C. BARRIERS TO ABORTION PROVISION BY APCS

As the rhetorical claims of the anti-abortion movement intersect with challenges to APC scope of practice from within and outside the professions, APCs face a multiplicity of barriers to abortion provision. These include the confusion occasioned by the interstate variation of APCs’ regulatory environments, each governed by complex set of laws, regulations, and education standards. In addition, the long-standing efforts of organized medicine to use the political process to control scope of practice generally must be reckoned with. For example, the American Medical Association (2006, 2007) and other physician organizations (coordinated through the AMA Scope of Practice Partnership Project) consistently and explicitly oppose any expansion of scopes of practice by providers “other than medical doctors”.7

FIGURE II.3

State Advocacy Efforts to Overcome Barriers

Since 2000, the Abortion Access Project (AAP) (www.abortionaccess.org) and coalition partners have been conducting legal research in individual states to assess opportunities for APCs to provide abortion care. Where conditions are favorable, AAP convenes stakeholders to develop suitable strategies and to address existing barriers. In some states, an effective strategy may focus on seeking an Attorney General Opinion or advocating for a change in legislation to incorporate provider-neutral language.

In other states, opinions from regulatory boards may be sought by institutions employing APCs, by professional associations advocating for APCs, or by individual clinicians. In some cases, decisions regarding APCs and abortion care have been triggered by challenges to individual clinicians’ scope of practice. Although these decisions have largely been favorable, the process is stressful, time-consuming, and costly for the clinician involved and requires coordinated effort on the part of advocates.

In states where conditions may not be favorable, stakeholders don’t proceed, or APCs are advised not to proceed to advance scope of practice to include abortion provision, there are incremental activities that clinicians can be involved in to promote access to early abortion care. Refer to the side-bar information on page 25 and/or contact the Abortion Access Project for more detailed information. In the next sections of the APC Toolkit, both proactive and reactive strategies are proposed to help clinicians before they are faced with a scope of practice challenge.

Increasing support and enthusiasm for APCs as abortion providers in recent years has been undermined by unclear laws and other regulatory and professional barriers that either explicitly discourage APCs from providing abortion care or create enough confusion that APCs and their advocates are hesitant to move forward with training and service provision for fear of reprimand or professional consequence.

As noted previously, many states have laws that specify that only physicians can perform abortion procedures. It is worth noting that in several physician-only states, subsequent interpretations of the law have authorized APCs to provide various types of abortion care. In addition, PAs are licensed to practice medicine under the supervision of a physician, which means that the supervising physician can delegate procedures or care to the PA (as long as the procedures have been recognized as within the PA’s skill set).

Lack of training opportunities is another barrier to abortion provision by APCs. A national survey conducted in 2005 found that only 53% of APC educational programs included didactic training in at least one abortion procedure (MVA, EVA, or medication abortion) and only 20% provided clinical training in at least one type of abortion procedure (Foster et al., 2006).8 Including the principles of abortion care in basic and post-graduate APC programs is an important way to disseminate the recognition that abortion is within the APC’s scope of practice.

FIGURE II.4

Critical Role of Professional Organizations

Professional organizations must continue to engage as allies in the effort to promote APCs as abortion care providers. In 1991 and 1992, four professional organizations adopted policy resolutions acknowledging the practice of abortion as within the scope of APCs. They are:

• the American Public Health Association (APHA, 1992),
• the National Association of Nurse Practitioners in Reproductive Health (NANPRH), now Nurse Practitioners in Women’s Health (NPWH, 1991),
• the American College of Nurse-Midwives (ACNM, 1991), and
• the American Association of Physician Assistants (AAPA, 1992).

Three physicians’ organizations have also adopted position statements to address the shortage of abortion providers:

• In 1994 ACOG “encouraged programs to train physicians and other licensed health care professionals to provide abortion care in collaborative settings” (National Abortion Federation, 1997, p. 17), and
• In 1999 both the American Medical Women’s Association (AMWA) and Physicians for Reproductive Choice and Health (PRCH) endorsed the training of APCs to provide abortion care. (National Abortion Federation & Clinicians for Choice, 2009)


7 AMA Scope of Practice Partnership: “Our AMA will take a lead role in coordinating medicine’s response to proposed scope expansions that are not warranted by non-physicians’ education, training or experience. The Scope of Practice Partnership (SOPP) provides a foundation for these activities.” (http://www.ama-assn.org/ama1/pub/ upload/mm/475/902.pdf )

8 See Specialty Education and Training in Abortion Care (Section V.A) for a thorough review of these studies and Section IV-C for educational and training resources.