MODULE ONE:
UNDERSTANDING ABORTION CARE

One of the goals of the APC Toolkit is to present abortion care as a normal part of primary care and to provide the evidence for abortion care as a natural extension of the work of APCs, who care for women at risk for or experiencing an unintended pregnancy.

Module One presents evidence regarding the safety of abortion, the need for more abortion providers, and the role of CNMs, NPs, and PAs in providing abortion in the United States. In addition, it describes the multiple barriers that APCs face in becoming abortion providers, including lack of clinical training opportunities, professional and abortion politics, isolation of abortion care from professional credentialing or legal/regulatory mechanisms, and the wide variation in state practice and regulatory environments.


SECTION I.
ABORTION IN CONTEXT

OBJECTIVES:

  1. Provide background information about the need for abortion in the United States.
  2. Describe the range of abortion care, and provide evidence of the safety and efficacy of early abortion procedures.
  3. Explain how terminology impacts interpretations of scope of practice.
  4. Provide an overview of abortion providers in the United States.

A. AN OVERVIEW OF THE ABORTION CARE SPECIALTY

As noted earlier, about half of all pregnancies in the United States are unintended (Finer & Henshaw, 2006). Healthy People 2010, an initiative of the U.S. Department of Health and Human Services, established a national goal to reduce unintended pregnancy (U.S. Department of Health and Human Services, 2000). Access to reproductive health care, including pregnancy options counseling and contraceptive counseling, is critical for reaching this goal.

Differences in adolescent and adult sexual and reproductive health indicators between the United States and other countries shed light on the important role of primary and secondary prevention strategies in reducing unintended pregnancies. Figure I.1 compares reproductive health outcomes in the United States with those in Sweden, France, Canada, and Great Britain.

The illustration shows that adolescents in the United States initiate sexual activity at basically the same age as their European and Canadian counterparts (Darroch, Singh, & Frost, 2001). However, U.S. adolescents are much less likely to use a form of contraception and far more likely to experience an unintended pregnancy. France has the lowest rate of adolescent pregnancy, 20.2 per 1,000 women aged 15–19, with Sweden just slightly higher at 25 per 1,000. Canada and Great Britain report 45.7 and 46.7 pregnancies per 1,000 women aged 15–19, whereas the United States reports 83.6 pregnancies per 1,000 women 15–19, a much higher rate than the other countries in the comparison.

Broadening the focus to include adult women further highlights the importance of preventing unintended pregnancies. For example, in the Netherlands, only 3% of pregnancies are unplanned, compared with 57% in the United States (Sedgh, Henshaw, Singh, Bankole, & Drescher, 2007). With its low rate of unplanned pregnancies, the Netherlands also has a much lower abortion rate than the United States: 9 abortions per 1,000 women aged 15–44, compared with 21 per 1,000 in the United States (Delbanco, Lundy, Hoff, Parker, & Smith, 1997; Sedgh et al., 2007). Ensuring and expanding access to contraception and comprehensive reproductive health care can help the United States achieve its goal of reducing unintended pregnancies.

FIGURE I.1

Sexual and Reproductive Health: Comparison Among Sweden, France, Canada, Great Britain, and the United States

Although abortion rates among adolescent and adult women in the United States have decreased somewhat since the late 1990s, approximately 1.2 million abortions were provided in the United States in 2005, making abortion one of the most common procedures women of reproductive age experience (Jones et al., 2008). The Guttmacher Institute estimates that approximately one-third of all women will have an abortion at some point in their lives (Boonstra et al., 2006).

FIGURE I.2

Number of Abortions per 1,000 Women Aged 15–44 in 2003

Despite the great need for abortion care, most women face multiple obstacles when accessing abortion. A scarcity of clinicians trained and empowered to provide abortions is one such obstacle. Women in rural areas are particularly affected; 35% of women in the United States live in counties without an abortion provider (Jones et al., 2008). Ninety-nine percent of all facilities that perform more than 400 terminations per year are located in metropolitan areas (Jones et al., 2008). Many states also have laws mandating that only physicians may perform abortions (“physician-only” laws). These laws further impede access to abortion care by denying appropriately trained APCs the opportunity to serve their patients’needs.4

FIGURE I.3

“Aspiration” versus “Surgical”: What’s in a Name?

This APC Toolkit uses the term aspiration abortion when discussing first trimester abortion care because it more accurately depicts a first trimester abortion than does surgical abortion. Surgical “implies incision, excision and suturing and is associated with the physician subpopulation of surgeons” (Weitz, Foster, Ellertson, Grossman, & Stewart, 2004, p. 78).

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 (Weitz et al., 2004).

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 APCs, provide a wide range of procedures, including intrauterine device (IUD) insertion, endometrial biopsy, management of early pregnancy loss, and abortion. Use of the term aspiration, rather than surgical, abortion to refer to these procedures is a small but important step that all of us can take to help de-mystify early abortion techniques.


4 To determine whether you are practicing in a physician-only state, contact the Abortion Access Project at http:// www.abortionaccess.org or the National Abortion Federation at http://www.prochoice.org. To see an overview of state laws relating to abortion, visit the Guttmacher Institute’s website at http://www.guttmacher.org/statecenter/ spibs/spib_OAL.pdf