE:The objective of this study is to investigate the association between the inclusion of abortion and contraception topics in UME curricula overall and state-level abortion restrictions. METHODS:A national cross-sectional survey of medical students was conducted from August 2022 to June 2023 using the American Medical Student Association Reproductive Medical Education Survey. Students reported whether abortion, contraception, options counseling, and values clarification were included in their schools' preclinical and clinical curricula. State-level abortion laws as of July 2024 were categorized as banned, banned before 12 weeks, banned after 12 weeks, or unrestricted. Logistic regression was used to evaluate the association between state law and inclusion of each curricular topic. RESULTS:Responses were received from 101 of 190 U.S. medical schools (53%) in 41 states. Preclinical coverage was 63.4% for abortion, 82.2% for contraception, 52.5% for options counseling, and 47.5% for values clarification. Clinical coverage was 53.5% for abortion, 61.4% for contraception, 56.4% for options counseling, and 44.6% for values clarification. While there was no association between state-level abortion restrictions and inclusion of abortion in preclinical curricula, schools in unrestricted states were more likely than those in banned states to include clinical education on abortion (OR: 2.83; 95% CI: 1.04-8.20) and values clarification (OR: 2.98; 95% CI: 1.08-8.91). CONCLUSION:Inclusion of reproductive health topics in UME remains limited, and our findings are the first to indicate that a decrease in clinical abortion education is seen in states with state-level abortion bans. All medical schools must strive to include contraception and abortion education to ensure a workforce trained to meet the community's health needs.

OBJECTIVE: To identify and examine strategies used by obstetrics and gynecology residents in abortion-restricted states to mitigate moral distress. METHODS: We analyzed one-on-one, semi-structured interviews with 21 obstetrics and gynecology residents in abortion-restricted states to identify and examine strategies used to mitigate moral distress related to training in abortion-restricted environments. RESULTS: We identified four themes that summarize the strategies that residents have used to mitigate moral distress experienced while training in abortion-restricted settings: maximizing clinical care, supplementing education, engaging in advocacy, and obtaining emotional support. Across all themes, participants described individual and institutional efforts that helped mitigate moral distress, as well as strengths and limitations of all strategies. Faculty and institutional leaders played a particularly pivotal role in mediating the effect of residents' moral distress. CONCLUSION: Strategies used by obstetrics and gynecology residents to combat moral distress from training in abortion-restricted states have varying effectiveness. The role of faculty and institutional leadership appears especially important in mediating the effect of resident moral distress and the success of efforts to combat it.

Objective: To assess the role of abortion training in fourth-year obstetrics and gynecology (OBGYN) residents' abortion care competence and practice intentions before the Dobbs decision. Study design: This is a planned secondary analysis of survey data of fourth-year U.S. OBGYN residents. Abortion training was defined as 'routine' if automatically included in schedules, "optional" if not scheduled but available, and "not available". Self-assessed competence was defined as feeling prepared to independently provide care. Participants were asked about their competence and post-residency intentions to provide specific aspects of pregnancy loss and induced abortion care. Results: Of 1241 fourth-year residents, 885 (71%) completed the questions of interest. For each skill, more residents with routine training reported competence compared to those with less comprehensive training. More residents with routine training reported intentions to include abortion care in practice (422, 79%) compared to residents with optional (171, 66%) or no training (51, 55%), p < 0.001). Residents with routine training were nearly six times more likely to intend to provide medication abortion post-residency compared to residents without training; more residents in all groups reported intentions to provide care for pregnancy loss compared to abortion. Conclusions: Pre-Dobbs, residents with routine abortion training had greater self-assessed competence in abortion care than those with optional or no training and were more likely to intend to provide this after residency. Given the evolving impacts of the 2022 reversal of Roe v Wade, residency training programs must work to ensure routine access to legally permissible abortion training as routine training is associated with intention to provide fundamental, reproductive healthcare. Implications: Routine training in abortion care during OBGYN residency is associated with higher competence and intention to provide post-residency - availability of this training Is severely compromised in restricted states post-Dobbs. (c) 2024 Elsevier Inc. All rights reserved.

Objectives We aimed to assess the impact of state and institutional policies in managing pregnancies of unknown location (PUL) at US Ryan residency programs. Methods We conducted a cross-sectional electronic survey of all US Ryan residency program directors (n=113) in March–April 2024. Using Guttmacher state abortion restriction classifications, we compared the perceived influence of institutional and state policies on PUL management among Ryan programs in restrictive vs. non-restrictive abortion climates. Provision of diagnostic uterine aspiration (UA) for undesired PUL was a secondary outcome. We compared response proportions with Fisher’s exact tests. Results Sixty-eight (60%) Ryan program directors responded from 31 states. Of these, 26 (38.2%) were from states with restrictive abortion policies. Six programs (8.8%) changed PUL management after the Dobbs v Jackson Women’s Health Organization decision. Compared to programs in protective states, programs in restrictive states were more likely to report that state policy “severely” or “somewhat” inhibits their ability to care for patients with PULs (50% vs. 2.4%, p<0.001), rarely or never offer diagnostic uterine aspiration (30.8% vs. 7.1%, p=0.02), and identify institutional leadership as a barrier to offering diagnostic UAs (19.2% vs. 2.4%, p=0.03). The most frequently cited institutional barriers to providing diagnostic UA were staffing and faculty comfort/willingness, which did not differ significantly by state abortion climate. Conclusions State abortion policy may impact the options available to patients with PULs. Programs should work to address barriers to providing diagnostic uterine aspiration in the setting of undesired PULs.

Since 2020, World Health Organization guidelines state that universal access to abortion care is critical for individual and community health, and for the realization of human rights. Yet the right to access safe abortion care is severely restricted in many countries. This article outlines institutional and educational systems in the USA, Sweden, and Ghana, which all require obstetrics and gynecology (ob-gyn) training to include abortion care but vary in implementation. It argues that regardless of the political environment, the specialty should protect abortion training worldwide. In Sweden and Ghana, ob-gyn residents are required to participate in abortion training, while in the USA they are permitted to opt out. In Sweden, practicing ob-gyn specialists are required to provide abortion care, whereas in Ghana and the USA, this care is optional, leading to geographic disparities in abortion care access in these two countries. In the USA, the Supreme Court's Dobbs ruling jeopardizes programs' abilities to meet the training mandate, a requirement that was insufficiently implemented even before the ruling. It is critical that all clinicians are well-equipped to provide accurate information to their patients and provide pre- and post-abortion care. For this reason, we recommend that abortion is included in all undergraduate medical education programs in accordance with the recommendations of FIGO (the International Federation of Gynecology & Obstetrics). To meet WHO guidelines that require ob-gyn specialists to provide abortion care in an emergency, we urge FIGO to create a guideline about expectations for abortion training integration in obstetrics and gynecology. This article emphasizes the necessity of educational institutions worldwide that offer abortion care training, and compares the current systems in the USA, Sweden, and Ghana.

State laws that restrict abortion also impede abortion training, which is required by the Accreditation Council for Graduate Medical Education for obstetrics and gynecology programs. After the enactment of Texas Senate Bill 8 in September 2021 and 1 year after Dobbs v. Jackson Women's Health Organization , the Ryan Program facilitated partnerships between 13 obstetrics and gynecology residency programs in restrictive states and 13 programs in protective states for resident training. We describe the experiences of residents who traveled within these partnerships through postrotation surveys about training experiences, practice intentions, and alignment with the learning objectives. From April 2022 to August 2023, 60 residents traveled and 35 completed surveys (58.3%). Residents reported that the rotation met learning objectives, including extensive exposure to all abortion methods, and most intend to provide abortions in practice.

OBJECTIVES:The Ryan Program collaborates with obstetrics and gynecology (OBGYN) residency programs in the United States (U.S.) to ensure that abortion and contraception care are incorporated into resident curriculum as required. We sought to understand the impact of the Dobbs v. Jackson decision on OBGYN residency abortion training programs from the perspective of Ryan directors and to understand barriers and facilitators to maintaining abortion training in OBGYN residency programs post-Dobbs. STUDY DESIGN:We conducted qualitative, semi-structured in-depth interviews with Ryan program directors at U.S. academic medical centers. We coded the data iteratively and analyzed the data thematically. RESULTS:From January to April 2023, we conducted 24 interviews, representing 21% (n = 23) of eligible U.S. Ryan directors. Participants were evenly distributed across four geographic regions of the U.S.; 50% (n = 12) of participants were from programs in abortion-restrictive settings. Two themes emerged: (1) Ryan directors experienced stressors related to the administration of Ryan programs post-Dobbs, including perceived difficulty satisfying requirements for abortion training in restrictive states, burnout, and increased financial needs to support training partnerships. (2) Directors face challenges in recruitment and clinical care post-Dobbs. CONCLUSIONS:Increased state restrictions on abortion place logistical and financial burdens on OBGYN abortion training programs. Dobbs impacted training experiences across the U.S. and made it more difficult for many OBGYN residencies to provide abortion training. IMPLICATIONS:The research findings will inform strategies for improving the delivery of abortion education post-Dobbs. We anticipate findings will enhance procedures to establish and maintain partnerships post-Dobbs and identify areas where philanthropy and advocacy can be effectively utilized.

BackgroundMany factors contribute to the decision to provide abortion in the United States. We aim to describe pre-residency experiences and decisions that contribute to choosing a career as an abortion provider in the United States. MethodsWe conducted 60-min semi-structured telephone interviews with 34 current abortion care providers about their career trajectories, decision-making and planning. Interviews were transcribed and coded by three members of the research team using thematic analysis. ResultsA majority of the participants considered (73.5%, n=25) and firmly committed (62.8%, n=22) to providing abortion care prior to entering residency. They described important professional experiences with women's health and reproductive rights, as well as personal experiences with abortion care, all of which inspired them to seek out abortion training during medical school and residency. Participants also described a dearth of mentors or role models until late in training, especially for family physicians. ConclusionsOur study suggests that the decision to provide abortion care is often made prior to residency training, before or during medical school, so additional support may be needed to promote exposure to abortion care during undergraduate medical education or even before. Further, there is a need for improved mentorship and role modelling during these periods, especially for family physicians. This may be especially critical after the overturn of Roe v Wade, as medical schools in restrictive states may not be able to provide abortions to patients, depriving students of role models who are abortion providers.

Hemorrhage after abortion is rare, occurring in fewer than 1% of abortions, but associated morbidity may be significant. Although medication abortion is associated with more bleeding than procedural abortion, overall bleeding for the two methods is minimal and not clinically different. Hemorrhage can be caused by atony, coagulopathy, and abnormal placentation, as well as by such procedure complications as perforation, cervical laceration, and retained tissue. Evidence for practices around postabortion hemorrhage is extremely limited. The Society of Family Planning recommends preoperative identification of individuals at high risk of hemorrhage as well as development of an organized approach to treatment. Specifically, individuals with a uterine scar and complete placenta previa seeking abortion at gestations after the first trimester should be evaluated for placenta accreta spectrum. For those at high risk of hemorrhage, referral to a higher-acuity center should be considered. We propose an algorithm for treating postabortion hemorrhage as follows: (1) assessment and examination, (2) uterine massage and medical therapy, (3) resuscitative measures with laboratory evaluation and possible reaspiration or balloon tamponade, and (4) interventions such as embolization and surgery. Evidence supports the use of oxytocin as prophylaxis for bleeding with dilation and evacuation; methylergonovine prophylaxis, however, is associated with more bleeding at the time of dilation and evacuation. Future research is needed on tranexamic acid as prophylaxis and treatment and misoprostol as prophylaxis. Structural inequities contribute to bleeding risk. Acknowledging how our policies hinder or remedy health inequities is essential when developing new guidelines and approaches to clinical services.

Background The 2022 Supreme Court ruling in Dobbs v Jackson Women’s Health Organization nullified the constitutional right to abortion, which led to effective bans in at least 14 US states and placed obstetrics and gynecology (OB/GYN) residents in dilemmas where they may have to withhold care, potentially causing moral distress—a health care workforce phenomenon less understood among resident physicians. Objective To identify and explore moral distress experienced by OB/GYN residents due to care restrictions post-Dobbs. Methods In 2023, we invited OB/GYN residents, identified by their program directors, training in states with restricted abortion access, to participate in one-on-one, semi-structured interviews via Zoom about their experiences caring for patients post-Dobbs. We used thematic analysis to analyze interview data. Results Twenty-one residents described their experiences of moral distress due to restrictions. We report on 3 themes in their accounts related to moral distress (and 4 subthemes): (1) challenges to their physician identity (inability to do the job, internalized distress, and reconsidering career choices); (2) participating in care that exacerbates inequities (and erodes patient trust); and (3) determination to advocate for and provide abortion care in the future. Conclusions OB/GYN residents grappled with moral distress and identified challenges from abortion restrictions.

The overturning of Roe v. Wade has resulted in substantial abortion access restrictions and clinic closures, highlighting the crucial role of hospital preparedness in delivering abortion and pregnancy loss care. This study explores the capacities of teaching hospitals in providing such care. Although most programs can manage health- and life-threatening situations, there are significant regional differences in service limitations and colleague support. For example, compared with faculty members in programs in protective states, those in restrictive states are more likely to report restrictions on first-trimester care (69.4% vs 10.9%, P<.001) and second-trimester care (75.0% vs 12.7%, P<.001). These findings underscore the vital role of teaching hospitals in ensuring abortion care access, emphasizing the need for enhanced integration of abortion services and training in hospital settings.