Brienna Milleson was a medical student working at the free clinic at Saint Louis University two years ago when a woman came in seeking a pregnancy test. It was positive, and the woman wasn’t sure whether she wanted to keep the pregnancy—a position many pregnant people are in each year. She wanted her doctor to explain her options.

Milleson didn’t know what to say to her, as her two years of medical school had never covered abortion, a procedure so common that 1 in 4 women have it by the time they’re 45. The more experienced student on duty didn’t know how to handle the situation either.

“I was just totally unprepared for this poor woman,” Milleson said. “I had no idea what to tell her.”

Milleson said her classes gave little detail about abortion. Abortion was mentioned in an ethics class, but the OB-GYN module did not go over common procedures. Saint Louis University is a Jesuit institution in Missouri, a state with a single abortion clinic also in St. Louis. It nearly became the first state with no abortion clinics until the health department relented in June and granted the remaining clinic a license, ending over a year of limbo.

This lack of training on abortion at medical schools is not unusual. In a recent study for Obstetrics & Gynecology, researchers spoke to directors at 169 OB-GYN programs about their institutions’ abortion policies. A majority, 57 percent, indicated their institution’s restrictions on abortion went beyond what state law requires.

In many cases, providers in the study reported that policies were unclear, as Milleson experienced, although it didn’t attempt to quantify how often that occurred. The study also found that a significant number of policies are unwritten: About one-third of teaching hospitals had tacit restrictions; another third of institutions had written policies.

These implied policies were a double-edged sword. “Vague or unwritten abortion policies, although difficult to navigate, gave health care providers some agency and flexibility over their practices,” the researchers wrote.

Lori Freedman, associate professor at University of California, San Francisco and one of the authors of the study, said the survey results reflect the stigmatization and politicization of abortion.

“When [abortion] became legal initially, hospitals and practices did do abortions. … Many doctors stopped providing, and the people filling that gap were the family planning clinics,” she said.

This politicization meant that, while more than half of abortions took place in hospitals right after Roe v. Wade made abortion a constitutional right, less than 14 percent did by 1989, according to Eyal Press’ 2006 book Absolute Convictions. According to the Guttmacher Institute, 95 percent of abortions took place in clinics in 2017. Although the lack of availability of hospital abortions can harm patients who need inpatient care, Freedman said that many times, having an abortion in a hospital isn’t necessary.

Inadequate training in abortion can also affect students’ training in miscarriage management, as many patients who miscarry need to be treated with the same procedures used in abortion, said Amy Caldwell, a clinical instructor of obstetrics and gynecology at the University of Chicago. The University of Chicago hospital limits abortions to 24 weeks as a matter of practice.

“Personally, I think it is incredibly important for medical students to have experience with abortion care as it is one of the most common procedures women in the U.S. experience (second perhaps to cesarean section),” Caldwell said. “Regardless of what type of medicine a medical student goes into, it is almost certain they will end up caring for patients with a history of abortion.”

While Catholic institutions have received a lot of attention over their strict restrictions on abortion, contraception, and gender-affirming care, they are not alone. Only 5 percent of the teaching hospitals surveyed were Catholic, meaning the vast majority of those with additional restrictions were non-Catholic.

The study didn’t ask about any religious affiliations other than with the Catholic church, but it did ask respondents what they believed to be the motivation for their hospital’s restrictions. About half said it was “personal beliefs or comfort.”

Stories like Milleson’s illustrate how restrictions can prevent medical professionals, including those who strongly believe in reproductive rights, from providing good care. Restrictions can also affect the readiness of more senior providers. Lee Hasselbacher, senior policy researcher at the University of Chicago’s Center for Interdisciplinary Inquiry and Innovation in Sexual and Reproductive Health, said she’s spoken to providers who want to provide abortions but don’t, even in situations when it’s allowed, because they don’t have experience in the procedure. Instead, they refer patients to a hospital or clinic that doesn’t have anti-choice restrictions.

Beyond the limits in training, Milleson noted some of her professors seem to not only object to abortion but also judge patients who’ve had one. A medical history for a patient seeking gynecological or obstetric care routinely includes their history of pregnancy and abortion. She worries how much of that attitude influences her classmates.

“Are they going to treat someone differently [if] they’ve had several abortions before?” she said. “It’s a legitimate concern of mine and several of my classmates.”

Milleson is currently undecided about her specialty, and doesn’t think the lack of instruction in abortion will necessarily limit her future options. Still, she worries that the anti-choice atmosphere will affect her OB-GYN rotation.

“A good or bad rotation can make or break your aspirations for a particular specialty,” she said.

Meanwhile, as a member of Medical Students for Choice, Milleson and other pro-choice medical students at Saint Louis University are working on getting official recognition for their chapter, which would let them do basic things like announce meetings via official mailing lists. The stigma against abortion means they have to take care to not ask the wrong professor to be their adviser.

The stigma affects faculty members as well. Hasselbacher spoke to a provider at a Protestant medical system who said the institution’s policies and attitudes interfered with the instruction they offer.

“When they give lectures on pregnancy loss and termination, they were very careful about how they talked about it and felt like they always had to be walking on eggshells a little bit so they weren’t going too far and [saying something] they might get reprimanded for,” she said.