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Texas clinic closures limit comprehensiveness of medical residents' abortion care education

Clinic closures and abortion stigma might impede medical residents' ability to learn how to provide abortion care and to garner experience working with women seeking abortion care in Texas, Houston Public Media reports (Feibel, Houston Public Media, 6/16).

Abortion restrictions and clinic closures

Following the implementation of an omnibus antiabortion-rights law (HB 2), the number of abortion clinics in Texas has dropped from 41 to 19 over the last three years. Among other things, HB 2 mandates that abortion clinics meet the same building standards as ambulatory surgical centers and requires abortion providers to have admitting privileges at local hospitals. The provisions were challenged in federal court, and the Supreme Court is expected to issue a ruling on the case later this month.

Some OB-GYN residency program directors have cited challenges arranging for abortion care training because the clinic nearest to them has closed (Women's Health Policy Report, 6/15). According to Houston Public Media, some of the 18 accredited medical residencies in Texas are in areas without outpatient abortion clinics.

Citing clinic closures in Lubbock, Odessa and other cities in the state, a physician at a Texas clinic that provides abortion care training noted, "There are places in Texas where there are [OB-GYN] residents who can't get anywhere to be trained." The doctor, who requested to remain anonymous, added, "We've been approached by many different residency programs about the ability to train their residents ... Unfortunately, we just don't have the capability to train everyone."

Separately, Lori Freedman, a medical sociologist at the University of California-San Francisco, said, "How can you have abortion provision if you don't have trained doctors? Especially the ones likely to stay in your state." She noted that abortion care training is more common in the United States tends to be limited to "relatively liberal, urban areas."

Implications for students

While the Accreditation Council for Graduate Medical Education requires OB-GYN programs to provide abortion care training, programs can meet the requirement by offering alternative instruction, such as teaching students how to provide abortion care in a hospital situation, as when the woman's life in in danger, or teaching students about abortion care via lectures and simulations.

According to Houston Public Media, many experts dispute that such training is comparable to the training residents need and would receive at an outpatient clinic, with patients. The medical procedure for a first-trimester surgical abortion is the same as the procedure to treat a miscarriage, as well as to take a uterine biopsy or treat excessive bleeding. However, while the underlying technique is the same, the process of terminating a pregnancy requires training unique to that procedure. Providers also have to learn how to provide medication abortion, as well as how to address various antiabortion-rights requirements in the state, such as reading state-mandated information about abortion to a patient and having a patient hear the fetal heartbeat. In order to address these requirements, many experts contend that residents need practice at outpatient clinics, where most abortion care is provided, Houston Public Media reports.

For example, Bernard Rosenfeld, an OB-GYN who provides abortion care in Texas, said residents will not be fully prepared to provide abortion care until they have provided it several dozen times.

Rosenfeld explained how the process of providing a first-trimester surgical abortion would differ between a hospital, where a woman likely would have general anesthetic, compared with an outpatient facility, where a woman receives local anesthetic or no anesthetic during the procedure. The outpatient treatment is safer for the patient, but it requires greater expertise from the doctor to minimize patient discomfort during the procedure, according to Rosenfeld and other experts. Rosenfeld noted, "[A]ll that is learned."

In addition, working at outpatient clinics with women seeking abortion care helps residents develop bedside skills, including compassion, empathy and political awareness, according to Houston Public Media. A medical resident who asked to be identified as Jane said, "Every woman has a different story and a different reason why she chooses to end her pregnancy."

Jody Steinauer, an OB-GYN professor and researcher at the Bixby Center for Global Reproductive Health at the University of California-San Francisco, has conducted research finding that training with women seeking abortion care can encourage young physicians to provide the service throughout their careers. Steinauer said, "When [residents] spend time in a setting that provides abortion care, they have real epiphanies ... They become more aware of their biases. They're surprised that more than half of women having abortion are already mothers, for example."

Separately, Jane reflected on how her abortion care training "makes it even more obvious how important it is for women to have access to abortions." She said, "If I think a woman needs access and I have the skills to provide access, I should" (Houston Public Media, 6/16).