- Improvement in patient safety by allowing early diagnosis and management of unintended pregnancy
- Improvement in patient and clinician satisfaction by integrating abortion care into existing women’s primary care
- Improvement in women’s health care delivery by integrating abortion into early pregnancy care, thereby reducing delays and unnecessary referrals
The authors and organizational sponsors would like to thank the following individuals, who helped contribute to the success of this publication. In addition, we are extremely grateful to our editors, Beverley J. DeWitt and Elizabeth Potter, CNM, MS, for their expertise.
Patricia Anderson, MPH
Molly Battistelli, BA
Margie Beal, CNM, PhD
Lisa McLennan Brown, JD
Joyce Cappiello, FNP, MS
Ann Davis, PA-C
Sue Davidson, PhD, RN, CNS
Catherine Dower, JD
Jennifer Dunn, JD
Carla Eckhardt, CPHQ
Nancy Foss, MA
Rivka Gordon, PA-C, MPH
Anita Kuennen, RN
Rebecca Lehman, MPAS, PA-C
Amy Levi, CNM, PhD
Francie Likis, CNM, NP, DrPH
Cathleen M. Mahoney, JD
Stephen Nunn, MPAS, PA-C
Jenny O’Donnell, BA
Elizabeth Potter, CNM, MS
Diane Ranieri, MA, RPAC
Erin Schultz, JD
Kathy Simmonds, NP, MSN, MPH
Janet Singer, CNM, MS
Jini Tanenhaus, PA-C, MA
Kirsten Thomsen, PA-C
Deborah VanDerhei, BSW
Tracy Weitz, PhD, MPA
Susan Yanow, MSW
Melanie Zurek, EdM
Participation by these individuals should not be interpreted as an endorsement, and any limitations of the curriculum are solely the responsibility of the authors.
ABOUT THE AUTHORS
Diana Taylor, RN P, PhD, FAAN, is a nurse practitioner, educator, and researcher and is Professor Emerita at the University of California, San Francisco (UCSF) School of Nursing where she provided leadership for interdisciplinary primary care education. Dr. Taylor has more than 100 scientific articles and publications in the area of women’s health. With over 35 years of experience in providing women’s health care and training health professionals, Dr. Taylor has been at the forefront of developing standards and scope of practice for advanced practice nurses, serving on national committees of the American Nurses Association, the National Organization of NP Faculties as well as state and local nursing practice committees. Dr. Taylor is an active board member of the Association of Reproductive Health Professionals, the Reproductive Options Education Consortium in Nursing; a board member of Clinicians for Choice; and Board chair (as well as a practicing clinician) of the San Francisco Women’s Community Clinic. Currently, she is the director of research for a statewide project to train advanced practice clinicians in first trimester abortion care using a standardized curriculum. The goal of the project is to increase the number of abortion providers and make professional and practice improvements to normalize abortion into women’s primary care.
Barbara Safriet, JD, LL M, is a consultant to the ANSIRH Program at UCSF. She has taught Health Law and Policy at Yale Law School and Lewis and Clark Law School and has lectured and published extensively on the regulation of health care providers, with a special focus on scope of practice. Professor Safriet has served as a member of The Pew Health Professions Commission, and its Taskforce on Health Care Workforce Regulation, and as a Health Law Consultant and Presenter for the Rockefeller Foundation, the W. K. Kellogg Foundation, the Commonwealth Fund, the Association of Academic Health Centers, the U.S. Agency for Health Care Policy and Research, the U.S. Public Health Service, the National Rural Health Association, the National Council of State Legislatures, and the Office of Technology Assessment of the U.S. Congress. In 1997, she served on a national interdisciplinary symposium establishing policy recommendations for establishing NPs, CNMs and PAs as qualified abortion services providers.
Grayson Dempsey has worked as a counselor, trainer, educator, and organizer in the field of reproductive health care since 1999. She is the founder and President of Backline, an organization that hosts an international Talk Line for women and their loved ones around all aspects of pregnancy, parenting, abortion and adoption. Ms. Dempsey has served as a consultant to the Abortion Access Project since 2003, during which time she coordinated efforts in the state of Oregon that led to the first explicit regulatory opinion on early abortion care and nurse practitioner scope of practice.
Beth Kruse, MS, ARN P, CNM, is a certified nurse-midwife with many years of clinical practice and research experience in midwifery, well-woman gynecology, family planning, and abortion care. She has helped to develop training programs in medication abortion and has served as faculty in meetings of numerous professional associations both in the United States and abroad, as well as contributing to several articles in peer-reviewed journals. She was the state of Washington’s first representative to Midwives for Choice and currently holds a seat on the National Advisory Committee for Clinicians for Choice. In 2005 she joined the National Abortion Federation as its Associate Director of Clinical Services and continues to practice direct patient care with the Department of Public Health Family Planning Program of Seattle/ King County.
Courtney Bangert Jackson, PhD, is a sociologist with expertise in evaluation research, reproductive health, the sociology of health professions, and quantitative data analysis. A former Charlotte Ellertson Fellow in Abortion and Reproductive Health, Ms. Jackson has conducted research on abortion training in residency training programs and APC provision of abortion. She has taught courses in research methods, women’s studies, and sociology at Suffolk University, Bowdoin College, and the University of Southern Maine. Dr. Jackson has more than 12 years experience conducting applied social science research in the areas of public health and community development. Currently, Dr. Jackson is the Director of Research & Evaluation at the Abortion Access Project.
Joyce Capiello, FNP, PhD(c)
Jennifer Templeton Dunn, JD
Jo Fortier, FNP, MS
Mindy Opper, PA-C
Shannon Rio, FNP, MS
Erin Cassard Schultz, JD
Karla Silverman, CNM, MS
Jini Tanenhaus, PA-C, MA
Deborah VanDerhei, BSW
Susan Wysocki, RNC, NP, FAANP
WELCOME TO THE APC TOOLKIT!
In the early 1990s, an experienced certified family medicine physician assistant (PA-C) in Montana became the object of a political effort to prevent her from continuing to offer abortion care within her primary care practice. With the support of her supervising physician, her professional organizations, state and national advocates, attorneys, and her community, she was able to meet and overcome this challenge successfully: the state law restricting her practice was reversed in 1999. She has recently opened a new practice and continues to provide abortion care as an essential part of primary care for the women in her remote community.
In 2006, an experienced family nurse practitioner (FNP) with a longtime primary care practice in rural Oregon was notified that the Oregon State Board of Nursing was investigating her provision of abortion in relation to scope of practice. This highly qualified NP was one of the few providers of abortion care in southern Oregon. The organizing and advocacy work this provider initiated with nursing professional organizations, pro-choice advocates, and attorneys in response to the investigation significantly furthered the in-depth evaluation by the Board of Nursing that led to the landmark ruling specifically affirming aspiration abortion care as within an Oregon NP’s scope of practice. In states across the country, advanced practice clinicians (APCs),1 physicians, reproductive rights advocates, and attorneys have joined together to revise outdated legislative and regulatory language specifying that only physicians may perform abortions. Where it exists, this language does not take into consideration the roles of nurse practitioner2, certified nurse-midwife, and physician assistant, nor does it acknowledge the experienced providers whose scope of primary and specialty practice includes management of conditions and procedures significantly more complex than early abortion. In hallmark cases, stakeholders have been able to obtain formal opinions, rulings, or changes in the law acknowledging that the provision of medication and/or aspiration abortion by qualified practitioners is not prohibited on the basis of their professional discipline, thus protecting both women’s access to abortion care and practitioners’ rights to provide appropriate care for their patients.
Providing Abortion Care: A Professional Toolkit for Nurse-Midwives, Nurse Practitioners and Physician Assistants (hereinafter referred to as the APC Toolkit) recounts legal accomplishments and other case histories as templates for action. These examples help to demonstrate how APCs who want to advance their existing practice, as well as those who are experienced in abortion care, can effectively develop relationships within existing professional networks, counter challenges to their scope of practice, and continue to meet the needs of the women they serve. We hope that the APC Toolkit will provide practical, field-tested resources for students, clinicians, administrators, and advocates as they pursue their goal of increasing women’s access
What is the APC Toolkit?
The APC Toolkit is a professional guide for APCs in the United States who are either currently providing or would like to offer abortion care within their practice. The information provided is based on specific definitions of United States professional disciplines, organizations, and legislative/regulatory systems. However, the APC Toolkit also offers background information, resources, and guidelines for professional advancement that could be adapted to other health care systems.
The APC Toolkit helps clinicians compile crucial evidence and documentation to support the integration of early abortion care as an essential part of women’s health care services. It guides APCs in the development of a professional portfolio that documents their basic and their abortion specialty education, knowledge, and training and the clinical and professional standards they use in providing safe care. It includes essential information and statistics about abortion care and access, professional standards and competencies, and the roles of state and national professional organizations and state licensing boards. Case studies demonstrating the establishment of abortion care as within the APC scope of practice provide strategies for success.
Why is the APC Toolkit Needed?
A significant proportion of the population needs abortion care.
In 2001, 49% of pregnancies in the U.S. were unintended (Finer & Henshaw, 2006), and half of those pregnancies were terminated. Abortion is one of the most common “surgical” procedures in the United States, with approximately one-third of all women having an abortion at some point during their lives (Boonstra, Benson Gold, Richards, & Finer, 2006). In 2005, the most recent year for which comprehensive data on abortion incidence are available, 22% of pregnancies (excluding miscarriages) ended in abortion (Jones, Zolna, Henshaw, & Finer, 2008). The same survey reports that 8% of women needed to travel more than 100 miles and 19% traveled 50–100 miles to obtain abortion care. The authors note that although the U.S. population is concentrated in metropolitan areas, 24% of metropolitan women and 92% of their nonmetropolitan counterparts lack an abortion provider in their county.
The need to seek out specialized abortion clinics may contribute to a delay in obtaining abortion care, along with increasing cost, especially for women in nonmetropolitan areas. Although abortion is an extremely safe procedure, at more advanced gestations it becomes more complicated and costly (Boonstra et al., 2006).
Advanced practice clinicians are essential providers of primary care.
NPs, CNMs, and PAs offer a competent source of women’s primary care and often practice in medically underserved settings (Institute of Medicine Committee on the Future of Primary Care & Donaldson, 1996). A 2003 study found that 49% of NPs and 69% of PAs in California serve rural and vulnerable populations, compared with 35% of obstetrician-gynecologists (Grumbach, Hart, Mertz, Coffman, & Palazzo, 2003). In 2004, APCs saw six times as many women for publicly funded family planning services as did physicians (Frost & Frohwirth, 2005). By 2006, there were approximately 76 primary care physicians, 42 NPs, and 17 PAs per 100,000 U.S. population (New York Center for Health Workforce Studies, 2006). As primary care providers APCs are an obvious entry point to the health care system for women facing unintended pregnancies. Clearly, if early aspiration and/or medication abortion care were included in a program of comprehensive reproductive health services, women would be much more likely to receive timely, low-risk intervention.
Early abortion care belongs within the realm of primary health care.
A primary goal of the APC Toolkit is to improve access to abortion care, an evidence-based public health strategy for serving women facing unintended pregnancy. The APC Toolkit will help to prepare clinicians and administrators across the country to respond to challenges and engage in proactive strategies to further establish early abortion care as part of the range of women’s health care services provided by APCs.
According to California’s Primary Care Initiative (Advancing New Standards in Reproductive Health, 2006), when properly trained clinicians offer early abortion care to their communities as part of comprehensive family planning and early pregnancy care, the following outcomes are seen:
Professional education, ethics, and experience shape scope of practice.
The APC Toolkit presents abortion as a scope of practice issue and further explores the provision of abortion care as a natural extension of the work of APCs. It is pro-patient and pro-clinician, acknowledging the political nature of abortion while encouraging a focus on patients’ and clinicians’ abilities to meet those needs.
When a specific clinical procedure is singled out as off-limits to a properly trained and competent health care professional for political purposes, this undermines the profession’s rights and responsibilities and reduces patient access to qualified health professionals. At a minimum, professional practice is curtailed; at worst, professional licenses may be suspended or lost, and women and communities lose access to services.
Professional practice environments vary widely from state to state and discipline to discipline. In addition, political, social, and professional attitudes toward unintended pregnancy, contraceptive services, and abortion care are complex and multilayered. Although the clinical management of abortion is relatively straightforward, these other factors constantly shift in response to a multitude of influences. Although not state-specific, the APC Toolkit provides a framework for understanding both barriers to and stratagems for advancing scope of practice at the state level.
Who Can Use the APC Toolkit?
- CNMs, NPs and PAs working in group or independent clinical practice as well as in primary care or reproductive health specialty areas.
- Administrators responsible for developing and maintaining systems for human resources as well as clinical policies and procedures.
- Advocates working with clinicians and administrators to protect and expand access to women’s reproductive health care.
- Faculty and administrators within APC education and training programs whose mission includes preparing health care professionals to provide comprehensive reproductive health care as a facet of primary care.
- Representatives from professional associations and regulatory boards who recognize the value of professional determination of scope of practice and seek to further their understanding of abortion care in that context.
How is the APC Toolkit Meant to Be Used?
The APC Toolkit is a professional development resource. It is intended to prepare clinicians, administrators, educators, and advocates to participate in developing a multi-level plan for advancing APC clinical practice in abortion care.
Strategies for integrating abortion care into APC practice include:
- developing a sophisticated professional portfolio, including professional practice regulations and guidelines on how to advance practice into new areas of knowledge and skill;
- acquiring familiarity with the structure and function of professional organizations and state licensing boards;
- developing relationships with the officers and members of local and regional chapters of professional organizations;
- building or strengthening existing relationships with professional colleagues known to be supportive of abortion care and/or professional autonomy;
- identifying actual and potential obstacles within and among professional organizations and regulatory boards; and
- creating pathways for incrementally advancing practice while building a network of support.
BEYOND THE APC TOOLKIT
Abortion care is multilayered and complex, and its provision involves dedication and rich resources of psychosocial and technical skills. Clinicians working in the field may feel overwhelmed when they consider confronting the sociopolitical and regulatory challenges that loom in the face of change. For those who want to participate in expanding necessary services for women through provider-neutral care but may have felt lost in the labyrinth of legal, governmental, and professional influences, we hope this APC Toolkit offers clarity and inspiration. The authors also encourage you to complete the evaluation and contact the sponsors of this project with comments, suggestions, and criticisms, as well as to ask questions and share the unique circumstances of your state and your practice. Please visit our websites and email us anytime at the following addresses:
REFERENCES: WELCOME TO THE APC TOOLKIT
Advancing New Standards in Reproductive Health. (2006). Abortion provision in California: A need for expanded access. San Francisco: Univ. California, San Francisco, ANSIRH/Primary Care Initiative. Available at http://www.ansirh.org/_documents/research/pci/pci_facts10-2006.pdf
American Academy of Physician Assistants. (2008f ). 2008–2009 AAPA policy manual (PA Definition, HP- 3100.1.3). Alexandria, VA: Author. Available at http://www.aapa.org/manual/profession.pdf
Boonstra, H., Benson Gold, R., Richards, C., & Finer, L. (2006). Abortion in women’s lives. New York: Guttmacher Institute.
Foster, A. M., Polis, C., Allee, M. K., Simmonds, K., Zurek, M., & Brown, A. (2006). Abortion education in nurse practitioner, physician assistant and certified nurse-midwifery programs: A national survey. Contraception, 73(4), 408–414.
Frost, J. J., & Frohwirth, L. (2005). Family planning annual report: 2004 summary, Part 1. New York: Guttmacher Institute.
Grumbach, K., Hart, L., Mertz, E., Coffman, J., & Palazzo, L. (2003). Who is caring for the underserved? A comparison of primary care physicians and nonphysician clinicians in California and Washington. Annals of Family Medicine, 1(2), 97–104.
Healthy People 2010. (2004). About healthy people. Retrieved February 25, 2009, from http://www. healthypeople.gov/About/
Institute of Medicine Committee on the Future of Primary Care, & Donaldson, M. S. (1996). Primary care: America’s health in a new era. Washington, DC: National Academy Press.
Joffe, C., & Yanow, S. (2004). Advanced practice clinicians as abortion providers: Current developments in the United States. Reproductive Health Matters, 12(24 Suppl), 198–206.
Jones, R. K., Zolna, M. R., Henshaw, S. K., & Finer, L. B. (2008). Abortion in the United States: Incidence and access to services, 2005. Perspectives on Sexual and Reproductive Health, 40(1), 6–16.
New York Center for Health Workforce Studies. (2006). The United States Health Workforce Profile (No. HRSA U79-HP000010801). Rensselaer, NY: School of Public Health, University at Albany, State University of New York.
Office of Population Affairs, & Department of Health and Human Services. (2001). Healthy People 2010—Reproductive health. Washington, DC: Office of Population Affairs.
1 The umbrella term advanced practice clinician (APC) is used to refer to the collected roles of nurse practitioner (NP), certified nurse-midwife (CNM), and physician assistant (PA) in this document. In the United States, CNMs, NPs and PAs have been categorically referred to as “midlevel provider” or “nonphysician provider,” which does not adequately reflect their contribution as independent and qualified primary care professionals.
2 Advanced practice nursing (APN) roles are defined to include those of nurse practitioner, nurse-midwife, nurse anaesthetist, and clinical nurse specialist. In addition, nurse practitioner titling in each state varies. For the sake of simplicity in this text, all nurse practitioner title references (ARNP, NP, APRN, RNC, etc.) are referred to by the generic “NP.”
3 The term, advanced practice clinician or APC is not accepted by the American Academy of PAs who have a published position on appropriate titles for PAs: “The AAPA believes that, whenever possible, PAs should be referred to as “physician assistants” and not combined with other providers in inclusive non-specific terms such “midlevel practitioner”, “advanced practice clinician”, or “advanced practice provider” (AAPA, 2008).