Expanding the Pool of Abortion Providers: Nurse–Midwives, Nurse Practitioners, and Physician Assistants

Abstract

Nearly half of all pregnancies in the United States are unintended, and approximately half of those are terminated (Finer & Henshaw, 2006). Abortion is one of the most frequently performed procedures among women of reproductive age, yet wide geographic disparities persist in the availability of abortion care. The abortion rate is as low as 1 per 1,000 women in some states (Wyoming) and as high as 40 per 1,000 women in others (Delaware; Jones & Kooistra, 2011). Women in nonmetropolitan areas have more limited access to abortion care; 97% of nonmetropolitan counties lacked an abortion provider in 2008 (Jones & Kooistra, 2011). Ensuring adequate access to a service that one in three women will need by age 45 remains a critical public health problem, especially in rural areas. Incorporating abortion into women’s primary care services is one way to ensure access that would also promote continuity of care. This would benefit women in all parts of the country, but especially in medically underserved areas. Nurse practitioners (NPs), certified nurse-midwives (CNMs), and physician assistants (PAs) are important providers of primary health care services to women of reproductive age, and their skills could be leveraged to improve access to abortion (Taylor, Safriet, Dempsey, Kruse, & Jackson, 2009). These clinicians already routinely provide important components of abortion care, including taking medical histories, confirming and dating pregnancies, providing pregnancy and abortion options counseling, and referring patients when complications arise. NPs, CNMs, and PAs also provide services that require procedural skills similar to those of early aspiration abortion, including inserting intrauterine devices and performing endometrial biopsies. PAs were among the first abortion providers in New England after Roe v. Wade (Joffe & Yanow, 2004), and PAs, NPs, and CNMs currently provide abortions in 15 states and many countries around the world (Abortion Access Project, 2011; Berer, 2009). Multiple studies have documented the safety of abortion care provided by these clinicians (Freedman, Jillson, Coffin, & Novick, 1986; Goldman, Occhiuto, Peterson, Zapka, & Palmer, 2004; Warrineret al., 2006). A number of barriers impede CNMs, NPs, and PAs from providing this care. Each profession practices under its own regulations, and these vary from state to state. These clinicians practice with a large degree of autonomy in some states, but in others their work must be closely supervised by a collaborating physician. Many states limit the provision of abortion care to licensed physicians by law. Most of these laws were enacted after Roe v. Wade in 1973, when public health officials were concerned about untrained providers harming women. Thus, these physician-only laws were not designed to constrain other