Comparing the Accessibility of Information Regarding Integrated Abortion Training for Family Medicine and Obstetrics/Gynecology Residency Applicants

Abstract

Introduction:

After the Dobbs v Jackson Women’s Health Organization decision, the U.S. health care workforce faces challenges responding to the critical reduction to access of abortion services. A recent study identified only 3,550 clinicians providing abortions; a majority identified their specialty as obstetrics and gynecology (OBGYN, 72%), family medicine (9%), and advanced practice registered nurses (8%). Integrated abortion training during residency is a strong predictor of future abortion provisions. We evaluated publicly accessible information about residency programs with integrated abortion training that applicants could access.

Methods:

A cross-sectional analysis of integrated abortion training family medicine residencies (RHEDI) and OBGYN residencies (Ryan) was performed to identify which online platforms and terminology were used to indicate a program offers integrated abortion training.

Result:

There are 34 RHEDI and 104 Ryan programs. Of those, 91.3% of programs had information on their website regarding integrated abortion training. Terms most used by RHEDI residency websites included reproductive (70.6%), abortion (67.6%), and RHEDI (50.0%). Terms used by Ryan residency websites included family planning (88.5%), Ryan (47.1%), and abortion (44.2%). The majority of RHEDI programs are in abortion-protective states, whereas Ryan programs are more evenly distributed (79.4% and 51.9%, p = 0.005). Integrated abortion training programs were commonly listed on other platforms including the RHEDI or Ryan website (100%) and Reddit (94.9%).

Conclusion:

Most integrated abortion training residencies included public-facing information. Students seeking residencies that provide integrated abortion training will likely find the information on the residency webpage; however, are most successful when identifying training through websites such as RHEDI, Ryan, or Reddit. As federal legislation moves to restrict abortion care, accessible training information is essential.

Keywords

internship and residency reproductive health family planning services abortion induced cross-sectional studies

Introduction

In 2021, there were 656,978 legally induced abortions in the United States.¹ Only 3,550 abortion service clinicians provided these services based on the most recent workforce estimates.² Providers identified their specialties as obstetrics and gynecology (OBGYN) (72%), family medicine (9%), advanced practice registered nurses (8%), nurse midwives (3%), physician assistants (1%), emergency medicine (1%), internal medicine (1%), and pediatrics (0.6%).² Post-Dobbs, there has been a critical reduction to abortion care access.³ In geographic areas of the United States with the largest barriers to abortion care,^4,5 the most common practicing specialty is family medicine.^6,7 Thus, family medicine physicians are in a unique position to help increase access to timely abortion care in areas with limited abortion services and limited availability of OBGYN providers. Integrated abortion training during OBGYN or family medicine residency has been shown to be a strong predictor for future abortion provision.^8,9 However, access to integrated abortion training is already limited and may be even more difficult to obtain post-Dobbs.¹⁰ While unstructured abortion training is essential, structured integrated abortion training programs such as RHEDI or Ryan provide formal pathways for abortion education. It is essential to identify whether applicants to family medicine and OBGYN residencies can access information regarding integrated abortion training. The public-facing transparency of training curriculum has not been extensively explored¹¹ but may be linked to residency applications and the ranking of residency programs. The transparency of participation in RHEDI and Ryan programs on public domains such as residency websites or peer data sharing sites is unclear. The objective of this novel investigation is to identify which online platforms and terminology are used to indicate a residency program is an integrated abortion training site.

Methods

This is a cross-sectional analysis of online platforms used for residency information gathering. We identified websites that contained information regarding abortion training and what mix of terminology is used to indicate participation in an integrated training program, specifically Reproductive Health Education in Family Medicine¹² (RHEDI, family medicine) and The Kenneth J. Ryan Residency Training Program in Abortion & Family Planning¹³ (Ryan, OBGYN). Available webpages were accessed and manually reviewed between September and October 2023 by three reviewers.

A list of verified integrated abortion training programs was obtained by directly contacting the national offices for RHEDI and Ryan. The reviewers accessed and manually reviewed the online platforms for RHEDI,¹² Ryan,¹³ Medical Students for Choice¹⁴ (MSFC), family medicine resident applicant Google Sheets (2020–2021,¹⁵ 2021–2022,¹⁶ and 2022–2023¹⁷), OBGYN resident applicant Google Sheets (2020–2021,¹⁸ 2021–2022,¹⁹ and 2022–2023²⁰), and Reddit²¹ to identify the percentage of programs listed on these platforms as RHEDI, Ryan, or abortion training sites. Due to the increased use of peer data sharing, such as Google Sheets and Reddit, these forums were included for evaluation.^22,23 All websites were accessed using Google as the primary search engine. Given Reddit is organized by subreddits, for the collection of data from Reddit, we used Google as our primary search engine and used the search term “Reddit integrated abortion training programs.” Because residency programs may not associate or self-identify themselves as an abortion training site, the reviewers accessed and manually reviewed individual residency program websites, known to participate in Ryan and RHEDI, to determine the percentage of programs that utilized the following terminology to describe their training: abortion, abortion care, abortion curriculum, abortion training, reproductive care, reproductive health, reproductive health care, reproductive medicine, family planning, RHEDI, and Ryan. We measured accessibility as the minimum number of clicks²⁴ to identify any of these terms, zero representing the first page from the search engine. In addition, using data from the Guttmacher Institute accessed in July 2023, we identified the restrictiveness of abortion laws of each state where RHEDI and Ryan programs are located using a 6-point rating, with ratings of “protective” and “most protective” considered as not restrictive.²⁵ Geographic information systems were also used to map the location of Ryan and RHEDI programs relative to state abortion restrictiveness.

Analysis

Online platforms and terms were summarized using descriptive statistics (frequencies and measures of central tendency). Fisher’s exact and Wilcoxon rank sum tests were used for comparing differences in categorical and continuous data, respectively. All inferential comparison tests were two-sided with a level of significance set at p < 0.05. Statistical analyses were performed using SAS (Version 9.4).

Results

Regarding online platform, there was no statistical difference between RHEDI and Ryan programs being noted as an integrated abortion training site, RHEDI program, or Ryan program among platforms such as the RHEDI or Ryan website (100% and 100%, p = 1.00), Reddit (100% and 93.3%, p = 0.19), and the residency website (94.1% and 90.4%, p = 0.73) (Table 1). These platforms were accessible with average clicks of 1.2, 0, and 0.7, respectively (Table 2). Notably, Google Sheets did not identify many programs. However, RHEDI programs were more likely than Ryan programs in the 2020–2021 application year (26.5% and 1.0%, p < 0.001) and the 2021–2022 application year (32.4% and 1.0%, p < 0.001) to identify integrated abortion training programs (Table 1). For the 2022–2023 application year, family medicine no longer had a sheet dedicated to abortion training, while OBGYN utilized this at a higher rate than previously (N/A and 15.4%) (Table 1). MSFC did not list any specific RHEDI or Ryan program on their website. However, it does list the RHEDI and Ryan national organization websites.

Table 1.

Comparing Online Platforms Which List RHEDI and Ryan Residency Programs

	Full RHEDI/Ryan sample (N = 138)		RHEDI program(n = 34, 25%)		Ryan program(n = 104, 75%)		p-Value^a
Online platforms	n	%	n	%	n	%	p-Value^a
RHEDI/Ryan platform	138	100.0	34	100.0	104	100.0	1.00
Google Sheets 2020–2021	10	7.2	9	26.5	1	1.0	<0.001
Google Sheets 2021–2022	12	8.7	11	32.4	1	1.0	<0.001
Google Sheets 2022–2023^b	16	15.4	N/A	N/A	16	15.4	N/A
Reddit	131	94.9	34	100.0	97	93.3	0.19
Residency website	126	91.3	32	94.1	94	90.4	0.73

No cases of MSFC in any record. RHEDI “affiliated programs” omitted.

Fisher’s exact test.

104 out of 138 programs applicable (no RHEDI programs applicable).

Table 2.

Comparing Accessibility (Number of Clicks^a) of Online Platforms Which List RHEDI and Ryan Residency Programs

Online platforms	Full RHEDI/Ryan sample (N = 138)	RHEDI program (n = 34, 25%)	Ryan program (n = 104, 75%)	p-Value^b
	Mean ± SD; median (IQR)
RHEDI/Ryan platform	1.2 ± 0.4; 1 (1,1)	2.0 ± 0; 2 (2,2)	1.0 ± 0; 1 (1,1)	<0.001
Google Sheets 2020–2021	1 ± 0; 1 (1,1)	1 ± 0; 1 (1,1)	1 ± 0; 1 (1,1)	1.00
Google Sheets 2021–2022	1 ± 0; 1 (1,1)	1 ± 0; 1 (1,1)	1 ± 0; 1 (1,1)	1.00
Google Sheets 2022–2023^c	1 ± 0; 1 (1,1)	N/A	1 ± 0; 1 (1,1)	N/A
Reddit	0 ± 0; 0 (0,0)	0 ± 0; 0 (0,0)	0 ± 0; 0 (0,0)	1.00
Residency website	0.7 ± 0.8; 0.5 (0,1)	0.9 ± 0.9; 1 (0,1.5)	0.6 ± 0.7; 0 (0,1)	0.03

No cases of MSFC in any record. RHEDI “affiliated programs” omitted.

Range is 0–3.

Wilcoxon rank-sum test.

104 out of 138 programs applicable (no RHEDI programs applicable).

The analysis of RHEDI and Ryan program residency websites showed that 94.1% of RHEDI programs and 90.4% of Ryan programs used at least one term that self-designated the program as an integrated abortion training site (Table 1). RHEDI programs were more likely than Ryan programs to use terms such as “reproductive” (70.6% and 25.0%, p < 0.001) and “abortion” (67.6% and 44.2%, p = 0.03) (Table 3). RHEDI programs were less likely than Ryan programs to use the term “family planning” (35.3% and 88.5%, p < 0.001) (Table 3). Other terms including “RHEDI” or “Ryan” (50.0% and 47.1%, p = −0.84) did not have any statistical difference (Table 3). RHEDI program websites were less accessible than Ryan program websites, requiring an average of 0.9 and 0.6 clicks (p = 0.03) for any term (Table 2). Specifically, the terms “abortion” (1.5 and 1.1 clicks, p = 0.04) and “family planning” (1.5 and 0.7 clicks, p < 0.001) were less accessible (Table 4).

Table 3.

Comparing Terms Used on RHEDI and Ryan Residency Websites to Indicate a Program Offers Integrated Abortion Training

	Full RHEDI/Ryan sample (N = 138)		RHEDI program (n = 34, 25%)		Ryan program (n = 104, 75%)
Terms	n	%	n	%	n	%	p-Value^a
Abortion (any)^b	69	50.0	23	67.6	46	44.2	0.03
Reproductive (any)^c	50	36.2	24	70.6	26	25.0	<0.001
family Planning	104	75.4	12	35.3	92	88.5	<0.001
RHEDI/Ryan	66	47.8	17	50.0	49	47.1	0.84

No cases of MSFC in any record. RHEDI “affiliated programs” omitted.

Fisher’s exact test.

Abortion (any): abortion, abortion care, abortion training, and abortion curriculum.

Reproductive (any): reproductive health, reproductive health care, and reproductive medicine.

Table 4.

Comparing Accessibility (Number of Clicks^a) of Information on RHEDI and Ryan Residency Websites Indicating a Program Offers Integrated Abortion Training

	Full RHEDI/Ryan sample (N = 138)	RHEDI program (n = 34, 25%)	Ryan program (n = 104, 75%)	p-Value^b
	Mean ± SD; median (IQR)
Abortion (any)^c	1.2 ± 0.8; 1 (1,2)	1.5 ± 0.8; 1 (1,2)	1.1 ± 0.8; 1 (1,2)	0.04
Reproductive (any)^d	1.0 ± 0.9; 1 (0,1)	0.9 ± 0.9; 1 (0,1)	0.7 ± 0.9; 0 (0,1)	0.18
family Planning	0.8 ± 0.7; 1 (0,1)	1.5 ± 0.8; 1.5 (1,2)	0.7 ± 0.7; 1 (0,1)	<0.001
RHEDI/Ryan	1.0 ± 0.9; 1 (0,1)	1.1 ± 0.8; 1 (1,1)	1.0 ± 0.9; 1 (0,1)	0.34

No cases of MSFC in any record. RHEDI website “Affiliated programs” omitted.

Range is 0–3.

Wilcoxon rank-sum test.

Abortion (any): abortion, abortion care, abortion training, and abortion curriculum.

Reproductive (any): reproductive health, reproductive health care, and reproductive medicine.

We also evaluated program distribution in relation to state abortion law restrictiveness (Table 5, Fig. 1). RHEDI programs are more prevalent in abortion protective states compared to Ryan programs (79.4% and 51.9%, p = 0.005 [Table 5]). Figure 1 shows clear geographic patterns, where both Ryan and RHEDI programs are mostly absent in states with the most restrictive abortion laws, particularly in the South. For all integrated abortion training programs, there was no difference in accessibility across online platforms and no difference in terminology used in an abortion-protection state as opposed to an abortion-restrictive state (Table 6).

Table 5.

Comparing Abortion State Law Restrictiveness for RHEDI and Ryan Residency Programs. N = 138 Programs

	Full RHEDI/Ryan sample (N = 138)		RHEDI(n = 34, 25%)		Ryan(n = 104, 75%)
Restrictiveness	n	%	n	%	n	%	p-Value^a
State restrictiveness							0.03
Most protective	1	0.7	1	2.9	0	0
Protective	80	58.0	26	76.5	54	51.9
Some restrictions	18	13.0	4	11.8	14	13.5
Restrictive	33	23.9	2	5.9	31	29.8
Very restrictive	1	0.7	0	0	1	1.0
Most restrictive	5	3.6	1	2.9	4	3.9
Protective or restrictive							0.005
Protective (any)^b	81	58.7	27	79.4	54	51.9
Restrictive (any)^c	57	41.3	7	20.6	50	48.1

RHEDI “affiliated programs” omitted.

Fisher’s exact test.

Protective (any): most protective and protective.

Restrictive (any): some restrictions, restrictive, very restrictive, and most restrictive.

FIG. 1.

Map showing distribution of RHEDI and Ryan residency programs by abortion state law restrictiveness.

Table 6.

Comparing Accessibility of Online Platforms and Terminology Indicating a Program Offers Integrated Abortion Training in Abortion Protective versus Restrictive States

	Full RHEDI/Ryan sample (N = 138)		Protective(n = 81, 58.7%)		Restrictive(n = 57, 41.3%)
Platform/terms	n	%	n	%	n	%	p-Value^a
RHEDI-Ryan Platform	138	100.0	81	100	57	100	1.00
Platform: Google Sheets
2020–2021	10	7.3	7	8.6	3	5.3	0.52
2021–2022	12	8.7	8	9.9	4	7.0	0.21
2022–2023^b	16	15.4	7	13.0	9	18.0	1.00
Platform: Reddit	131	94.9	76	93.8	55	96.5	0.70
Platform: Residency website	126	91.3	75	92.6	51	89.5	0.55
Abortion (any)^c	69	50.0	43	53.1	26	45.6	0.49
Reproductive (any)^d	50	36.2	33	40.7	17	29.8	0.19
Family Planning	104	75.4	57	70.4	47	82.5	0.11
RHEDI/Ryan Term	66	47.8	39	48.2	27	47.4	1.00

No cases of MSFC in any record. RHEDI “affiliated programs” omitted.

Fisher’s exact test.

104 out of 138 programs applicable (no RHEDI programs applicable).

Protective (any): most protective and protective.

Restrictive (any): some restrictions, restrictive, very restrictive, and most restrictive.

There are several limitations of the study. Limited information regarding abortion training is available to applicants. However, quantitative data regarding which platforms residency applicants use to attain this information is unknown. This study only identifies if specific online tools for residency applicants provide information regarding integrated abortion training. It does not analyze the degree to which these resources are being utilized by applicants. Future studies could survey residency applicants to determine which tools are being utilized to identify information regarding integrated abortion training and to analyze how well these tools identify integrated abortion training programs. Although our study did find that information is relatively accessible on residency program webpages, residency program websites are not standardized, which can make it difficult for an individual applicant to succinctly find information on their website regarding abortion training. In addition, state laws regarding abortion care are rapidly changing. Our study is not able to assess the recency of information provided on online platforms. We were also not able to ascertain the reasons information is or is not public-facing on residency websites. Future studies could survey RHEDI and Ryan program directors to assess strategies for informing applicants of their training and any barriers they may face in providing this information.

Conclusions

Identifying family medicine and OBGYN residency programs with verified integrated abortion training is most accessible using the RHEDI or Ryan website (100%), Reddit (94.9%), and residency websites (91.3%). However, this requires applicants to be aware of the training RHEDI and Ryan programs offer. The programs RHEDI and Ryan are also not explained on many of the program sites, making this a barrier for applicants when assessing information related to these programs. Most common terms used on program websites among all integrated abortion training programs include “family planning” (75.4%), “abortion” (50.0%), and “RHEDI” or “Ryan” (47.8%). In addition, RHEDI programs are more prevalent in abortion-protective states compared to Ryan programs (79.4% and 51.9%). Future studies could survey RHEDI/Ryan program directors and family medicine/OBGYN residency applicants to identify possible areas for improving accessibility of information regarding integrated abortion training. Of note, since the conclusion of this study, RHEDI announced in October 2024 their organization would be closing due to insufficient funding following the discontinuation of their primary funding source. However, they subsequently stated RHEDI programs have transitioned to being under the Training in Early Abortion for Comprehensive Healthcare program. The changes to the RHEDI organization will potentially impact the ability of family medicine trainees to obtain full-scope reproductive health training. Further studies are needed to quantify the impact of abortion provision after the transition of RHEDI.

Authors’ Contributions

A.M.A.: Conceptualization, methodology, validation, investigation, data curation, writing—original draft, writing—review and editing, visualization, and project administration. C.H.: Investigation, writing—original draft, writing—review and editing. L.N.: Investigation, writing—original draft, writing—review and editing. M.T.: Conceptualization, software, and visualization. K.S.: Formal analysis, data curation, writing—original draft, and visualization. A.D.C.: Formal analysis, data curation, writing—original draft, and visualization. A.H.: Conceptualization, methodology, writing—review and editing, and supervision.

Footnotes

Acknowledgments

A.M.A. would like to thank the Robert Graham Center for the encouragement to pursue this project as a Larry A. Green Scholar.

Presentations

North American Primary Care Research Group Conference 2023, November 1, 2023, San Francisco, California, USA; University of Utah Women’s Health in the Cross Hairs Symposium 2024, May 16, 2024, Salt Lake City, Utah, USA.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article. Gross Endowment.

Supplemental Material

Abbreviations Used

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Supplementary Material

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