Radical or routine? Nurse practitioners, nurse-midwives, and physician assistants as abortion providers

Abstract

Abstract

In 2013 California passed legislation that expanded the pool of eligible aspiration abortion providers to include advanced practice nurses, nurse-midwives, and physician-assistants. This law, enacted in 2014, is based on evidence generated by the Health Workforce Pilot Project #171, which examined the safety and effectiveness of aspiration abortion care provided by these clinicians as well as patient acceptability and satisfaction. This evidence and the resulting policy change build on international research and established workforce strategies used to expand access to safe abortion services for women worldwide, representing a radical departure from the legislative trend of constricting access in the United States.

Résumé

En 2013, la Californie a adopté une législation qui élargissait la liste des professions autorisées à pratiquer les avortements par aspiration pour y inclure les infirmières de pratique avancée, les infirmières sages-femmes et les assistants médicaux. Cette loi, promulguée en 2014, est fondée sur les données générées par le projet pilote n° 171 sur le personnel de santé, qui a examiné la sécurité et l’efficacité de l’avortement par aspiration assuré par ces cliniciens ainsi que l’acceptabilité de la procédure et la satisfaction des patientes. Ces données et le changement de politique en résultant se fondent sur des recherches internationales et des stratégies reconnues de gestion des personnels de santé utilisées pour élargir l’accès à des services d’avortement sûr pour les femmes dans le monde, ce qui tranche radicalement sur la tendance législative à une réduction de l’accès aux États-Unis.

Resumen

En el año 2013 California aprobó legislación que amplió la reserva de prestadores de servicios de aborto por aspiración elegibles, para incluir enfermeras de práctica avanzada, enfermeras-obstetras y asociados médicos. Esta ley, promulgada en el 2014, se basa en evidencia generada por el Proyecto Piloto de la Fuerza Laboral de Salud No. 171, que examinó la seguridad y eficacia de los servicios de aborto por aspiración proporcionados por estos profesionales de la salud, así como la aceptación y satisfacción por parte de las pacientes. Esta evidencia y la política resultante del cambio se basan en investigaciones internacionales y estrategias establecidas en la fuerza laboral utilizadas para ampliar el acceso a los servicios de aborto seguro para las mujeres mundialmente, lo cual representa un cambio radical en la tendencia legislativa a restringir el acceso en Estados Unidos.

Key Words:

• abortion law and policy
• abortion providers and services
• USA

In 2013, one state in the United States (US) made a highly significant policy change based on evidence that nurse practitioners (NPs), certified nurse-midwives (CNMs), and physician assistants (PAs) can safely and competently provide early aspiration abortion, with training. NPs, CNMs, and PAs (henceforth referred to as “clinicians”) in the US have graduate level training and provide direct care to patients independently and/or in partnership with physicians. California legalized the provision of early aspiration abortion by these health care professionals, thereby expanding the pool of available abortion care providers. The passage of California’s new law (CA AB154),¹ was made possible by a strong coalition of patient advocates, health care providers, and researchers. This coalition worked with the state’s health professional boards and members of the state legislature for over two years to enact this evidence-based change.

The safety and acceptability of clinicians (or comparable professionals) as providers of early abortion care has been demonstrated for vacuum aspiration abortion ² and medical abortion ³ in both developed and developing countries.⁴ In Europe, such providers are responsible for the administration and supervision of the majority of medical abortion in three countries: France, Great Britain, and Sweden.⁵ Additionally, in the US as of 2015, 12 states allow for NP, CNM, and/or PA provision of medical abortion.⁶ In Bangladesh, Cambodia, Mozambique, Nepal, South Africa, and Vietnam, such providers are able to provide both manual vacuum aspiration (MVA) abortions and medical abortion in the first trimester -- allowing for greatly expanded access to safe abortion services for women.^4,7,8 The 2012 revised Safe Abortion: Technical and Policy Guidance for Health Systems ⁹ from the World Health Organization now acknowledges that abortions can be safely performed by such providers and, where abortion is legal, recommends the training of midwives, nurse practitioners, clinical officers, physician assistants, family welfare visitors, and others in abortion provision in order to ensure access to safe abortion for all women.

California’s new law,¹ which followed this long established international standard, was particularly meaningful in the American context because it was the only abortion policy that expanded abortion access, in a sea of policies designed to restrict abortion passed that year.¹⁰ State legislatures and courtrooms have been the primary battleground of abortion rights in the US for about two decades, with exponentially increased activity since 2011.¹⁰ Given that policies restricting abortion are increasingly common, California’s AB154 was a radical departure.

But how radical was it really?

It wasn’t radical for patient safety. Actually, a large study conducted between 2007 and 2013 demonstrated no difference between the complication rates of physician and clinician abortion providers.¹¹ The study, entitled the Health Workforce Pilot Project (HWPP) #171 was led by investigators at the University of California, San Francisco (UCSF), in collaboration with Planned Parenthood affiliates and Kaiser Permanente of Northern California. In total, 16,998 patients received aspiration abortions in the study, 53% performed by clinician providers and 47% by physician providers. The study showed that clinicians and physicians had comparable rates of complications, which were extremely low – lower than most existing published rates. During the study, experienced clinicians were trained in aspiration abortion provision according to a competency-based UCSF didactic and clinical protocol. To comply with sponsor requirements, the training included a minimum of 40 procedures performed under the direct supervision of a physician trainer and required all trainees to pass a didactic exam. This proved to be more than ample training for most clinicians. Like their physician colleagues (who were not trained as part of this study), clinicians frequently cite experience with aspiration abortion and related procedures, as well as the frequency of provision, as key components of developing confidence in their competence. The new California law advises following the same training protocol for experienced clinicians until 2016. Multiple publications detail the evidence generated by the study, including the safety of clinician provided aspiration abortion care,¹¹ multiple aspects of confidence development among clinicians while learning this skill,¹² patients’ positive experience of early abortion care,^13,14 and the effective use of research to inform policy change.¹⁵

It wasn’t radical as far as the patients were concerned either. Over the six-year study period, 81% of patients agreed to have their abortion procedure provided by a clinician, demonstrating that the large majority of women are likely to accept clinicians as their abortion care providers.¹³ In surveys of patients during the study, the patients reported high satisfaction with their abortion care experience, regardless of who provided the abortion.^13,14 Rather, patients identified several factors that influenced how they ranked their care experience, including interventions to decrease shame and/or stigma, their experiences of pain and pain management, the clinical environment, and waiting times associated with their appointment.¹⁴ These findings found no association with the type of professional (clinician or physician) who delivered the abortion care, and reflect systemic issues common in diverse health care settings.

It wasn’t radical to the clinicians themselves either. They were largely already well-trained, reproductive health care specialists providing family planning and, since 2001 in California, medical abortion care.^16,17 In interviews conducted as a sub-study of the main study, clinicians regarded aspiration abortion as the natural next step in their skill building.¹² Many were already doing closely related procedures, such as inserting intrauterine devices (IUDs), performing biopsies and colposcopies, placing laminaria and more; they had, as their trainers noted in qualitative interviews, sophisticated hand skills and competence with ultrasound, uterine sizing, and Pap smears. The experienced clinicians who were trained as part of the study grasped the skill of aspiration abortion quite seamlessly.

As such, training clinicians as abortion providers is not a radical notion. But it is unfortunately not routine yet either. With the promise of dramatically improving abortion access, time will show if other US states will follow suit with this policy change.