On paper, it should not be difficult for Dr Sebastian Ramos to learn to perform abortions. As a family medicine doctor, Ramos works in a specialty that frequently provides the procedure. He lives in deep-blue California, where it is still allowed. And the administrators running Ramos’s residency program – a kind of apprenticeship that US doctors must undergo to become full-fledged physicians – support Ramos’s desire to learn how to do it.But over the course of his three-year-long residency, Ramos is guaranteed just three days’ worth of training at Planned Parenthood. Residents get to participate in only a handful of abortions.“That’s just not enough if you want to practice abortion care,” said Ramos, who asked to go by a shortened version of his last name to protect his privacy. “I knew that if I wanted to do this, I needed more experience.”That’s why, earlier this month, Ramos traveled to a clinic in Mexico City for two weeks’ worth of training in abortion provision. During his first week at the clinic, which is run by the global organization MSI Reproductive Choices and its Mexican arm Fundación MSI, Ramos performed roughly 60 abortions.In the years since the US supreme court overturned Roe v Wade, paving the way for more than a dozen states to ban virtually all abortions, a small but growing number of would-be abortion providers have begun to leave the country in search of an education. In 2023, MSI trained nine American doctors to perform abortions at clinics in Mexico. In 2024, it trained 27. So far this year, it is on track to double that number.View image in fullscreen“On one hand, it’s a tremendous relief to know that medical students and residents aren’t going to have to forego this very important part of their training in their education,” said Pamela Merritt, executive director of Medical Students for Choice. Last year, Merritt’s organization helped eight medical students and residents receive abortion training in Mexico and the UK.Merritt continued: “It’s also incredibly sad that in the United States, we are failing to train people even to the standard of care indicated by abortion bans.”Every abortion ban in the US permits abortions to save a patient’s life. But without adequate training, doctors may not be skilled enough to perform abortions even in those dire circumstances.‘It’s a shame’Medical schools and residency programs are run by massive hospitals that are heavily dependent on public funding; such institutions tend to be, by nature, leery of anything as controversial as abortion. The Accreditation Council for Graduate Medical Education (ACGME) has required OB-GYN residencies to teach doctors how to perform abortions since the 1990s, but rather than offer training in-house, hospitals have often farmed their residents out to freestanding abortion clinics for training.Even before Roe fell, this system was faulty: a 2019 study found that, despite the ACGME requirement, just 64% of OB-GYN residency programs offered “routine training with dedicated time” for abortions. Family medicine residents who want to learn to perform abortions face a greater disadvantage, since the ACGME does not require their residency programs to offer any kind of abortion training.View image in fullscreenEven most OB-GYN residents, program directors reported in the 2019 study, did not achieve what doctors call “competency” when it came to abortion. Without competency – a qualification that’s measured through a melange of doctors’ knowledge, skills and attitudes – doctors may not be able to safely perform abortions on their own.Abortion training and competency is now even harder to come by. Since Roe’s collapse, more than 100 abortion clinics have closed. Those that are left are often besieged by patients fleeing abortion bans, leaving them without the time and space to teach everybody who wants to learn.If an OB-GYN residency program is located in a state that bans abortion, ACGME rules currently dictate that the residency “must provide access to this clinical experience in a different jurisdiction where it is lawful”. The ACGME declined to respond to a request for information about how many residency programs are currently compliant with its abortion-training requirement, although records show that no OB-GYN programs have lost their accreditation status in the last year. Patricia Lohr serves as the director of research and innovation for the British Pregnancy Advisory Service (Bpas), a UK non-profit that provides abortions up until about 24 weeks of pregnancy. Lohr trained to become an OB-GYN in the US. “Having been a resident and a medical student in the United States, I could really see the importance of having access to abortion education that wasn’t entirely reliant on what was being delivered within academic training programs,” Lohr said. “Because often, abortions weren’t being provided in those academic hospitals.”View image in fullscreenWhen Lohr moved to the UK, she quickly moved to create a two-week training program at Bpas where medical students could learn about abortions and observe – but not perform – the procedure. In the years since Roe fell, that training program has received a surge of applications from American medical students and residents.“It’s a shame that people would have to travel to learn a basic part of women’s health care,” Lohr said. “There are many trainees out there at the moment who would like to obtain abortion skills, but cannot get it locally, and so they get diverted into doing something else.”Lauren Wiener, a New Jersey medical student, had originally planned to travel to Arizona in summer 2022 to learn how to provide abortions. But when Roe’s fall led Arizona abortion providers to temporarily stop working, Wiener had to cancel her trip. Instead, she ended up undergoing a week-long training at Bpas last fall.“It is something that you need to know how to do, because there are emergency situations,” Wiener said of abortions. “You might not want to electively perform an abortion at 24 weeks, but if someone comes in and they’re miscarrying, you need to know how to evacuate that uterus. It’s a skill you need to have to save a life.”‘We will be there’While training in the US dwindles, the country’s increasingly conservative approach to abortion has also put it at odds with much of the rest of the world. Only four countries – including the US – have tightened their abortion laws over the last 30 years, while more than 60 countries and territories have loosened theirs, according to a tally by the Center for Reproductive Rights.Mexico is one of them. In 2023, its supreme court decriminalized abortion nationwide; the procedure is now available in about half of all Mexican states. And providers aren’t the only people taking advantage of Mexico’s liberalized abortion laws: last year, Fundación MSI provided first-trimester abortions to 62 women from the United States.“Training, training, training – it is key, to have less danger for actual patients,” said Araceli López-Nava, managing director of MSI Latin America. “We understand how difficult the situation is becoming in the US, so we’re happy to help.”The organization has the capacity to train up to 300 doctors a year to perform abortions, López-Nava estimated.View image in fullscreenMSI is not, however, a solution for everybody. Would-be trainees need to speak Spanish. And although the organization has in past years trained medical students, MSI’s Mexico clinics have started focusing on teaching residents who have already performed 20 abortions. Because residents have already chosen their specialties and secured berths in residency programs – which can be highly competitive – they are more likely to become abortion providers.Training in Mexico can also be pricey, especially since the program does not pay for travel and lodging. Ramos’s entire trip cost about $5,000, although a scholarship helped him cover most of the costs.“It’s a way, at least for me, to be exposed to a different medical system, learn from different providers from a different country, exchange knowledge,” Ramos said. “I feel like I’m being adequately prepared to meet the needs of my patients in the US.” More
