Last week, two federal judges issued conflicting rulings on the abortion drug mifepristone, setting the stage for a clash that is likely to end up in the Supreme Court. First, a judge in Texas ruled that mifepristone would be banned nationwide in seven days. Then, a judge in Washington ordered the F.D.A. not to make any changes to the availability of the drug, which the agency approved for use more than two decades ago and which has an extensive safety record. While the legal process unfolds, abortion providers and health professionals are caught in limbo, exacerbating the challenges they have faced since last year’s Dobbs decision.
I recently spoke by phone with Jody Steinauer, the director of the Bixby Center for Global Reproductive Health at the University of California, San Francisco, to better understand how abortion care changed after Dobbs and what a ban on mifepristone would mean for women’s health care. Our conversation, edited for length and clarity, is below.
How might a ban on mifepristone affect reproductive health, and how could it impact the jobs and training of medical professionals?
This is just another attempt to limit access for people who need abortion care. There’s a strong evidence base for mifepristone—and for the safety of mifepristone followed by misoprostol. We do have the option of using misoprostol without the pretreatment of mifepristone, and so there are ways around [a ban]. But lots of systems are going to have to change protocols, which is going to lead to confusion for patients and confusion for providers.
Again, this will just put another obstacle in place for people who provide the care that patients need and for patients to get that care. In terms of medical students and residents learning to provide abortion care, it adds a bunch of confusing structures. We’ve spent so much time trying to make sure that every doctor graduates meeting the core requirements of knowledge of different methods of abortion. This is going to be yet another dimension that we’re going to have to teach them.
And what will misoprostol-only abortion mean in practice? How is it different?
It’s not going to be that much different than mifepristone and misoprostol. Generally, there are a bunch of protocols out there, and misoprostol is used safely by itself around the world by people who need abortion care. It’s generally a little bit of a higher dose: usually at least two doses of misoprostol instead of just one dose of misoprostol when paired. Clinics and hospitals will just have to make sure that they have enough misoprostol available, and they’ll have to change a lot of their patient-education materials, and all of those kinds of things.
You wrote in an op-ed last year that if health-care professionals are “not in a place that stocks mifepristone, which is used for medication abortion, they may not learn how to medically manage a miscarriage using the most effective medication.” Can you talk more about what you meant?
When we teach people to provide abortion care, there are also skills that we use for pregnancy-loss care. Medical management for miscarriage is the same as medical management for abortion, or what we call medication abortion. In states where we’re unable to provide that care for patients, we’re also unable to teach residents how to do it. We’ll have to go back to a misoprostol-only management of miscarriage, which, for the most part, is very effective, but not as effective as mifepristone plus misoprostol. And that’s true for abortion, too. With many doses of misoprostol you can get up close to the efficacy rate with mifepristone, but, again, it’s just making us go backward to use medications that aren’t quite as effective. We’re being forced to provide non-evidence-based care.
Is the training of young medical professionals dictated by state law, or are there national standards? In other words, can you train doctors in certain procedures even if the particular states where they’re practicing outlaw those procedures?
You can only be trained in an aspect of clinical care that you can actually provide. You can learn about aspects of medicine and clinical care from didactic training, small-group learning, and simulation, even for things like counselling and procedures. But, in terms of clinical training, the problem we’re seeing in the states that have banned abortion care is that ob-gyn residents are only rarely able to provide direct care for a patient needing an abortion, because it has to be within the state’s exceptions.
Ob-gyns are required by the Accreditation Council for Graduate Medical Education to be able to do an abortion to save someone’s life. Really, every ob-gyn has to be trained in abortion care. Of course, we take care of people with miscarriages all the time. We have to be able to provide miscarriage care, which we now more frequently call early-pregnancy-loss care. The accreditation council requires that all ob-gyn programs have routine, integrated, clinical abortion training. And there are more than eleven hundred ob-gyn residents currently training in the states with the most restrictive abortion bans. This is a national crisis in obstetrics and gynecology. We have to ask, “How can we make sure that those residents, in addition to every other resident, are trained to competence?”
If we can’t solve that problem, we’re all very worried that, for however many years these laws are in place, there will be a group of residents who are going to finish and not be able to be as competent in those skills as they could have been. They might end up practicing anywhere, not just necessarily in that state. Are they going to be able to provide the most evidence-based, patient-centered care for people who need an abortion? Or even if they personally don’t want to do abortions, do they have the skills they need to save someone’s life in an emergency? That’s kind of where we are.
Medication abortion is very simple to provide, but it does require learning to counsel patients about what to expect and also knowing, based on history, what constitutes a completed medication abortion. That’s just another piece they’ll miss out on if they can’t be providing that care directly in the states with bans.
How have you been trying to deal with training people in states with these restrictions?
Well, we can support training hospitals and institutions to provide the maximal care they can within the state law. That’s really important so that people who have pregnancy complications or significant medical disease aren’t having to leave the state for their care. We’re trying to ramp up didactic education and simulation training. Didactic training refers to lectures, small-group teaching, online teaching, online modules. Just to make sure that they are really learning everything they can outside of direct clinical care. What are the medications used for medication abortion? What are the steps of the procedures? How to minimize risk. I mean, abortion is very safe, but it is a procedure.
Simulation takes it one step further. You could have simulations around communication skills, such as the counselling that’s necessary before a medication abortion. You can learn a lot of those skills through role-play or some kind of interactive online module. Also, understanding the experience of a medication abortion so that you know when it’s likely to have been successful and complete—and under what circumstances you have to worry that someone is bleeding a little too much. A lot of those pieces can be taught through simulation.
We do have some basic simulation workshops for how to do a uterine-aspiration abortion. They don’t teach you the skills outside of seeing a patient. You really need to provide direct clinical care, but you can learn the basics: how to hold the instruments, how to do the suction procedure, how to do dilation. You can at least learn the very basics so that, when you do have direct clinical experience, you come in with better skills, and there’s some evidence that you don’t need to see as many patients to get up to a level of competence. We’re putting all those things in place.
Then there’s travel. A lot of these programs are trying to partner with institutions in nonrestricted states so that their residents can actually travel. Residents travel to different programs for specific rotations. It’s just that this is a puzzle because it’s so many residents. How do we make sure that all of the institutions in these states can actually send their residents to another state? The Ryan Program supports efforts to integrate the required abortion training. We have at least twelve programs that are in restricted or banned states right now, and we’ve matched them with programs in permitted states that are going to host them. The problem with that is it ends up being just many months of logistics—setting up training agreements and all those things. But they’re actually starting to travel, which is great.
A couple times in your answers you’ve mentioned miscarriages. Can you talk about how the training for abortions and miscarriages goes hand in hand, and why being trained for both is so important?
Let’s say someone is eight weeks pregnant, has a miscarriage, and you’re providing some counselling. You’re giving them options about whether they want to just expectantly manage the miscarriage and see what happens—or they might want medical management of their miscarriage, for which the most effective regimen is mifepristone plus misoprostol. Do they want a procedural management of their miscarriage? In fact, that’s basically doing an abortion.
For places that don’t provide abortion care, often the only real pathway to helping a miscarrying patient who wants a procedure is in an operating room under either deep sedation or general anesthesia. What we find is that a lot of people who have miscarriages and who want procedural management actually prefer it in an outpatient setting—not to be heavily sedated, to actually have moderate sedation or lighter sedation, or even just a paracervical block, which is anesthesia in the cervix. If you are in a system where you really can offer all these regimens, including outpatient management, that’s all very similar to what abortion looks like. In other words, that basically can be very overlapping.
The thing that we’ve found is that, if you’re in a program with no abortion training and only caring for the few patients that are having a miscarriage, you just don’t learn the skills that well. Often, you don’t learn outpatient management, with the handheld, manual uterine-aspiration technique and all these different procedures. Residents in programs with routine integrated abortion training end up graduating feeling much more prepared to independently provide miscarriage management.
Look at our studies, and look at programs with routine training, and compare them with optional training—which is generally a program where it’s not really in your resident schedule, but you have the option of working in an abortion-care setting. Then there are programs that really identify as having no abortion training. You go from the majority feeling competent and ready to provide miscarriage care, and then it goes down for optional and then down even further for the no-training group. There are some people who are in programs with no abortion training who feel competent to provide miscarriage care, but it’s not the majority.
Obviously, we had abortion restrictions pre-Dobbs. I just wanted some sense of how things have changed post-Dobbs.
Thank you for asking that, because I think some people have this idea that everything was fine, and all of a sudden there were restrictions. I’m very focussed on ob-gyn training and ob-gyn programs that have for a long time been struggling with integrating abortion training and have jumped through lots of hoops and worked with the abortion clinics in their communities to make sure their residents are trained. It was already hard, and now the difference is that it’s really, really hard. Their clinics are not providing care. The hospitals barely provide any care. People are having to travel.
Added to just the not being able to get trained, there’s a lot of moral distress happening with these residents, and, of course, attendants and nurses and others, where they have to see people who just need care, and they know the patients will either have to travel or some of them just can’t afford to travel and are forced to continue their pregnancies. They’re having to provide very suboptimal care in patients who need, for example, ectopic-pregnancy treatment or miscarriage management. Sometimes they have to wait for days before they can prove definitively to the hospital lawyers that this patient deserves the treatment that they need.
There are just some serious challenges causing these doctors and these doctors-in-training to feel like they are not doing the right thing for patients. What I’m hearing from residents and faculty is that it’s causing almost an identity crisis. Like, “I am a good doctor, I abide by the values of our profession and the ethical values of our profession, and I cannot do the right thing.” ♦
