SECTION II.
ADVANCED PRACTICE CLINICIANS
AS ABORTION PROVIDERS

OBJECTIVES:

  1. Describe the differences and similarities among CNMs, NPs and PAs.
  2. Summarize the history of APCs in providing abortion care.
  3. Supply evidence of the safety of abortion care provided by APCs.
  4. Examine the barriers APCs face in providing abortion care.

A. APCS WITHIN THE HEALTH CARE SYSTEM

Healthy People 2010 articulates a national health goal of decreasing unintended pregnancies.6 Although abortion rates have decreased overall since the late 1990s, they have risen among poor and low-income women, in part due to limited access to family planning services (Jones, Darroch, & Henshaw, 2002). Limited access to quality health care services is not a new problem. Over the past several decades, one response to our population’s burgeoning demand for health care services has been to educate and credential additional categories of health care professionals in the workforce. NPs, CNMs, and PAs have been recognized as qualified and effective primary care providers for the past 40 years. Figure II.1 explains the differences and similarities among three groups of health professionals.

NPs, CNMs, and PAs are especially important in our health care delivery system because they are more likely than physicians to practice in medically underserved settings (IOM Committee on Primary Care & Donaldson, 1996). Clearly, APCs are especially well positioned within the health care system to address women’s need for comprehensive primary preventive health care that includes abortion care.

In 1990, the National Abortion Federation (NAF) and the American College of Obstetricians and Gynecologists (ACOG), concerned about the increasing shortage of abortion providers, convened a national symposium: Who Will Provide Abortions? Ensuring the Availability of Qualified Practitioners. The final report from this symposium concluded that “appropriately trained midlevel clinicians…offer considerable promise for expanding the pool of abortion providers” and recommended abortion training for CNMs, NPs, and PAs (National Abortion Federation, 1990). The following year, the American Public Health Association issued a resolution acknowledging the public health impact of unintended pregnancy and confirming the organization’s support for training APCs to provide abortion care (American Public Health Association, 1992). In 1997, NAF convened a second national symposium: The Role of Physician Assistants, Nurse Practitioners, and Nurse-Midwives in Providing Abortions: Strategies for Expanding Abortion Access. It was determined that strategies for expanding abortion access should be centered on overcoming notions that abortion is a dangerous procedure that only physicians can perform safely; developing a carefully planned state-by-state effort to overcome current legal restrictions; and increasing and expanding education and training for CNMs, NPs, and PAs (National Abortion Federation, 1997).

As primary care providers for women, APCs can be part of the solution to increase community access to early abortion and postabortion contraceptive care. The marginalization and separation of reproductive health services, including abortion, from other health care services interfere with continuity of care and disrupt the protective effect of primary care. The skills used in early aspiration abortion are also necessary tools for safely managing other causes of early pregnancy loss, common conditions that affect the health status of a significant proportion of women during their reproductive years.

FIGURE II.1

NPs, CNMs, and PAs: Training and Clinical Roles

Nurse Practitioner
A nurse practitioner (NP) is an advanced practice registered nurse who has advanced education (typically a master’s degree) and extensive clinical training in both the NP role (e.g., acute or primary care) and one or more population practice areas (e.g., family, women’s health) and specialty practice areas (e.g., high-risk perinatal, infertility, abortion care). NPs diagnose and manage patient care for many acute and chronic illnesses, and they also provide preventive care. Most states require that an NP achieve either a master’s degree or national certification (or both). NPs are independently licensed, work collaboratively with other health care professionals, and have prescriptive authority in some form in all states. There are more than 140,000 NPs in the United States (New York Center for Health Workforce Studies, 2006).

Certified Nurse-Midwife
A certified nurse-midwife (CNM) is an advanced practice registered nurse who has advanced education (masters or doctorate) and training in both midwifery and nursing and is certified by the American Midwifery Certification Board. The American College of Nurse-Midwives (ACNM), the professional organization for CNMs, defines midwifery practice as “the independent management of women’s health care, focusing particularly on common primary care issues, family planning and gynecologic needs of women, pregnancy, childbirth, the postpartum period and the care of the newborn” (American College of Nurse-Midwives, 2004). CNMs have prescriptive authority in some form in all states. There are approximately 11,500 certified CNMs (29,000 dually certified NPs and CNMs) in the United States (New York Center for Health Workforce Studies, 2006; ACNM, 2009).

Physician Assistant
Physician assistants (PAs) are certified to practice medicine with physician supervision (indirect); they provide health care services that range from primary care to very specialized surgical services. PAs, regulated by state medical boards, diagnose and treat illnesses, counsel on preventive health care, assist in surgery, and write prescriptions. There are approximately 66,000 licensed PAs in the U.S. who are graduates of accredited PA programs associated with medical schools (American Academy of Physician Assistants, 2009).


6 Healthy People 2010, a public health compendium of national health goals, objectives, and tracking methods, is a roadmap for improving the health of all Americans. It includes 10 leading health indicators that are used to measure the nation’s health over one decade (Healthy People 2010, 2004). Grounded in science, the Healthy People 2010 national health indicators were selected because they motivate action and are important public health issues and data are available to measure progress. Improving responsible sexual behavior with the goal of improving pregnancy planning, preventing unintended pregnancy, and improving the health and well-being of women, infants, and families is the cornerstone of the national reproductive health goals in Healthy People 2010 (Office of Population Affairs & Department of Health and Human Services, 2001)