Joint statement of support for the inclusion of contraception and abortion in sexual and reproductive health and wellbeing education for all medical students

The International Federation of Gynecology and Obstetrics (FIGO), the International Federation of Medical Students Associations (IFMSA) and the World Association of Trainees in Obstetrics and Gynecology (WATOG) consider it essential to incorporate sexual and reproductive health and rights (SRHR) and wellbeing education into the core structures of all medical school curricula.  

Inclusion of contraception and abortion in SRHR elements of curricula would provide students with a strong and relevant foundation for their professional lives and prepare them to be competent and caring practitioners. It may also promote the normalisation of, and positive attitudes towards, SRHR as basic medical care – in particular, abortion and contraception. This would contribute to efforts to remove stigma and support the assurance of future provision of essential sexual and reproductive health (SRH) services, care and rights across the lifespan. 

Every person should be provided with essential sexual and reproductive health care 

SRH is a basic element of health care.1 It represents a continuum from conception through contraception, and the evaluation and treatment required to address women’s health. Contraception and abortion provision represent two SRH requirements common to people of reproductive age around the world, and for which current provision of care is inadequate. Every year approximately 121 million unintended pregnancies occur, of which 61% end in abortion.2 Around 45% of all abortions are unsafe and represent a leading – and preventable – cause of maternal death and disability.3 According to the Guttmacher Institute, if all SRH needs in low- and middle-income countries (LMICs) were met, around two-thirds of all unintended pregnancies, unsafe abortions and maternal deaths would not occur.4 Lack of access to high-quality contraception and abortion care is a critical public health and human rights issue.

Existing gaps in medical education

Teaching in medical schools often does not include clinical SRH education in the core curriculum. One study found that abortion content is limited or missing in most medical schools in the world.5 When abortion is included in curricula, teaching is often focused on ethical and legal aspects, which further stigmatises it as an unusual or controversial subject rather than a normalised part of essential health care. The same is true for postgraduate training, even for fields such as obstetrics and gynaecology.6 Such stigmatisation is a contributor to maternal death and disability.

Medical curricula often do not include ‘non-clinical’ SRHR topics either, such as sexual violence, unsafe abortion, sexuality, gender sensitivity, wellbeing and other aspects of SRHR. Failing to identify the issues women face through their gendered lives leaves future practitioners unable to position their developing biomedical skills within the larger context in which they train and work.7,8

Similarly absent is the placement of health as a fundamental human right, which particularly for SRH requires a rights-based conceptualisation and framework for discussions and learning.

There is evidence that these gaps in curricula are not due to a lack of interest or willingness among students to learn such components.9 In fact, many medical students and associations representing them – including the organisations authoring this statement – have expressed dissatisfaction about the lack of SRH education. They recognise and support the right to safe abortion and contraception services, and call for medical training to be more inclusive.5,10,11 Likewise, the cultural and clinical pressure around fertility treatment is of global importance.

For medical students to become competent health care professionals, it is essential for their training to include SRH. Given concerns in many countries of declining numbers of health care professionals able and willing to provide abortion care, the need to ensure early-career training is urgent and essential. Failure to ensure the next generation of professionals have appropriate levels of SRHR skills will be a failure to commit to meeting the basic health care needs of women and girls.5,9

Our recommendations

A gold standard curriculum for a strong foundation for all medical students

FIGO, IFMSA and WATOG recommend the curriculum in Appendix 1, which is attached to this statement. Sexual and reproductive health and rights curricula should include training around contraception and abortion across all areas of:

  • basic biomedical sciences
  • behavioural and social sciences, including public health and population medicine
  • medical ethics, human rights and medical jurisprudence
  • clinical sciences (including clinical skills with respect to diagnostic procedures, practical procedures, communication skills, treatment and prevention of disease, health promotion, wellbeing, rehabilitation, clinical reasoning and problem solving).

The curriculum – endorsed by all three organisations – represents the gold standard for a reproductive health curriculum that should be incorporated by all medical schools.

Advocacy and implementation

In addition to integration of the curriculum into all medical school training, FIGO, IFSMA and WATOG recommend that:

  • international, regional and national organisations concerned with SRH, bodily autonomy, human rights and public health call for the inclusion of SRHR education, including abortion and contraception, in medical schools
  • governments commit to ensuring future provision of basic health care for their population by highlighting the need for comprehensive SRHR training in medical schools
  • medical school faculty without comprehensive SRHR modules use the model curriculum outline and other resources (including the World Health Organization [WHO] competencies and curriculum development toolkits for family planning and comprehensive abortion for primary health care12) to develop an inclusive curriculum
  • professional medical associations, student associations and other related organisations petition national councils/boards to review undergraduate medical curricula to include these SRHR components for all students
  • students form collaborations with their medical school authorities, professors and medical students’ associations to reform curricula.8

Our commitments

FIGO, IFSMA and WATOG commit to:

  • sharing the model curriculum in Appendix 1 and WHO toolkits on family planning and abortion12 with our members and partners
  • encouraging and supporting the implementation of SRHR curricula within medical schools
  • generating and sharing evidence for advocacy on the impact of the lack of SRHR elements in curricula and the need for the inclusion of these topics in all medical school curricula.

References

1. FIGO Statements on SRHR and in particular safe abortion. www.figo.org/resources/figo-statements?field_themes_target_id%5B0%5D=278

2. Bearak J, et al. Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990–2019. Lancet Global Health. 2020; 8(9):e1152–e1161. https://doi.org/10.1016/S2214-109X(20)30315-6

3. World Health Organization (WHO). Abortion. www.who.int/news-room/fact-sheets/detail/abortion. Based on Bearak J, et al. Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990–2019. Lancet Global Health. 2020; 8(9):e1152-e1161. https://doi.org/10.1016/S2214-109X(20)30315-6

4. Sully et al. Adding It Up: Investing in Sexual and Reproductive Health 2019. Guttmacher Institute. 2020. www.guttmacher.org/report/adding-it-up-investing-in-sexual-reproductive-health-2019

5. Ipas and the International Federation of Medical Students’ Associations. Most medical students want training in abortion care—but schools don’t provide it. 2020. www.ipas.org/wp-content/uploads/2020/07/MEDTRG-E20.pdf

6. Steinauer J, DePiñeres T. The importance of including abortion in undergraduate medical education. In: Landy U, Darney PD, Steinauer J (Eds). Advancing women’s health through medical education: A systems approach in family planning and abortion. 2021.

7. Sanghvi, R Gender perspectives in medical education. Indian Journal of Medical Ethics. 2018;4(2):148. https://ijme.in/articles/gender-perspectives-in-medical-education

8. Endler et al. Are sexual and reproductive health and rights taught in medical school? Results from a global survey. IJGO. 2022. https://doi.org/10.1002/ijgo.14339

9. Cohen P, et al. What should medical students be taught about abortion? An evaluation of student attitudes towards their abortion teaching and their future involvement in abortion care. BMC Med Educ. 2021;21(4). https://doi.org/10.1186/s12909-020-02414-9

10. Medical Students for Choice. Curriculum Reform. 2018. https://msfc.org/wp-content/uploads/2019/10/Curriculum-Reform-Guide-2018.pdf

11. Coleman E. Sexual health education in medical school: a comprehensive curriculum. Virtual Mentor. 2014;16(11):903-908. https://doi.org/10.1001/virtualmentor.2014.16.11.medu1-1411

12. WHO. Curriculum toolkit (unpublished).

Published

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Appendix 1: Model curriculum on sexual and reproductive health and rights

Background

Sexual and reproductive health is a basic element of health care, with reproductive processes, functions and systems relevant to the provision of high-quality care across all life stages. As the Partnership for Maternal, Newborn and Childhood Health (PMNCH) states, “for UHC [universal health care] to be realised, especially for women, girls and adolescents, we must commit to building a collective health-for-all movement, inclusive and promotive of sexual and reproductive health and rights (SRHR).”1 Incorporation of SRHR into medical school curricula is essential to ensure health care professionals develop a strong foundation of knowledge and skills to provide the best care possible. Inclusion of SRHR will also enable them to become a part of the movement to bring the highest attainable standards of SRHR for all.

Audience

The intended audience of this model curriculum is medical school faculty who should support an inclusive curriculum on SRHR for all students, as well as students, who may use it to advocate for inclusion of these elements in their programmes.

Purpose of the curriculum

The purpose of this model curriculum is to provide an outline or standardised approach for building a comprehensive SRHR curriculum for medical students. While the consensus on inclusion of certain topics will likely vary by country and institution, this inclusive list serves as the gold standard: a target for all curriculum and course designers as they make improvements to their curricula.

Development of the curriculum and what it does not include

This work was initiated by FIGO’s Safe Abortion Committee who started creating the outline building on two key sources.2,3 It was developed further in collaboration with other FIGO committees, WATOG and IFMSA and is endorsed by all three organisations.

The model curriculum does not include guidance on strategic implementation and assessment. The World Health Organization (WHO) has developed tools for the development of competencies, programmes and curricula on abortion and contraception, aimed at the primary health care workforce – these can be used for further guidance and implementation.4

Topics for inclusion

Basic biomedical sciences

  • Reproductive physiology, including menstruation, ovulation, fertilisation, pregnancy physiology, contraception, pregnancy loss, abnormal pregnancy, medical illness that can be negatively affected by pregnancy, abnormal foetal development, abortion, sexual dysfunction, infertility, stimulation of ovulation and methods of assisted reproduction, cancers of the reproductive organs and HPV vaccination, menopause.
  • Pharmacology, including of contraception, emergency contraception, and contraceptive technologies; and of medical abortion methods

Behavioural and social sciences, including public health and population medicine

  • Access to sexual and reproductive health and rights (SRHR) including contraception and safe abortion as a public health and human rights priority.
  • Overarching concepts such as human rights, gender and sexuality, interculturality and multiculturality, and intersectoral approaches to health and care.
  • Understanding of national, regional and global incidence, management and consequences of the following SRHR violations: unsafe abortion, gender-based and domestic violence, sexual violence and rape, female genital mutilation, and child marriage.
  • Social, biological, psychological and structural determinants of health as complex factors that affect health, health care access, and health care decision-making related to uptake of contraception, undesired pregnancy and abortion. Understanding of the impact of undesired pregnancy and unsafe abortion on these factors.
  • Cultivating compassion and empathy towards patients regardless of personal beliefs on issues, ensuring the provision of better and more inclusive care.
  • SRH in adolescents and older women.
  • The vulnerability of certain populations in SRHR access, namely: elderly, adolescents, LBGTQ+ individuals, minorities, those in humanitarian crises, migrants and refugees, and people with disabilities. Diversity awareness when offering care to marginalised communities.
  • Communication with patients, including collecting medical history in the area of SRH, discussing SRH topics that might be taboo for a patient or a trigger (for example, a result of sexual harassment), respecting patients’ autonomy.

Medical ethics, human rights and medical jurisprudence relevant to the practice of medicine

  • National laws, regulations and policy related to abortion, contraception, assisted reproductive technology, gender-based and domestic violence, sexual violence and rape, female genital mutilation, and child marriage.
  • International human rights laws, standards and recommendations concerning sexual and reproductive rights, including human rights specific to women and girls, governments’ legal obligations, and comments and observations.
  • Ethical principles involved in SRH care, including abortion care: patient autonomy, respect, privacy, confidentiality and medical secrecy, primacy of patient welfare, social justice, principles of informed consent, and human rights.
  • Support and promotion of autonomy in women and girl’s reproductive health decision-making. 
  • The limits of refusal of abortion care through invoking “conscientious objection”, conscientious provision of SRH care including contraception and abortion.
  • Mechanisms for accountability of the health sector, i.e. systems of redress that promote access to justice in cases where rights may be neglected or violated.

The clinical sciences

  • These include clinical skills with respect to diagnostic procedures, practical procedures, communication skills, treatment and prevention of disease, health promotion, rehabilitation, clinical reasoning and problem solving.
  • Contraceptive rights-based counselling and voluntary, non-directive counselling about pregnancy options using evidence-based information, pre- and post-abortion counselling.
  • Pregnancy decision-making, including contraception methods and abortion.
  • Pregnancy complications such as foetal abnormalities or maternal health conditions that might make an individual with a desired pregnancy choose to terminate.
  • Pre- and post-abortion care.
  • Quality abortion care for all pregnancy durations, medical and procedural; ensuring women/girls choice and option of telemedicine and self-management routes where possible; abortion complications and their management.
  • Counselling and management of pregnancy loss and obstetric emergencies including methods of uterine evacuation.
  • Managing complications of unsafe abortion including sepsis, septicaemia, haemorrhage, renal failure, uterine perforation and other genital tract and gastro-intestinal tract injuries.
  • Topics inclusive of:
    • contraception (barrier methods, chemical methods, long-acting methods, sterilisation, WHO eligibility criteria, emergency contraceptives); postpartum and post-abortion contraception; management of side effects and/or complications
    • comprehensive abortion care strategies: medical abortion, vacuum aspiration, surgical abortions; comprehensive care for women suffering from abortion complications
    • strategies for early detection and diagnosis of factors that have a considerable effect on female or male SRH; HPV vaccinations, prevention and treatment of HIV and other sexually transmitted infections (STIs). 

Life-long learning and professionalism

  • The importance of promoting social justice as a core professional value of medicine defined by the global Charter on Professionalism for the New Millennium, which includes advocating for access to health care services.5
  • Mechanisms to reflect on and reconcile personal beliefs with patient autonomy and the primacy of patient welfare (including values clarification exercises) – both core pillars of professionalism.5 

References

1. PMNCH. Sexual and Reproductive Health and Rights: An essential element to achieving universal health coverage. 2019. https://pmnch.who.int/news-and-events/news/item/12-02-2019-a-call-to-action-srhr-an-essential-element-to-achieving-universal-health-coverage

2. Steinauer J, DePiñeres T. Medical Education in Sexual and Reproductive Health: a Systems Approach to Provider Competence in Abortion and Contraception (In Press).

3. Gomez PI, Oizerovich S, Jefferson L. Propuesta de contenidos en Salud Sexual y Reproductiva para incorporar en currículos de Pre-Posgrado. FLASOG. 2011.

4. World Health Organization (WHO). Curriculum toolkit (unpublished).

5. ABIM Foundation, ACP Foundation, European Federation of Internal Medicine. Medical Professionalism in the New Millennium: A Physician Charter. Ann Intern Med. 2002;136(3):243-6. https://doi.org/10.7326/0003-4819-136-3-200202050-00012 

About our organisations

FIGO

FIGO is a professional organisation that brings together more than 130 obstetrical and gynaecological associations from all over the world. FIGO’s vision is that women of the world achieve the highest possible standards of physical, mental, reproductive and sexual health and wellbeing throughout their lives. We lead on global programme activities, with a particular focus on sub-Saharan Africa and South East Asia.

FIGO advocates on a global stage, especially in relation to the Sustainable Development Goals (SDGs) pertaining to reproductive, maternal, newborn, child and adolescent health and non-communicable diseases (SDG3). We also work to raise the status of women and enable their active participation to achieve their reproductive and sexual rights, including addressing female-genital mutilation (FGM) and gender-based violence (SDG5).

[email protected] / +44 (0)7383 025 731

IFMSA

The International Federation of Medical Students’ Associations (IFMSA), founded in 1951, is one of the world’s oldest and largest student-run organizations. It represents, connects and engages every day with medical students from 138 NMOs in 129 countries around the globe.

Our work is divided into four main global health areas: Public Health, Sexual and Reproductive Health and Rights, Medical Education and Human Rights and Peace. The IFMSA brings people together to exchange, discuss and initiate projects to create a healthier world. It trains its members to give them the skills and resources needed to be health leaders. It advocates for the pressing issues that matter to us to shape the world we want.

[email protected] / +45 301 177 13

WATOG

The World Association of Trainees in Obstetrics & Gynecology (WATOG) is a non-profit organization that represents the first worldwide network of young obstetricians and gynaecologists (OBGYN). WATOG’s main mission is to help every OBGYN trainee to access the highest level of education, to overcome cultural and gender barriers, and to facilitate contact and exchange between members from different countries.

WATOG’s first concern is to promote the foundation and sustainment of OBGYN trainee associations at national and regional levels. To achieve this WATOG encourages and helps trainee initiatives but also it collaborates with the FIGO and other national and regional senior associations to strengthen the connection between young and senior representatives of our profession. The final goal is to potentiate the involvement of OBGYN trainees in global issues pertaining to reproductive health care, specifically those of the mother, foetus and newborn but also women’s health care in general.

[email protected] / +33 6 61 14 39 24