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Family planning training at Catholic and other religious hospitals: a national survey
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Family planning training at Catholic and other religious hospitals: a national survey Maryam Guiahi, MD, MSc; Stephanie Teal, MD, MPH; Kimberly Kenton, MD, MS; Julie DeCesare, MD; Jody Steinauer, MD, MPH
BACKGROUND: Catholic and other faith-based hospitals often restrict
family planning service provision based on institutional doctrine. Approximately 11% of US accredited obstetrics and gynecology residency programs occur at such hospitals, creating a challenge to educational leaders who must ensure comprehensive family planning training. OBJECTIVE: To evaluate and summarize family planning training at obstetrics and gynecology residency programs that are affiliated with Catholic and other faith-based hospitals that restrict reproductive services. MATERIALS AND METHODS: Using an online database search and survey screening questions, we identified 30 of 278 accredited 2017e2018 programs in which at least 70% of resident time is spent in faith-based hospitals that restrict family planning services; Jewish programs were excluded. We queried program leaders between March 2017 and April 2018 about education and training using an online or paper survey, and asked them to report on training settings, provision of family planning services in such settings, and to rate aspects of training as “poor,” “adequate,” or “strong.” We compared responses at Catholic versus other faith-based programs using Fisher exact tests, c2 analyses, and median tests. RESULTS: Among 30 programs, 25 responded (83%); the majority of respondents were program directors (88%) and represented Catholic hospitals (76%). All reported adequate contraceptive training, with 47% of Catholic programs relying on off-site locations. The majority of Catholic sites (84%) relied on off-site sterilization training sites. Survey respondents
R
esidency training in obstetrics and gynecology is aimed at developing physicians with expertise in all aspects of women’s healthcare. Since 1996, the Accreditation Council for Graduate and Medical Education (ACGME) has recognized that family planning and abortion training are essential components of training, and have set forth an expectation that all obstetrics and gynecology residency programs, regardless of their institutional affiliation, provide comprehensive training as part of
Cite this article as: Guiahi M, Teal S, Kenton K, et al. Family planning training at Catholic and other religious hospitals: a national survey. Am J Obstet Gynecol 2019;XX:x.ex-x.ex. 0002-9378/$36.00 ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ajog.2019.09.012
from Catholic programs most commonly endorsed concerns for inadequate training in postpartum tubal ligations (53% of Catholic respondents versus 0% of other faith-based program respondents, P ¼ .05). Approximately one-half (56%) offered abortion training as part of the curriculum (“routine”), 32% offered residents the opportunity to arrange training (“elective”), and 12% did not offer; the majority (84%) relied on off-site collaborations. Catholic sites were more likely than other religious programs to report poor abortion training (47% versus 0%, P ¼ .04). Five Catholic programs (26% of Catholic programs) reported that their residents did not meet the graduate training requirement for completion of 20 dilation and curettage procedures. One-third reported a prior Residency Review Committee family planning citation(s), and many commented that these citations helped provide leverage for improved training. CONCLUSION: Although Catholic and other restrictive, faith-based obstetrics and gynecology residency training programs have developed strategies in response to institutional restrictions, many report ongoing deficiencies, and almost one-half reported they were noncompliant with abortion training requirements. Programs with deficient trainings may benefit from strategic approaches, including enhanced onsite education and collaborations with off-site facilities. Key words: Catholic, contraception, faith-based, family planning,
gynecology/education, induced abortion, obstetrics and gynecology, religious hospitals, residency, resident education
their planned curriculum (“routine training”).1 ACGME also recognizes that those residents with religious or moral objections to abortion training may decline (“opt-out”).1 Multiple studies have since demonstrated that incorporation of adequate residency training is a key predictor of later provision of family planning services.2e5 A recent national survey of obstetrics and gynecology residency programs found that directors at religiously affiliated programs were more likely to report abortion training restrictions, often secondary to hospital policies.6 Catholic hospitals are expected by the United States Conference of Catholic Bishops to follow the Ethical and Religious Directives for Catholic Health Care Services, which restricts not only abortions but also most contraceptive and sterilization services.7 Many obstetrics and
gynecology residency programs rely on training at faith-based hospitals,8 and the proportion may increase as Catholic healthcare systems increasingly acquire non-Catholic hospitals and as more osteopathic programs transition to ACGME status. In our survey of educational leaders at religious hospital training programs, we aimed to delineate the current provision and adequacy of family planning training, and to highlight strategies and training gaps so as to inform best practices in these settings.
Materials and Methods To identify US ACGME-accredited obstetrics and gynecology allopathic programs that primarily train residents at religious hospital(s) that have institutional restrictions to family planning services (termed “restrictive, faith-based hospitals”), we examined all obstetrics
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AJOG at a Glance Why was this study conducted? To understand how Catholic and other religious hospital training programs provide comprehensive family planning training to their residents, despite institutional restrictions to service provision. Key findings Catholic programs were more likely than other religious hospital training programs to rely on partnerships with other healthcare facilities to achieve contraception and sterilization training. The majority of religious hospital training programs relied on off-site healthcare facilities to provide abortion training. Educational leaders at Catholic programs most commonly endorsed concerns for inadequate training in postpartum sterilization and abortion methods. Onefourth of Catholic programs reported that all of their residents do not meet the minimum Residency Review Committee requirement for completion of 20 dilation and curettage procedures, and 37% reported prior family planning citations. What does this add to what is known? This study provides a more in-depth understanding of the limitations to training in contraception, sterilization, and abortion that occur at Catholic hospital obstetrics and gynecology residency training programs compared to other religious hospital training sites.
and gynecology programs listed in the Fellowship and Residency Electronic Interactive Database (FREIDA) online site as part of the American Medical Association database.9 This database provides information about sponsoring institutions in which residents train and, at the time of review (2016), acknowledged religious ownership of training hospitals. We also cross-referenced the primary hospital’s website to confirm religious affiliation. In addition, we relied on data from a recent national survey,6 input from educational policy consultants at the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning program, and other educational stakeholders. We excluded Jewish hospital training programs because we were unaware of institutional restrictions to reproductive service. We chose to enrich our pool of respondents with programs that face primarily religious institutional restrictions to family planning care, as opposed to other programs that may also face state-specific restrictions to reproductive care or those that have adequate time at a nonCatholic site. To do so, we included only programs that reported at least 70%
of resident training at a restrictive, faithbased hospital(s) in survey screening responses, as we assumed that this would be a marker for working primarily in a religious setting without sufficient opportunities to otherwise receive family planning training. Between March 2017 and April 2018, we contacted residency program directors by e-mail as listed by FREIDA Online, with an invitation to participate in an online survey; each program director received up to 3 requests and was provided a $40 gift card for survey completion. We informed potential participants that the survey was voluntary and that they did not need to report their name or program name. If we did not get a response, we sent a paper survey with a self-addressed envelope and a $10 gift card as incentive with the remainder of the incentive provided upon completion. If we still did not obtain a response, we subsequently recruited other relevant program leaders at these sites that are physicians and involved in medical education (eg, associate program directors) using e-mail addresses found on publicly available websites. The University of Colorado Multiple Institutional Review
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ajog.org Board deemed this study exempt based on minimal risk to participants. Based on review of prior surveys and input from all the authors who have each served educational roles in graduate medical training, we created a survey that consisted of 43 discrete questions that incorporated branching logic and 5 additional open-ended questions. We first assessed survey eligibility by addressing program characteristics including the percentage of time spent at faith-based hospitals. If eligible, we asked participants to rate how important they believed it was to be compliant with the ACGME family planning and abortion requirements; to assess, we used a 5point Likert scale (1 ¼ unimportant, 2 ¼ of little importance, 3 ¼ somewhat important, 4 ¼ important, 5 ¼ very important). We similarly asked representatives at Catholic programs to report how important it was to be compliant with the Ethical and Religious Directives for Catholic Health Care Services, which are institutional guidelines that they are expected to follow. We inquired about any prior Residency Review Committee citations relevant to family planning. We surveyed family planning educational activities, including formal lectures and simulation sessions and whether residents receive formalized industry training with respect to contraceptive implants. We then assessed contraceptive training by inquiring about the outpatient clinical site in which their residents obtain most of their clinical contraceptive training and the methods available for contraceptive indications. We also inquired about sterilization, abortion, and ectopic pregnancy procedures that are routinely provided at the primary faith-based hospital site, and whether any special circumstances allowed for approval. ACGME sets forth a minimum requirement of 20 “abortion” procedures prior to graduation.10 To assess this, we inquired about the percentage of residents who complete 20 D&C procedures prior to graduation and did not specify whether they were for induced or spontaneous abortions, as ACGME does not specify. We also inquired about off-site locations where residents gain
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FIGURE 1
Program recruitment. Description of recruitment of education representatives in obstetrics and gynecology residency programs in which residents spend more than 70% of time at faith-based hospitals Review of American Medical Associaon website, hospital websites, and input from educaonal consultants idenfied 48 programs associated with religious hospitals
8 Jewish programs 4 nonreligious programs 5 spend <70% of me at religious hospital 1 Osteopathic program
30 ACGME obstetrics and gynecology residency programs that spend more than 70% of resident me within restricve faith-based hospitals
25/30 completed survey (83% response rate) 19 Catholic sites 6 non-Catholic sites
5/30 non-respondents (17% nonrespondent rate) 3 Catholic sites 2 non-Catholic sites
ACGME, Accreditation Council for Graduate Medical Education. Guiahi et al. Family planning training at religious hospitals. Am J Obstet Gynecol 2019.
additional training. Participants were asked to self-assess trainings as either “strong,” “adequate,” or “poor.” After each training section, we asked, using open-ended queries, whether they had any additional comments. Our online survey ended with participant questions, including religious characteristics. All survey results were analyzed using SPSS 25 (IBM Corp., Armonk, NY). We first performed descriptive frequencies. With respect to importance of compliance with the religious directives and the ACGME training requirements, we dichotomized based on a Likert value 4 (either “important” or “very important”). As the institutional restrictions
for family planning services are broader at Catholic facilities, we also compared aspects of training at Catholic compared to the other restrictive, faith-based programs using the Fisher exact tests or c2 analyses; we considered a P value of .05 significant. We also compared continuous variables using medians tests. We incorporated any relevant clarifications from open-ended questions.
Results We identified 48 ACGME-accredited programs that may be associated with religious hospitals, for which we excluded 18 sites that did not meet our inclusion criteria (Figure 1). Five
programs were excluded because they spent 50% of time in a religious setting. The 30 eligible programs accounted for 10.8% of the 278 accredited obstetrics and gynecology programs in existence during survey recruitment (2017e2018).11 We successfully recruited 25 of 30 programs (83% survey response rate); 23 completed surveys online, and 2 on paper. The majority of respondents were program directors (88%), 50 years old (84%), and identified as white (80%) and/or non-Hispanic (96.0%). Most (76%) represented programs that train the majority of the time in a Catholic setting. Additional respondent and
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TABLE 1
Respondent and program characteristics in survey of education representatives in obstetrics and gynecology residency programs where residents spend more than 70% of time at faith-based hospitals n ¼ 25
Respondent characteristics Educational Leader position Program Director
88%
Associate Program Director
4%
Chair
4%
Clerkship Director
4%
Years in role, median (range)
3 (1e39)
Male sex
56%
Identifies as Catholic
48%
Attends religious activity at least monthly
40%
Reported “not religious at all”
44%
Important/very important to be compliant with ACGME requirements for family planning
100%
Important/very important to be compliant with ERDsa
90%
Residency program characteristics
n¼25
Number of graduating residents per year, median (range)
4 (2e6)
Percentage of time spent at primary faith-based hospital, median %, (range)
90% (70e100%)
Religious affiliation of primary hospital Catholic
76%
Lutheran
12%
Methodist
8%
Seventh Day Adventist
4%
Reported all graduating residents meet RRC requirement for 20 D&Cs
80%
Reports at least 1 prior RRC citation about family planning
32%
ACGME, Accreditation Council for Graduate Medical Education; D&C, dilation and curettage; ERDs, Ethical and Religious Directive for Catholic Health Care Services; RRC, Residency Review Committee. a
Percentage of Catholic program representatives. Guiahi et al. Family planning training at religious hospitals. Am J Obstet Gynecol 2019.
program characteristics are listed in Table 1. Eight programs (7 Catholic sites, 1 other faith-based site) reported a total of 10 prior Residency Review committee citations. Citations included insufficient sterilization exposure (n ¼ 1), insufficient sterilization and abortion training (n ¼ 2), or insufficient abortion training either because it was unclear/opt-out (n ¼ 2) or because no abortion training was offered (n ¼ 3). These respondents often commented that these citations helped them advocate for improved training.
Over 90% of programs reported formal didactics on short-acting, longacting, and emergency contraceptive methods, and on sterilization, ectopic pregnancy, and miscarriage management. Comparatively fewer provided lectures on natural family planning (64%), barrier methods (72%), and abortion (76%). Procedural simulations were common for long-acting reversible contraceptives: 92% incorporated industry-sponsored implant training, 88% provided simulation for levonorgestrel intrauterine device (IUD); and
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68% provided simulation for copper IUD. With respect to other sterilization and abortion procedures, 36% provided laparoscopic sterilization simulation, 20% provided postpartum sterilization simulation, and 40% provided uterine evacuation simulation. Table 2 describes contraceptive training at the outpatient clinic identified as the primary training site; almost half (47%) of the Catholic programs relied on a clinic not owned by the hospital, whereas the remaining programs relied on a clinic owned by or affiliated with the primary hospital. The majority provided training in all methods, with slight downward trends at Catholic programs for methods considered by the Catholic Church to be abortifacients, despite lack of scientific evidence (eg, emergency contraception [79%] and copper IUD [63%]).12 All programs rated contraceptive training as either adequate or strong. Table 3 demonstrates results related to sterilization training. Most Catholic hospital respondents (79%) reported no onsite sterilization services, whereas other restrictive, faith-based sites reported that they did not have limitations. Most Catholic programs (84%) relied on laparoscopic sterilization training at offsite locations (eg, nearby community hospital, ambulatory surgical center), and the remainder reported that they were unable to facilitate an off-site training location. Although Catholic programs were more likely than others to report inadequate training in postpartum tubal ligations following vaginal deliveries (53% Catholic vs 0% other faith-based programs, P ¼ .05), only 21% of Catholic sites provided off-site postpartum training. One-third of Catholic programs cited poor sterilization training compared to none of the other sites (P ¼ .11). Table 4 describes abortion training experiences. All Catholic sites and many of the other faith-based sites reported onsite restrictions to routine abortion. Catholic hospitals were less likely than other restrictive, faith-based sites to perform abortions for indications such as rape/incest or fetal anomalies. Just over half of the programs (56%)
ajog.org reported that they provided routine, optout training, and 16% of Catholic sites reported no abortion training; 1 cited the reason as being because they are unable to facilitate, and 1 reported that this training was not needed based on adequate exposure during obstetrics rotation. Most (84%) described relying on external family planning clinic sites for abortion training (eg, Planned Parenthood). When off-site training occurred, residents were more likely to obtain first-trimester compared to second-trimester training. Approximately half (47%) of the Catholic programs reported poor abortion training, compared to none of the other sites (P ¼ .04). When we inquired about the Residency Review Committee expectation for completion of 20 D&C procedures prior to obstetrics and gynecology graduation, 80% reported that all graduating residents meet this requirement. Among the 5 that did not, all were Catholic sites (26% of Catholic programs): 1 had recently initiated their program and did not yet have a graduating class of residents, and so reported 0%, 1 cited 30%, and 3 cited 90%. None of the respondents reported ectopic pregnancy restrictions, and all rated such training as adequate (20%) or strong (80%). Only 1 restrictive, faithbased program that was not Catholic reported strong training in all aspects of family planning methods; this program has unrestricted opportunities for contraceptive methods and sterilization provision onsite and an ongoing off-site abortion rotation collaboration.
Comment Obstetrics and gynecology residency programs at restrictive, faith-based hospitals in the United States accounted for approximately 11% of all ACGME programs during our recruitment period, for which we had an 83% response rate.
Principal findings Respondents from Catholic programs expressed broad training concerns that reflected onsite restrictions to contraceptive methods (particularly those deemed by the Catholic Church as abortifacients), tubal ligations, and
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TABLE 2
Contraceptive training in obstetrics and gynecology residency programs where residents spend ‡70% of time at faith-based hospitals, as described by education leaders
Primary site for contraceptive training
Catholic programs (n ¼ 19)
Other faith-based programs (n ¼ 6)
.01b
Relationship between primary site for contraceptive training and hospital Owned by hospital
P valuea
47%
50%
5%
50%
47%
0%
Staffed by core faculty
63%
67%
Residents can opt out of attending
26%
0%
.29
95%
83%
.43
Affiliated with but not owned by hospital Not affiliated/owned by hospital
1.0
Methods available Natural family planning counseling All BC counseling
100%
100%
n/a
Prescription of short-acting methods
90%
100%
1.0
Provision of depot-medroxyprogesterone acetate
90%
100%
1.0
Provision of emergency contraception
79%
100%
.54
Insertion of implant
84%
100%
.55
Removal of implant
95%
100%
Insertion of copper intrauterine device
63%
100%
Insertion of levonorgestrel intrauterine device
84%
100%
.55
100%
100%
n/a
Removal of intrauterine devices
.14
1.0b
Overall rating of contraceptive training Strong
58%
50%
Adequate
42%
50%
0%
0%
Poor
1.0
BC, birth control; n/a, not applicable. a P value based on Fisher exact test; b P value based on c2 analysis. Guiahi et al. Family planning training at religious hospitals. Am J Obstet Gynecol 2019.
abortions. Despite a prior report of ectopic pregnancy care restrictions at some Catholic sites,13 none of our respondents reported training concerns. Our findings add to the growing body of literature that demonstrates that family planning service restrictions exist in Catholic healthcare settings, but that specific restrictions often vary across settings and are not always consistent with the institutional directives.14 Among the remaining restrictive, faithbased programs, training concerns were limited to abortion services secondary to onsite restrictions.
Results In a recent national survey of obstetrics and gynecology residency programs, Steinauer et al reported that 64% reported routine training with dedicated time, 31% optional, and 5% not available, but did not find a difference between those respondents who stated that they were at a religious hospital (27 programs) vs other respondents.15 Our study of religious training sites found a lower rate of routine abortion training (56%) and higher rate of no abortion training (12%). These differences may be accounted for by our strict inclusion
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TABLE 3
Sterilization training in obstetrics and gynecology residency programs in which residents spend ‡70% of time at faith-based hospitals, as described by education leaders Catholic programs (n ¼ 19)
Other faith-based programs (n ¼ 6)
P valuea
On-site sterilization training 0%
100%
<.001
21%
100%
.001
0%
100%
<.001
0%
83%
<.001
79%
0%
.001
Postpartum vaginal delivery
21%
17%
1.0
Postpartum cesarean delivery
26%
17%
1.0
Interval laparoscopic sterilization
84%
33%
.03
Interval hysteroscopic sterilizationb
53%
33%
.64
53%
0%
.05
Postpartum vaginal delivery Postpartum cesarean delivery Interval laparoscopic sterilization Interval hysteroscopic sterilization No sterilizations performed
b
c
Sterilization training at off-site location
Inadequate sterilization training Postpartum vaginal delivery Postpartum cesarean delivery
21%
0%
.54
Interval laparoscopic sterilization
16%
0%
.55
Interval hysteroscopic sterilizationb
47%
33%
.66 <.001c
Overall rating of sterilization training Strong Adequate Poor
0%
67%
68%
33%
32%
0%
P value based on Fisher exact test; Hysteroscopic sterilization methods were available at the time of this assessment; c P value based on c2 analysis. Guiahi et al. Family planning training at religious hospitals. Am J Obstet Gynecol 2019.
a
b
criteria, which ensured at least 70% of time at a restrictive, faith-based hospital and because we excluded Jewish hospital sites. By surveying the range of family planning services, we were also better able to delineate the impact of institutional restrictions on contraceptive and sterilization services, which have largely been missed in prior family planning program surveys. Our findings that Catholic program leaders have concerns, particularly for inadequate sterilization and abortion training, is consistent with prior reports. Residents at faith-based programs previously reported lower rates of competency in such methods compared to their peers, despite similar intentions for
provision, suggesting that the majority do not intentionally seek out religious programs because they reflect their religious values or practice goals.8 Graduates from Catholic programs have also reported delayed competency in methods such as postpartum tubal ligation and low provision of abortion counseling or services, despite interest.16 Although some programs were able to compensate with off-site training in abortion, we found few established offsite collaborations for postpartum tubal ligations.
Clinical implications Our survey highlights the tension that restrictive, faith-based programs,
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particularly at Catholic sites, face in complying with institutional restrictions to care and also meeting the ACGME requirement for family planning training. When Catholic program leaders were asked about how important it was to be compliant with both the religious directives and the ACGME requirement, the overwhelming majority (90%) reported it was “important” or “very important” to meet both, despite the contradictions that these requirements pose. Although we did not define “importance” and recognize it may have been invariably attributed to concerns such as maintaining employment or receiving a program citation, these findings highlight the difficult position that these leaders are in and the need for support in finding opportunities to accomplish training. Our findings support the implementation of best practices to include enhanced onsite education with specific didactics and simulations on reproductive topics and off-site procedural training to address deficiencies in training. Both of these strategies ensure that learning and training objectives are met without direct violation of institutional guidelines. In our cohort, many respondents voiced concerns about abortion training, yet 24% did not provide formal didactics. Improving onsite education with didactics and simulations has proved successful in these settings. A 1-day session at Loyola University Medical Center in Maywood, IL, that incorporated lectures from external family planning specialists and family planning simulation sessions resulted in improved knowledge, both immediately and 10 months later.17 A contraceptive simulation laboratory18 developed at Saint Joseph Hospital in Denver, CO, similarly resulted in improved knowledge and included an abdominal postpartum tubal ligation simulation, which may be of benefit for programs that struggle to gain off-site training. As some residents may seek a Catholic residency program because it is in line with their own religious beliefs, Catholic programs should also strengthen education on acceptable methods; in our study, 32% of Catholic
ajog.org programs did not provide a lecture on natural family planning. Although graduates from programs that trained primarily at Catholic hospitals have reported that educational activities improved their family planning knowledge and counseling skills, they also reported that such exposure was insufficient for procedural competency.16 Off-site collaborations with high-volume family planning centers are needed to ensure that residents have exposure to procedures and opportunities to participate when desired in order to achieve procedural competency. In Denver, CO, a unique collaboration was formed between the Saint Joseph residency program (a Catholic hospital) and the University of Colorado program (a nearby secular hospital) with the assistance of a Kenneth J. Ryan Residency Training Program in Abortion and Family Planning training grant.19 Replication of this model by other programs would improve the proportion of residents at Catholic and other faith-based hospitals who receive adequate family planning training.
Research implications Future qualitative work should focus on exploring strategies and workarounds used to improve training at Catholic sites, and also to describe ongoing barriers. We chose not to inquire about miscarriage management, as residents in a prior survey did not suggest concerns.8 However, our survey found that onefifth of programs surveyed did not think that all of their residents would complete 20 D&C procedures prior to graduation, suggesting that there may be limitations to miscarriage training that were missed. Other aspects of reproductive health training, including infertility care, should also be explored.
Strengths and limitations We recognize that concerns exist over a lack of comparison of respondents from nonreligious hospital training programs. Our decision to do this was intentional for several reasons. First we were aware
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TABLE 4
Abortion training in obstetrics and gynecology residency programs in which residents spend ‡70% of time at faith-based hospitals, as described by education leaders Catholic programs (n ¼ 19)
Other faith-based programs (n ¼ 6)
P valuea
Onsite abortion training Medication abortion
0%
17%
.24
First-trimester D&C in operating room
0%
50%
<.01
First-trimester D&C in outpatient setting
0%
0%
n/a
Second trimester D&E in operating room
0%
17%
Second trimester D&E in outpatient setting
0%
0%
Second trimester induction termination
0%
17%
.24
100%
50%
<.01
No abortions for nonmedical reasons
.24 n/a
Onsite abortion exceptions 0%
50%
<.01
Threat to life secondary to pregnancy complication
95%
83%
.43
Threat to life secondary to maternal disease
68%
83%
. 63
Fetal anomalies compatible with life
0%
67%
<.01
11%
83%
<.01
Rape/incest
Fetal anomalies incompatible with life
.41b
Abortion training Routine/opt out
58%
50%
Elective/opt in
26%
50%
None
16%
0%
Medication abortion
68%
100%
.28
First-trimester D&C in operating room
37%
100%
.02
First-trimester D&C in outpatient setting
63%
100%
.14
Second trimester D&E in operating room
21%
100%
<.01
Second trimester D&E in outpatient setting
37%
83%
.07
Second trimester induction termination
16%
50%
.13
Off-site abortion training
Guiahi et al. Family planning training at religious hospitals. Am J Obstet Gynecol 2019.
(continued)
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Conclusion TABLE 4
Abortion training in obstetrics and gynecology residency programs in which residents spend ‡70% of time at faith-based hospitals, as described by education leaders (continued) Catholic programs (n ¼ 19)
Other faith-based programs (n ¼ 6)
P valuea
Report of inadequate training Medication abortion
32%
17%
.64
First-trimester D&C in operating room
21%
0%
.54
First-trimester D&C in outpatient setting
32%
50%
.63
Second trimester D&E in operating room
63%
33%
.35
Second trimester D&E in outpatient setting
68%
50%
.63
Second trimester induction termination
37%
0%
.14 .09b
Overall rating of abortion training Strong
11%
33%
Adequate
42%
67%
Poor
47%
0%
D&C, dilation and curettage; D&E, dilation and evacuation; n/a, not applicable. a P value based on Fisher exact test; b P value based on c2 analysis. Guiahi et al. Family planning training at religious hospitals. Am J Obstet Gynecol 2019.
of prior and evolving evidence15 about induced abortion for all US obstetrics and gynecology residency programs. Second, we did not suspect, and were unaware of, significant institutional restrictions to contraceptive and sterilization services at nonreligious sites; however, as little is known about family planning provision in religious sites that are not Catholic, we wanted to explore provision of these services. The significant differences in contraceptive and sterilization training between Catholic and the other faith-based programs were important to report, despite the small numbers. These findings highlight the severity of restrictions to comprehensive family planning training at Catholic sites, and provide evidence that institutional restrictions on family planning seem otherwise to be limited to abortion care in other religious hospital settings; such information is relevant to applicants of obstetrics and gynecology residencies. Furthermore, we were
interested in obtaining an in-depth understanding of how Catholic and other faith-based sites overcome institutional barriers to graduate medical training. Our survey of educational leaders provides a better understanding of how religious programs navigate conflicting demands, and also highlights training deficiencies. Although educational stakeholders, such as the program directors surveyed, may have a conflict of interest and inaccurately self-report, we believed that such representatives were the best sources of case numbers and training provision. Among the few respondents who were not program directors, each had significant educational roles (eg, associate program director, former program director) making their inputs relevant. We also benefited from a high response rate, but cannot comment on nonrespondents who potentially have even lower rates of training.
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The Residency Review Committee is expected to ensure that all residents, irrespective of institutional affiliation, are offered comprehensive training in family planning. We found that almost half of respondents reported noncompliance with the ACGME requirement for abortion routine training, even though this guideline was first implemented in 1996. At present, the only procedural requirement related to family planning services that is assessed in the Program Information Form is the requirement for 20 abortions/D&C procedures prior to graduation; 5 Catholic programs (26%) had concerns for meeting this requirement. The Residency Review Committee may need to consider better measures to flag inadequate family planning training, particularly at Catholic sites, including measures of procedural training in IUDs, postpartum sterilization, and improved abortion training assessments. Programs that reported prior Residency Review Citations reported that these citations often helped them argue for improved training, and thus may be of benefit to programs that face deficiencies. If adequate training is not ensured, the harm ultimately falls on the women in the United States who seek out these physicians when they need these common reproductive services. n References 1. Accreditation Council for Graduate Medical Education Review Committee for Obstetrics and Gynecology Clarifications of Program Requirements. Available at: http://www.acgme. org/acgmeweb/Portals/0/PFAssets/Program Requirements/220obstetricsandgynecology0101 2008.pdf. Accessed March 20, 2019. 2. Allen RH, Raker C, Steinauer J, Eastwood KL, Kacmar JE, Boardman LA. Future abortion provision among US graduating obstetrics and gynecology residents. Contraception 2004;81: 531–6. 3. Steinauer J, Landy U, Filippone H, Laube D, Darney PD, Jackson RA. Predictors of abortion provision among practicing obstetriciangynecologists: a national survey. Am J Obstet Gynecol 2008;198:39. 4. Steinauer JE, Landy U, Jackson RA, Darney PD. The effect of training on the provision of elective abortion: a survey of five residency programs. Am J Obstet Gynecol 2003;188: 1161–3.
ajog.org 5. Dalton VK, Harris LH, Bell JD, et al. Treatment of early pregnancy failure: does induced abortion training affect later practices? Am J Obstet Gynecol 2011;204:493. 6. Turk JK, Landy U, Chien J, Steinauer JE. Sources of support for and resistance to abortion training in obstetrics and gynecology residency programs. Am J Obstet Gynecol 2019;22:156. 7. United States Conference of Catholic Bishops. Ethical and religious directives for Catholic health care services, sixth edition. 2018. Available at: http://www.usccb.org/ about/doctrine/ethical-and-religious-directives/ upload/ethical-religious-directives-catholic-healthservice-sixth-edition-2016-06.pdf. Accessed May 28, 2019. 8. Guiahi M, Westhoff CL, Summers S, Kenton K. Training at a faith-based institution matters for obstetrics and gynecology residents: results from a regional survey. J Grad Med Educ 2013;5:244–51. 9. FREIDA, the AMA Residency & Fellowship Database 2015. Available at: https://freida.amaassn.org/Freida/#/. Accessed March 7, 2019. 10. Minimum Numbers: Obstetrics and Gynecology, Review Committee for Obstetrics and Gynecology. 2018. Available at: https://www.acgme.org/Portals/0/PFAssets/ ProgramResources/220_Ob_Gyn_Minimum_ Numbers_Announcement.pdf?ver¼2018-0625-104354-993. Accessed August 29, 2019. 11. Accreditation Council for Graduate Medical Education. Number of accredited programs,
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2017-2018. Available at: https://apps.acgme. org/ads/Public/Reports/ReportRun. Accessed March 20, 2019. 12. Rivera R, Yacobson I, Grimes D. The mechanism of action of hormonal contraceptives and intrauterine contraceptive devices. Am J Obstet Gynecol 1999;181:1263–9. 13. Foster AM, Dennis A, Smith F. Do religious restrictions influence ectopic pregnancy management? A national qualitative study. Womens Health Issues 2011;21:104–9. 14. Thorne NB, Soderborg TK, Glover JJ, Hoffecker L, Guiahi M. Reproductive health care in Catholic facilities: a scoping review. Obstet Gynecol 2019;133:105–15. 15. Steinauer JE, Turk JK, Pomerantz T, Simonson K, Learman LA, Landy U. Abortion training in US obstetrics and gynecology residency programs. Am J Obstet Gynecol 2018;219:86. 16. Guiahi M, Hoover J, Swartz M, Teal S. Impact of Catholic hospital affiliation during obstetrics and gynecology residency on the provision of family planning. J Grad Med Educ 2017;9:440–6. 17. Guiahi M, Cortland C, Graham MJ, et al. Addressing OB/GYN family planning educational objectives at a faith-based institution using the TEACH program. Contraception 2011;83: 367–72. 18. Wollschlager K, White K. A contraception simulation lab developed for OB/GYN residents in Catholic hospitals. Obstet Gynecol 2016;12: 58S.
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19. Fennimore R, Guiahi M, Gottesfeld M, Ricciotti H. Enhancing family planning training at a Catholic OBGYN residency program. Obstet Gynecol 2017;130:56S.
Author and article information From the Department of Obstetrics and Gynecology (Drs Guiahi and Teal), University of Colorado School of Medicine, Aurora, CO; Department of Obstetrics & Gynecology and Urology (Dr Kenton), Northwestern University, Feinberg School of Medicine, Chicago, IL; Department of Obstetrics and Gynecology (Dr Decesare), University of Florida Pensacola, Pensacola, FL; Bixby Center for Global Reproductive Health (Dr Steinauer), University of California, San Francisco, San Francisco, CA. Received May 29, 2019; revised Aug. 29, 2019; accepted Sept. 6, 2019. The authors report no conflict of interest. The Society of Family Planning Research Fund Junior Investigator Career Grant SFPRF10-JI1 provided support for time and project expenses (M.G.). The views and opinions are those of the authors and do not necessarily represent the views and opinions of the Society of Family Planning. Study findings were presented at the annual Council on Resident Education in Obstetrics and Gynecology (CREOG) and Association of Professors of Gynecology and Obstetrics (APGO) Annual Meeting, New Orleans, LA, Feb. 26March 1, 2019. Corresponding author: Maryam Guiahi, MD, MSc. [email protected]
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Family planning training at Catholic and other religious hospitals: a national survey Maryam Guiahi, MD, MSc; Stephanie Teal, MD, MPH; Kimberly Kenton, MD, MS; Julie DeCesare, MD; Jody Steinauer, MD, MPH
BACKGROUND: Catholic and other faith-based hospitals often restrict
family planning service provision based on institutional doctrine. Approximately 11% of US accredited obstetrics and gynecology residency programs occur at such hospitals, creating a challenge to educational leaders who must ensure comprehensive family planning training. OBJECTIVE: To evaluate and summarize family planning training at obstetrics and gynecology residency programs that are affiliated with Catholic and other faith-based hospitals that restrict reproductive services. MATERIALS AND METHODS: Using an online database search and survey screening questions, we identified 30 of 278 accredited 2017e2018 programs in which at least 70% of resident time is spent in faith-based hospitals that restrict family planning services; Jewish programs were excluded. We queried program leaders between March 2017 and April 2018 about education and training using an online or paper survey, and asked them to report on training settings, provision of family planning services in such settings, and to rate aspects of training as “poor,” “adequate,” or “strong.” We compared responses at Catholic versus other faith-based programs using Fisher exact tests, c2 analyses, and median tests. RESULTS: Among 30 programs, 25 responded (83%); the majority of respondents were program directors (88%) and represented Catholic hospitals (76%). All reported adequate contraceptive training, with 47% of Catholic programs relying on off-site locations. The majority of Catholic sites (84%) relied on off-site sterilization training sites. Survey respondents
R
esidency training in obstetrics and gynecology is aimed at developing physicians with expertise in all aspects of women’s healthcare. Since 1996, the Accreditation Council for Graduate and Medical Education (ACGME) has recognized that family planning and abortion training are essential components of training, and have set forth an expectation that all obstetrics and gynecology residency programs, regardless of their institutional affiliation, provide comprehensive training as part of
Cite this article as: Guiahi M, Teal S, Kenton K, et al. Family planning training at Catholic and other religious hospitals: a national survey. Am J Obstet Gynecol 2019;XX:x.ex-x.ex. 0002-9378/$36.00 ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ajog.2019.09.012
from Catholic programs most commonly endorsed concerns for inadequate training in postpartum tubal ligations (53% of Catholic respondents versus 0% of other faith-based program respondents, P ¼ .05). Approximately one-half (56%) offered abortion training as part of the curriculum (“routine”), 32% offered residents the opportunity to arrange training (“elective”), and 12% did not offer; the majority (84%) relied on off-site collaborations. Catholic sites were more likely than other religious programs to report poor abortion training (47% versus 0%, P ¼ .04). Five Catholic programs (26% of Catholic programs) reported that their residents did not meet the graduate training requirement for completion of 20 dilation and curettage procedures. One-third reported a prior Residency Review Committee family planning citation(s), and many commented that these citations helped provide leverage for improved training. CONCLUSION: Although Catholic and other restrictive, faith-based obstetrics and gynecology residency training programs have developed strategies in response to institutional restrictions, many report ongoing deficiencies, and almost one-half reported they were noncompliant with abortion training requirements. Programs with deficient trainings may benefit from strategic approaches, including enhanced onsite education and collaborations with off-site facilities. Key words: Catholic, contraception, faith-based, family planning,
gynecology/education, induced abortion, obstetrics and gynecology, religious hospitals, residency, resident education
their planned curriculum (“routine training”).1 ACGME also recognizes that those residents with religious or moral objections to abortion training may decline (“opt-out”).1 Multiple studies have since demonstrated that incorporation of adequate residency training is a key predictor of later provision of family planning services.2e5 A recent national survey of obstetrics and gynecology residency programs found that directors at religiously affiliated programs were more likely to report abortion training restrictions, often secondary to hospital policies.6 Catholic hospitals are expected by the United States Conference of Catholic Bishops to follow the Ethical and Religious Directives for Catholic Health Care Services, which restricts not only abortions but also most contraceptive and sterilization services.7 Many obstetrics and
gynecology residency programs rely on training at faith-based hospitals,8 and the proportion may increase as Catholic healthcare systems increasingly acquire non-Catholic hospitals and as more osteopathic programs transition to ACGME status. In our survey of educational leaders at religious hospital training programs, we aimed to delineate the current provision and adequacy of family planning training, and to highlight strategies and training gaps so as to inform best practices in these settings.
Materials and Methods To identify US ACGME-accredited obstetrics and gynecology allopathic programs that primarily train residents at religious hospital(s) that have institutional restrictions to family planning services (termed “restrictive, faith-based hospitals”), we examined all obstetrics
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AJOG at a Glance Why was this study conducted? To understand how Catholic and other religious hospital training programs provide comprehensive family planning training to their residents, despite institutional restrictions to service provision. Key findings Catholic programs were more likely than other religious hospital training programs to rely on partnerships with other healthcare facilities to achieve contraception and sterilization training. The majority of religious hospital training programs relied on off-site healthcare facilities to provide abortion training. Educational leaders at Catholic programs most commonly endorsed concerns for inadequate training in postpartum sterilization and abortion methods. Onefourth of Catholic programs reported that all of their residents do not meet the minimum Residency Review Committee requirement for completion of 20 dilation and curettage procedures, and 37% reported prior family planning citations. What does this add to what is known? This study provides a more in-depth understanding of the limitations to training in contraception, sterilization, and abortion that occur at Catholic hospital obstetrics and gynecology residency training programs compared to other religious hospital training sites.
and gynecology programs listed in the Fellowship and Residency Electronic Interactive Database (FREIDA) online site as part of the American Medical Association database.9 This database provides information about sponsoring institutions in which residents train and, at the time of review (2016), acknowledged religious ownership of training hospitals. We also cross-referenced the primary hospital’s website to confirm religious affiliation. In addition, we relied on data from a recent national survey,6 input from educational policy consultants at the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning program, and other educational stakeholders. We excluded Jewish hospital training programs because we were unaware of institutional restrictions to reproductive service. We chose to enrich our pool of respondents with programs that face primarily religious institutional restrictions to family planning care, as opposed to other programs that may also face state-specific restrictions to reproductive care or those that have adequate time at a nonCatholic site. To do so, we included only programs that reported at least 70%
of resident training at a restrictive, faithbased hospital(s) in survey screening responses, as we assumed that this would be a marker for working primarily in a religious setting without sufficient opportunities to otherwise receive family planning training. Between March 2017 and April 2018, we contacted residency program directors by e-mail as listed by FREIDA Online, with an invitation to participate in an online survey; each program director received up to 3 requests and was provided a $40 gift card for survey completion. We informed potential participants that the survey was voluntary and that they did not need to report their name or program name. If we did not get a response, we sent a paper survey with a self-addressed envelope and a $10 gift card as incentive with the remainder of the incentive provided upon completion. If we still did not obtain a response, we subsequently recruited other relevant program leaders at these sites that are physicians and involved in medical education (eg, associate program directors) using e-mail addresses found on publicly available websites. The University of Colorado Multiple Institutional Review
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ajog.org Board deemed this study exempt based on minimal risk to participants. Based on review of prior surveys and input from all the authors who have each served educational roles in graduate medical training, we created a survey that consisted of 43 discrete questions that incorporated branching logic and 5 additional open-ended questions. We first assessed survey eligibility by addressing program characteristics including the percentage of time spent at faith-based hospitals. If eligible, we asked participants to rate how important they believed it was to be compliant with the ACGME family planning and abortion requirements; to assess, we used a 5point Likert scale (1 ¼ unimportant, 2 ¼ of little importance, 3 ¼ somewhat important, 4 ¼ important, 5 ¼ very important). We similarly asked representatives at Catholic programs to report how important it was to be compliant with the Ethical and Religious Directives for Catholic Health Care Services, which are institutional guidelines that they are expected to follow. We inquired about any prior Residency Review Committee citations relevant to family planning. We surveyed family planning educational activities, including formal lectures and simulation sessions and whether residents receive formalized industry training with respect to contraceptive implants. We then assessed contraceptive training by inquiring about the outpatient clinical site in which their residents obtain most of their clinical contraceptive training and the methods available for contraceptive indications. We also inquired about sterilization, abortion, and ectopic pregnancy procedures that are routinely provided at the primary faith-based hospital site, and whether any special circumstances allowed for approval. ACGME sets forth a minimum requirement of 20 “abortion” procedures prior to graduation.10 To assess this, we inquired about the percentage of residents who complete 20 D&C procedures prior to graduation and did not specify whether they were for induced or spontaneous abortions, as ACGME does not specify. We also inquired about off-site locations where residents gain
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FIGURE 1
Program recruitment. Description of recruitment of education representatives in obstetrics and gynecology residency programs in which residents spend more than 70% of time at faith-based hospitals Review of American Medical Associaon website, hospital websites, and input from educaonal consultants idenfied 48 programs associated with religious hospitals
8 Jewish programs 4 nonreligious programs 5 spend <70% of me at religious hospital 1 Osteopathic program
30 ACGME obstetrics and gynecology residency programs that spend more than 70% of resident me within restricve faith-based hospitals
25/30 completed survey (83% response rate) 19 Catholic sites 6 non-Catholic sites
5/30 non-respondents (17% nonrespondent rate) 3 Catholic sites 2 non-Catholic sites
ACGME, Accreditation Council for Graduate Medical Education. Guiahi et al. Family planning training at religious hospitals. Am J Obstet Gynecol 2019.
additional training. Participants were asked to self-assess trainings as either “strong,” “adequate,” or “poor.” After each training section, we asked, using open-ended queries, whether they had any additional comments. Our online survey ended with participant questions, including religious characteristics. All survey results were analyzed using SPSS 25 (IBM Corp., Armonk, NY). We first performed descriptive frequencies. With respect to importance of compliance with the religious directives and the ACGME training requirements, we dichotomized based on a Likert value 4 (either “important” or “very important”). As the institutional restrictions
for family planning services are broader at Catholic facilities, we also compared aspects of training at Catholic compared to the other restrictive, faith-based programs using the Fisher exact tests or c2 analyses; we considered a P value of .05 significant. We also compared continuous variables using medians tests. We incorporated any relevant clarifications from open-ended questions.
Results We identified 48 ACGME-accredited programs that may be associated with religious hospitals, for which we excluded 18 sites that did not meet our inclusion criteria (Figure 1). Five
programs were excluded because they spent 50% of time in a religious setting. The 30 eligible programs accounted for 10.8% of the 278 accredited obstetrics and gynecology programs in existence during survey recruitment (2017e2018).11 We successfully recruited 25 of 30 programs (83% survey response rate); 23 completed surveys online, and 2 on paper. The majority of respondents were program directors (88%), 50 years old (84%), and identified as white (80%) and/or non-Hispanic (96.0%). Most (76%) represented programs that train the majority of the time in a Catholic setting. Additional respondent and
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TABLE 1
Respondent and program characteristics in survey of education representatives in obstetrics and gynecology residency programs where residents spend more than 70% of time at faith-based hospitals n ¼ 25
Respondent characteristics Educational Leader position Program Director
88%
Associate Program Director
4%
Chair
4%
Clerkship Director
4%
Years in role, median (range)
3 (1e39)
Male sex
56%
Identifies as Catholic
48%
Attends religious activity at least monthly
40%
Reported “not religious at all”
44%
Important/very important to be compliant with ACGME requirements for family planning
100%
Important/very important to be compliant with ERDsa
90%
Residency program characteristics
n¼25
Number of graduating residents per year, median (range)
4 (2e6)
Percentage of time spent at primary faith-based hospital, median %, (range)
90% (70e100%)
Religious affiliation of primary hospital Catholic
76%
Lutheran
12%
Methodist
8%
Seventh Day Adventist
4%
Reported all graduating residents meet RRC requirement for 20 D&Cs
80%
Reports at least 1 prior RRC citation about family planning
32%
ACGME, Accreditation Council for Graduate Medical Education; D&C, dilation and curettage; ERDs, Ethical and Religious Directive for Catholic Health Care Services; RRC, Residency Review Committee. a
Percentage of Catholic program representatives. Guiahi et al. Family planning training at religious hospitals. Am J Obstet Gynecol 2019.
program characteristics are listed in Table 1. Eight programs (7 Catholic sites, 1 other faith-based site) reported a total of 10 prior Residency Review committee citations. Citations included insufficient sterilization exposure (n ¼ 1), insufficient sterilization and abortion training (n ¼ 2), or insufficient abortion training either because it was unclear/opt-out (n ¼ 2) or because no abortion training was offered (n ¼ 3). These respondents often commented that these citations helped them advocate for improved training.
Over 90% of programs reported formal didactics on short-acting, longacting, and emergency contraceptive methods, and on sterilization, ectopic pregnancy, and miscarriage management. Comparatively fewer provided lectures on natural family planning (64%), barrier methods (72%), and abortion (76%). Procedural simulations were common for long-acting reversible contraceptives: 92% incorporated industry-sponsored implant training, 88% provided simulation for levonorgestrel intrauterine device (IUD); and
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68% provided simulation for copper IUD. With respect to other sterilization and abortion procedures, 36% provided laparoscopic sterilization simulation, 20% provided postpartum sterilization simulation, and 40% provided uterine evacuation simulation. Table 2 describes contraceptive training at the outpatient clinic identified as the primary training site; almost half (47%) of the Catholic programs relied on a clinic not owned by the hospital, whereas the remaining programs relied on a clinic owned by or affiliated with the primary hospital. The majority provided training in all methods, with slight downward trends at Catholic programs for methods considered by the Catholic Church to be abortifacients, despite lack of scientific evidence (eg, emergency contraception [79%] and copper IUD [63%]).12 All programs rated contraceptive training as either adequate or strong. Table 3 demonstrates results related to sterilization training. Most Catholic hospital respondents (79%) reported no onsite sterilization services, whereas other restrictive, faith-based sites reported that they did not have limitations. Most Catholic programs (84%) relied on laparoscopic sterilization training at offsite locations (eg, nearby community hospital, ambulatory surgical center), and the remainder reported that they were unable to facilitate an off-site training location. Although Catholic programs were more likely than others to report inadequate training in postpartum tubal ligations following vaginal deliveries (53% Catholic vs 0% other faith-based programs, P ¼ .05), only 21% of Catholic sites provided off-site postpartum training. One-third of Catholic programs cited poor sterilization training compared to none of the other sites (P ¼ .11). Table 4 describes abortion training experiences. All Catholic sites and many of the other faith-based sites reported onsite restrictions to routine abortion. Catholic hospitals were less likely than other restrictive, faith-based sites to perform abortions for indications such as rape/incest or fetal anomalies. Just over half of the programs (56%)
ajog.org reported that they provided routine, optout training, and 16% of Catholic sites reported no abortion training; 1 cited the reason as being because they are unable to facilitate, and 1 reported that this training was not needed based on adequate exposure during obstetrics rotation. Most (84%) described relying on external family planning clinic sites for abortion training (eg, Planned Parenthood). When off-site training occurred, residents were more likely to obtain first-trimester compared to second-trimester training. Approximately half (47%) of the Catholic programs reported poor abortion training, compared to none of the other sites (P ¼ .04). When we inquired about the Residency Review Committee expectation for completion of 20 D&C procedures prior to obstetrics and gynecology graduation, 80% reported that all graduating residents meet this requirement. Among the 5 that did not, all were Catholic sites (26% of Catholic programs): 1 had recently initiated their program and did not yet have a graduating class of residents, and so reported 0%, 1 cited 30%, and 3 cited 90%. None of the respondents reported ectopic pregnancy restrictions, and all rated such training as adequate (20%) or strong (80%). Only 1 restrictive, faithbased program that was not Catholic reported strong training in all aspects of family planning methods; this program has unrestricted opportunities for contraceptive methods and sterilization provision onsite and an ongoing off-site abortion rotation collaboration.
Comment Obstetrics and gynecology residency programs at restrictive, faith-based hospitals in the United States accounted for approximately 11% of all ACGME programs during our recruitment period, for which we had an 83% response rate.
Principal findings Respondents from Catholic programs expressed broad training concerns that reflected onsite restrictions to contraceptive methods (particularly those deemed by the Catholic Church as abortifacients), tubal ligations, and
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TABLE 2
Contraceptive training in obstetrics and gynecology residency programs where residents spend ‡70% of time at faith-based hospitals, as described by education leaders
Primary site for contraceptive training
Catholic programs (n ¼ 19)
Other faith-based programs (n ¼ 6)
.01b
Relationship between primary site for contraceptive training and hospital Owned by hospital
P valuea
47%
50%
5%
50%
47%
0%
Staffed by core faculty
63%
67%
Residents can opt out of attending
26%
0%
.29
95%
83%
.43
Affiliated with but not owned by hospital Not affiliated/owned by hospital
1.0
Methods available Natural family planning counseling All BC counseling
100%
100%
n/a
Prescription of short-acting methods
90%
100%
1.0
Provision of depot-medroxyprogesterone acetate
90%
100%
1.0
Provision of emergency contraception
79%
100%
.54
Insertion of implant
84%
100%
.55
Removal of implant
95%
100%
Insertion of copper intrauterine device
63%
100%
Insertion of levonorgestrel intrauterine device
84%
100%
.55
100%
100%
n/a
Removal of intrauterine devices
.14
1.0b
Overall rating of contraceptive training Strong
58%
50%
Adequate
42%
50%
0%
0%
Poor
1.0
BC, birth control; n/a, not applicable. a P value based on Fisher exact test; b P value based on c2 analysis. Guiahi et al. Family planning training at religious hospitals. Am J Obstet Gynecol 2019.
abortions. Despite a prior report of ectopic pregnancy care restrictions at some Catholic sites,13 none of our respondents reported training concerns. Our findings add to the growing body of literature that demonstrates that family planning service restrictions exist in Catholic healthcare settings, but that specific restrictions often vary across settings and are not always consistent with the institutional directives.14 Among the remaining restrictive, faithbased programs, training concerns were limited to abortion services secondary to onsite restrictions.
Results In a recent national survey of obstetrics and gynecology residency programs, Steinauer et al reported that 64% reported routine training with dedicated time, 31% optional, and 5% not available, but did not find a difference between those respondents who stated that they were at a religious hospital (27 programs) vs other respondents.15 Our study of religious training sites found a lower rate of routine abortion training (56%) and higher rate of no abortion training (12%). These differences may be accounted for by our strict inclusion
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TABLE 3
Sterilization training in obstetrics and gynecology residency programs in which residents spend ‡70% of time at faith-based hospitals, as described by education leaders Catholic programs (n ¼ 19)
Other faith-based programs (n ¼ 6)
P valuea
On-site sterilization training 0%
100%
<.001
21%
100%
.001
0%
100%
<.001
0%
83%
<.001
79%
0%
.001
Postpartum vaginal delivery
21%
17%
1.0
Postpartum cesarean delivery
26%
17%
1.0
Interval laparoscopic sterilization
84%
33%
.03
Interval hysteroscopic sterilizationb
53%
33%
.64
53%
0%
.05
Postpartum vaginal delivery Postpartum cesarean delivery Interval laparoscopic sterilization Interval hysteroscopic sterilization No sterilizations performed
b
c
Sterilization training at off-site location
Inadequate sterilization training Postpartum vaginal delivery Postpartum cesarean delivery
21%
0%
.54
Interval laparoscopic sterilization
16%
0%
.55
Interval hysteroscopic sterilizationb
47%
33%
.66 <.001c
Overall rating of sterilization training Strong Adequate Poor
0%
67%
68%
33%
32%
0%
P value based on Fisher exact test; Hysteroscopic sterilization methods were available at the time of this assessment; c P value based on c2 analysis. Guiahi et al. Family planning training at religious hospitals. Am J Obstet Gynecol 2019.
a
b
criteria, which ensured at least 70% of time at a restrictive, faith-based hospital and because we excluded Jewish hospital sites. By surveying the range of family planning services, we were also better able to delineate the impact of institutional restrictions on contraceptive and sterilization services, which have largely been missed in prior family planning program surveys. Our findings that Catholic program leaders have concerns, particularly for inadequate sterilization and abortion training, is consistent with prior reports. Residents at faith-based programs previously reported lower rates of competency in such methods compared to their peers, despite similar intentions for
provision, suggesting that the majority do not intentionally seek out religious programs because they reflect their religious values or practice goals.8 Graduates from Catholic programs have also reported delayed competency in methods such as postpartum tubal ligation and low provision of abortion counseling or services, despite interest.16 Although some programs were able to compensate with off-site training in abortion, we found few established offsite collaborations for postpartum tubal ligations.
Clinical implications Our survey highlights the tension that restrictive, faith-based programs,
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particularly at Catholic sites, face in complying with institutional restrictions to care and also meeting the ACGME requirement for family planning training. When Catholic program leaders were asked about how important it was to be compliant with both the religious directives and the ACGME requirement, the overwhelming majority (90%) reported it was “important” or “very important” to meet both, despite the contradictions that these requirements pose. Although we did not define “importance” and recognize it may have been invariably attributed to concerns such as maintaining employment or receiving a program citation, these findings highlight the difficult position that these leaders are in and the need for support in finding opportunities to accomplish training. Our findings support the implementation of best practices to include enhanced onsite education with specific didactics and simulations on reproductive topics and off-site procedural training to address deficiencies in training. Both of these strategies ensure that learning and training objectives are met without direct violation of institutional guidelines. In our cohort, many respondents voiced concerns about abortion training, yet 24% did not provide formal didactics. Improving onsite education with didactics and simulations has proved successful in these settings. A 1-day session at Loyola University Medical Center in Maywood, IL, that incorporated lectures from external family planning specialists and family planning simulation sessions resulted in improved knowledge, both immediately and 10 months later.17 A contraceptive simulation laboratory18 developed at Saint Joseph Hospital in Denver, CO, similarly resulted in improved knowledge and included an abdominal postpartum tubal ligation simulation, which may be of benefit for programs that struggle to gain off-site training. As some residents may seek a Catholic residency program because it is in line with their own religious beliefs, Catholic programs should also strengthen education on acceptable methods; in our study, 32% of Catholic
ajog.org programs did not provide a lecture on natural family planning. Although graduates from programs that trained primarily at Catholic hospitals have reported that educational activities improved their family planning knowledge and counseling skills, they also reported that such exposure was insufficient for procedural competency.16 Off-site collaborations with high-volume family planning centers are needed to ensure that residents have exposure to procedures and opportunities to participate when desired in order to achieve procedural competency. In Denver, CO, a unique collaboration was formed between the Saint Joseph residency program (a Catholic hospital) and the University of Colorado program (a nearby secular hospital) with the assistance of a Kenneth J. Ryan Residency Training Program in Abortion and Family Planning training grant.19 Replication of this model by other programs would improve the proportion of residents at Catholic and other faith-based hospitals who receive adequate family planning training.
Research implications Future qualitative work should focus on exploring strategies and workarounds used to improve training at Catholic sites, and also to describe ongoing barriers. We chose not to inquire about miscarriage management, as residents in a prior survey did not suggest concerns.8 However, our survey found that onefifth of programs surveyed did not think that all of their residents would complete 20 D&C procedures prior to graduation, suggesting that there may be limitations to miscarriage training that were missed. Other aspects of reproductive health training, including infertility care, should also be explored.
Strengths and limitations We recognize that concerns exist over a lack of comparison of respondents from nonreligious hospital training programs. Our decision to do this was intentional for several reasons. First we were aware
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TABLE 4
Abortion training in obstetrics and gynecology residency programs in which residents spend ‡70% of time at faith-based hospitals, as described by education leaders Catholic programs (n ¼ 19)
Other faith-based programs (n ¼ 6)
P valuea
Onsite abortion training Medication abortion
0%
17%
.24
First-trimester D&C in operating room
0%
50%
<.01
First-trimester D&C in outpatient setting
0%
0%
n/a
Second trimester D&E in operating room
0%
17%
Second trimester D&E in outpatient setting
0%
0%
Second trimester induction termination
0%
17%
.24
100%
50%
<.01
No abortions for nonmedical reasons
.24 n/a
Onsite abortion exceptions 0%
50%
<.01
Threat to life secondary to pregnancy complication
95%
83%
.43
Threat to life secondary to maternal disease
68%
83%
. 63
Fetal anomalies compatible with life
0%
67%
<.01
11%
83%
<.01
Rape/incest
Fetal anomalies incompatible with life
.41b
Abortion training Routine/opt out
58%
50%
Elective/opt in
26%
50%
None
16%
0%
Medication abortion
68%
100%
.28
First-trimester D&C in operating room
37%
100%
.02
First-trimester D&C in outpatient setting
63%
100%
.14
Second trimester D&E in operating room
21%
100%
<.01
Second trimester D&E in outpatient setting
37%
83%
.07
Second trimester induction termination
16%
50%
.13
Off-site abortion training
Guiahi et al. Family planning training at religious hospitals. Am J Obstet Gynecol 2019.
(continued)
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Conclusion TABLE 4
Abortion training in obstetrics and gynecology residency programs in which residents spend ‡70% of time at faith-based hospitals, as described by education leaders (continued) Catholic programs (n ¼ 19)
Other faith-based programs (n ¼ 6)
P valuea
Report of inadequate training Medication abortion
32%
17%
.64
First-trimester D&C in operating room
21%
0%
.54
First-trimester D&C in outpatient setting
32%
50%
.63
Second trimester D&E in operating room
63%
33%
.35
Second trimester D&E in outpatient setting
68%
50%
.63
Second trimester induction termination
37%
0%
.14 .09b
Overall rating of abortion training Strong
11%
33%
Adequate
42%
67%
Poor
47%
0%
D&C, dilation and curettage; D&E, dilation and evacuation; n/a, not applicable. a P value based on Fisher exact test; b P value based on c2 analysis. Guiahi et al. Family planning training at religious hospitals. Am J Obstet Gynecol 2019.
of prior and evolving evidence15 about induced abortion for all US obstetrics and gynecology residency programs. Second, we did not suspect, and were unaware of, significant institutional restrictions to contraceptive and sterilization services at nonreligious sites; however, as little is known about family planning provision in religious sites that are not Catholic, we wanted to explore provision of these services. The significant differences in contraceptive and sterilization training between Catholic and the other faith-based programs were important to report, despite the small numbers. These findings highlight the severity of restrictions to comprehensive family planning training at Catholic sites, and provide evidence that institutional restrictions on family planning seem otherwise to be limited to abortion care in other religious hospital settings; such information is relevant to applicants of obstetrics and gynecology residencies. Furthermore, we were
interested in obtaining an in-depth understanding of how Catholic and other faith-based sites overcome institutional barriers to graduate medical training. Our survey of educational leaders provides a better understanding of how religious programs navigate conflicting demands, and also highlights training deficiencies. Although educational stakeholders, such as the program directors surveyed, may have a conflict of interest and inaccurately self-report, we believed that such representatives were the best sources of case numbers and training provision. Among the few respondents who were not program directors, each had significant educational roles (eg, associate program director, former program director) making their inputs relevant. We also benefited from a high response rate, but cannot comment on nonrespondents who potentially have even lower rates of training.
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The Residency Review Committee is expected to ensure that all residents, irrespective of institutional affiliation, are offered comprehensive training in family planning. We found that almost half of respondents reported noncompliance with the ACGME requirement for abortion routine training, even though this guideline was first implemented in 1996. At present, the only procedural requirement related to family planning services that is assessed in the Program Information Form is the requirement for 20 abortions/D&C procedures prior to graduation; 5 Catholic programs (26%) had concerns for meeting this requirement. The Residency Review Committee may need to consider better measures to flag inadequate family planning training, particularly at Catholic sites, including measures of procedural training in IUDs, postpartum sterilization, and improved abortion training assessments. Programs that reported prior Residency Review Citations reported that these citations often helped them argue for improved training, and thus may be of benefit to programs that face deficiencies. If adequate training is not ensured, the harm ultimately falls on the women in the United States who seek out these physicians when they need these common reproductive services. n References 1. Accreditation Council for Graduate Medical Education Review Committee for Obstetrics and Gynecology Clarifications of Program Requirements. Available at: http://www.acgme. org/acgmeweb/Portals/0/PFAssets/Program Requirements/220obstetricsandgynecology0101 2008.pdf. Accessed March 20, 2019. 2. Allen RH, Raker C, Steinauer J, Eastwood KL, Kacmar JE, Boardman LA. Future abortion provision among US graduating obstetrics and gynecology residents. Contraception 2004;81: 531–6. 3. Steinauer J, Landy U, Filippone H, Laube D, Darney PD, Jackson RA. Predictors of abortion provision among practicing obstetriciangynecologists: a national survey. Am J Obstet Gynecol 2008;198:39. 4. Steinauer JE, Landy U, Jackson RA, Darney PD. The effect of training on the provision of elective abortion: a survey of five residency programs. Am J Obstet Gynecol 2003;188: 1161–3.
ajog.org 5. Dalton VK, Harris LH, Bell JD, et al. Treatment of early pregnancy failure: does induced abortion training affect later practices? Am J Obstet Gynecol 2011;204:493. 6. Turk JK, Landy U, Chien J, Steinauer JE. Sources of support for and resistance to abortion training in obstetrics and gynecology residency programs. Am J Obstet Gynecol 2019;22:156. 7. United States Conference of Catholic Bishops. Ethical and religious directives for Catholic health care services, sixth edition. 2018. Available at: http://www.usccb.org/ about/doctrine/ethical-and-religious-directives/ upload/ethical-religious-directives-catholic-healthservice-sixth-edition-2016-06.pdf. Accessed May 28, 2019. 8. Guiahi M, Westhoff CL, Summers S, Kenton K. Training at a faith-based institution matters for obstetrics and gynecology residents: results from a regional survey. J Grad Med Educ 2013;5:244–51. 9. FREIDA, the AMA Residency & Fellowship Database 2015. Available at: https://freida.amaassn.org/Freida/#/. Accessed March 7, 2019. 10. Minimum Numbers: Obstetrics and Gynecology, Review Committee for Obstetrics and Gynecology. 2018. Available at: https://www.acgme.org/Portals/0/PFAssets/ ProgramResources/220_Ob_Gyn_Minimum_ Numbers_Announcement.pdf?ver¼2018-0625-104354-993. Accessed August 29, 2019. 11. Accreditation Council for Graduate Medical Education. Number of accredited programs,
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2017-2018. Available at: https://apps.acgme. org/ads/Public/Reports/ReportRun. Accessed March 20, 2019. 12. Rivera R, Yacobson I, Grimes D. The mechanism of action of hormonal contraceptives and intrauterine contraceptive devices. Am J Obstet Gynecol 1999;181:1263–9. 13. Foster AM, Dennis A, Smith F. Do religious restrictions influence ectopic pregnancy management? A national qualitative study. Womens Health Issues 2011;21:104–9. 14. Thorne NB, Soderborg TK, Glover JJ, Hoffecker L, Guiahi M. Reproductive health care in Catholic facilities: a scoping review. Obstet Gynecol 2019;133:105–15. 15. Steinauer JE, Turk JK, Pomerantz T, Simonson K, Learman LA, Landy U. Abortion training in US obstetrics and gynecology residency programs. Am J Obstet Gynecol 2018;219:86. 16. Guiahi M, Hoover J, Swartz M, Teal S. Impact of Catholic hospital affiliation during obstetrics and gynecology residency on the provision of family planning. J Grad Med Educ 2017;9:440–6. 17. Guiahi M, Cortland C, Graham MJ, et al. Addressing OB/GYN family planning educational objectives at a faith-based institution using the TEACH program. Contraception 2011;83: 367–72. 18. Wollschlager K, White K. A contraception simulation lab developed for OB/GYN residents in Catholic hospitals. Obstet Gynecol 2016;12: 58S.
Original Research
19. Fennimore R, Guiahi M, Gottesfeld M, Ricciotti H. Enhancing family planning training at a Catholic OBGYN residency program. Obstet Gynecol 2017;130:56S.
Author and article information From the Department of Obstetrics and Gynecology (Drs Guiahi and Teal), University of Colorado School of Medicine, Aurora, CO; Department of Obstetrics & Gynecology and Urology (Dr Kenton), Northwestern University, Feinberg School of Medicine, Chicago, IL; Department of Obstetrics and Gynecology (Dr Decesare), University of Florida Pensacola, Pensacola, FL; Bixby Center for Global Reproductive Health (Dr Steinauer), University of California, San Francisco, San Francisco, CA. Received May 29, 2019; revised Aug. 29, 2019; accepted Sept. 6, 2019. The authors report no conflict of interest. The Society of Family Planning Research Fund Junior Investigator Career Grant SFPRF10-JI1 provided support for time and project expenses (M.G.). The views and opinions are those of the authors and do not necessarily represent the views and opinions of the Society of Family Planning. Study findings were presented at the annual Council on Resident Education in Obstetrics and Gynecology (CREOG) and Association of Professors of Gynecology and Obstetrics (APGO) Annual Meeting, New Orleans, LA, Feb. 26March 1, 2019. Corresponding author: Maryam Guiahi, MD, MSc. [email protected]
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