Imagine that there’s a surgical residency program —a program to train general surgeons— located within a country, or state, that has decided to prohibit some particular surgical procedure. Let’s imagine that the banned procedure is appendectomy, removal of the vermiform appendix, but it could be anything. In such cases, surgical trainees would not be able to learn the procedure, because the attending surgeons in teaching hospitals would not be permitted to perform it. Or, if they did, they’d be arrested for violating state law. For a little while, residents in the program would continue learning numerous other life-saving procedures. Fairly soon, however, the training program would lose its accreditation and the same would happen to other programs within the state. The state would no longer be a source of new surgeons and it would become less attractive to many general surgeons, who normally perform appendectomies frequently. In addition to not being able to perform appendectomies on patients who need them, leading many such patients to die, the loss of surgical training programs, possibly in combination with the exodus of fully-trained general surgeons would make the problem even bigger than it would be from the simple lack of appendectomies. Surgical care would become less accessible than it was previously.
The example that I gave above may sound ridiculous. Nobody would prohibit appendectomies. But this imaginary appendectomy ban and its consequences is analogous to something that is happening before our eyes in the wake of the Supreme Court of the United States (SCOTUS) decision on the Dobbs versus Jackson Women’s Health Organization abortion case. As you already may know, this recent decision overturned the Roe V Wade decision of 1973. Consequently, abortion prohibitions already on the books on many states are going into effect, along with new antiabortion laws. For teaching hospitals running, or affiliated with, residency training programs in obstetrics and gynecology, such laws will prohibit them from performing abortions. This means that they also will not be able to teach abortion procedures to budding obstetrician-gynecologists.
The talk that began to emerge over the weekend among ob/gyns and other women’s healthcare providers, including some who direct ob/gyn residency programs immediately following the SCOTUS decision of Friday June 24th had a common ring. The idea circulating on social media and elsewhere among ob/gyn professionals was that any training program that ceases performing procedural abortions (abortions carried out invasively with instruments, in contrast with medical abortions which generally can be offered through the 10th gestational week), and thus ceases to provide residents opportunities to learn how to perform abortions, will lose its accreditation.
The reason for this is very simple. The same set of skills that enable an obstetric provider to conduct a procedural abortion, achieving the safe, complete removal of all products of conception, also enables the safe, complete removal of the remains of an embryo or fetus that has died in the womb, not by the hand of a healthcare provider. As we discussed in the recent post about the terminology of spontaneous abortion (miscarriage), most abortions occur naturally, rather than as an elective procedure, and they occur along a spectrum.
At one end of the spectrum is a situation called a threatened abortion. This part of the spectrum technically is not a kind of pregnancy loss, because it only means that a spontaneous abortion is gearing up to occur, but may not. There is a threat that it may occur, because there are symptoms (pain and/or bleeding) and on ultrasound it looks as though the uterus is getting ready to expel the products of conception. But there is time to intervene with the possibility of preventing the expulsion, because the cervical os, the passageway between the uterus and the vagina, remains closed.
Next on the spectrum is an inevitable abortion, which we can include within the realm of pregnancy loss, since inevitable means that the abortion will happen no matter what, because the cervical os is open. Spontaneous abortion also includes a missed abortion, meaning that the embryo or fetus is no longer viable, but the uterus forgot to expel it. This is dangerous, because the products of conception can cause in infection of the uterus, such as endometritis. If the products of conception do not come out on their own soon, doctors need to intervene, medically or surgically, to remove them. An abortion that causes an infection is called a septic abortion (term that can apply either to a spontaneous abortion or an induced abortion, as either can become infected). There also can be an incomplete abortion. In this situation, the embryo or fetus becomes non-viable and is only partly expelled. Pieces remain unexpelled, requiring intervention to protect the mother from potential infection and bleeding. In contrast, there is a complete abortion, in which all products of conception exit the uterus. Often, this requires no intervention other than supportive therapies.
Also, there are numerous cases of ectopic pregnancy, when from the onset of pregnancy, there was no chance at all that the pregnancy would result in an infant. Unless the expulsion of an ectopic pregnancy is spontaneous and complete, doctors must intervene to remove the products of conception to prevent complications that can be fatal to the mother. The same is true in cases of spontaneous abortion, with the exception of a complete abortion. Furthermore, during the second half of pregnancy, there is the possibility of a stillbirth, a situation in which the fetus dies in the womb, and it too may not come out completely, or on its own, leading again to a situation in which the obstetrician-gynecologist must remove the products of conception.
What all of this means is that, to become a board certified ob/gyn, even an an ob/gyn who does not perform elective abortions because of his or her personal beliefs, the trainee must learn how to get products of conception safely out of a woman’s uterus. Learning how to perform abortions of any kind, trainees are learning how to perform elective abortion and how to rescue women from the complications of spontaneous abortion, ectopic pregnancy, and stillbirth. It’s not possible to learn one without the other, because it’s all basically the same set of skills. As a consequence of this reality, some of the new anti-abortion laws going into effect in certain states as a result of the SCOTUS decision would criminalize treatment for ectopic pregnancy and could make any women who vocalizes second thoughts about her pregnancy, if she later suffers a miscarriage or a stillbirth. But even in jurisdictions where laws and prosecutors distinguish better between elective abortion and treatment for miscarriage, ectopic pregnancy, or stillbirth, all pregnant women will be at risk, due to a growing shortage of obstetrical care.