Routine abortion training matters for obstetrics and gynecology residents
Open Journal of Obstetrics and Gynecology, 2013, 3, 727-731 OJOG
http://dx.doi.org/10.4236/ojog.2013.310134 Published Online December 2013 (http://www.scirp.org/journal/ojog/)
Routine abortion training matters for obstetrics and
gynecology residents
Sahnah Lim1, Corey Westover2, Rini B. Ratan2, Maryam Guiahi3
1John Hopkins School of Public Health, Baltimore, USA
2Department of Obstetrics and Gynecology, Columbia University, New York, USA
3Department of Obstetrics and Gynecology, University of Colorado Anshutz, Aurora, USA
Email: slim28@jhu.edu
Received 13 November 2013; revised 2 December 2013; accepted 10 December 2013
Copyright © 2013 Sahnah Lim et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In accor-
dance of the Creative Commons Attribution License all Copyrights © 2013 are reserved for SCIRP and the owner of the intellectual
property Sahnah Lim et al. All Copyright © 2013 are guarded by law and by SCIRP as a guardian
ABSTRACT
Background: We set out to compare resident pers-
pective regarding self-rated ability to perform abor-
tion procedures, abortion attitudes and satisfaction
with training at programs with routine and optional
abortion training. Methods: We distributed surveys
and conducted 1-h focus groups for 62 residents at six
New York City OB/GYN programs; three offer rou-
tine abortion training. We compared resident survey
responses at programs with routine versus optional
training regarding self-rated ability to perform abor-
tion procedures, abortion attitudes and satisfaction
with training. We reviewed focus group transcripts to
understand differences related to satisfaction with
abortion training. Results: Residents at routine pro-
grams reported higher proportions of self-rated abi-
lity to perform abortion procedures (all surveyed pro-
cedures p 0.05) and were more likely to fully par-
ticipate in abortion services than residents at optional
programs (42/45 vs. 12/17, p = 0.03). Residents at rou-
tine programs were more likely to be “very satisfied”
with training (44/45 vs. 12/17, p < 0.001) based on
three aspects of training: patient care management,
self-rated ability to perform abortion procedures and
rotation characteristics. Conclusion: Residents who
received routine abortion training have higher rates
of self-reported procedural competency and are more
likely to be satisfied with training than residents who
were offered optional training.
Keywords: Family Planning; Abortion Training;
Obstetrics and Gynecology
1. INTRODUCTION
An integral part of obstetrics and gynecology (OB/GYN)
training is abortion instruction [1,2]. As a result of po-
litical and religious controversies, however, many pro-
grams do not routinely train residents in abortion [3,4].
In an effort to improve OB/GYN resident training, the
Accreditation Council for Graduate Medical Education
(ACGME) set forth a requirement in 1996 stating that
“access to experience with induced abortion must be part
of residency education”[5]. Since the 1996 ACGME re-
quirement, there have been two other notable efforts to
improve and formalize abortion training. Starting in 1999,
the privately funded Ryan residency program has as-
sisted 67 OB/GYN programs in the US, Puerto Rico, and
Canada to integrate or formalize abortion training either
in the hospital setting or by collaboration with a free-
standing clinic (personal communication with Ryan pro-
gram staff on 3/13/2013)[6]. In response to advocacy
efforts of the National Abortion Reproductive Rights
Action League (NARAL) chapter of New York, Mayor
Michael Bloomberg introduced an abortion training ini-
tiative for OB/GYN residents at New York City (NYC)
public hospitals in 2002 [7].
Despite these efforts, approximately half of US OB/
GYN program directors in 2004 reported that routine
abortion training was not offered [3]. When routine abor-
tion training occurs all residents are scheduled to par-
ticipate in abortion services and may choose to opt out of
certain aspects of the rotation based on personal object-
tions. In contrast, when optional training is offered,
residents must request or individually arrange participa-
tion in abortion services either on-site or at an outside
institution or clinic. A national survey of recent 2007
OB/GYN graduates demonstrated that less than half of
the respondents reported residency training in the full
range of common first-trimester procedures; residents
who trained at programs with optional training were less
OPEN ACCESS
S. Lim et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 727-731
728
likely to be trained [8]. Discrepancies in training limit
the number of new providers and contribute to the short-
age of providers in many areas of the US [9].
We separately described the Bloomberg residency
training initiative and enablers and barriers to abortion
training within this context [7,10]. Of the six NYC train-
ing programs that we surveyed in our primary analysis,
three continued to offer optional training. As an addi-
tional analysis, we compared residents’ self-rated ability
to perform abortion procedures, abortion attitudes and
satisfaction with abortion training according to whether
their training was routine or optional. To our knowledge,
no previous studies have used a mixed-methodology ap-
proach to measure OB/GYN resident attitudes about
abortion provision and training at routine versus optional
programs.
2. METHODS
The objective of this study was to determine whether
residents at routine training programs have differing rates
of self-reported procedural competency, different abor-
tion attitudes and different rates of satisfaction with
abortion training when compared to residents who were
offered optional training. We used a mixed-methods ap-
proach; we distributed surveys and used focus group data
to understand differences. The focus group data was part
of a larger qualitative study [10]. By using a mixed-
method approach we were able to combine the strength
of both qualitative and quantitative research methods: the
ability to describe resident perspective in greater detail
combined with statistical reliability and the opportunity
for data triangulation [11].
We obtained Institutional Review Board approval from
Columbia University Medical Center and from seven
NYC public hospital facility research review committees.
An eighth research review committee did not reply to our
request and was therefore omitted from recruitment. One
residency director replied but declined resident participa-
tion, leaving six programs eligible for participation.
We contacted the residency director or an attending
physician at each eligible program to organize enroll-
ment of their residents into this study. We collected pro-
gram characteristics from these contacts and arranged
1-h meetings during residents’ protected educational time.
At each program, all available residents participated in a
30-60 min focus group led by the primary investigator
(MG) and an assistant; no residents were excluded. Un-
available residents included those who were on night
rotations or on vacation. If we received permission, we
tape-recorded the interview. During our introduction, we
obtained oral consent, and explained to the residents that
any institution or employee name would be de-identified
during transcription. We used detailed, semi-structured
interview guides to discuss resident training experience.
After the interview, we distributed paper surveys. The
surveys assessed personal characteristics and residency
ranking considerations, their self-assessed ability to per-
form abortion procedures, abortion attitudes and assessed
satisfaction with training. For ranking considerations we
asked residents if they desired abortion training when
applying and if abortion training was favorably/unfa-
vorably considered when ranking. We asked residents to
rate their ability according to whether they “can perform
on own” “can perform with help” or “cannot perform”
the following abortion procedures: medication abortion,
suction curettage [manual vacuum aspiration (MVA),
electric vacuum aspiration (EVA)] and dilation and
evacuation (D&E). For attitudes, we asked residents,
“How important do you think it is that OB/GYN resi-
dents receive abortion training?” using a 4-point scale (1
= very unimportant, 2 = somewhat unimportant, 3 =
somewhat important, 4 = very important) and if they
opted out of abortion services during residency. Regard-
ing future practice intentions, we asked residents whether
they “plan to” “may” or “will not” perform a list of pro-
cedures. Finally, we assessed satisfaction with train- ing
by asking “How satisfied are you with the abortion
training at your residency program?” and using a 4-point
scale to respond (1 = very unsatisfied, 2 = unsatisfied, 3
= satisfied. 4 = very satisfied).
We analyzed survey data using SPSS (version 18.0;
SPSS Chicago, IL, USA). We compared residents at rou-
tine versus optional programs with respect to personal
characteristics, self-assessed procedural competencies,
attitudes and training satisfaction using Fisher’s exact
test and Pearson’s chi-square. For all comparisons of
self-assessed competencies based on type of training,
postgraduate year was included in our regression models.
For abortion attitudes and satisfaction with training we
included desire for abortion training in our models.
Although this manuscript focused on data from the
survey, we integrated relevant focus group data in order
to elucidate the substantive reasons for resident satisfac-
tion with training. The details of our qualitative approach
have been described elsewhere [10]. In brief, we re-
viewed focus group transcripts and engaged in an itera-
tive and comparative form of analysis, using grounded
theory to allow themes to emerge as it related to differ-
ences found in our survey.
3. RESULTS
Six programs in NYC participated in our study; three
provided routine training and three offered optional
training. Sixty-two of the 150 residents (44%) who train
at these programs participated in our focus group and
completed surveys. Participation rates in each program
ranged from 25% to 58%. The remaining residents were
unavailable due to scheduling constraints. We tape-re-
Copyright © 2013 SciRes. OPEN ACCESS
S. Lim et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 727-731 729
corded five of the six focus groups and took handwritten
notes at one program that declined audio recording.
Program and resident characteristics are described in
Tables 1 and 2, respectively. Programs with routine
training were larger, had a Ryan program, and offered
training for a full range of abortion procedures. Although
most Ryan programs have formalized routine abortion
training curriculums, one Ryan program surveyed in our
study continued to offer optional on-site training. None
of the three optional training programs provided medical
abortion training. Most of the residents who participated
in the study were female, less than 30 years old, married
or with a long-term partner, and attended a religious ac-
tivity less than once a month. Residents at programs with
routine training were younger (28 versus 31, mean age),
more likely to be Caucasian or Asian, and less likely to
attend monthly religious services. They were also more
likely to have desired abortion training compared to res-
idents at programs with optional training (p = 0.01). Only
one resident in our cohort reported that he/she ranked
programs with abortion training lower; this resident ma-
tched into a program with routine training.
Table 3 compares differences in self-rated ability to
perform abortion procedures based on whether residents
received routine or optional training. When we controlled
for level of training (i.e. post-graduate level 1, 2, 3, and
4), residents at programs with routine training were more
likely to report that they can independently perform all of
the listed abortion procedures (Table 3), as compared to
residents at optional programs.
Resident abortion attitudes and satisfaction with abor-
tion training are described in Table 4. Over 90% of par-
ticipating residents, regardless of type of training, rated
abortion training as very important. Residents at pro-
grams with routine training, however, were less likely to
opt out of abortion training and more likely to plan to
perform various abortion procedures after residency
completion. We examined the impact of desire for abor-
tion training and found that desire for abortion training
prior to residency was an important contributor to plans
to perform EVA (p = 0.02) and D&E (p < 0.001) after
graduation; type of training did not remain significant in
our adjusted model.
Residents at routine programs were also more likely to
be satisfied with their abortion training, even after ac-
counting for desire for abortion training (p < 0.001).
Given this significant difference, we reviewed focus
group transcripts from our larger mixed-methods study to
understand. This review revealed that residents at pro-
grams with routine training reported satisfaction based
on three aspects of their training experience: patient care
management, procedural competency and rotation char-
acteristics. First, residents at routine programs reported
that exposure to a substantial number of patients desiring
Table 1. Characteristics at routine versus optional training pro-
grams.
Routine
programs (n = 3)
Optional
programs (n = 3)
Mean number of
residents/year (range) 8 (7 - 11) 3 (3 - 4)
Affiliation with medical school
Secular medical school
Faith-based medical school
100%
100%
0%
33%
0%
100%
Collaboration with Ryan program100% 33%
Abortion experience
Medical abortion training 100% 0%
Manual vacuum aspiration training100% 33%
Electric vacuum aspiration
training 100% 100%
Dilation and evacuation
for fetal/maternal indications 100% 100%
Dilation and evacuation
for any indication* 100% 33%
*Varying gestational age limit.
abortion services improved their ability to provide care,
ultimately leading to higher satisfaction with their train-
ing.
Second, residents at routine training programs ex-
plained that participating in the family planning rotation
improved their procedural competency specifically re-
lated to first trimester ultrasound, outpatient procedures
such as MVAs, and D&E. Residents at programs with
optional training, on the other hand, reported low expo-
sure to all aspects of abortion care and some reported
that this hindered their ability to appropriately provide
options counseling when patients needed referrals. They
also explained that lack of procedural training affected
their ability to provide abortion care after graduation.
Third, residents at programs with routine training
described several rotation characteristics that contributed
to their high level of satisfaction. In these settings, only
one resident was assigned to the rotation at a time.
Residents enjoyed this because they directly reviewed
patient care plans with the attending physician(s) and
participated in all aspects of patient care management. At
these programs, the residents who opted out appreciated
how their modified rotations were tailored by the attend-
ing(s) to meet their learning goals. They also described
that the curriculum was structured and included assigned
readings, educational lectures and related journal clubs.
Another rotation characteristic that residents cited was
rotating within a dedicated women’s options clinic where
residents appreciated patient-centered care and reported
receiving administrative and psychosocial support from
the support staff.
4. CONCLUSIONS
The value of abortion training and its impact on future
Copyright © 2013 SciRes. OPEN ACCESS
S. Lim et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 727-731
730
Table 2. Respondent characteristics at routine versus optional
training programs.
Respondent characteristics
Routine
programs
N = 45
Optional
programs
N = 17
P
Gender 0.33
Male 3 (6.7) 3 (17.6)
Female 42 (93.3) 14 (82.4)
Age, years 0.01
< 30 34 (75.6) 5 (29.4)
30 11 (24.4) 12 (70.6)
Postgraduate year level 0.68
1 17 (37.8) 4 (23.5)
2 9 (20.0) 5 (29.4)
3 9 (20.0) 3 (17.6)
4 10 (22.2) 5 (29.4)
Race 0.02
Caucasian 26 (57.8) 2 (11.8)
Hispanic 5 (11.1) 3 (17.6)
Black/African American 6 (13.3) 4 (23.5)
Asian 8 (17.8) 8 (47.1)
Religion 0.08
Catholic 19 (42.2) 5 (29.4)
Other Christian denomination 7 (15.6) 3 (17.6)
Other religions 11 (24.4) 9 (52.9)
Unaffiliated 8 (17.8) 0 (0)
Frequency of religious activity . 0.02
Once per month 7 (15.6) 8 (47.1)
< Once a month 38 (84.4) 9 (52.9)
Marital status 1.00
Never married/divorced 17 (37.8) 7 (41.2)
Married/long-term 28 (62.2) 10 (58.8)
Desired abortion training at time
of residency application
Definitely/Probably Yes
Definitely/ Probably No
30 (66.7)
15 (33.3)
5 (29.4)
12 (70.6)
0.01
Programs with more abortion
training were ranked:
Higher (preferred training)
Lower (did not prefer training)
Not applicable
32 (71.1)
1 (2.2)
12 (26.7)
5 (29.4)
0 (0)
12 (70.6)
<0.01
service provision has been highlighted by previous in-
vestigators using single and multi-site study descriptions
at both OB/GYN and family medicine training programs
[12-15]. Our study is the first to compare OB/GYN resi-
dent experience and perspectives at both routine and op-
tional abortion training programs using mixed-method-
ology.
In our study, we found that residents who desired
abortion training were more likely to rank programs with
routine training higher and subsequently match. This
desire impacted their plans for provision of abortion ser-
Table 3. Self-reported ability to perform abortion procedures at
routine versus optional training programs.
Self-reported ability to
perform abortion methods
(Can “perform on own”)
Routine
N = 45
Optional
N = 17
Unadjusted
P
Adjusted
P*
Medication abortion 24 (53.5) 4 (23.5) 0.05 0.03
Manual vacuum aspiration33 (73.3) 6 (35.3) <0.01 <0.01
Electric vacuum aspiration36 (80.0) 10 (58.8) 0.11 0.05
Dilation and evacuation 17 (37.8) 2 (11.8) 0.07 0.04
Data shown for routine and optional programs are n (%). P values are Fisher’s
exact test. *Adjusted for level of training.
Table 4. Residents’ abortion attitudes and satisfaction with
abortion training at routine versus optional programs.
Abortion attitude
Routine
N = 45
(73%)
Optional
N = 17
(27%)
Unadjusted
P
Adjusted
P
Abortion training is
very important 43 (95.6) 14 (82.4) 0.12 0.28
Opted-out of
abortion training 3 (6.7) 5 (29.4) 0.03 0.05
Plans to perform manual
vacuum aspiration* 38 (84.4) 1 (58.8) 0.04 0.16
Plans to perform electric
vacuum aspiration* 38 (84.4) 10 (58.8) 0.04 0.23
Plans to perform dilation
and evacuation* 34 (75.6) 7 (41.2) 0.02 0.19
Plans to perform
medication abortion* 37 (82.2) 11 (64.7) 0.18 0.27
Very satisfied with
abortion training 44 (97.5) 5 (29.4) <0.001<0.001
Data for routine and optional programs are n (%). P values are Fisher’s exact
test. Adjusted P values account for desire for abortion training when ranking.
*“Will perform” or “may perform” vs. “will not perform”.
vices after graduation. Although a self-selection process
seemed to exist, all of the residents in our study valued
abortion training and none of the residents at optional
programs reported that they did not want training. Con-
sistent with Jackson’s national survey [8], residents at rou-
tine programs in our study were more likely to be expo-
sed to a comprehensive abortion curriculum. It appears
that comprehensive training favorably impacts residents’
procedural confidence level.
Our study documents increasing evidence of the im-
portance of inclusion of routine structured abortion
training with an opt-out provision at all programs. Ac-
cording to the ACGME, all OB/GYN residents are ex-
pected to have adequate training in induced abortion.
Even if residents do not plan to perform abortions, they
must be exposed to training in order to better understand
and care for women who may seek information and ser-
vices from them. Exposure to induced abortion training
improves resident competency and likelihood to perform
abortion care [9,16,17] and other reproductive health
Copyright © 2013 SciRes. OPEN ACCESS
S. Lim et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 727-731
Copyright © 2013 SciRes.
731
care services, such as management of early pregnancy
failures, after graduation [17]. Offering optional training
is not only insufficient but also problematic; residents
should not be held responsible for arranging off-site op-
portunities.
OPEN ACCESS
There are limitations to our study. We used conven-
ience sampling to recruit residents, which led to income-
plete participation. Participation, however, was not based
on interest in the study; focus groups took place during
residents’ protected academic time so all available resi-
dents participated including residents who opted out of
abortion training. We also had small overall participation
numbers which precluded us from measuring the effects
of other potential confounders. Finally, although we did
not survey the number of procedures performed by resi-
dents or use a validated measure to assess competency,
Mandel et al. [18] have demonstrated that OB/GYN resi-
dents self-assess well compared to faculty observers.
Residents at routine programs in our study expressed
more favorable views about their abortion training when
a dedicated family planning rotation was offered, which
has been previously described [12,15]. In our study, struc-
tured abortion training occurred with the assistance of
the Ryan program. The Ryan program helps provide cur-
ricular support and assists with training opportunities
either on-site or by collaboration with a freestanding cli-
nic. We encourage program directors looking to imple-
ment or improve induced abortion training to collaborate
with this program. By increasing the number of programs
that provide routine instruction, we may potentially in-
crease the number of abortion providers throughout the
US. Such improvements may ultimately ensure that wo-
men throughout the country have access to well-trained,
competent providers to meet their reproductive health
care needs.
REFERENCES
[1] The Council on Resident Education in Obstetrics and Gy-
necology: Educational Objectives: Core Curriculum in
Obstetrics and Gynecology, Ed., CREOG. 2009, Profes-
sional Publishing Group, Ltd., New York.
[2] (2009) ACOG Committee Opinion No. 424: Abortion ac-
cess and training. Obstetrics & Gynecology, 113, 247-
250.
[3] Eastwood, K.L., Kacmar, J.E., Steinauer, J., Weitzen, S.
and Boardman, L.A. (2006) Abortion training in United
States obstetrics and gynecology residency programs. Ob-
stetrics & Gynecology, 108, 303-308.
http://dx.doi.org/10.1097/01.AOG.0000224705.79818.c9
[4] Almeling, R., Tews, L.and Dudley, S. (2000) Abortion
training in US obstetrics and gynecology residency pro-
grams, 1998. Family Planning Perspectives, 32, 268-271,
320. http://dx.doi.org/10.2307/2648194
[5] ACGME (2011) Obstetrics/Gynecology Program Re-
quirements.
http://www.acgme.org/acgmeweb/Portals/0/PFAssets/Pro
gramRsources/220_OBGYN_Abortion_Training_Clarific
ation.pdf
[6] Ryan Program. (2011) The Kenneth J. Ryan Residency
Training Program in Abortion and Family Planning.
http://www.ryanprogram.org
[7] Guiahi, M., Westover, C., Lim, S. and Westhoff, C.L.
(2012) The New York City mayoral abortion training ini-
tiative at public hospitals. Contraception, 86, 577-582.
http://dx.doi.org/10.1016/j.contraception.2012.02.010
[8] Jackson, C.B. and Foster, A.M. (2012) Ob/Gyn training
in abortion care: Results from a national survey. Contra-
ception, 86, 407-412.
http://dx.doi.org/10.1016/j.contraception.2012.02.007
[9] Shanahan, M.A., Metheny, W.P., Star, J. and Peipert, J.F.
(1999) Induced abortion. Physician training and practice
patterns. The Journal of Reproductive Medicine, 44 428-
432.
[10] Guiahi, M., Westover, C., Lim, S. and Westhoff, C.L.
(2011) Enablers and barriers to abortion training in New
York City. Contraception, 84, 308-309.
http://dx.doi.org/10.1016/j.contraception.2011.05.027
[11] Creswell, J.W., Fetters, M.D. and Ivankova, N.V. (2004)
Designing a mixed methods study in primary care. The
Annals of Family Medicine, 2, 7-12.
http://dx.doi.org/10.1370/afm.104
[12] Steinauer, J., Drey, E.A., Lewis, R., Landy, U. and Lear-
man, L.A. (2005) Obstetrics and gynecology resident sat-
isfaction with an integrated, comprehensive abortion ro-
tation. Obstetrics & Gynecology, 105, 1335-1340.
http://dx.doi.org/10.1097/01.AOG.0000158859.35943.be
[13] Steinauer, J.E., Landy, U., Jackson, R.A. and Darney,
P.D. (2003) The effect of training on the provision of
elective abortion: A survey of five residency programs.
American Journal of Obstetrics & Gynecology, 188, 1161-
1163. http://dx.doi.org/10.1067/mob.2003.309
[14] Paul, M., Nobel, K., Goodman, S., Lossy, P., Moschella,
J.E. and Hammer, H. (2007) Abortion training in three
family medicine programs: Resident and patient out-
comes. Family Medicine Journal, 39, 184-189.
[15] MacIsaac, L. and Vickery, Z. (2012) Routine training is
not enough: structured training in family planning and
abortion improves residents’ competency scores and in-
tentions to provide abortion after graduation more than ad
hoc training. Contraception, 85, 294-298.
http://dx.doi.org/10.1016/j.contraception.2011.06.014
[16] Steinauer, J., Landy, U., Fillipone, H., Laube, D., Darney,
P.D. and Jackson, R.A. (2008) Predictors of abortion pro-
vision among practicing obstetrician-gynecologists: A na-
tional survey. American Journal of Obstetrics & Gyne-
cology, 198, 39 E1-E6.
[17] Dalton, V.K., Harris, L.H., Bell, J.D., et al. (2011) Treat-
ment of early pregnancy failure: Does induced abortion
training affect later practices? American Journal of Ob-
stetrics & Gynecology, 204, E1-E6.
[18] Mandel, L.S., Goff, B.A. and Lentz, G.M. (2005) Self-as-
sessment of resident surgical skills: Is it feasible? Ame-
rican Journal of Obstetrics & Gynecology, 193, 1817-
1822.