Impact of Dobbs on U.S. Medical School Abortion Curricula

Impact of the United States Supreme court Dobbs versus Jackson Health Women’s Organization Decision on Abortion Curricula in United States Medical Schools

Alyssa Stephenson-Famy, MD,¹ Angela Fleming, DO,² Laura Baecher-Lind, MD, MPH,³ Rashmi Bhargava, MD,⁴ Katherine T. Chen, MD, MPH,⁵ Helen Kang Morgan, MD,⁶ Christopher M. Morosky, MD,⁷ Celeste S. Royce, MD,⁸ Jonathan A. Schaffir, MD,⁹ Shireen Madani Sims, MD,¹⁰ Jill M. Sutton, MD,¹¹ Tammy Sonn, MD,¹² on behalf of the Undergraduate Medical Education Committee; Association of Professors of Gynecology and Obstetrics

Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
Department of Obstetrics and Gynecology, Corewell Health, Farmington Hills, MI
Department of Obstetrics and Gynecology, Tufts School of Medicine, Boston, MA
Department of Obstetrics and Gynecology, University of Saskatchewan College of Medicine, Regina, Saskatchewan, Canada
Department of Obstetrics, Gynecology, Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY
Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
Department of Obstetrics and Gynecology, University of Connecticut School of Medicine, Farmington, CT
Reproductive Biology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
Department of Obstetrics and Gynecology, The Ohio State University, Wexner Medical Center, Columbus, OH
Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL
Department of Obstetrics and Gynecology, East Carolina University Brody School of Medicine, Greenville, NC
Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO

OPEN ACCESS

PUBLISHED: 30 November 2024

CITATION: Stephenson-Famy, A., Fleming, A., et al., 2024. Impact of the United States Supreme Court Dobbs versus Jackson Health Women’s Organization Decision on Abortion Curricula in United States Medical Schools. Medical Research Archives, [online] 12(11). https://doi.org/10.18103/mra.v12i11.5962

COPYRIGHT © 2024 European Society of Medicine. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

DOI https://doi.org/10.18103/mra.v12i11.5962

ISSN: 2375-1924

Abstract

This study investigatede the effect of the reversal of Roe versus Wade, with the 2022 United States (U.S.) Supreme Court Dobbs1 decision, on medical school reproductive health curriculum in U.S. An electronic survey was distributed to 248 U.S. medical school obstetrics and gynecology clerkship directors in March 2023 to assess faculty demographics, reproductive health topics included in medical school curriculum and challenges in abortion education after Dobbs. One hundred forty-eight faculty completed the survey (60% response rate) from 40 states and the District of Columbia; 45% of respondents were from states with abortion restrictions in the first and second trimesters. There were no significant changes in curricular content during the months following Dobbs. Thematic analysis of text responses indicates concerns about legal implications of teaching, state audits and restrictions on materials, as well as limits on abortion education in medical schools in states with restrictive abortion laws, even prior to Dobbs.

PRECIS: In the months following the Dobbs decision, there was no change in abortion curricula in pre-clerkship courses or Obstetrics and Gynecology clerkship in U.S. medical schools.

Keywords

Dobbs decision, abortion education, medical schools, reproductive health curriculum

Introduction

After 1972, national access to abortion care was protected by the decision of the United States (U.S.) Supreme Court in the case of Roe v. Wade. In June 2022, this decision was overturned by Supreme Court with the Dobbs v. Jackson Health Women’s Organization case,1 which gave individual states the option to decide on whether abortion care should remain legal and had immediate effects on abortion care access for patients. Following this decision, 26 of 50 states had abortion restrictions in the first and second trimester many of which were immediate trigger laws.

Medical educators in obstetrics and gynecology (Ob/Gyn) have reported on state level disparities in graduate medical education abortion training following Dobbs3 with nearly 50% of residents in Ob/Gyn projected to have inadequate abortion training in restrictive states. Educators and students alike raised concerns that the effect of Dobbs would expand beyond Ob/Gyn residency training and would have detrimental impacts on medical students and the education of the future physician workforce.

The American College of Obstetricians and Gynecologists (ACOG) recommended in 2014 that abortion education be included in all medical schools in the U.S.7 Prior data on whether U.S. medical schools included abortion education in pre-clinical and clerkship curricula in the era before Dobbs is limited. In the most recent published survey of U.S. medical schools in 2019, only 59% of medical schools’ pre-clerkship curricula included abortion and 74% included abortion clinical experience for medical students.9 In 2021, the Association of American Medical Colleges reported only 80% of medical schools included any formal abortion education before the Dobbs decision.10 It is estimated that 48% of matriculants to MD-granting medical schools now receive their medical education in states with significant abortion restrictions or bans following Dobbs.11 While Ob/Gyn residency programs have standardized requirements for abortion training and the Ryan Residency Training Program national abortion curriculum,12 barriers to implementation have included hospital and institutional restrictions.13 The Association of Professors of Gynecology and Obstetrics (APGO) have established medical student objectives for family planning and abortion education,14 however use of these education materials is variable among U.S. medical schools and calls to standardize abortion education predated the Dobbs decision.15

In this study, we sought to investigate the inclusion of abortion and reproductive health topics in U.S. medical schools before and after the June 2022 Dobbs decision to estimate its effect on medical student curricula.

Methods

In March 2023, the Undergraduate Medical Education Committee (UMEC) of APGO developed an 11-item electronic survey to assess the immediate impact of Dobbs on reproductive health curricula in U.S. medical schools. The survey was designed for the Ob/Gyn clerkship director list maintained by APGO and queried faculty role in the Ob/Gyn clerkship, type of medical school, geographic state, and religious affiliation of the institution. The survey asked whether abortion and reproductive health topics were covered in pre-clerkship courses and the Ob/Gyn clerkship, prior to and after the Dobbs decision (yes, no, unsure). Specific reproductive health topics included in this survey were contraception, emergency contraception, care of patients with rape or incest, septic abortion, incomplete abortion, ectopic pregnancy, patient counseling for abortion, referral to other facilities for abortion, early pregnancy loss, molar pregnancy, management of lethal fetal anomalies, and management of severe pregnancy complications. The survey also included free text response questions about resources used to teach about abortion and challenges with abortion education. This study was considered exempt by the University of Michigan institutional review board.

The survey was sent to individuals with active APGO memberships self-identified as having duties of a clerkship director. Two additional automated reminders were sent to non-responders. UMEC members then emailed remaining individuals who didn’t complete survey. The survey was closed after 6 weeks. State abortion laws were categorized using Guttmacher Institute (ref) data accessed in March 2023 as complete ban/first trimester restriction, second trimester restriction, or unrestricted. Demographic data were tabulated. The Stuart-Maxwell test for marginal homogeneity was used to assess differences in curricular topics pre- and post-Dobbs and the Fisher’s exact test was used to assess abortion curricula by state level restriction. General themes from text responses were independently determined by 2 authors using an inductive process of thematic analysis16 and predominant themes are presented with representative comments.

Results

A total of 148 faculty (60%) responded to the survey. One hundred thirty (88%) identified their primary role as clerkship director, 10 (7%) as Ob/Gyn clerkship site director, and 6 (4%) as assistant/associate clerkship director. The majority were from allopathic (n=135, 91%) and non-religiously affiliated (n=141, 95%) institutions. Respondents’ institutions were located in 40 states and the District of Columbia. Twenty-nine (20%) of respondents were from states with an abortion ban/first trimester restriction, 35 (25%) were from states with second trimester abortion restriction and 78 (55%) had no restriction in abortion, as of March 2023. Across the entire cohort, before the Dobbs decision, 74% reported that abortion was included in their institution’s pre-clerkship courses and 87% reported that abortion was included in the Ob/Gyn clerkship. There was no significant change in education about abortion after Dobbs. Similarly, closely related reproductive health topics were not significantly changed before and after Dobbs including contraception, emergency contraception, care of patients with rape or incest, septic abortion, incomplete abortion, ectopic pregnancy, patient counseling for abortion, referral to other facilities for abortion, early pregnancy loss, molar pregnancy, management of lethal fetal anomalies, and management of severe pregnancy complications. While not statistically significant, abortion was included in pre-clerkship and clerkship curricula less frequently in states with greater abortion restrictions (see Table 1).

State Abortion Restriction	Pre-Dobbs (n=%)	Post-Dobbs (n=%)	Pre-Dobbs (n=%)	Post-Dobbs (n=%)
Ban/1st trimester (N=29)	13 (62%)	13 (62%)	16 (76%)	16 (76%)
2nd trimester (N=35)	19 (68%)	20 (71%)	20 (83%)	21 (88%)
Unrestricted (N=78)	50 (81%)	50 (81%)	59 (92%)	60 (94%)
All respondents (N=142)	82 (74%)	83 (75%)	95 (87%)	97 (89%)

In the qualitative analysis, four predominant themes were identified from text responses (n=105) regarding challenges with abortion education (Table 2). Respondents expressed concern over legal audits and state/institutional oversight of abortion education materials, for which faculty could be found legally liable or scrutinized. Respondents highlighted increased student interest in abortion education following Dobbs and demand for additional attention and time allotted for abortion education during medical school. Additional responses indicated that students felt anxiety regarding their own education and medical care. Lastly, some respondents indicated that their medical school abortion curriculum did not change following Dobbs, as abortion was not included or emphasized, mirroring pre-existing state-level restrictions. Examples of text responses shown in Table 2 demonstrate conflicting responses from educators based on state restrictions and institutional priorities abortion care and education.

Theme of comment	Number of comments	Example comment
Legal oversight of abortion education materials	14	“My institution is funded by state funds, so we have to be careful about curriculum as it can be audited by anyone.”
		“Being a state school, I am always being asked to show my teaching material on abortion to the school lawyers.”
		“Misinformation, especially from non OBGYN faculty, about what we are allowed to talk about or not talk about; we have halted student participation in family planning clinic out of administrative fears of putting students in potentially criminal situations.”
		“Severe restrictions on even basic education on abortion in [my state], where we have preclinical and clinical students.”
Increased attention/time for abortion education	9	“Students have become much more inquisitive and engaged with regarding questions of abortion care since Dobbs.”
		“Pro-life student group was just formed for the first time post-Dobbs. However, the majority of students wanted to make sure abortion education would remain in place and a panel discussion was organized to address this by the school of medicine.”
		“My institution has wanted more abortion education since the Dobbs decision-I have been adding it into the pre-clerkship setting with plan to add it to the clerkship in the next academic year.”
No change after Dobbs due to pre-existing restrictions	6	“There was little emphasis on abortion education for medical students pre-Dobbs. Residents were never able to perform terminations due to state laws, so their education is unchanged.”
		“Not much has changed as we were already so restricted in [my state].”
		“No change due to the fact that there was little emphasis on abortion education for medical students pre-Dobbs.”
Medical student anxiety regarding abortion education	5	“Students want to be involved with providing resources for patients. Students are confused and scared. Even related to their own healthcare.”
		“Students applying into Ob/Gyn are rightfully concerned about weighing this in their application process.”

Discussion

In the immediate aftermath of Dobbs, access to clinical abortion care and residency training across the U.S. was greatly disrupted. Our results show that inclusion of abortion in pre-clerkship or clerkship curricula was not significantly changed in the academic year following the Dobbs decision. However, abortion was not consistently present in medical school curricula even prior to the Dobbs decision. We found that only three-quarters of medical schools included abortion in their pre-clerkship curriculum, which was similar to rates reported by the prior national survey. One concern raised in prior publications on the impact of Dobbs is that state restrictions would produce inadequate education for a wide range of reproductive health topics adjacent to the topic of abortion. We did not find a difference in pre-clerkship or clerkship curricula for topics including emergency contraception, ectopic pregnancy, septic abortion or management of severe complications of pregnancy. While these reproductive health topics are crucial for learners in Ob/Gyn programs, educators from other medical specialties have reported concerns about the impact of Dobbs on competency and skills for learners and providers outside of the field of Ob/Gyn.

In our survey, analysis of text responses suggest that abortion education was limited prior to the Dobbs decision, especially in states with greater restrictions. Faculty expressed that “no change” in the curriculum reflected lack of abortion education at baseline. Thematic analysis showed respondent concern regarding the effect of Dobbs on state legal oversight or audit of teaching materials and limited inclusion of abortion in medical school curricula prior to Dobbs. Qualitative researchers have identified similar themes when assessing Ob-Gyn leader and learner concerns following Dobbs including learner competency, training disparities and the conflict between law-based and evidence-based medicine. Residents in Ob-Gyn have indicated several subthemes of moral distress following Dobbs including determination to advocate for and provide abortion care in the future, which is in keeping with our respondents who reported increased students interest in retaining abortion curriculum in medical school.

There are several limitations of this study. The heterogeneity of survey respondents reflects the complexity of clerkship faculty roles and decentralized U.S. medical schools with many clerkship sites. Some respondents may not have roles that align with the curricula or lack of knowledge of the inclusion of abortion and reproductive health curricula in pre-clerkship courses. While respondents had broad geographic representation, there was a limited response from osteopathic institutions. Thus, results may not represent the breadth of reproductive health curricula in all medical schools across the U.S. Further, it is unclear whether missing data or incomplete survey responses reflect concern regarding legal implications of responding to the survey, especially for educators in restrictive states. Lastly, as higher education curricula evolve over time, this study may not have detected a change across medical school reproductive health education due to the short time interval between Dobbs and the administration of the survey, which was conducted within the academic year following the decision.

Conclusions

Altogether, the results show minimal curricular change in the short time frame post-Dobbs, a finding that could be partially explained by pre-existing disparities in abortion curricula across states. Longitudinal study is needed to determine whether disparities in abortion education are amplified in the years following Dobbs. Development and dissemination of a national abortion curriculum to all students regardless of state level restrictions would serve to standardize U.S. reproductive health education and decrease educator concern regarding legal implications of teaching this content.

Funding:

None

Conflict of interest:

none

Acknowledgments: