C. EVIDENCE OF EDUCATION AND TRAINING IN ABORTION CARE

To establish abortion care as within the scope of practice of CNMs, NPs, or PAs, there must be evidence of training programs at the entry level and/or advanced-practice-level education for obtaining abortion care knowledge and skills. Academic and postgraduate training programs must be based on established practice standards and competencies.

APCs in virtually all areas of specialization encounter patients with needs and concerns about contraception, sexually transmitted infections, unintended pregnancy, infertility, and intimate partner violence. Content and clinical guidelines related to these important reproductive health issues are therefore essential in APC education and training programs. Indeed, incorporating reproductive health into health service professional training has gained increased attention in recent years (Beatty, 2000; Lazarus, Brown, & Doyle, 2007). Professional associations and accreditation bodies have repeatedly identified the need to include reproductive health in the standard curricula. The American Association of Colleges of Nursing (AACN), the National Organization of Nurse Practitioner Faculties (NONPF), the AAPA, and the ACNM have all developed guidelines that recognize the need for their graduates to possess competence in providing care related to sexual and reproductive health (AACN, 1998; AAPA, 2008c; ACNM, 1997a, 2008; NONPF, 2002). Although these guidelines differ by program type, they generally require training dedicated to counseling, health promotion, risk assessment, clinical interventions, and/or referrals. Consistent with findings from graduate and undergraduate medical education (Espey, Ogburn, & Dorman, 2004; Helton, Skinner, & Denniston, 2003; Prine, Lesnewski, & Bregman, 2003), several studies have demonstrated that routine incorporation of reproductive health issues into health professional education improves exposure to abortion care and influences attitudes toward intention to provide comprehensive services (Breitbart, 2000; Hwang, Koyama, Taylor, Henderson, & Miller, 2005; Simmonds, Zurek, Polis, & Foster, in press).

Abortion Care Education and Clinical Training in APC Education Programs

How NP, CNM, and PA faculties operationalize reproductive health and abortion care competencies and educational standards within a particular education program varies. In NP, CNM, and PA education programs, abortion care is considered specialty practice within the broader curriculum of reproductive health, women’s primary care, or obstetrics-gynecology medicine. For this reason, clinical training is often assigned to elective courses. In family NP, women’s health NP, and CNM training programs, curricula include didactic and clinical education in the independent provision of women’s primary care and reproductive health care, such as comprehensive early pregnancy care (including miscarriage management), gynecologic care, fertility prevention and protection, prevention of unintended pregnancy, and procedural skill training (e.g., endometrial biopsy, IUD placement, procedural pain management, colposcopy, cryosurgery, artificial insemination, and ultrasound). PAs are educated in a primary care medical model where they receive basic training in women’s reproductive medical assessment and treatments. About one-third of PAs practice in primary care (family and general internal medicine), where they provide care to women of reproductive age at risk for unintended pregnancy (AAPA, 2007). All PA programs are required to provide supervised clinical practice experiences in prenatal care and women’s health care (Accreditation Review Commission on Education for PAs, 2007). According to APAOG (2008), PAs receive education and training in annual Pap/ pelvic and breast exams, gynecologic complaints, family planning, menopause management, and prenatal care. Some PA students receive didactic knowledge of abortion care during classes they take with medical students in ob-gyn courses.

A 2001 survey of 486 accredited NP, PA, and CNM programs in the United States on the subject of didactic education and clinical training in reproductive health competencies including abortion care found that the majority taught family planning methods and skills (IUD insertions) and therapeutic skills (endometrial biopsy, uterine aspiration for abnormal bleeding or miscarriage management) (Foster, Polis, Allee, Simmonds, Zurek, & Brown, 2006). Of the 202 programs that responded (42% response rate), family planning and contraception (including emergency contraception) received near-universal didactic coverage (96%) and significant clinical coverage (89%). The majority of respondent programs also indicated inclusion of pregnancy options counseling in both didactic (74%) and clinical (63%) education. However, only half of all responding programs offered didactic instruction and only 21% offered routine clinical training in any pregnancy termination procedure.

Accredited CNM programs (61% response rate; n = 27 programs) reported the highest rates of didactic instruction in abortion among all advanced practice education programs: 100% of programs included pregnancy options counseling in didactic education, and most CNM programs also included didactic instruction on surgical abortion (89%), manual vacuum aspiration (MVA) (89%), medication abortion (93%), and postabortion care (96%) (Foster et al., 2006). Fewer than 20% of the CNM programs included clinical training in surgical/aspiration (15%) and medication (19%) abortion.

Accredited NP programs (39% response rate; n = 127 programs) reported the lowest rates of didactic and clinical instruction in abortion among all advanced practice education programs. NP programs reported didactic teaching in surgical abortion (39%), medication abortion (37%), and MVA abortion (26%). And 13% of NP programs included clinical training in early aspiration and medication abortion (Foster et al., 2006).

Accredited PA programs (42% response rate; n = 48 programs) were more likely to provide clinical instruction in any abortion procedure (24%) than were CNM programs (15%) and NP programs (13%). PA programs reported didactic teaching in surgical abortion (46%), medication abortion (46%), and MVA abortion (33%).

A survey of PA educators by APAOG (2000) found that abortion care is considered a subspecialty or elective practice. According to APAOG, many PAs learn reproductive options care, without performing the actual procedures, by doing pre- and post-abortion counseling, ultrasound diagnosis, inserting laminaria and paracervical blocks, assisting with procedures, managing care after abortions (including complications), family planning, and call coverage. Generally, abortion care is covered in the OB-Gyn didactic curriculum. However, clinical training in abortion procedures and related competencies must be scheduled on an elective basis (K. Thomsen, PA educator, personal communication, December 2008).

A study of Massachusetts nursing programs provides a focused look at reasons for the low rate of representation in NP education of some reproductive health practices (Foster, Simmonds, Jackson, & Martin, 2008). In a 2007 survey of 67 program directors from all accredited Massachusetts nursing programs of their programs’ didactic and clinical curricula on reproductive health, the majority of program directors (overall response rate, 60%) reported a high level of curricular adequacy for prenatal care (93%), HIV/AIDs (85%), STIs (85%), and pregnancy loss (75%). In contrast, roughly half of all respondents agreed that infertility and abortion were adequately covered (53% and 48%, respectively), with 57% and 14% of religious-based institutions reporting that reproductive health content and abortion, respectively, were adequately covered. For abortion, contraception, and infertility, additional barriers were repeatedly cited, including religious restrictions prohibiting instruction and the lack of appropriate facilities and/or qualified faculty.

Clearly, despite barriers, there is evidence of abortion care education and training in APC programs. Due to the expanding knowledge and skills required for APC practice competency, specialty practice is often assigned to elective or postgraduate courses. Examples of postgraduate training in reproductive health might include additional specialty training in abortion care, infertility treatment, or advanced procedures in family planning and obstetric-gynecologic medicine. Reproductive health procedural skill training at the postgraduate level includes ultrasound; colposcopy (including endocervical curettage, LEEP, and cryosurgery) and endometrial biopsy; IUD and contraceptive implant insertion and removal; artificial insemination; vulvar/ cervical/breast biopsy; pessary fitting; vaginal delivery; abortion; D&C; hysteroscopy; laminaria inserts; and male circumcision. Although many NP, CNM, and PA programs do not include medication and aspiration abortion skills training, APCs who want clinical training in unintended pregnancy prevention and management, including abortion provision, have options for clinical training electives, either during their initial education program or in a postgraduate program. See Section V.A for postgraduate abortion training resources.