Provision of Abortion Care by Advanced Practice Nurses and Physician Assistants

The American Public Health Association (APHA) has, since 1967, recognized access to safe abortion services in the United States as a public health issue.^1–3 Further, APHA has called for federal funding for abortion services,^4–6 increased training,^7,8 and safeguarding abortion as a reproductive choice.^1,2 There is currently no active APHA policy addressing the issues associated with nurse practitioners, nurse-midwives, and physicians’ assistants as abortion providers. The present policy replaces archived APHA Policy Statement 9917, which was written in 1999 and addressed the need to advocate for the provision of abortion care by nurse practitioners (NPs), nurse-midwives (CNMs), and physician assistants (PAs).⁹

Problem Statement
In the United States, nearly 50% of all pregnancies are unintended, making unintended pregnancy a persistent public health problem in this country.¹⁰ Abortion, recognized as one choice for women experiencing unintended pregnancy, is one of the most common and safest gynecologic interventions in the United States. Approximately one third of all women in the United States will have an abortion at some point during their lives.¹¹ Recent studies show that US abortion rates are declining for all but the nation’s poorest women.¹² Nationwide, the number of abortions peaked in 1990 at 1.6 million; the number had dropped by 25%, to 1.2 million, by 2005 and increased by 1%, to 1.21 million, in 2008.¹²

Most women face multiple obstacles to obtaining abortion care. Currently, nearly 87% of US counties do not have an abortion provider; this shortage is precipitated by factors including inadequate or unavailable abortion training for women’s health professionals, state abortion provider restrictions, and the worsening of anti-abortion harassment and violence.¹² 

A shortage of abortion providers creates barriers to abortion, with related negative health consequences. Empirical evidence shows that nationwide, 26% of women receiving abortion services have traveled at least 50 miles; in some regions, this figure is as high as 43%. Almost half of women having later abortions, which have higher complication rates, report problems finding or getting to a provider, resulting in a delay of their abortion.^13,14

Many states also have laws mandating that only licensed physicians may perform abortions. In some states, these laws were enacted following the legalization of abortion in 1973, in an effort to protect women from unqualified abortion providers. More recently, newer laws were passed to specifically limit the provision of abortion in states that were generally opposed to legal abortion. In either case, physician-only provisions do not acknowledge the roles and experience of NPs, CNMs, and PAs, whose scope of primary and specialty practice includes management of conditions and procedures significantly more complex than medication or aspiration abortion. 

Since the 1990s, professional organizations representing nurses have called for efforts to expand the pool of clinicians who perform abortion to include NPs, PAs, and CNMs.^15–22 Position statements by these groups are also referenced in 2 symposia proceedings published by the National Abortion Federation.^23,24 More recently, a growing number of professional organizations (e.g., Nursing Students for Choice, Clinicians for Choice, and state-based grassroots networks, such as the Washington State Abortion Providers Network) are advocating for the list of recommendations and actions outlined at the conclusion of this policy statement. Also, organizations that focus on education and curriculum development for health professionals, such as the National Organization of Nurse Practitioner Faculties, American Academy of Physician Assistants, Association of Physician Assistants in Obstetrics and Gynecology, and Association of Reproductive Health Professions support comprehensive sexual and reproductive education and training.

Evidence for Advanced Practice Nurses and Physician Assistants as Safe, Competent Primary Care Clinicians

Approximately 200,000 licensed NPs, CNMs, and PAs currently practice in the United States; the majority of these clinicians provide primary care to women of reproductive age who are at risk for unintended pregnancy.^25–27 These clinicians care for patients in diverse settings, are more likely to provide care to poor and underserved populations, and are critical to the expansion of health care access.^15,28–31 Therefore, these clinicians are well positioned within the health care system to address women’s needs for comprehensive primary care and preventive reproductive health services that include abortion care. 

In the United States, NPs, CNMs, and PAs have been categorically referred to as “midlevel provider” or “physician extender,” which does not adequately reflect their contribution as independent, safe, and qualified primary care professionals and more than physician substitutes. The Institute of Medicine Committee on the Future of Primary Care²⁸ and, more recently, the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act (known together as the Affordable Care Act of 2010) have defined NPs, CNMs, and PAs, along with generalist physicians, as primary care clinicians. 

Advanced Practice Nurses and Physician Assistants Improve Access to Reproductive Health Services, Including Abortion Care

There is evidence that with appropriate education and training, NPs, CNMs, and PAs can competently provide all components of medication abortion care (pregnancy testing counseling, estimating gestational age by exam and ultrasound, medical screening, administering medications, and postabortion follow-up care) and can perform the added components of aspiration abortion (administering paracervical blocks, dilating the cervix, and evacuating or aspirating the contents of the uterus).^32–37

In this document, we use the term aspiration abortion when discussing first-trimester abortion care because it more accurately depicts a first-trimester abortion than does the term surgical abortion. Most abortions performed during the first trimester use electric or manual suction to empty the uterus. These simple procedures require only local or oral analgesics and can easily be performed in a primary care setting. Using the term surgical abortion to describe both less invasive aspiration procedures as well as more invasive procedures blurs the boundary between these very different types of procedures.^37,38 Not only does the term aspiration abortion clarify the important differences between types of abortions, its use can assist with efforts to challenge the thinking that only physicians should provide abortion care. Surgeons perform surgery. Aspiration abortion is not surgery. Primary care providers, including NPs, CNMs, and PAs, provide a wide range of procedures, including intrauterine device (IUD) insertion, endometrial biopsy, management of early pregnancy loss, and abortion. 

Empirical evidence also demonstrates the competency of NPs, CNMs, and PAs in providing all aspects of medication abortion.²⁴ Furthermore, research findings indicate the ability of primary care clinicians—including NPs, CNMs, and PAs—to provide first trimester aspiration abortions with complication rates comparable to those of physician abortion providers.^39–41 In addition, there is a decades-long history of these clinicians providing first trimester aspiration abortions in collaborative settings and training doctors in abortion care in states where physician-only restrictions do not exist.^42,43

In states without laws prohibiting NPs, CNMs and PAs from providing medication or aspiration abortions, these clinicians play an essential role in increasing patient access to abortion care and coordinated primary prevention of unintended pregnancy (e.g., family planning and contraceptive prescription services).⁴⁴ Despite the presence of physician-only restrictions for abortion in many states, by 2004, NPs, CNMs and PAs with appropriate training were providing medication or aspiration abortions in approximately 14 states.^12,45,46

Barriers to Advanced Practice Nurses and Physician Assistants Performing Abortion: Training, Regulations and Politics

Regulatory and Political Barriers

Significant barriers exist to expanding abortion access with NPs, CNMs, and PAs. Scope-of-practice restrictions in two thirds of states specific to NPs, CNMs, and PAs as abortion providers are a major barrier to abortion access and clinical training.^37,47–49 Typically, the general parameters of nursing and PA scope of practice are established under state practice acts, and through licensing board rules and regulations, which are intended to assess and validate the ever-evolving clinical competencies of licensees. Provider-specific restrictions, however, place abortion outside of this typical governance model by excluding abortion procedures from NP, CNM, or PA scope of practice. While some states place these provider restrictions within practice acts, many of these laws appear within targeted abortion statutes, some of which are located within state penal codes.⁴⁶

More recently, the politicalization of abortion care has led some state legislatures to exclude abortion from the legal scope of practice of clinicians other than physicians (in some states, there are also restrictions on physicians who are not gynecologists or obstetricians).³⁷ These ideologically based statutes contradict the evidence that these clinicians are capable of safely performing medication and aspiration abortion care.⁴⁸ It is contradictory to a modern evidence-based framework for health care regulation that emphasizes public protection as the principal priority of scope of practice and assumes the necessity of collaboration and overlap among professions.^46,50 (For more information on provider-specific restrictions for abortion, see ANSIRH’s Key Legal Barriers to Provision of Abortion by Advanced Practice Clinicians, available at: www.ansirh.org/_documents/issue_briefs/ansirh_brief2legal.pdf.) 

Unfortunately, abortion rights opponents are not the only forces working at the state level to restrict the scope of practice of NPs, CNMs, and PAs. Some state and national organizations representing doctors of medicine and osteopathy (MDs and DOs), under the auspices of the American Medical Association’s Scope of Practice Partnership, are actively working to influence legislators, consumers, regulators, policymakers, or payers to limit the scope of practice of other licensed health care professionals whose practices are authorized by law.^51,52 The Institute of Medicine’s report on the future of nursing concludes that limiting the ability of health care professionals to practice and provide appropriate care places an enormous and unnecessary burden on the American health care system.⁵³ The Federal Trade Commission recently evaluated proposed laws in 3 states and found several whose stringent requirements for physician supervision of nurses might be considered anticompetitive.⁴⁷ Other independent groups are calling for a rational approach to scope-of-practice expansions for health professions as well as managing scope-of-practice disputes from a consumer or a health-reform-planning approach.^54,55

Training Barriers

Even though the majority of patients seen by NPs, CNMs, and PAs are at risk for unintended pregnancy, competency-based education and training has lagged in reproductive health and unintended pregnancy prevention. Abortion care training is limited for all primary care clinicians, including physicians as well as NPs, CNMs, and PAs. National and regional studies suggest gaps in training in these critical areas.^56,57 These studies document 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 care and only 21% offered clinical training in abortion procedures. Furthermore, competency-based abortion care education standards have not developed to the same extent as other reproductive health curricula.^37,58,59

Because of legal and interprofessional barriers, training in abortion care is often difficult to access for NPs, CNMs, and PAs. Many facilities with established training programs have already committed their training slots to medical residents, students, or their own staff, and nonphysicians may face prejudice from trainers who are not supportive of abortion as part of nursing and PA scope of practice, or who see new abortion providers as possible competitors. Required competency in all aspects of abortion care, such as ultrasound, pregnancy options counseling, paracervical anesthesia, conscious sedation, and complication management, may also be restricted as training slots for these procedures are equally competitive.³⁷

Fragmented Service Delivery

In addition to these silos of health professional education and training, a fragmented system of reproductive health service delivery exists in the United States that is not coordinated across public health and primary care. According to an integrative and global consensus on the definition of reproductive health care,^60–63 reproductive health services, such as maternal child health, family planning, abortion services, preconception care, and fertility protection, should be delivered as a collection of integrated or coordinated treatment and prevention services that address the full range of sexual and reproductive health needs for men, women, and children, including adolescents, across their lifespan. Thus, the ability to reach all patients who might benefit from this move toward reproductive health promotion and prevention necessitates more than just women’s health providers, and requires the inclusion of all health professionals who care for populations with reproductive potential to intervene. A public health prevention model that addresses the prevention of unintended pregnancy (including early abortion as secondary prevention) as a way to promote reproductive health for use by health professionals caring for populations with reproductive potential has been proposed by Taylor et al.⁶⁴

From Policy to Action

Twenty years have passed since a multidisciplinary group called for expanding the pool of clinicians able to perform abortions to include NPs, CNMs, and PAs.²³ Unfortunately, little progress has been made and new barriers are being erected as a result of both the politics of health professional regulation and education, and the politics of abortion.⁴⁸ It is time for the public health community to reaffirm that PAs, NPs, and CNMs are capable and qualified to provide abortion care services. The provision of this care, however, must be based on whether the “professional can provide this proposed service in a safe and effective manner”^65(p4) and not solely on the lack of physicians available to provide the service.^54,65

Outdated laws, restrictive regulations, lack of clinical training opportunities, anticompetitive professional practices, and politically motivated challenges impede qualified clinicians’ ability to provide abortion care. All health professionals, reproductive health and rights advocates, attorneys, and regulators must join together to promote the provision of abortion by NPs, CNMs, and PAs, thereby protecting both women’s access to abortion care and practitioners’ rights to provide essential care for their patients.

Proposed Recommendations

APHA recommends—

1. The provision of medication and aspiration abortion by appropriately trained and competent NPs, CNMs, and PAs; 
2. That all health professionals educate themselves, their colleagues, and the public about the value of NPs, CNMs, and PAs and their capacity to increase access to safe abortions;
3. Collaboration and coalition building among state health professional organizations, regulators, legislators, and advocates to address barriers to NPs, CNMs, and PAs as qualified primary care clinicians and safe providers of abortion services; 
4. The adoption of the World Health Organization’s core competencies in sexual and reproductive health[63] by public health and primary care professional educators, which integrates peri-abortion care competencies within a broader framework of public and primary health care services;
5. Collaboration among medical and nursing educators to provide didactic and clinical training in core reproductive health services, such as unintended pregnancy options counseling, care coordination and pre- and postabortion care, and in abortion techniques, for those who elect training;
6. That all health care professionals apply the bioethical principles of respect, autonomy, beneficence, and fairness in order to advance reproductive justice, eliminate health disparities, and improve access to abortion services.

Action Steps

APHA urges—

1. State legislatures and health regulators to approach scope-of-practice disputes with the purpose of affirming that public protection, not professional self-interest, is the purpose of regulation and that all health professional practice acts should require licensees to demonstrate requisite training and competence to provide a service (see guidelines from Citizen Advisory Center[55]);
2. All medical and nursing education bodies providing education and training to primary care clinicians to integrate abortion training into their didactic and clinical reproductive health curricula;
3. The pharmaceutical manufacturer of medication abortion to petition for, and the Food and Drug Administration to grant inclusion of, NPs, CNMs, and PAs in the labeling of medication abortion pharmaceuticals to reduce barriers to provision of medication abortion by all competent clinicians with appropriate prescriptive authority;
4. Insurance companies to reimburse care provided by NPs, CNMs, and PAs consistent with their scope of practice. 

References

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