Throughout the country, women in many medically underserved and rural areas who choose to terminate a pregnancy must leave their communities—often driving long distances and delaying access to care—to find a clinician who provides abortions. The growing shortage of abortion providers creates a significant barrier for women and girls living in the 87% of U.S. counties that do not have a healthcare practitioner providing abortion services (see footnote #1). Fortunately, three categories of licensed health care providers nurse practitioners (NPs), certified nurse-midwives (CNMs), and physician assistants (PAs) (see footnote #2)—are increasingly trained and competent in abortion care. Allowing these skilled primary care clinicians to incorporate early abortion services into comprehensive reproductive health care helps to secure and promote access to abortion care across the country.
CNMs, NPs & PAs are clinically competent to perform medication abortions
CNMs, NPs and PAs already have and use the skills necessary to provide medication abortions. With the exception of administering mifepristone, clinicians involved in women’s health care routinely perform all of the steps involved in medication abortion provision as current providers of gynecological, pre-natal, and peri-abortion care. Skills needed to provide medication abortion include the ability to:
- Take medical history to detect contraindications; perform physical examination and laboratory tests
- Determine gestational age
- Provide counseling, education, and informed consent, including discussion of known side effects and possible complications
- Administer mifepristone orally
- Provide instructions and information including expected length of bleeding, signs and symptoms of incomplete abortion, and any other pertinent medical information;
- Provide follow-up care for assessment of potential complications.
These activities are well within the skill sets of certified nurse-midwives, nurse practitioners and physician assistants who provide other gynecological and other reproductive health care.
CNMs, NPs & PAs are clinically competent to perform aspiration abortions
Studies have shown that APCs provide aspiration abortion care that is of equivalent quality to that offered by physicians. For example, a two-year study examined 1,363 aspiration abortion procedures performed at two New England clinics. One clinic had NPs and PAs providing abortions whereas the other clinic had physicians providing abortions. The complication rate at both clinics was very low and the study concluded that “physicians and mid-level clinicians are equally competent, safe surgical abortion providers.” (see footnote #3) In a Vermont clinic, where physician assistants have been performing uterine aspiration abortions since 1975, a researcher found “no difference between procedures performed by physicians and those performed by physician assistants with respect to overall, immediate, or delayed complication rates.” (see footnote #4).
In an effort to explore this further, ANSIRH sponsored Health Workforce Pilot Project (HWPP) #171 to evaluate the safety, effectiveness and acceptability of certified nurse-midwives, nurse practitioners, and physician assistants in providing aspiration abortion. HWPP #171 operated under the auspices of California’s Office of Statewide Health Planning and Development (OSHPD) to improve health care access. A six year study (2007-2013), HWPP #171 collected data from almost 20,000 patients and trained nearly 50 CNMs, NPs, and PAs to competency in aspiration abortion care.
Study results from HWPP #171 confirm previous results (see footnote #5 and footnote #6):
- CNMs/NPs/PAs can provide early abortion care that is clinically as safe as physicians
- CNMs/NPs/PAs can be successfully trained to competence in aspiration abortion care
- Outpatient abortion is very safe, whether performed by a CNM/NP/PA or a physician
- Patients report high satisfaction during their abortion experience whether they are seen by a CNM/NP/PA or a physician
As a result of the evidence provided by HWPP #171, Assembly Bill 154 (AB154) was introduced and passed in the California legislature in October 2013. AB154 removed barriers to abortion provision for CNMs, NPs, and PAs allowing them to maximize their existing skillset and provide aspiration abortion care in California.
Restrictions on CNMs, NPs & PAs
While CNMs, NPs and PAs currently provide medication abortion in at least 15 states and aspiration abortion in 5 states, in most states these clinicians are barred from providing abortions, both by abortion-specific laws, and by state practice acts with varying scope of practice regulations and restrictions. States hold much of the authority to regulate both abortion provision and clinician scope of practice. Fostering increased understanding among state-level experts on health professional regulation and education, as well as reproductive rights, could contribute to more effective strategies for the integration of early abortion into the scope of practice of all trained and qualified clinicians.
2This site uses the umbrella term advanced practice clinician (APC) to refer collectively to the roles of nurse practitioner (NP), certified nurse-midwife (CNM), and physician assistant (PA). We recognize the clear distinctions among these three professional roles and, with this caveat, use the term of advanced practice clinician for the sake of convenience throughout these documents. In the United States, CNMs, NPs, and PAs have also been categorically referred to in some policy statements, statutes and regulations as “midlevel providers” or “non-physician providers,” neither of which adequately reflects their contribution as fully licensed, qualified primary care professionals. We recognize that the ideal taxonomy has yet to be identified and thank you for your understanding.
5Weitz, TA, Taylor, D, Desai, S, Upadhyay, UD, Battistelli, MF, Waldman, J, Drey, EA. January 2013. Safety of Aspiration Abortion Performed by Nurse Practitioners, Certified Nurse Midwives and Physician Assistants under a California Legal Waiver. American Journal of Public Health [Epub ahead of print.].
6Taylor, Diana, Postlethwaite, Debbie, Desai, Sheila, James, Angel J, Calhoun, Amanda W, Sheehan, Katherine, Weitz, Tracy. April 2013. Multiple Determinants of the Abortion Care Experience: From the Patient’s Perspective. American Journal of Medical Quality [Epub ahead of print.].