History of Provision

History of Advanced Practice Clinicians (APCs) as Abortion Providers

A Timeline of APCs as Abortion Providers from Roe v. Wade to Today

Pre-Roe Eras

Pre-Roe Eras

Indigenous healers and Black enslaved midwives provided abortion care before the professionalization and organization of medicine. In the Reconstruction Era, Black Grand midwives and community birth workers continued to provide full scope pelvic care in people's homes. As Midwifery, Nursing Advanced Practice Nursing, and Physician Associate scope and practice environments established, abortion care continued within these expertise areas until, through, and after Roe.

In 1973, PAs first started providing procedural abortion care at the Vermont Women’s Health Center.

In 1976, Susan Cahill started providing abortion care as a PA in Montana.

Throughout the 1980s, nurse practitioners in Vermont started to provide abortion care.

In 1994, the New York Civil Liberties Union (NYCLU) obtained a Declaratory Ruling from the New York Department of Health (NYDH) stating that PAs can provide early abortions in New York under their practice act, despite the state’s APC ban.

In 1999, Montana’s prohibition against PAs providing abortion was struck down by the Montana Supreme Court in Armstrong v. State.

In the 2000s, several states passed laws recognizing APCs practicing to their full scope to provide medication abortions.

Between 2007 and 2013, Advancing New Standards in Reproductive Health conducted a 6-year study, Health Workforce Pilot Project (HWPP) #171, demonstrating that CNMs, NPs, and PAs could safely and competently provide early procedural abortion care. HWPP #171 allowed for crucial legislation in California to be passed in 2014, AB 154, which removed barriers prohibiting CNMs, NPs, and PAs from providing abortion care.

In the past decade, several states have moved forward with striking down their APC bans and recognizing APCs practicing to the full extent of their education and scope of practice.

APCs are Skilled Clinicians in Sexual and Reproductive Care

APCs provide a wide range of procedures and skills within their scope of practice. Examples of these abound in specialty care (i.e. cardiovascular procedures such as central venous catheter insertion), and clinicians who focus on sexual and reproductive health and/or primary care have also acquired numerous procedural skills that are now common practice: administering local anesthesia including paracervical blocks, inserting long-active reversible contraceptives including intrauterine devices, performing colposcopies and biopsies, performing and interpreting ultrasound exams, conducting intrauterine inseminations, performing and repairing episiotomies, suturing lacerations, etc. They also prescribe a wide variety of medications, including hormonal contraception, misoprostol and mifepristone for sexual and primary health conditions, and, in many states and depending on the APC’s license, controlled substances. For many years, APCs providing sexual and reproductive health care have provided pregnancy assessment, care, referrals, and follow-up for patients seeking pregnancy termination and parallel miscarriage care. Providing abortion care is a vital part of this practice.

In fact, APCs  have been providing safe abortion care to patients since 1973, the same year that Roe v. Wade made abortion legal throughout the United States. APCs have long played a vital role in community care – providing comprehensive sexual and reproductive health care, particularly in clinics and other settings serving low-income populations. In 2021, APCs accounted for 64% of all clinical service providers delivering Title X-funded care. 

Eight years after the major social, legal, and medical milestone of legal abortion care, the first study was conducted in Vermont comparing PA and physician complication rates in early abortion. The study found no difference in overall, immediate, or delayed complication rates between physicians and PAs providing abortion care. Subsequent studies have continued to document the safety of abortion care provided by APCs. 

Conclusive Evidence:

Abortion is very safe, whether it is provided by a Certified Nurse Midwife (CNM), Nurse Practitioner (NP), Physician Associate (PA), Medical Doctor (MD), or Doctor of Osteopathic Medicine (DO).

 

The California Health Workforce Pilot Project #171 (HWPP-171) was a California-based, multi-site, six-year study of APCs as providers of early procedural abortion care in community-based clinics. Between 2007 and 2013, researchers with HWPP #171 collected data from almost 20,000 patients, and the program resulted in the training of nearly 50 APCs to competency in early procedural abortion care resulting in conclusive evidence that abortion is very safe, whether it is provided by an APC or a physician. Additionally, more than 2,500 patients surveyed at 25 separate facilities across the state of California rated the abortion care they received in this study as being extremely positive (9.4/10), regardless of whether the care had been provided by an APC or a physician.

In addition to confirming the safety of abortion by trained professionals, the California study findings also:

The study and findings were published in the American Journal of Public Health article Safety of Aspiration Abortion Performed by Nurse Practitioners, Certified Nurse Midwives, and Physician Assistants Under a California Legal Waiver in March 2013

The data generated from this pilot project provided the evidence base for California Assembly Bill 154 (AB 154), passed on October 9, 2013. The bill permanently removed the physician-only requirement and allowed properly trained CNMs, NPs, and PAs to perform first-trimester aspiration abortions. Following the passage of AB 154, core competencies, standardized procedures and fact sheets on the safety and acceptability of APCs as abortion providers and what APCs need to know to provide abortion care in California were released by Advancing New Standards in Reproductive Health (ANSIRH). The background information and findings from the California HWPP study, along with fact sheets on standardized procedures and requirements for APCs in California to provide abortion care, can be found on ANSIRH's website.

In March of 2018, the National Academies of Sciences, Engineering, and Medicine published a report confirming the safety and quality of abortion care in the United States. They concluded that both trained physicians and Advanced Practice Clinicians can safely and effectively provide medication and procedural abortion care.