A comparison of medical student competency, attitudes and knowledge of abortion care after a structured clinical curriculum

Background: Abortion care is a core educational objective according to the Association of Professors of Gynecology and Obstetrics (APGO), but clinical exposure is variable in medical education. The authors sought to compare professional competency, attitudes, and knowledge regarding abortion between students who attended a structured clinical experience in abortion care to those who chose a less-structured family planning clinical environment. Methods: All medical students participating in the Obstetrics & Gynecology clerkship from 2014-2015 were invited to complete a pre- and post-clerkship survey and grouped based on their attendance to a structured clinical abortion experience at Planned Parenthood (PPCW) versus an alternative Family Planning Clinic (FPC) experience. Competency and attitudes about abortion were assessed using a 100-mm visual analog scale (VAS). Authors assessed knowledge about abortion with multiple-choice questions. Results: A total of 89 students completed the surveys (PPCW: 74; FPC: 15). Students attending PPCW were more likely to observe counseling about abortion and ultrasound prior to abortion (PPCW: 67/74, 91%; FPC: 4/15, 27%, p=<0.01). More PPWC students observed a surgical abortion (91% versus 7% of FPC students). Competency scores improved with composite mean difference in VAS for PPCW of 42.2 mm and FPC of 27.3 mm (p=0.02). Attitude scores were unchanged in those with initial VAS <80 mm. Knowledge improved overall, with greater changes among the PPCW group. Conclusions: A structured clinical abortion experience met APGO educational objectives more than an alternative experience. Future physicians should universally be exposed to clinical abortion care in order to ensure evidence-based education about abortion.

medically inaccurate counseling. 2,4 Physicians are also an unfortunate source of inaccurate information and stigmatization about abortion, possibly due to educational gaps. 5−8 Abortion procedure training is typically only undertaken at the resident level among ob/gyn programs and is critical to ensure the presence of competently trained providers. However, undergraduate medical education that includes the medical necessity of safe abortion and professional obligations for patient referral is essential to ensure a knowledgeable healthcare workforce that will undoubtedly encounter patients requiring or requesting abortion care.
Medical student education has the potential to provide a broad-based understanding of abortion by all physician types, including medically-accurate counseling about abortion and recognition of complications. However, survey data demonstrate that exposure to abortion care during medical school, either via lectures or clinical observation is highly variable. 9,10 Most medical school curricula for abortion care are set up as "opt-in" programs, where interested students seek out individual experience and training. Fewer programs are "opt-out" or "partial participation" programs. These clinical experiences in abortion care are typically included in the standard clerkship schedule, with direct or indirect clinical involvement in abortion.
Family planning educational curricula is well received by medical students. 11−13 After the University of New Mexico School of Medicine instituted a preclinical and clinical abortion curriculum with an optional clinical training opportunity, 96% of students surveyed reported that abortion was an appropriate topic for medical school education and 84% of the students who participated in the clinical training experience reported it was very important to their education. 12 We hypothesized that a partial participation program during the Ob/Gyn clerkship would result in increased competency, attitudes and knowledge about abortion care. We were specifically interested in the effect of a clinical abortion environment on a student's self-reported competence to counsel a patient about what to expect from an abortion. We hypothesized that those who attended a structured clinical experience in abortion care would have increased competency by the end of the clerkship, regardless of whether they observed an abortion, compared to those who had ad hoc exposure in a general family planning practice setting. We used self-reported response to the post-clerkship survey about participation at PPCW to classify students into structured clinical attendance (PPCW) and non-attendance (FPC) groups. We classified students this way because the environment for abortion care at PPCW provides consistent educational opportunities and we wanted to measure whether attending a structured clinical experience changes attitudes or knowledge about abortion compared to ad hoc participation. Any student who reported experience in both clinics was classified in the "attendance" group.

Methods
We used a 100 mm Visual Analog Scale (VAS) to ask competency and attitude questions. The VAS is a 100 mm unmarked line with anchors on either side stating "Definitely No," and "Definitely Yes." Respondents were advised to make a single perpendicular mark on the line. Individual responses were averaged into a mean composite score for three VAS questions regarding competency and four questions assessing student attitudes regarding abortion and abortion education. We assessed the proportion of correct responses to five knowledge questions with multiple correct answer choices. We expected improvement in both groups, with group differences mainly for questions related to clinical procedures.

Data management and statistical analysis
We based our sample size calculation on an anticipated mean response on the post-clerkship survey to the following competency question, "I could adequately counsel a patient about what to expect from an abortion," of 90 mm in the clinical abortion care attendance group and 60 mm in the nonattendance group, with an estimated standard deviation of approximately 30 mm for each group. We estimated that approximately 75% of students would attend the clinical abortion experience. Therefore, we planned to obtain completed surveys for at least 32 subjects in the attendance group and 11 in the non-attendance group to show a significant difference between group means using a one-sided t-test with 80% power and alpha of p < 0.05.
We managed data using REDCap electronic data capture tools hosted at OHSU. REDCap (Research Electronic Data Capture), is a secure web-based application designed to support data capture for research studies. 14 Paper surveys were batched for data entry at two time-points to ensure anonymity. Data were then exported for analysis in STATA/IC 14.2 (StataCorp LP, College Station, TX).
Data were analyzed using t-test for means and chi-square test of proportions as well as nonparametric tests where appropriate.

Results
Eighty-nine students provided responses to the pre and post-clerkship surveys. The majority attended PPCW (74/89, 83%) and 15/89 (17%) attended FPC. 67/74 (91%) of students who attended the structured clinical abortion experience at PPCW participated in clinical abortion care, while only 4 of the fifteen (27%) FPC students observed any part of clinical abortion care.
Clinical experience with abortion included observation of a surgical abortion procedure for 68/89 (76%) of students at both sites, which primarily occurred at PPCW (Table 1). More often, students observed either patient counseling about abortion (71/89, 80%) or an ultrasound examination prior to abortion (71/89, 80%). A majority of PPCW students (67/74; 91%) and no FPC students participated in the examination of products of conception, a critical step in confirming sufficient uterine evacuation.   It should be noted that pre-clerkship competency self-evaluation was higher among the FPC cohort, yet that group did not report as much of an increase and a lower overall competency following their clinical experience.
Nineteen students had an initial composite attitude score less than 80 mm, eight of whom observed an abortion. Self-perceived competence increased in all but one of these students, independent of attendance. However, of those with low initial composite attitude who attended PPCW (n = 11), there was a mean 43.4 mm increase on the competence VAS, compared to only a mean 27.1 mm increase in those who did not attend (n = 8; p = 0.08).
No students responded correctly to all answer choices on either the pre-or post-clerkship surveys.
Following the clerkship, 59/74 (80%) of PPCW attendees and 9/15 (60%) of FPC group correctly identified that 50% of pregnancies in the US are unintended. More students in both groups could identify that all types of contraception can be initiated immediately following a surgical abortion: 35-57% for PPCW and 20-40% for FPC.

Discussion
Medical student attendance in a structured clinical abortion experience improved students selfperceived level of competence in providing accurate information regarding abortion procedures and effectively counseling future patients about all options related to terminating a pregnancy, compared to ad hoc clinical abortion experience, regardless whether they observed an abortion. It is possible to provide medical student education about abortion while recognizing that some students may have strong moral beliefs that oppose abortion. Varying levels of participation in a clinical environment focused on abortion care may increase a future medical provider's ability to administer medically accurate information to their patients.
The limitations of this study include a small sample size, and the selection bias inherent in a study dependent on self-reported surveys. Fewer students opted out of the clinical experience than we had initially predicted so the proportion of non-attendees may be too low for statistical comparison. A strength of this study is that we grouped students based on the educational environment that they attended and separately assessed the educational exposures that actually occurred.

Both the Association of Professors of Gynecology and Obstetrics (APGO) and the American College of
Obstetricians and Gynecologists (ACOG) recommend that all medical school curricula include training in family planning, including contraception and abortion care. Learning about abortion is a core educational objective according to APGO, which sets national standards for medical student education. 15 The three objectives related to abortion that students are expected to learn are: (1) to provide scientifically accurate nondirective counseling to patients surrounding pregnancy options, (2) to explain surgical and nonsurgical methods of pregnancy termination, and (3) to identify potential complications of induced abortion. However, medical students are frequently not provided with education to meet these objectives. 9,10,16 A 2009 study of medical schools in the US and Canada reported that 67% included an abortion lecture in the preclinical curricula. 9 The remaining 33% did not include any discussion of abortion procedures, pregnancy options counseling, post-abortion care, or abortion law/policy/availability in their curriculum. A survey of Ob/Gyn medical student clerkship directors showed that 17% of programs had no formal abortion education and 55% did not offer clinical training or exposure. 10 Abortion education is inconsistently received by students. In 2009, only 24% of medical students at the University of Colorado reported clinical exposure to abortion and 57% did not have any formal didactic training in abortion. 16 Ob/Gyn residents who morally object to performing abortion are offered partial participation in abortion training up to their level of comfort at many institutions, a practice which has been shown to improve knowledge, capability, and the improved ability to care for patients with miscarriage. 17,18 Even among Ob/Gyn residency training programs dedicated to increasing exposure to abortion care, many centers in non-restrictive environments still face significant barriers to providing adequate training around abortions. 19 When a partial participation format is applied to undergraduate medical education with structured access to clinical abortion, a larger proportion of students are exposed to abortion education, regardless of chosen specialty training, potentially increasing knowledge and professionalism among future healthcare providers.

Conclusions
Learning about abortion medical care is a core educational objective according to the Association of Professors of Gynecology and Obstetrics (APGO). We assessed medical student competency, attitudes, and knowledge about abortion medical care before and after a partial participation program in clinical abortion during the Ob/Gyn clerkship. Those who participated in a structured clinical abortion environment, at a local Planned Parenthood affiliate, experienced increased competency, attitudes and knowledge scores, compared to those who attended a family planning clinic not primarily focused on abortion. In particular, the structured clinical abortion environment resulted in an increase in the student's self-reported competence to counsel a patient about what to expect from an abortion, regardless whether they observed an abortion. We demonstrate that partial participation programs are acceptable to students regardless of moral beliefs and that a structured clinical abortion environment provides more effective learning outcomes, even with partial participation.