Dr. Maryam Guiahi was concerned when she applied for Loyola University Medical Center’s obstetrics and gynecology residency program. It was the mid-2000s, and family planning was becoming a more prominent component of OB/GYN care. Guiahi knew she wanted to learn how to provide abortions, but because Loyola was a Catholic-affiliated program, she wanted to make sure she could get this training during her residency.

Guiahi says during her residency interview, faculty downplayed the work she’d have to do to learn about abortions. All OB/GYN residencies are required to train students to competency in certain skills. Some have a specific minimum, like completing 20 dilation and curettages, but training for other skills can be more subjective. At Loyola, faculty said they knew an off-site provider she could train with, but when she started her residency there, she discovered that the trainer only performed abortions occasionally.

“To actually get over there…was very difficult when you were expected to be on other rotations,” Guiahi said.

Rates of residents receiving abortion training have increased over the past few decades, but programs with religious affiliations or in states with strict abortion regulations still sometimes fall short, a new study has found. And, those programs are facing larger barriers as policymakers place tighter restrictions on abortion providers.

The study, released in June and conducted by researchers at the University of California, San Francisco Bixby Center for Global Reproductive Health, found that 73 percent of OB/GYN residency directors reported experiencing institutional or government restrictions on abortion training. Hospital policy “was the most common restriction, followed by state law.”

Related research found that 64 percent of obstetrics and gynecology residency programs provide routine, scheduled abortion training. That’s up from about 51 percent in 2004. Outside of routine, scheduled training, 31 percent of residencies reported optional training, while 5 percent said it was unavailable.

A majority of residency directors believed their graduates are competent in various types of abortions: 71 percent said graduates are competent in first-trimester aspiration, 66 percent said the same for medication abortion and 67 percent for induction termination. However, only 22 percent of respondents believed graduates were competent in dilation and evacuation, the most common procedure for second-trimester abortions.

Dr. Jody Steinauer, an author on these studies and a UCSF professor of obstetrics and gynecology, said residents who know they want to be able to provide abortions will do whatever they have to to find the training they need, regardless of where their residency is.

“I’m not worried about those” residents, Steinauer said. “I’m worried about the residents who don’t actually think it’s a priority for them but will be caring for women who are pregnant, and…in both the first and second trimesters, they’ll need to have the skills to safely remove a pregnancy in a setting that’s urgent or an emergency.”

Medical students in their first few years of school may have lectures or opportunities to shadow abortion providers, but most physicians who want to learn how to provide abortions do so during their residency or later in family planning fellowships. Obstetrics and gynecology residency programs are required to provide access to abortion training if they want to be accredited with the Accreditation Council for Graduate Medical Education (ACGME). If a program has restrictions on family planning services or abortions because of their institution—say, a Catholic university—they must make arrangements for training elsewhere.

Loyola allowed Guiahi to take the lead in finding ways to learn about abortion care—most significantly when she wanted to do an elective rotation at Columbia University, where she later completed a family planning fellowship.

Loyola “knew they had to report to the ACGME…so I think when I wanted to do things, they were OK with it because they felt like it could check a box, but it was definitely with a lot of initiative on my own,” Guiahi said.

The Ryan Residency Training Program is one of the largest programs in the United States that works to expand abortion training. The program helps hospitals expand abortion services, facilitates collabortation with abortion clinics, and provides educational material for residents. Guiahi, now an associate professor at the University of Colorado School of Medicine, is part of that program, working with religiously affiliated residency programs to provide training.

Guiahi says OB/GYN residency directors and other program administrators at Catholic institutions are in a tough position because they not only have to figure out how to follow the ethical and religious directives for Catholic health-care service, but they’re also required to provide abortion training if they want to be accredited. Guiahi, who has co-authored multiple studies on the effects of Catholic health-care expansion, estimates that about 10 percent of OB/GYN residencies are Catholic-affiliated.

“People don’t want to lose their jobs, and so really it takes Catholic facilities being creative in terms of finding off-site clinic collaborations,” Guiahi said. “Sometimes when Catholic institutions are trying to get that arrangement, there’s a lot of like ‘which rule matters more’ kind of issue.”

Many residencies, especially if they can’t provide abortions themselves, teach abortion care by having students work with people experiencing pregnancy loss; caring for the two situations is often very similar, though Steinauer says learning about abortion care only through miscarriages and pregnancy loss means residents miss out on other aspects of that process, like pre-abortion counseling.

Residencies working with off-site clinics is another common way for programs to provide training. The Ohio State University Wexner Medical Centers’ OB/GYN residents learn about abortions through patients experiencing pregnancy loss and also as an elective rotation students can take at the local Planned Parenthood.

Assistant Residency Director Dr. Michael Cackovic said of their 44 residents, one chose to not take the Planned Parenthood elective because of religious or ideological beliefs.

“It should be a personal choice,” Cackovic said. “It should be a personal story for patients. It should be a personal choice for physicians. It shouldn’t be something that’s designated by politics or legislation.”

Guiahi says residency programs finding ways to navigate their circumstances tend to try to fly under the radar because they worry that attracting too much attention could get them in trouble. And, she says, finding ways to train residents is hardest in places with state restrictions. Connecting a Catholic program with a clinic in California, for example, is easy, but she says if you’re in the Midwest, that’s becoming a much bigger challenge because there aren’t as many clinics.

Ohio, for example, faces significant restrictions on abortions after the state passed its six-week ban, which bans abortions after electrical activity is detected in the fetal pole, typically at six weeks. Cackovic estimates the medical centers there have about six months of gray area before they would have to make any changes, partially dependent on lawsuits relating to the law.

Residencies in other states are facing more pressing situations. Missouri’s only abortion clinic, also a Planned Parenthood, has been battling to stay open. The clinic has been where St. Louis-area medical residents received abortion training. Nearby Hope Clinic in Granite City, Illinois, has trained residents from Ohio, Illinois, and elsewhere; it may continue such training with local residents if and when it’s needed.

“This is a real crisis because if [residencies] can’t provide abortion training, they are at risk of being cited,” Steinauer said.

To help programs find ways to connect students with abortion training, Guiahi has started a model with Saint Joseph Hospital in Denver that she’s working to replicate in other states. She provides on-site lectures about abortion education, and residents go to the University of Colorado to learn to provide contraception and abortion care.

“We know that 1 in 4 women seek abortion or are faced with decisions about abortion,” Guiahi said. “And so to become an expert in women’s health and leave out this chunk of care is kind of unacceptable.”

CORRECTION, July 6, 2019, 10:30 a.m.: This article has been updated to reflect where in the St. Louis area students may go for abortion training.