Early pregnancy loss is a common medical problem, and recommended treatments overlap with those used for induced abortion. The American College of Obstetricians and Gynecologists (ACOG) recommends incorporation of clinical and patient factors when applying conservative published imaging guidelines to determine timing of intervention for early pregnancy loss. However, in places where abortion is heavily regulated, clinicians managing early pregnancy loss may cautiously rely on the strictest criteria to differentiate early pregnancy loss from potentially-viable pregnancy. ACOG also notes that specific treatment modalities frequently used to induce abortion, including use of mifepristone in medical therapy and surgical aspiration in an office setting, are cost-effective and beneficial for patients with early pregnancy loss.
To determine how U.S. OB/GYN residency training institutions adhere to ACOG recommendations for early pregnancy loss management, including timing and types of interventions, and to evaluate the relationship with institutional and state abortion restrictions.
From November 2021 to January 2022, we conducted a cross-sectional study of all 296 U.S. OB/GYN residency programs, emailing and requesting a faculty member complete a survey about early pregnancy loss practices at their institution. We asked about location of diagnosis, use of imaging guidelines before offering intervention, treatment options available at their institution, and program and personal characteristics. We used chi square tests and logistic regression to compare availability of early pregnancy loss care based on institutional indication-based abortion restrictions and state legislative hostility to abortion care.
Of the 149 programs that responded (50.3% response rate), 74 (49.7%) reported not offering any intervention for suspected early pregnancy loss unless rigid imaging criteria were met, while the remaining 75 (50.3%) programs reported incorporation of imaging guidelines with other factors. In unadjusted analysis, programs were less likely to incorporate other factors with imaging criteria if they were in a state with legislative policies hostile to abortion (33% vs. 79% p<0.001) or if the institution restricted abortion by indication (27% vs. 88%, p<0.001). Mifepristone was used less often at programs in hostile states (32% vs. 75%, p<0.001) or with institutional restrictions (25% vs. 86%, p<0.001). Similarly, office-based suction aspiration use was lower in hostile states (48% vs. 68%, p=0.014) and with institutional restrictions (40% vs. 81%, p<0.001). After controlling for program characteristics including state policies and affiliation with family planning training programs or religious entities, institutional abortion restrictions were the only significant predictor of rigid reliance on imaging guidelines (OR 12.3, 95%CI: 3.2-47.9).
In training institutions that restrict access to induced abortion based on indication for care, residency programs are less likely to holistically incorporate clinical evidence and patient priorities in determining when to intervene for early pregnancy loss, as recommended by ACOG. Programs in restrictive institutional and state environments are also less likely to offer the full range of early pregnancy loss treatment options. With state abortion bans proliferating nationwide, evidence-based education and patient-centered care for early pregnancy loss may also be hindered.

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