By Rachel Crumpler
Rachel Jensen was excited to embark on the next phase of her training in obstetrics and gynecology — a fellowship in complex family planning in North Carolina.
But when it came time for her to pack her bags and move from Baltimore, Maryland, to the Triangle last summer, Jensen found a legal landscape much different than what she had signed on for.
North Carolina’s increased abortion restrictions took effect July 1, 2023, significantly diminishing abortion access in the state and dropping the time frame for seeking most abortions from 20 weeks of pregnancy to 12 weeks.
“It was a huge blow to myself, to the program, to the patients that we care for,” Jensen said.
Immediately, Jensen worried about how the stricter abortion law would affect her training. The purpose of her two-year fellowship is to build her skills in complex abortion and contraception, with the goal of positioning her as a specialist who’d be brought in on more complicated cases.
Honing those skills is now more difficult in North Carolina, she said, because there are fewer complicated second-trimester abortions. Jensen is providing abortions after 12 weeks of pregnancy only to people who meet one of the state’s exceptions for rape, incest, fetal anomalies and risk to the mother. And even the first trimester procedures she provides require a more challenging two-visit process and legal web than in some nearby states such as Virginia.
Had she known the abortion law would be changing, Jensen said, she would likely not have come to North Carolina, opting instead for a state with more abortion protections where she could learn and practice in a less constrained environment.
Jenna Beckham, an OB-GYN and abortion provider who has been practicing in North Carolina for more than seven years, sees why the state’s abortion restrictions would be a deterrent. If she were making her decision about where to train today, she said, she’d think about North Carolina differently.
Fourteen states now have complete bans on abortion, and even more states have gestational restrictions in place, so new doctors are more often factoring state abortion laws into their decisions about where to train and start their careers.
Abortion restrictions add another layer of complexity to an already difficult transition into advanced practice, Beckham said.
“Our trainees are really supposed to just be learning kind of clear-cut how to take care of patients, and now they’re having to go through these sort of mental exercises of, ‘I think I know what’s the right thing to do, but am I legally allowed to do it?’” Beckham said.
Producing competent providers in North Carolina who are equipped to provide comprehensive abortion care is harder now, Beckham said, which raises concerns about the abilities of the next generation of OB-GYNs. In response, medical schools in North Carolina are making adjustments to ensure adequate training, including more simulation work and arranging training opportunities out of state for hands-on experience in second-trimester abortions.
“We’re worried about these next classes that are coming up that haven’t had adequate exposure and are really monitoring it right now to figure out what we need to do to get folks additional training,” said Beverly Gray, residency director of Duke’s OB-GYN program.
Adjusting training
Brianna Frame, a fourth-year OB-GYN resident in the Triangle, had just days left of her one-month complex planning family rotation and was providing abortion care at a Planned Parenthood clinic the day the Supreme Court issued its Dobbs decision in June 2022.
The landmark ruling triggered increased restrictions in several states, and Frame said she was glad she’d finished that portion of her training before further restrictions were enacted in North Carolina.
Just over a month later, abortion access in the state shrank after a federal judge reinstated North Carolina’s 20-week ban, cutting the limit of time pregnant people have for seeking abortions in the state from the point of fetal viability, which typically occurs between 24 and 26 weeks of pregnancy. Then the gestational limit dropped further after Republican supermajorities in the state General Assembly passed the state’s stricter abortion law, Senate Bill 20, in May 2023 over the objections of medical professionals and a gubernatorial veto.
“I do feel very sad for the residents that are now coming after me — even just the rotation after me — and that their experience was very drastically limited in North Carolina,” Frame said.
Beckham, who teaches and trains residents, said the biggest training gap emerging after a year of Senate Bill 20 is limited exposure to second-trimester abortion procedures. The reduced volume means trainees don’t have as many opportunities to learn and longtime practitioners may struggle to adequately maintain their skills.
Jensen said she performs one dilation and evacuation — a surgical abortion procedure typically performed between 13 and 24 weeks of pregnancy — per week in North Carolina, if that. That’s not enough to build her competency adequately, she said.
Her fellowship program arranges out-of-state opportunities for training and clinical practice, so about once a month Jensen travels two and half hours to a Planned Parenthood clinic in Virginia. Abortion is legal there up to 26 weeks, and she provides care and gains more exposure to second-trimester abortions.
Jensen said she’s grateful for the opportunity to learn in Virginia, but making the trek can be logistically and physically burdensome, as well as disruptive to her clinic duties in North Carolina and her personal life. And she wouldn’t have had to do it before Senate Bill 20.
“I could make arrangements to stay overnight, but that feels honestly like more work than it’s worth, so I usually drive home the same day,” she said. “So it becomes a very, very long day.”
Other North Carolina OB-GYN residents are traveling to help round out their skill sets, but there’s limited capacity for trainees coming from states with restrictive abortion laws to train.
“Even if every resident could get a training license and get it arranged, there’s just not places for them to do all that training, and that shifts the burden unfairly on those programs to train all the residents from the whole Southeast,” Beckham said.
Medical schools have also turned to increased use of simulations to help students pick up the skills, but Frame said there’s no substitute for the hands-on experience.
“Having done second-trimester dilation and evacuation procedures and having had that training pre-Dobbs, simulation is not the same,” Frame said. “I don’t think that just doing simulation would make you a competent and confident physician in performing the care for a patient, especially in the event of an emergency. That comes from sheer numbers and experience.”
Care in jeopardy
Hands-on experience providing abortion care is a crucial component of an OB-GYN’s training, even for physicians who don’t plan on becoming abortion providers, Beckham said.
The medications and procedures for abortion care overlap with other aspects of maternity care, such as miscarriage management, that require the uterus to be evacuated.
“It could be your partner, your sister, your daughter whose water breaks at 18 weeks, and then becomes very sick and infected and septic, or who has a placenta previa — a placenta that’s low-lying that puts them at risk of bleeding — and has an acute hemorrhage at 19 weeks and comes into the hospital,” Beckham said. “The only way to save their life is to do a dilation and evacuation procedure, which is something that you would learn doing primarily abortion care.”
North Carolina has nine OB-GYN residency programs. Four of them participate in the Ryan residency training program, which has a dedicated focus on helping new physicians learn the skills for managing abortions. While the curriculum varies based on the institution, the Accreditation Council for Graduate Medical Education requires all OB-GYN residency programs to provide access to abortion training and recommends a minimum number of procedures performed by trainees.
Gray said trainees in North Carolina are meeting the minimums, but reaching those marks now is harder. She worries that reduced exposure to abortion procedures will result in a dwindling pool of providers equipped to provide care, particularly in emergencies.
Beckham shares that concern.
“Often the instances where second-trimester procedures arise are real emergencies in situations … sometimes in the middle of the night when you’re the only obstetrician in the hospital,” Beckham said.
“If you don’t even have the experience, the competency and the comfort of doing them in planned settings, when … it’s two o’clock in the morning and you have someone who’s hemorrhaging at 18 weeks? I think that the future generations of our physicians are just not going to feel comfortable managing that on their own, and that’s going to be a detriment to patients beyond those who are seeking and needing abortion care.”
Abortion laws factor into decision-making
North Carolina has several highly sought-after medical training destinations, but Gray said that recruiting amid the tighter abortion restrictions is more difficult and affects the talent that will come to the state.
For example, Duke is launching a complex family planning fellowship this year — a program that will be more difficult to operate than when the university received approval for it before the Dobbs decision. The first fellow will start in August, Gray said, but the state’s increased abortion restrictions deterred some candidates.
“The type of person who wants to come here to get training might change,” Gray said. “I understand that. I live here. I would love to be able to provide the care that I’m capable of providing, in my own community.”
That reluctance mirrors a national trend.
Analysis released in May by the Association of American Medical Colleges Research and Action Institute found that for two consecutive years, the number of applicants to residency programs in states with abortion restrictions has dropped. During the 2023-24 application cycle, the number of applicants to residency programs in states with near-total abortion bans declined by 4.2 percent and by 1.9 percent in states with gestational limits, compared with a 0.6 percent drop in states where abortion remains legal.
Notably, the organization tracked a decrease in interest in residencies in states with abortion restrictions across a range of specialties, not just among those most likely to treat pregnant patients like OB-GYNs and emergency room doctors.
Catherine Kuhn, Duke University’s associate dean for graduate medical education, monitors these trends closely. She said it makes sense for medical residents to factor abortion laws into where they go, considering their demographics.
“They themselves are at peak childbearing age — and if not the resident themself, their spouse or their significant other — and are considering what would happen if they got pregnant while they were in the state,” Kuhn said.
“They can’t really juggle their schedules around,” she said, noting that medical residents are usually pressed for time. “Most residents have a lot of debt and have limited financial resources, so trying to go to another state and pay for an abortion or whatever is untenable.”
Despite restrictions, programs are filling up, as there are still more applicants than residency slots. But since a large portion of the country’s programs are in states with abortion restrictions, Gray worries that the overall variation of providers’ training and skills will become more pronounced over time.
After training: Stay or go?
After people complete training in North Carolina, they will then have to decide whether to stay and practice or seek a less restrictive state. Decisions are mixed.
Frame, who plans to be an OB-GYN generalist, said she will likely stay in North Carolina after she graduates, despite the restrictions. The legal landscape is certainly a strike against staying, she said, but her ties in the community and proximity to family will likely outweigh it.
But Jensen, who will have put two years into gaining increased training around abortion care when she concludes her fellowship next year, doesn’t plan on staying.
“It’s hard because I really found a wonderful community of people here in North Carolina,” Jensen said. “But professionally, it probably doesn’t make sense for me to do that, and so I will definitely be considering going to a less restrictive state for my next move.”
Decisions like Jensen’s may become more frequent and have ripple effects on the workforce and patient care in the coming years, particularly as North Carolina already faces a physician shortage and maternity care deserts.
“If medical students, residents and people choosing jobs don’t feel like they can learn, practice, teach and provide the full spectrum of care if it’s restricted, then you lose out on the best and the brightest because they want to go places that will offer them everything,” said Matt Zerden, an OB-GYN and abortion provider in North Carolina.
“I worry that it’s going to contribute to a brain drain, or prevent smart, talented folks from coming here.”
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