Update, December 20: This article was updated with additional background reporting.

Hanna Amanuel recalls observing a second-trimester abortion at a hospital, in part because her OB-GYN clerkship allowed her to shadow a doctor familiar with abortion training. Outside of medical school classes and pro-abortion groups such as Medical Students for Choice, where Amanuel is the incoming president, the opportunities to receive comprehensive abortion training remain limited.

“Among our board members and student chapter organizers, a lot of people are a lot less interested or not interested at all in going to residency programs in states that are likely to or have banned abortion,” said Amanuel, a medical and doctoral student at Harvard University who’s seeking abortion training.

Nearly 15 years ago, half of the U.S. obstetrics and gynecology residency directors reported routine abortion training, and 10 percent denied any training, according to a national survey of 190 residency program directors. The results showed that abortion training has increased since 2004, but many graduate residents lack enough training to perform dilation and evacuation, a common procedure after the first trimester of pregnancy.

“Abortion was mentioned in our preclinical curriculum, but it wasn’t until our OB-GYN clerkship that we had more focused training,” Amanuel said.

Access to abortion training can affect the types of communities served. Research published in 2017 found that women below the federal poverty level had the highest abortion rates, compared to other women with higher incomes.

The desire to support racial groups, such as Black and brown women, inspired students like Amanuel to seek abortion training.

“For medical students, we’re trying to figure out where can we get the training to provide the essential care that patients need?” Amanuel said. “For a lot of us, in particular, we came to medical school to support Black, brown, and poor communities, and this is very much a racial justice issue as well.”

Although the Accreditation Council for Graduate Medical Education requires obstetrics and gynecology residency programs to provide access to abortion training, many residents lack sufficient training. Hospital policy, according to a national survey of U.S. teaching hospitals, restricts training.

“Training in medical school around abortion, in general, is fairly limited,” said Aisha Wagner, medical director of Training in Early Abortion for Comprehensive Healthcare (TEACH).

Even decades after the landmark 1973 Supreme Court decision in Roe v. Wade made abortion a constitutional right, the practice was still stigmatized. The overturn of that right in June has narrowed the scope of training available in states near California, such as Arizona, where a near-total abortion ban recently went into effect.

“Medicine for a long time has cared less about women or people with uteruses’ reproductive systems,” Wagner said. “In liberal states, the stigma of abortion is very much present.”

“It’s incredibly important to start as early as you can with abortion training to normalize abortion,” Wagner added.

TEACH helps residents and family medicine specialists train in abortion care, but trainees also fly to other states.

“A lot of it is trying to figure out, how do we support our residents? How do we support our colleagues?” Wagner said. “The community of people who provide and support abortion—it’s small in the medical field. It’s always been kind of, ‘we’re in this together,’ and I think it is now even more so.”

Amid the uncertainty of abortion laws, training programs have relied on legal experts to help practitioners protect the privacy of patients.

“We are trying to bring in experts who can help residents understand what is within their legal boundaries, but also, really importantly, how to not criminalize patients because patients are coming in from other states to have medication abortions and procedural abortions,” Wagner said.

Medication abortions rely on pills, typically administered via telehealth. The pills are also used to self-manage a pregnancy. Even before the Court overturned Roe, half of the abortions in the United States were medication abortions. But medication abortion works most effectively early in pregnancy, and state laws vary regarding telehealth.

The advanced training program Wagner uses with third-year residents has a revised curriculum.

“We’re trying to really focus that curriculum on medication abortion, which clearly is not the solution and is not going to be the answer for everyone who’s seeking an abortion,” Wagner said. “But it is a way to increase access to abortion for a lot of people, especially people in banned states.”

With 14 states already completely banning abortion and a dozen more expected to join them, Dr. Deborah Bartz, an associate professor of OB-GYN at Harvard Medical School and Med Students for Choice board member, has seen demand for training skyrocket.

“We cannot accommodate all the students that are interested in learning about this topic because the interest is so high at the moment,” Bartz said. “People are so interested in incorporating abortion training into their careers.”

Many abortion clinics are found within a close radius of medical schools and urban areas, according to Bartz. A 2017 study found that half of U.S. women live within 11 miles of an abortion clinic, but 20 percent of them have to travel 43 miles.

“The fall of Roe means that many, even close to half of all OB-GYN residencies, will no longer have abortion provisions for patients and therefore abortion training for their residents, which has foundational implications for the desirability for the students to want to train within those institutions,” Bartz said.

In some cases, the overturn of Roe eliminated even the conversation about abortion in training. Ella Nonni, a third-year medical student at Texas A&M University, was instructed by her mentors not to offer any information about abortion to a patient, in case the advice comes off as a suggestion to undergo the procedure.

“Patients have to ask us directly, and we don’t, based on the legal advice for our clinic, provide them any written information about abortion care,” Nonni said. “We just name clinics that they can go to out of state, and then it’s on them to do the research.”

Before the fall of Roe, Nonni had experienced limited exposure to abortion training. Unless medical students were looking do to a rotation at Planned Parenthood, the training focused on conversations and a few minutes of abortion care mentioned in a reproductivity class.

“Now it’s impossible unless you go out of state, but even the conversations around abortion or options counseling are almost negated completely,” Nonni said.

Raised in New York and New Jersey, Nonni considered staying in a state like Texas, where currently SB 8 bans abortion at six weeks, before most people know they’re pregnant. Nonni had hoped that the benefit to serve abortion to people who needed it the most, especially in a red state, but residency in Texas makes little sense, given that she will insist on family planning training.

“Now that it’s completely illegal in the state, there’s no point in being here. I can’t help those patients the way that I want to,” Nonni said. “I can only help them in states where it’s safe.”