A global study on the abortion views and knowledge of trainee obstetrician‐gynecologists

To assess the knowledge and views of trainee obstetrician‐gynecologists (ObGyn) on abortion.

remains a significant public health problem.4][5] Low-income countries are disproportionately more affected than developed countries.More than 97% of unsafe abortions and 99.8% of unsafe abortion-related deaths take place in developing countries, where 220 women die for every 100 000 unsafe abortions, compared with 30 deaths per 100 000 unsafe abortions in developed countries. 2,3,5Seven million women in the developing world are treated for complications of unsafe abortion every year. 6e lack of access to safe abortion care poses significant risks to the physical, mental, social, financial, and overall health and wellbeing of women.Even though there is a globally increasing trend towards liberalization of abortion laws, some 753 million women, representing 40% of reproductive-age women worldwide, still live in countries with restrictive abortion laws. 7Unintended pregnancy and unsafe abortion rates are generally higher in countries where abortion is restricted than in countries where it is broadly legal/liberal.In 2015-2019, the unintended pregnancy rate in countries with restrictive abortion laws was 73 per 1000 women, with a safe abortion rate of 25.2%.Comparatively, in countries with broadly legal/ liberal abortion laws, the unintended pregnancy and safe abortion rates were, respectively, 58 per 1000 women and 87.4%. 1,8Unsafe abortion rates also differentiate with the income status of countries, with reported safe abortion rates of 82.2%, 67.1%, and 21.8%, in high-, upper-middle-, and low-income countries, respectively. 8e major causes of the high incidence of unsafe abortions, especially in low-resource and low-income countries, include the shortage of healthcare facilities, the shortage of trained providers, and provider resistance/refusal to provide abortion care services for cultural, social, and religious reasons. 9,10The willingness of providers to provide abortion care is influenced by their knowledge, experiences, and opinions on abortion.Therefore, this study sought to explore the knowledge, perspectives, and training of trainee obstetrician-gynecologists (ObGyn) on abortion, globally.Understanding these is critical to averting the highly preventable deaths from unsafe abortion, given that trainees play a significant role in WATOG is an international body of all ObGyn trainees and early career ObGyns, who are within 10 years of the start of their residency training, in 85 countries, across six regions of the world, including Africa, Asia, Europe, North America, South America, and Oceania.
The study was conducted over 17 months, from October 2021 to March 2023.

| Study instrument
A study-specific 33-item web-based questionnaire, designed with Google Forms®, was used for this study.The questionnaire was designed by the second author in consultation with three experts in abortion care.It collected information on the sociodemographic characteristics of the study participants, their perceptions, and knowledge of abortion.The questionnaire was electronically disseminated via email and social media platforms, including WhatsApp and Telegram, to study participants in all WATOG member countries and regions, by WATOG Executive Officers, Regional and National Representatives.To ascertain the reliability and validity of the study questionnaire, the questionnaire was pretested on some WATOG members prior to final and wide distribution.Participation in the study was voluntary; no incentive was offered to study participants.

| Operational definitions
The following operational definitions were used in this study: Abortion: Termination of an intrauterine pregnancy before the age of fetal viability, which varies from 20 to 28 weeks depending on the geographical region. 12safe abortion: Any procedure for terminating an unwanted pregnancy that is performed either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both. 13fe abortion: Termination of an unwanted pregnancy using a method recommended by WHO, appropriate to the pregnancy duration and by someone with the necessary skills. 2

| Data analysis
Collected data were analyzed using the IBM Statistical Package for the Social Sciences (SPSS) Statistics for Windows, version 25 (IBM Corp., Armonk, NY, USA), and presented as frequencies and percentages in tables.

| Ethics
The survey questionnaire was completely anonymized with no respondent-identifying information.All respondents consented to participate in the study before completing the questionnaire and submitting the survey responses.Being a completely anonymized online survey, with no patient-related data, ethics clearance was not sought for this study.

| RE SULTS
In total, 187 ObGyn trainees and young specialists participated in the study.The study participants were drawn from 47 countries, constituting 55.3% of all WATOG member countries, across six regions of the world, including Africa (12), Asia (8), Europe (10), North America (6), South America (10), and Oceania (1).Abortion laws are broadly legal/liberal, with no legal restrictions before 6-28 weeks in 22 (46.8%) of the 47 countries, and restrictive in 20 (42.6%) countries, with legal exemptions to save the life of the woman/preserve physical/mental health 1,14 (Table 1).In 5 (10.6%) countries, abortion is completely prohibited, with no legal exemptions. 1,14
Iraq (1), Turkey (1), and the USA (2), with prohibitive and liberal abortion laws, respectively, were wrongly reported as having restrictive TA B L E 1 Countries of the trainee obstetrician-gynecologists by region and legality of abortion.

| Training of ObGyn trainees on abortion and safe abortion
Most of the ObGyn trainees reported that module(s) on abortion/ safe abortion were included in both the medical school curricula volunteered that ObGyn trainees in their countries were required to have completed at least 10 abortion procedures before the completion of their residency training, as in Table 5.

| DISCUSS ION
Globally, there has been an increasing trend towards the liberalization of abortion laws, with more than 60 countries liberalizing their abortion laws over the past 30 years. 7Of the 47 countries in the study, abortion is legal in nearly 90% (without legal restrictions in 46.8% and legally restricted in 42.6%).Despite this positive trend, barriers to accessing safe abortion still exist, including provider refusal/opposition to providing abortion services on account of moral and religious beliefs among others. 10Six percent of the ObGyn trainees in the study did not support the legalization of abortion for predominantly religious concerns.More than 70% of them would also not provide abortion services, despite residing in countries where abortion is legal.
Another barrier limiting eligible women from accessing safe abortion services even in countries where abortion is legal, is the limited knowledge of ObGyns, especially the younger and less experienced ones, of the abortion laws and legal requirements for abortion in their countries. 9,15,16Of the ObGyn trainees who prohibitive abortion laws in their countries in the study, 70% did not know that abortion was legal in their countries, and not prohibitive, as they had reported.They would potentially deny eligible women safe abortion services even though the law permits the same.More so, 26% of the trainees who reported broadly legal/liberal abortion laws actually came from countries with restrictive abortion laws, while 15% of those residing in countries with prohibitive and liberal abortion laws wrongly reported that the abortion laws in their countries were restrictive.These are despite the fact that 70% and more than 80% of the trainees, respectively, reported that module(s) on abortion/safe abortion were included in the medical school and residency training curricula in their countries.
The disparity between trainees' knowledge of safe abortion and their awareness of the legality of the same may not be unconnected with the fact that some of the trainees resided in countries like Mexico and the USA, where abortion laws vary from one state to another. 17,18In Mexico, for instance, abortion is decriminalized in 10 of 32 states. 17In the USA, following the Supreme TA B L E 3 (Continued) ban.In four other states, abortion is prohibited beyond specific gestational ages. 18With such differentials in abortion laws between states in the same country, formal training on abortion may not exist in all residency training programs, as reported by 10% of our study respondents.
Steinauer et al. 19 reported that only 64% of the ObGyn residency programs in the USA offered routine and dedicated abortion training to residents, while 31% offered optional training.Given the significant roles that ObGyn resident doctors play (both as trainees and would-be specialists) in providing access to safe abortion, every resident should be trained on the knowledge, skills, and legal requirements for abortion.This is especially so as shortage of trained providers remains a barrier to safe abortion access globally. 10Recognizing this challenge, the American College of Obstetricians and Gynecologists (ACOG) recommends that abortion education should be included in the curricula of all medical schools and all ObGyn residency should offer abortion training to residents. 20re than a half of the ObGyn trainees from countries where abortion is legalized, and almost 40% of those from SSA, reported that minors required parental/guardian consent to access safe abortion in their countries.The unmet need for contraception among adolescents in SSA is high, resulting in a high rate of unwanted pregnancy, with an adolescent pregnancy rate of 19.3% and a maternal mortality ratio secondary to unsafe abortion that is 950 times (520 per 100 000 live births) higher than in the USA (0.6 per 100 000 live births). 4,21It has been argued that parental involvement laws reduce both abortion rates and the possible negative consequences and complications of abortion for minors. 22However, such laws do not guarantee that all minors would negotiate abortion decisions with their parents.In fact, many minors may be afraid, ashamed, or simply unwilling to inform their parents, and may go ahead to clandestinely procure the abortion, in which case, the risk of an unsafe abortion and its attendant complications is high.
The limitations of this study include its descriptive design and convenience sampling method, which predisposes to selection bias.
The small sample size limits the generalization of the study findings.
These notwithstanding, the study provides a useful insight on the views and knowledge of ObGyn trainees on abortion globally.The study also provides important data upon which targeted interventions can be planned and larger scale studies to further explore the subject can be conducted in the future.

| CON CLUS ION
There is a disparity between ObGyn trainees' knowledge of safe abortion and their awareness of the legality of the same in respective countries.Even though most of the trainees support the legalization of abortion, abortion laws remain restrictive in many countries.There is a need for all countries to include abortion education in the curricula of medical schools and all ObGyn residency programs should offer abortion training to all residents.Local, regional, and international ObGyn organizations, women's societies, women's rights groups, healthcare practitioners, and all relevant stakeholders should sustain advocacies for the decriminalization of abortion in countries and states where abortion remains prohibited, and the liberalization of abortion in countries where the laws are currently restrictive.

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providing access to safe abortion services.Identifying and tackling any gaps in knowledge and training can contribute significantly to achieving the Sustainable Development Goal (SDG) 3 target of reducing the global maternal mortality ratio from 216 to less than 70 per 100 000 live births by 2030. 11 | MATERIAL S AND ME THODS2.Study design and study populationThis cross-sectional survey of ObGyn trainees globally was conducted by the World Association of Trainees in ObGyn (WATOG).

and attitudes of ObGyn trainees on abortion
a Legal exemptions exist to save the woman's life/preserve physical/ mental health.bNolegalexemptions.TA B L E 1(Continued)abortion laws by more than one-tenth (4/27, 14.8%) of those who reported restrictive abortion laws in their countries.In countries with restrictive abortion laws, abortion was legally permitted in cases of pregnancy resulting from sexual assault/rape (13/27, 48.1%), life-Medical abortion with misoprostol and mifepristone was the most common method of abortion, as reported by an overwhelming majority (136/140, 97.1%) of the trainees whose countries legally permitted abortion.Most of the trainees (142, 75.9%) volunteered that misoprostol and mifepristone could only be obtained on medical prescription in their countries, as shown in Table3.3.3 | PerceptionMost (171, 91.4%) of the trainees supported the legalization of abortion.Of these, 145 (77.5%) agreed that abortion should be made liberal without any restrictions, while 26 (13.9%) were of the opinion that abortion should be legalized, but with restrictions.Those who More ObGyn trainees from countries where abortion is legal supported the legalization of abortion compared with those from countries where abortion is prohibited (158/171, 92.4% vs 13/16, 81.2%).Conversely, more trainees from countries where abortion is not legal did not support the legalization of abortion (3/16, 18.8% vs 8/171, 4.7%).Five (2.9%) of the trainees from countries where abortion is legal neither agreed nor disagreed with the legalization of abortion.
Trainee obstetrician-gynecologists' knowledge of termination of pregnancy (TOP) and abortion laws and practices in their countries.
Court overturning Roe v. Wade in June 2022, as of January 2023, near-total bans on abortion exist in 12 US states, with abortion care unavailable in two states, even though there is officially no TA B L E 3 Perception and attitudes of trainee obstetriciangynecologists on abortion.
TA B L E 5 Abortion/safe abortion training of trainee obstetriciangynecologists (ObGyn).TA B L E 4a Multiple responses by some respondents, hence n > 26 and 11.