B. APCS' HISTORY OF PROVIDING COMPREHENSIVE WOMEN'S HEALTH CARE, INCLUDING ABORTION
APCs play a large and vital role in providing women with comprehensive reproductive health
care services and reaching the goals set forth in the Healthy People Initiative (U.S. Department
of Health and Human Services, 2000). Women in particular are more likely to receive care from
APCs than from physicians. A 2004 study found that APCs saw six times as many women as
did physicians for publicly funded family planning services (Frost & Frohwirth, 2005). Another
study found that APCs performed 73% of initial contraceptive exams in publicly funded clinics
(Finer, Darroch, & Frost, 2002).
APCs in all specialties, including primary care, are prepared in a wide range of procedures
that are recognized to be within their scope of practice and require the development of specialized
skills. Examples include: cardiovascular procedures such as central venous catheter
insertion and stabilization of cardiovascular penetrating injuries; circumcision; dermatologic
procedures such as abscess incision and drainage, cyst excision, skin biopsy and removal, and
suturing of simple lacerations; orthopedic procedures such as dislocation reduction, arthrocentesis,
and lumbar puncture; foreign body removal; gastrointestinal procedures such as nasogastric
(NG) tube placement, paracentesis, and sigmoidoscopy; and respiratory procedures such
as chest tube insertion, suturing and removal, cricothyrotomy, and thoracentesis (Springhouse,
2001). All of these specialized procedures can be found within APC scope of practice as defined
by various professional associations and state regulatory boards.
Likewise, APCs specializing in women’s reproductive health have acquired numerous
advanced skills that are now considered common practice. For example, these clinicians may
administer paracervical anesthesia, insert intrauterine devices, perform intrauterine aspirations
and vulvar biopsies, perform colposcopies and cervical biopsies, perform and interpret
ultrasound exams, conduct intrauterine inseminations, perform and repair episiotomies, suture
lacerations, and incise and drain abscesses. They also prescribe a wide variety of medications,
including hormonal contraception and, in many states, controlled substances (Barber, 1997;
Luterzo, Mahoney, Armstrong, Parker, & Alvero, 2004; Springhouse, 2001). For many years,
APCs providing reproductive health care have provided assessment and appropriate referrals as
well as follow-up care for patients seeking pregnancy termination. It is a natural extension of
practice for these APCs to provide early abortion as a part of comprehensive care. Figure II.2
lists studies documenting the safety of APC provision of abortion care.
FIGURE II.2
Studies Documenting Safety of Abortion Care by APC's
In 4 studies and almost 10,000 patient procedures, no significant differences were found between
nurse practitioners, midwives, physician assistants and physicians in the outcomes of first trimester
abortion provision. No major complications such as hospitalizations or deaths were reported for
physicians or APCs. For a comprehensive review of the literature on PA, NP, and CNM provision of
abortion care in the U.S. and globally, see Berer (2009).
Warriner et al. (2006) reported findings from randomized, control trials conducted in South Africa
and Vietnam (n=2,789 procedures). In both countries, the patient outcomes provided by PAs and
midwives were comparable to those of physicians.
Goldman et al. (2004) compared outcomes of 1,363 aspiration abortions provided by PAs with those
of physicians. They found no differences in complications related to the type of providers.
Boyman et al. (2004) examined 1,976 first trimester aspiration abortion procedures. They compared
outcomes for 10 physicians with those for 5 NPs and 2 PAs and found no significant differences
between physician and APC outcomes: immediate complications were rare (<1%), and delayed
complication rates were low (<2%).
Freedman et al. (1986) found no differences in complication rates between experienced PAs and MDs
with respect to overall, immediate, or delayed complications in 2,458 procedures.
In fact, APCs have been providing safe abortion care to women since 1973, the same year that Roe v. Wade made abortion legal throughout the United States (National Abortion Federation, 1997). Eight years after this major social, legal, and medical milestone, the first study was conducted in Vermont comparing PA and physician complication rates in first trimester abortion; the study found no difference in overall, immediate, or delayed complication rates between physicians and PAs providing abortion care (Freedman, Jillson, Coffin, & Novick, 1986). Several years later, a similar study confirmed these results (Goldman, Occhiuto, Peterson, Zapka, & Palmer, 2004). Other studies have documented the safety of APCs providing abortion, comparing outcomes of NPs and PAs with those of physicians, and confirmed comparable rates of safety and efficacy (Boyman, Gibson, & Forman, 2004; Vaz, Bergstrom, Vaz Mda, Langa, & Bugalho, 1999; Warriner et al., 2006). Most studies, particularly in the United States, have focused on comparing rates of complications using aspiration procedures.