by Cerisa Obern, Emmanual Morhe, Kristina Gemzell-Danielsson, Jody Steinauer
International Journal of Gynecology & Obstetrics, 16 June 2024 (Open access)
https://doi.org/10.1002/ijgo.15733
Abstract
Since 2020, World Health Organization guidelines state that universal access to abortion care is critical for individual and community health, and for the realization of human rights. Yet the right to access safe abortion care is severely restricted in many countries. This article outlines institutional and educational systems in the USA, Sweden, and Ghana, which all require obstetrics and gynecology (ob-gyn) training to include abortion care but vary in implementation. It argues that regardless of the political environment, the specialty should protect abortion training worldwide. In Sweden and Ghana, ob-gyn residents are required to participate in abortion training, while in the USA they are permitted to opt out. In Sweden, practicing ob-gyn specialists are required to provide abortion care, whereas in Ghana and the USA, this care is optional, leading to geographic disparities in abortion care access in these two countries. In the USA, the Supreme Court’s Dobbs ruling jeopardizes programs’ abilities to meet the training mandate, a requirement that was insufficiently implemented even before the ruling. It is critical that all clinicians are well-equipped to provide accurate information to their patients and provide pre- and post-abortion care. For this reason, we recommend that abortion is included in all undergraduate medical education programs in accordance with the recommendations of FIGO (the International Federation of Gynecology & Obstetrics). To meet WHO guidelines that require ob-gyn specialists to provide abortion care in an emergency, we urge FIGO to create a guideline about expectations for abortion training integration in obstetrics and gynecology.
Introduction
Since 2020, World Health Organization (WHO) guidelines state that universal access to abortion care is critical for individual and community health, and for the realization of human rights. Yet the right to access safe abortion care is severely restricted in many countries. This right is of great importance for the 73 million people who annually undergo induced abortions worldwide. Access to abortion is inversely linked with the number of unsafe abortions, which can lead to permanent injury or death.
FIGO (the International Federation of Gynecology & Obstetrics) clearly states that an individual obstetrics and gynecology (ob-gyn) physician’s right to their own beliefs about abortion must not negatively affect patient care and that they must provide abortion care in the setting of an emergency when no one else can provide the care. WHO says that all who have the skills to provide abortion care must provide the services in urgent and emergent situations, even if they otherwise would object to providing care based on their conscience. Therefore, all ob-gyn physicians must learn abortion skills so that they can provide life-saving care if necessary. In 2023, FIGO, in collaboration with the International Federation of Medical Students Associations and the World Association of Trainees in Obstetrics and Gynecology, published guidelines for undergraduate medical education. They stated that all medical students should learn about abortion as part of their comprehensive sexual and reproductive health training so that they can counsel and refer patients, and provide pre- and post-abortion care, in accordance with their countries’ laws and the scope of their clinical practice. Three countries, the USA, Sweden, and Ghana, all currently offer abortion care training to their ob-gyn residents, varying from compulsory to optional. This article seeks to outline three distinct institutional and educational systems that exist in these countries and argues that regardless of the political environment, the ob-gyn specialty should continue to protect and support the institutions and educational systems worldwide that offer abortion care training.
1. Abortion rights are under threat in the USA. Educational institutions should continue to safeguard abortion care training
….
2. Sweden’s institutional system obliges those involved in women’s health to provide abortion care
In contrast to the US approach to training, in Sweden it is obligatory that ob-gyn residents and midwives learn to provide abortion care. This aspect of professional identity is supported by a system that requires all healthcare professionals involved in women’s health to ensure swift and safe access to abortion….
3. Ghana created a formal program to legitimize the specialty and increase access to abortion
Despite Ghana having the second most liberal abortion law in sub-Saharan Africa, abortion care still faces a number of challenges. First, the apparent ambiguity of the law and its inclusion in the colonial era criminal code cause confusion when enforcing policy to provide abortion care to the full extent of the law. Second, there is a scarcity of healthcare providers who will offer comprehensive abortion care. Third, there is sparse accurate information about the legality and availability of abortion care in the country. Fourth, men are often recognized as the primary decision makers regarding the fertility choices of couples. Lastly, stigma exists around both seeking and providing abortion care.
The interpretation of the law can offer flexibility and a more liberal inclusion, or hinder healthcare providers from understanding the breadth of circumstances under the law that allow for an abortion. Over the years, abortion prosecutions have been very rare or non-existent in the country’s law reports. Indeed, the country has made some progress in improving access to abortion care.
In Ghana, abortion has been liberalized since 1985 and is permitted in cases of rape, defilement, incest, fetal abnormalities incompatible with life, or where continuation of the pregnancy poses a risk to the woman’s life, and physical or mental health. Ghana signed the Cairo (1994) Consensus on definition and scope of reproductive health. In 2003, Ghana adopted a policy strategy to provide abortion care to the full extent of the law to reduce preventable maternal morbidity and mortality from unsafe abortion.
The Ghana Health Service highlighted safe abortion as one of five components of reducing maternal morbidity and mortality intervention. Despite this distinction, research indicates that policy makers do not regularly disseminate updated CAC standards and protocols. Many practitioners and healthcare providers are not aware of current policy and practice guidelines, with one study finding as many as half of all healthcare providers unaware of the legality of abortion.
Nonetheless, the CAC standards and protocols have been progressively revised to address many of the issues commonly raised by researchers; notably gestational age limit, the definition of “mental health” and legal service providers. Most of the revisions follow the WHO guidelines that were modified to suit the local situation. This created an enabling environment for training various cadres of healthcare professionals in support of task-sharing, a key strategy adopted to improve access to care….
[Each section above and the article as a whole continue at length and are full of useful information.]