Nearly half of all pregnancies in the United States are unintended, and approximately half of those are terminated (
Finer and Henshaw, 2006
). Abortion is one of the most frequently performed procedures among women of reproductive age, yet wide geographic disparities persist in the availability of abortion care. The abortion rate is as low as 1 per 1,000 women in some states (Wyoming) and as high as 40 per 1,000 women in others (Delaware; Jones and Kooistra, 2011
). Women in nonmetropolitan areas have more limited access to abortion care; 97% of nonmetropolitan counties lacked an abortion provider in 2008 (Jones and Kooistra, 2011
). Ensuring adequate access to a service that one in three women will need by age 45 remains a critical public health problem, especially in rural areas.Incorporating abortion into women’s primary care services is one way to ensure access that would also promote continuity of care. This would benefit women in all parts of the country, but especially in medically underserved areas. Nurse practitioners (NPs), certified nurse-midwives (CNMs), and physician assistants (PAs) are important providers of primary health care services to women of reproductive age, and their skills could be leveraged to improve access to abortion (
Taylor et al., 2009
). These clinicians already routinely provide important components of abortion care, including taking medical histories, confirming and dating pregnancies, providing pregnancy and abortion options counseling, and referring patients when complications arise. NPs, CNMs, and PAs also provide services that require procedural skills similar to those of early aspiration abortion, including inserting intrauterine devices and performing endometrial biopsies. PAs were among the first abortion providers in New England after Roe v. Wade (Joffe and Yanow, 2004
), and PAs, NPs, and CNMs currently provide abortions in 15 states and many countries around the world (Abortion Access Project, 2011
, Abortion Access Project. (2011). Advance Practice Clinicians. Available: http://www.abortionaccess.org. Accessed January 24, 2011.
Berer, 2009
). Multiple studies have documented the safety of abortion care provided by these clinicians (Freedman et al., 1986
, Goldman et al., 2004
, Warriner et al., 2006
).A number of barriers impede CNMs, NPs, and PAs from providing this care. Each profession practices under its own regulations, and these vary from state to state. These clinicians practice with a large degree of autonomy in some states, but in others their work must be closely supervised by a collaborating physician. Many states limit the provision of abortion care to licensed physicians by law. Most of these laws were enacted after Roe v. Wade in 1973, when public health officials were concerned about untrained providers harming women. Thus, these physician-only laws were not designed to constrain other adequately trained clinicians from providing abortion care, but to protect women from untrained providers. CNMs, NPs, and PAs were not such important components of our health care system when these regulations were passed and thus were not included in the laws regulating abortion. Antichoice organizations have used physician-only laws to prohibit PAs from providing abortions in Arizona. Physician-only laws present obstacles for CNMs, NPs, and PAs who have the technical skills to provide abortion care. Advocates in some states, including a few with physician-only laws on the books, have worked in partnership with the Abortion Access Project, Clinicians for Choice, and Advancing New Standards in Reproductive Health to use the state legislative process, state judicial rulings, and regulatory board actions to explicitly include abortion as part of the scope of practice of CNMs, NPs, and PAs (
Schultz, 2009
).Overcoming legal and regulatory barriers is only one part of the equation. If abortion care is to be fully integrated into the scope of CNM, NP, and PA practice, training programs must include abortion in both their didactic and clinical curricula. One study found that the most common reason for not providing abortion care was lack of adequate training (
Hwang et al., 2005
). National and regional studies suggest gaps in training in these critical areas. Foster et al., 2006
documented a discrepancy between training in abortion care and other reproductive health. For example, although nearly all programs included didactic (96%) and clinical (87%) training in contraception, only half offered didactic instruction on abortion and only 21% clinical training in abortion procedures (Foster et al., 2006
). Preliminary analysis of qualitative interviews conducted by the author support the importance of training in how CNMs, NPs, and PAs understand the boundaries of their scope of practice (C. Jackson, Unpublished manuscript). Clinicians who received both didactic and clinical exposure to abortion care were more likely to regard abortion as within their scope of practice; clinicians who were not offered this training expressed skepticism that they were qualified to provide such care despite their competency in similar procedures.Improving training for CNMs, NPs, and PAs and removing the legislative and regulatory barriers that impede them from providing abortion care are both urgently needed. CNMs, NPs, and PAs are essential to ensuring that women have access to comprehensive reproductive health care. Expanding the pool of clinicians able to provide abortion care and situating medication and early aspiration abortion within primary care could greatly improve women’s access to the abortion services they need. Women in rural areas could especially benefit from the provision of abortion care by primary care providers, specifically, CNMs, NPs, and PAs.
References
Abortion Access Project. (2011). Advance Practice Clinicians. Available: http://www.abortionaccess.org. Accessed January 24, 2011.
- Provision of abortion by mid-level providers: International policy, practice, and perspectives.Bulletin of the World Health Organization. 2009; 87: 58-63
- Disparities in rates of unintended pregnancy in the United States, 1994 and 2001.Perspectives on Sexual and Reproductive Health. 2006; 38: 90-96
- Abortion education in nurse practitioner, physician assistant and certified nurse-midwifery programs: A national survey.Contraception. 2006; 73: 408-414
- Comparison of complication rates in first trimester abortions performed by physician assistants and physicians.American Journal of Public Health. 1986; 76: 550-554
- Physician assistants as providers of surgically induced abortion services.American Journal of Public Health. 2004; 94: 1352-1357
- Advanced practice clinicians’ interest in providing medical abortion: Results of a California survey.Perspectives on Sexual and Reproductive Health. 2005; 37: 92-97
- Advanced practice clinicians as abortion providers: Current developments in the United States.Reproductive Health Matters. 2004; 12: 198-206
- Abortion incidence and access to services in the United States, 2008.Perspectives on Sexual and Reproductive Health. 2011; 43: 41-50
Schultz, E. C. (2009). Issue Brief #2: Key legal barriers for provision of abortion by Advanced Practice Clinicians. San Francisco, CA: University of California San Francisco.
- Providing abortion care: A Professional toolkit for nurse-midwives, nurse-practitioners, and physician assistants.University of California, San Francisco, San Francisco2009
- Rates of complication in first-trimester manual vacuum aspiration abortion done by doctors and mid-level providers in South Africa and Vietnam: A randomised controlled equivalence trial.Lancet. 2006; 368: 1965-1972
Biography
Courtney B. Jackson was the Ellertson Fellow at Ibis Reproductive Health in Cambridge, MA from 2006–2008. She received a PhD in Sociology and a Graduate Certificate in Women's Studies from Rutgers, The State University of New Jersey.
Article info
Publication history
Accepted:
January 27,
2011
Received in revised form:
January 27,
2011
Received:
January 14,
2011
Identification
Copyright
© 2011 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.
