The Toolkit seeks to support abortion care as a normal part of primary care. It provides evidence for abortion care as a natural extension of the work of Nurse Practitioners (NPs), midwives, and Physician Assistants (PAs) who care for patients at risk for or experiencing an unintended pregnancy. It is built on evidence regarding the safety of abortion; the need for more abortion providers; and the role of NPs, midwives, and PAs in providing abortion. The Toolkit also acknowledges the barriers clinicians face in becoming abortion providers–lack of clinical training opportunities, professional and abortion politics, isolation of abortion care from professional credentialing or legal/regulatory mechanisms, and the wide variation in state practice and regulatory environments.
What is the Abortion Provider Toolkit?
The Abortion Provider Toolkit follows closely the model of the APC Toolkit (2009), a collaboration of the Abortion Access Project, Advancing New Standards in Reproductive Health Care at UCSF, and the National Abortion Federation (NAF). It is a professional guide for NPs, midwives,1 and PAs in the United States (U.S.) who are either currently providing or would like to offer abortion care. The information provided is based on definitions of U.S. professional disciplines, organizations, and legislative/regulatory systems although some of the information, resources, and guidelines for professional advancement could be adapted to other health care systems. The Toolkit helps clinicians compile evidence to support the integration of early abortion care as an essential part of patients’ health care services. It guides NPs, midwives, and PAs in the development of a professional portfolio that documents their education, knowledge, and training and the clinical and professional standards used to provide safe care, including both basic competencies and abortion care. It includes essential information and statistics about abortion care and access, professional standards and competencies, and the roles of state and national professional organizations and state licensing boards.
Why is the updated Toolkit Needed?
In 2011, nearly half of pregnancies in the U.S. were unintended.2 Forty-two percent of those pregnancies (excluding miscarriages) were terminated, a small shift from 2008, when 40% ended in abortion. While the precise percentage of all patients who will have an abortion at some point during their lives remains an elusive and politically charged data point, it is clear that abortion remains one of the most common “surgical” procedures in the United States. The need to seek out specialized abortion clinics may contribute to a delay in obtaining abortion care, along with increasing cost, especially for patients in nonmetropolitan areas. Although abortion is an extremely safe procedure, at more advanced gestations it becomes more complicated and costly.3
NPs, midwives, and PAs have long been recognized as a competent source of patients’ primary care, particularly in medically underserved settings.4 In 2015, PAs, NPs and CNMs accounted for 63% of the total FTEs providing publicly funded family planning services. On average, there were 2.9 FTEs filled by PAs, NPs and CNMs for every 1.0 physician FTE.5 Despite the partisan divide that has impacted health system reform, it is clear that there is rising demand for primary care and a growing realization that NPs, midwives and PAs have an important role to play.6 Primary care providers are an obvious entry point to the health care system for patients facing unintended pregnancies and if early aspiration and/or medication abortion care were included in a program of comprehensive reproductive health services, patients would be much more likely to receive timely, low-risk intervention.
When properly trained clinicians offer early abortion care to their communities as part of comprehensive family planning and early pregnancy care, the following outcomes are seen:7
- Improvement in patient safety by allowing early diagnosis and management of unintended pregnancy
- Improvement in patient and clinician satisfaction by integrating abortion care into existing patients’ primary care
- Improvement in patients’ health care delivery by integrating abortion into early pregnancy care, thereby reducing delays and unnecessary referrals.
The Toolkit presents abortion as a scope of practice issue and explores the provision of abortion care as a natural extension of the work of NPs, midwives and PAs. It is pro-patient and pro-clinician, acknowledging the political nature of abortion while encouraging a focus on patients’ and clinicians’ abilities to meet those needs. When a specific clinical procedure is singled out as off-limits to a properly trained and competent health care professional, this undermines professional rights and responsibilities and reduces patient access to care. At a minimum, professional practice is curtailed; at worst, professional licenses may be suspended or lost. In any event, patients and communities lose access to services. Professional practice environments vary widely from state to state and discipline to discipline. In addition, political, social, and professional attitudes toward unintended pregnancy, contraceptive services, and abortion care are complex and multilayered. Although the clinical management of abortion is relatively straightforward, these other factors constantly shift in response to a multitude of influences. Although not state-specific, the Toolkit provides a framework for understanding both barriers to and stratagems for advancing scope of practice at the state level.
Scope of practice addresses the questions of who can do what for whom in what clinical setting and under what circumstances. It underpins the framework of our health provider licensing system. With increased attention to the need for interprofessional, team-based care, the focus of clinical competencies is shifting from the specific health professional toward patient needs and conditions. While the Toolkit provides background information and documents specific to the NP, midwife, and PA role, it is important to look for opportunities to establish standards and education that are provider-neutral and/or encompass all clinicians who can competently provide abortion care.
Who Can Use the Toolkit and how?
The Toolkit is intended to prepare clinicians, educators, administrators, and advocates to play various roles in improving access to abortion care.
For clinicians in particular, it is a professional development resource. NPs, midwives, and PAs working in group or independent clinical practice as well as in primary care or reproductive health specialty areas can use the Toolkit to create an individual plan for advancing clinical practice in abortion care.
Administrators responsible for human resources as well as clinical policies and procedures can help create supportive clinical environments and can be influential in addressing barriers.
Educators–both faculty and administrators within education and training programs whose mission includes preparing health care professionals–can ensure that comprehensive reproductive health care is taught as an integral component of primary care. They can ensure that clinicians have the knowledge base and skills to prevent and manage unintended pregnancies.
Advocates are playing an increasingly critical role in influencing policy, working with clinicians and administrators to protect and expand access to patients’ reproductive health care.
Representatives from professional associations and regulatory boards who recognize the value of professional determination of scope of practice and seek to further their understanding of abortion care in that context can ensure that the health and safety of patients are protected.
- In this Toolkit, “midwife” refers to certified nurse-midwives (CNMs) and certified midwives (CMs) who have been certified by the American Midwifery Certification Board (AMCB, formerly ACNM Certification Council, Inc.), and “midwifery” refers to the education and practice of CNMs and CMs. ↵
- Finer LB and Zolna MR, Declines in unintended pregnancy in the United States, 2008–2011, New England Journal of Medicine, 2016, 374(9):843–852, http://nejm.org/doi/full/10.1056/NEJMsa1506575. ↵
- Boonstra, H., Benson Gold, R., Richards, C., & Finer, L. (2006). Abortion in women’s lives. New York: Guttmacher Institute ↵
- Institute of Medicine Committee on the Future of Primary Care, & Donaldson, M. S. (1996). Primary care: America’s health in a new era. Washington, DC: National Academy Press ↵
- Fowler, C. I., Gable, J., Wang, J., & Lasater, B. (2016, August) Family Planning Annual Report: 2015 national summary. Research Triangle Park, NC: RTI International Accessed at https://www.hhs.gov/opa/sites/default/files/title-x-fpar-2015.pdf ↵
- Van Vleet A & Paradise J. Tapping Nurse Practitioners to Meet Rising Demand for Primary Care. Kaiser Family Foundation Issue Brief, January 2015, accessed at http://www.kff.org/medicaid/issue-brief/tapping-nurse-practitioners-to-meet-rising-demand-for-primary-care/ ↵
- Taylor D, Battistelli M, Nobel K, Weitz T. Advanced practice clinicians as abortion providers: preliminary findings from the California primary care initiative. Contraception (2009), Volume 80 , Issue 2 , 199. http://www.contraceptionjournal.org/article/S0010-7824(09)00177-2/fulltext ↵
- Foster, A. M., Polis, C., Allee, M. K., Simmonds, K., Zurek, M., & Brown, A. (2006). Abortion education in nurse practitioner, physician assistant and certified nurse-midwifery programs: A national survey. Contraception, 73(4), 408–414. ↵