Barriers to Care
Barriers to Abortion Provision by Advanced Practice Clinicians (APCs)
As the rhetorical claims of the anti-abortion movement intersect with challenges to scope of practice, NPs, midwives, and PAs face multiple barriers to abortion provision, including:
Confusing and rapidly changing state abortion laws
Each state is governed by a complex set of laws, regulations, and education standards.
Long-standing efforts of organized medicine to use the political process to control the scope of practice
For example, the American Medical Association and other national physician organizations launched the Scope of Practice Partnership in 2006 and consistently and explicitly opposed any expansion of scopes of practice by providers “other than medical doctors.” APC scope of practice is not defined by law but rather determined by relevant laws, regulations, and professional organization opinions. Given that professional APC organizations, as well as major medical and public health organizations, have recognized abortion care as within APC professional scope of practice, when APCs provide this care, they are working to their full scope of practice. Thus, efforts to increase access to abortion care should not be treated as an expansion but rather as bringing the law in line with professional scope.
Physician-only laws
Approximately half of all states have laws specifying that only physicians can perform abortion procedures. While the intent may have been ostensibly to protect patients, there is no evidence that they accomplished this goal, and some historical data suggests that this was instead an intentional exclusion of midwives and other providers in an effort to consolidate power in the nascent allopathic medical profession.
Lack of training opportunities
National surveys have shown that both didactic and clinical training in abortion are limited. Including the principles of abortion care in basic and post-graduate educational programs is an important way to disseminate the recognition that abortion is within the scope of practice of NPs, midwives, and PAs, both in the US and globally. Since Dobbs, the growth of APC abortion training programs has expanded, thus increasing access to patients in neighboring restrictive states. To learn more about these expanding resources, see Section 13, Training and Curricular Resources.
Misleading terminology
The misuse of language in abortion care has hindered the provision of care by APCs. For instance, the use of ‘surgical abortion’ can confound legislative efforts at overturning physician-only laws and add to general confusion about the complexity and safety of procedural abortion care. As APCs, we must become fluent in accurate, informative messaging around these (and other) aspects of abortion care to help mitigate public misperception, misinformation, disinformation, and misunderstanding.
Fear of reprimand
Increasing support and enthusiasm for NPs, midwives, and PAs as abortion providers in recent years has been undermined by unclear laws and other regulatory and professional barriers that either explicitly discourage these clinicians from providing abortion care or create enough confusion that clinicians and their advocates are hesitant to move forward with training and service provision for fear of reprimand or professional consequence. Particularly in a post-Dobbs landscape this is very evident in ban states, where ER clinicians and staff are unsure of how to proceed with early pregnancy loss care and abortion care in the context of maternal mortality.This uncertainty reflects well-documented experiences of providers and patients within religiously-affiliated healthcare systems even before the Dobbs decision. APCs providing care in ban states must balance the urgent need for care with the legal ramifications of providing in states where provision is completely prohibited or where permissible abortion is ill-defined, often adding a distressing emotional toll to their work and impacting their mental health.