Ian Peake, a medical student at the University of Oklahoma, spent four years shadowing doctors at a Tulsa abortion clinic because his school did not offer abortion courses or training.

The Tulsa Women’s Clinic, however, ceased abortion services in May after Oklahoma enacted a near-total ban, and the provider closed permanently after the United States Supreme Court repealed constitutional abortion protections in June. Peake, 33, now had no local abortion education options.

“Getting abortion education in the state is basically impossible,” said Peake, who is now applying to residency programs outside of Oklahoma. “There will be large swaths of the country where medical students will not understand how these procedures work.”

In interviews, a dozen doctors, activists, and medical students expressed concern that the next generation of doctors trained in states with strict abortion laws would lack critical skills for treating women.

Even before the Supreme Court overturned Roe v. Wade, which legalized abortion nationwide in 1973, some conservative states prohibited institutions from teaching how to perform abortions. With the June ruling allowing states to decide whether abortion is legal, more medical schools and residency programs are unable to provide comprehensive obstetrics and gynecology training.

According to a study published in April by the American College of Obstetricians and Gynecologists’ journal, 92% of obstetrics and gynecology residents reported having access to some level of abortion training in 2020. Following Roe’s decision, the researchers predicted that number would fall to 56% at most.

According to the Guttmacher Institute, an abortion rights research organization, seven states, including Texas and Alabama, already have no abortion clinics.

Dilation and curettage, the procedure used to perform elective abortions, is required in emergencies such as when a pregnant woman has a heart attack, stroke, or begins hemorrhaging. It is also necessary to remove tissue from the uterus following an incomplete miscarriage in order to avoid infection and sepsis.

“It goes beyond what people call abortion,” Maya Hammoud, an obstetrics and gynecology professor at the University of Michigan Medical School, explained. “It’s going to have an impact on everything else in women’s healthcare.”

Abortion education is not required in medical schools. However, the ACGME, which evaluates and certifies residency programs, requires that all residents learn how to perform abortion procedures before graduating.

Following Roe’s decision, the council proposed changes to its obstetrics and gynecology guidelines, stating that programs in states that restrict abortion access must assist aspiring doctors in traveling to another state for training. If a resident is unable to travel, programs must still train them in the classroom and through simulation.

Several doctors and an activist expressed doubts that simulation, which is frequently performed on dragonfruit or papaya, could adequately prepare residents for real-world treatment.

“I’m very concerned that very well-respected medical schools will graduate students who have not received a modern medical education at some point,” said Pamela Merritt, executive director of Medical Students for Choice, an abortion rights advocacy group. “Even if they get the go-ahead to intervene to save a pregnant woman’s life, they won’t be able to do so.”

Medical schools and residency programs, according to anti-abortion advocates, will continue to teach emergency procedures to save a woman’s life even if they do not teach how to perform voluntary abortions.

“We’ve seen abortion activists use misinformation and scare tactics on women who don’t deserve to be stressed,” said Kristi Hamrick, a spokesperson for Students for Life of America, an anti-abortion group.

According to Louito Edje, associate dean of graduate medical education at the University of Cincinnati College of Medicine and an ACGME member, most institutions will assist their residents in traveling for real-world training.

However, she believes that training could suffer if more students are crammed into fewer institutions and there isn’t enough patient flow to provide everyone with hands-on practice.

The University of Michigan has formed a task force to prepare for an influx of residents coming to Ann Arbor for training, according to Lisa Harris, an obstetrics and gynecology professor and task force co-chair.

Given the state’s ever-changing legal landscape surrounding abortions, Harris said the task force is also planning ways to help residents travel for out-of-state training if Michigan implements a ban.