Barriers to comprehensive abortion education in UK medical schools

UK medical students are missing out on comprehensive abortion care education, amid highly variable curriculum provision and multiple barriers to effective teaching cited by their educators, finds research published online in BMJ Sexual & Reproductive Health.

Given how common the procedure is, to say nothing of its legal, ethical, and emotional complexities, it is essential that future doctors receive comprehensive education on abortion care, insist the researchers.

And whatever a doctor's personal cultural or religious beliefs, all doctors need to know about the clinical complications of abortion so they can treat patients effectively in an emergency, they add.

One in three women in the UK will have an abortion before the age of 45. And the importance of abortion education has been emphasized by several medical bodies, including the Royal College of Obstetricians and Gynaecologists, the Institute for Medical Ethics, and the National Institute for Health and Care Excellence (NICE).

Because of its complex legal history in all four UK nations, and the attendant ethical issues, the researchers wanted to find out the extent to which abortion features in medical school curricula and the scope of the ethico-legal and clinical aspects of abortion teaching.

They sent two separate surveys to ethics leads and clinical curriculum leads in obstetrics and gynecology, sexual health, and women's health at the 33 UK medical schools that were publicly funded as of February 2019.

The surveys were similar in structure, and both included time spent on teaching abortion, teaching methods, content, assessment, barriers to teaching, and desire for further guidance on teaching abortion care.

In all, 25 medical schools responded to at least one survey. Of these, six responded to both. Some 40% (13/32) of clinical surveys and 55% (18/33) of ethico-legal surveys were completed.

All ethico-legal survey respondents said their medical school provided compulsory education on ethical and legal aspects of abortion care. But this wasn't the case for clinical survey respondents, although most (85%) said that teaching on the clinical aspects of abortion care was compulsory.

One medical school provided optional clinical education, and one respondent stated that they didn't provide any clinical education as the procedure was illegal in their location at that time (Northern Ireland).

The number of hours spent on abortion teaching varied widely, ranging from less than 1 hour to more than 8 on ethico-legal aspects, and under 1 hour up to 5-6 hours on clinical aspects.

A period of 1-2 hours was the most commonly cited in each of the surveys: 9 (50%) ethico-legal respondents;  6 (46%) clinical respondents.

Lectures were the most popular teaching method while multiple-choice questions were the most popular format for assessments.

Some medical schools also assessed ethico-legal aspects of abortion in objective structured clinical examinations. But only around a third (31%; 4/13) of clinical leads indicated that abortion was included in clinical assessments.

"Students often establish the importance of a topic based on its value in assessments: if it is not assessed, it is deemed to be less important. This may also have negative implications for future service provision, as medical student exposure to a subject influences their career choices in later years," write the researchers.

All ethico-legal respondents said that their institution's teaching covered current UK law on abortion and doctors' right to conscientiously object to participating in abortion care.

Topics covered in clinical teaching were inconsistent among medical schools, however, with no single topic covered by all of them.

"Worryingly, this is likely to produce significantly different abortion-related knowledge among graduates from different institutions," warn the researchers.

More than half (56%) of ethico-legal curriculum leads felt they experienced barriers to delivering abortion teaching, particularly insufficient curriculum time and too few qualified or willing staff to teach it.

Most (85%) clinical respondents also reported experiencing barriers to teaching. Nearly half (45%) felt that abortion was a sensitive topic and that this acted as a barrier while nearly 1 in 5 (18%) had ethical concerns about teaching abortion.

Around three out of four respondents to each survey wanted further guidance on how best to teach abortion care.

"Open-access educational resources on abortion are available [eg Making Abortion Safe] and, if used, may help address some of the barriers cited by educators," point out the researchers.

"This, in turn, could improve the quality of abortion teaching in UK medical schools, equipping future doctors with the knowledge, attitudes and skills to treat people seeking abortions with confidence and respect," they conclude.