What the end of Roe v. Wade will mean for the next generation of obstetricians

For a long time, Cara Buskmiller has known two things about herself: she wants to give birth, and she is called by her faith to a life of virginity. Growing up in Dallas in the 1990s with six younger siblings, Buskmiller knew a bit about pregnancy and childbirth and had an interest in medicine. But she really decided on midwifery in seventh grade, after visiting an obstetrician’s office with her Girl Scout troop. She saw posters promoting contraception on every wall – something her parents, devout Catholics, had taught her were wrong – and she thought, Oh my God, I have to become an obstetrician to fight. against it!

His second vocation took longer to discern. She tried dating in college, carefully considering all the eligible Catholic men she knew, but no one felt like an obvious match. She flirted with the Catholic Church’s version of a sorority rush for nuns, visiting convents and talking with nuns to see if that should be her path. But it turned out that the answer lay in her own family: her great-aunt Marjorie, a former teacher, was a consecrated virgin, dedicated to chastity and obedience while still being able to lead an independent professional life. Today, Buskmiller isn’t fazed by questions about why a professed virgin would specialize in an area of ​​medicine that relates to sex. “Hasn’t God got a sense of humor? she asked, laughing.

But in 2010, as Buskmiller prepared to apply to medical school, she worried that admissions committees would be skeptical of her beliefs and that her personal objections to abortion and birth control would affect her. practice as an obstetrician. What would program directors think of her volunteer time at a crisis pregnancy center? And, at the time of residency, could she refrain from certain clinical rotations to avoid assisting with abortions?

Buskmiller entered Texas A. & M. School of Medicine, and then did her residency at St. Louis University, a Catholic school. But she felt students like her needed more support. So in her second year as a resident, she started a website called Conscience in Residency, a support network for doctors-in-training who have moral objections to abortion. The site’s slogan is “You are not crazy and you are not alone”. Buskmiller maintains a crowdsourced spreadsheet where residency applicants note which institutions hosted them and which did not. An “abortion mecca, someone commented about Oregon Health & Science University, Portland: “Two faculty members have said directly at medical student conferences that they believe anyone with a conscientious objection to abortion should reconsider whether it is ethical to be an ob-gyn. Another commenter wrote, from Southern Illinois University, Springfield, that the program director “seemed very shocked when I asked not to participate in sterilizations.” Most residents, the commentator added, “are very involved in ‘abortion advocacy.’ ”

Even at a time when Roe v. Wade seems likely to be overthrown, residents who describe themselves as pro-life are counter-cultural in their field. They believe that fetuses are human persons with moral status; When Buskmiller meets a woman even at the very beginning of her pregnancy, she sees two patients, not one. The American College of Obstetricians and Gynecologists, or ACOGon the other hand, holds firmly that abortion is a form of health care and supports a patient’s right to terminate a pregnancy prior to fetal viability. Progressive doctors and students argue that access to abortion is not only crucial for the health of their patients, but for a more economically and racially just society. They believe abortion can help keep families out of poverty and protect the lives of black women who, according to the Centers for Disease Control and Prevention, are three times more likely than white women to die from causes. related to pregnancy. Meanwhile, residency program directors may balk when encountering students who refuse to participate in abortion education, which involves learning how to care for patients in emergencies as well as before and after. the procedure. Even physicians who do not perform abortions are likely to encounter patients who have had them. Learning more about that experience makes for better practitioners, said Jody Steinauer, professor of obstetrics and gynecology at the University of California, San Francisco (UCSF).

Yet there is a surprising amount of subtle variation in how members of the medical community think about this issue. All students and young doctors must settle questions about how they wish to practice medicine; Aspiring gynecologists’ views on abortion could determine what training they seek, what specialties they pursue, and where they choose to live. In a post-Roe world, this process of self-sorting would become even more intense: in about half of the country, abortion would be anything but illegal, according to the Guttmacher Institute, a reproductive rights think tank. Resident doctors in those states would likely have to go elsewhere to learn about abortions, just as patients would have to travel to get the procedure. In the other half of the country, the demand for abortions would almost certainly increase, putting pressure on doctors, hospitals and clinics to serve out-of-state patients. For all doctors and interns, regardless of their views, this geographic divide could pose dilemmas, even for anti-abortion students who would likely welcome Roe’s reversal. Simple slogans and tidy categories are useful for politics but not for medicine. “Pro-life people don’t understand why gynecologists talk about the need for abortion until they see a woman dying before their eyes because they’re pregnant,” Buskmiller said. “I think it is possible to be pro-life, despite these situations. But you can’t wear rose-colored glasses and think the situation is easy. It’s not.”

Doctors have not always viewed abortion as a form of health care. The text of Roe v. Wade alludes to the differences between doctors in the early seventies; the Supreme Court assumed that some physicians would oppose abortion on moral or religious grounds. Feminist scholars have noted that judges seem to be just as concerned about the rights of doctors as they are about the rights of women. “The abortion decision in all its aspects is inherently and primarily a medical decision, and the fundamental responsibility for it must rest with the physician,” Judge Harry Blackmun wrote in the court opinion.

Around the time the Court was considering the case, however, about 100 doctors signed a letter advocating a new patient-centered approach to health care. “Physicians will need to realize that abortion has become an essentially social and medical responsibility,” they write. “For the first time . . . doctors will be expected to do an operation simply because the patient asks for it to be done. They were advocating for a new way of thinking about medicine: at least as far as the pregnancy, doctors should not be the decision makers, patients should.

It took many years for medical schools and health institutions to adopt this attitude. In the decades after Roe, “contraception was not considered a worthy training subject for an obstetrician,” Eve Espey, chair of the department of obstetrics and gynecology at the School of Medicine, told me. the University of New Mexico. “Abortion was just a taboo. It was felt to be an activity dominated by older men for profit. Even in 1992, only twelve percent of obstetrics and gynecology residency programs included training in abortion procedures.

In the early 1990s, however, a major shift began, led in part by students. In 1993, while Steinauer was a medical student at UCSF, she founded an organization called Medical Students for Choice, with the goal of expanding access to abortion. Many doctors who had started practicing before Roe, Steinauer told me, performed abortions out of necessity: they had seen women die and were committed to preventing it from happening again. “I would say my generation started thinking about it a little differently,” she said. “It was a bit more activist and advocacy focused.” They did not want a woman’s right to an abortion to be purely theoretical.

The best way to expand access to abortions, Steinauer believed, was to train more doctors to perform them. She and her fellow students began lobbying the Accreditation Council for Higher Medical Education to make elective abortion training mandatory for obstetrics and gynecology residency programs, and in 1995 it became the norm – all residents were required to learn about abortion. But the following year, after Catholic hospitals and other groups refused, Congress passed an amendment to a public health law, prohibiting discrimination against medical training programs that refused to teach medical procedures. abortion. The amendment underscored a growing tension in the field: legally, no one could be forced to perform abortions. But, culturally, pro-choice voices were growing louder in the midwifery world, asserting that abortion is a necessary part of reproductive health care.

In 1999, Susan Thompson Buffett, wife of multi-billionaire Warren Buffett, funded a new initiative called the Ryan Residency Training Program, which provided funding, program assistance, and other resources to residency programs that teach residency procedures. ‘abortion. When I spoke with Steinauer, the principal, she said that as the program became more well known, students who were serious about family planning started asking about Ryan’s rotations in their interviews. of residence: obstetricians. (A sister program, RHEDI, also provides family medicine programs with resources to train residents in abortion.) Now, if a medical student wants to focus on abortion, she can choose from over a hundred programs that follow the model of Ryan, which has been adopted by approximately one-third of obstetrics and gynecology residency programs. She will learn how to counsel patients on birth control and medications that can induce abortion during the first few weeks of pregnancy and at some point in her training she will likely perform dilation and evacuation on patients during their second trimester of pregnancy, a process that involves opening a woman’s cervix and removing the fetus. If the student wants to learn how to perform abortions on patients in complex medical situations, including those far into their pregnancies, she can pursue a fellowship in complex family planning—a specialty that has only been fully accredited. two years ago.

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