- Identify resources to help NPs, CNMs, and PAs become clinically competent in the provision of abortion care.
- Help educators identify their role in advancing abortion care for NPs, CNMs, and PAs.
- Provide a template for documenting professional credentials, clinical competency, education, and experience in a professional portfolio.
Education and Training in Abortion Care: Opportunities and Resources
Many clinicians are interested in being trained to provide abortion care, yet lack training opportunities.1 These examples show how some programs are helping to advance education and training in reproductive health, including abortion care:
At the University of California, San Francisco School of Nursing’s Family and Patient’s Primary Care Program (NP and CNM students), required coursework includes didactic information on primary prevention of unintended pregnancy (contraception, emergency contraception) and secondary prevention of unintended pregnancy (pregnancy options counseling and first-trimester abortion methods). Clinical training includes procedural skill training in IUD insertion, ultrasound, and MVA for miscarriage management and abnormal bleeding, along with pain management (such as paracervical blocks) for these procedures. For those students who want more experience, supervised clinical training is arranged.
At the Stonybrook University Physician Assistant Education Program, the reproductive health curriculum includes both required didactic coursework and elective clinical training in abortion and assisted reproductive technology. In addition, as part of the general ethics course taken by all PA students, one class focuses on the history of abortion and infertility treatments in the U.S. as well as the ethical considerations facing patients’ health professionals who provide these reproductive health services.2
Some faculty have been successful in promoting reproductive rights and health in curriculum and educational policy. For example, the faculty of the Nurse-Midwifery and Patient’s Health Nurse Practitioner Program at the University of Illinois at Chicago support the international definition of reproductive health that: “All people have the right to decide freely and responsibly the number and spacing of their children, and to have the information, education and means to do so; and the right to make decisions concerning reproduction free of discrimination, coercion, and violence.”3 This definition provides the foundation for educational requirements for students, as their policy on this subject states: “[w]hile individuals may have beliefs that differ, students are required to learn the full range of reproductive options available to patients throughout the world and be able to counsel and refer patients appropriately”4.
As part of the California Health Workforce Pilot Project Study (California HWPP-171, 2008-2013), a standardized, competency-based curriculum and training plan was evaluated in the education and training of primary care clinicians in early abortion care. The final version of the Early Abortion Training curriculum guidelines, core competencies and training plan integrates the HWPP-171 Training Program findings with the revised Training in Early Abortion for Comprehensive Healthcare (TEACH) Program Workbook and training resources (2016). The guidelines, core competencies, and TEACH workbook can be used in academic or post-graduate training programs as well as for professional self-study.
Postgraduate Education and Training in Abortion Care
NPs, midwives, or PAs who did not receive didactic and clinical training in reproductive health and abortion care in their basic education program must look to postgraduate or continuing education programs for that training. National professional organizations and a few academic or residency training groups, in addition to developing standards, curricula, and training guidelines for prelicensure health professional students and medical residents, also offer resources for patients’ health professionals who wish to incorporate abortion care into their practice.
However, training in abortion care can be difficult to access. Many abortion care facilities with established training programs have already committed their training slots to medical residents, students, or their own staff. Depending on the clinician’s prior experience, training in skills such as ultrasound, pregnancy options counseling, paracervical anesthesia, conscious sedation, medication abortion, and endometrial biopsy using MVA may also be necessary, and the training slots for these procedures may be equally competitive.
The following three resources are suggestions for self-study as well as guidelines for training to competency in abortion care.
The interdisciplinary Association of Reproductive Health Professionals (ARHP) has developed educational standards and curricula for training in reproductive health. ARHP and its organizational partners have developed an innovative web-based curriculum: CORE (Curricula Organizer for Reproductive Health Education). CORE is a collection of peer-reviewed, evidence-based teaching materials that allows clinicians and educators to (1) access up-to-date teaching materials on reproductive health topics including abortion care; (2) build their own curricula and other educational presentations; and (3) download activities, case studies, and other handouts for learners. The ARHP website, www.arhp.org, lists a number of publications on abortion care from multiple organizations as well as practice guidelines, clinical reports, interactive tools, and other resources designed for health care providers. In the area of abortion, the ARHP website provides:
- Abortion-related clinical publications and resources, such as practice guidelines, clinical reports, interactive tools, and other resources designed for health care providers.
- Online continuing education programs in abortion-related topics.
- The National Abortion Federation (NAF) is the professional association of abortion providers. NAF sets the standard for quality abortion care in North America through its evidence-based Clinical Policy Guidelines (CPGs). In Standard 1, these guidelines explicitly recognize NPs, midwives and PAs as qualified practitioners.
- NAF was the first organization to train U.S. providers in early medication abortion and professional education continues to be essential to NAF’s mission. NAF’s extensive educational resources include a textbook, Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care, accredited continuing education for health care professionals, an annual meeting and regional workshops, and online and self-study modules on topics such as Pregnancy of Unknown Location, Ultrasound in Abortion Care, and Infection Prevention. For information on how to access these resources contact firstname.lastname@example.org.
- NAF’s CME programming is appropriate not only for physicians, but also for others who are important to the successful provision of abortion care, including, nurses, NPs, midwives, PAs, counselors, clinic administrators, and medical assistants. A full listing of resources can be found on the NAF website.
- Planned Parenthood Federation of America’s Consortium of Abortion Providers (CAPS) has provided both remote and onsite didactic and practicum training since 2001, using material that has been reviewed by expert clinicians and presented by licensed staff with extensive experience in provision of abortion. CAPS also provides onsite didactic and hands-on training for administration of conscious sedation, values clarification, regulated medical waste management, and supports introductory ultrasound training. For sites starting to offer aspiration or medication abortion, Tele-MAB (medication abortion offered through a telemedicine platform), or that are interested in expanding gestational limits of existing abortion services, CAPS provides training and program planning support , with a focus on client selection; contraindications; informed consent; laboratory testing; techniques of aspiration abortion; emergency triage; emergency drills; operational workflow; common complications; and client questions, follow-up, and contraception, among other topics. Medication abortion training topics include client selection, client assessment, the medication regimens, the pharmacologic action of the medicines, timing of medicines, expected course of medication abortion, side effects and their management, assessment of after-hours emergencies, and assessment at the follow-up visit.
- In collaboration with Affiliate Risk Management Services (the risk management corporation of Planned Parenthood) and with support from NAF, CAPS created an ACCME-accredited interactive CD, Ultrasound in Abortion Care. This widely used CD provides a series of interactive learning exercises to teach the proper techniques and skills for accurately dating a pregnancy, evaluating the intrauterine position of a pregnancy, screening for ectopic pregnancy, screening for first trimester variants, and assessing the uterine cavity following medication abortion.
The TEACH Early Abortion training Workbook is an all-inclusive curriculum developed by ANSIRH with materials on a variety of topics including gender spectrum and pregnancy, pregnancy of unknown location, and ultrasound criteria for early pregnancy loss.
Education and training is essential to integrating abortion care within patients’ primary health care. All primary care providers need the knowledge and skills to prevent and manage unintended pregnancies. Regulatory boards look to educators for the reproductive health standards and clinical competencies when assessing whether a procedure such as abortion care is within the scope of practice of an NP, midwife or PA.
Educators have been in the lead in developing reproductive health curriculum and core competencies for patients’ health. We urge them to continue their dedication to high-quality education by aligning curriculum and core competencies in women’s and reproductive health with those for unintended pregnancy prevention, including abortion care. For example:
- Situate the abortion care curriculum within a broader public health model of unintended pregnancy prevention and management. Currently, all programs teach primary prevention of unintended pregnancy (such as preconception counseling, family planning, and contraception skills including emergency contraception). Secondary prevention of unintended pregnancy focuses on knowledge and skills of pregnancy diagnosis, pregnancy options counseling, and early abortion care such as knowledge and skills for medication and aspiration abortion provision. It is this secondary unintended pregnancy prevention component that needs to be developed and incorporated into education and clinical training.
- Specify core competencies for unintended pregnancy prevention and management across primary, secondary, and tertiary prevention competencies. For NP faculty, this can mean specification of the patients’ health core competencies. For PA faculty, the APAOG could work with PAEA to develop curriculum in secondary prevention of unintended pregnancy.
- Integrate core competencies into curriculum. Establish clinical opportunities for students to learn medication and/or aspiration abortion skills.
Unintended Pregnancy Prevention and Care: A public health approach
When focused and coordinated, preventive efforts are viable ways to reduce rates of unintended pregnancy in the United States. These include strategies such as normalizing contraceptive and preconception care (primary prevention), as well as pregnancy options coordination of adoption, prenatal care, and abortion care (secondary prevention), and assessment, management, and follow-up of unintended pregnancy (tertiary prevention) in a public health framework that is integrated into the broader health care system. See summary of the literature.
Reproductive Health in Nursing (RhN) is a home for nurses providing sexual and reproductive health (SRH) and abortion care. Its purpose is to build community, create opportunity, and be the go-to resource for nurses providing and teaching SRH and abortion care. Here are a few highlights of this online resource:
- Historical briefing of nurses working individually and collectively to advance access to evidence-based SRH and abortion care, education, research, and policy, with a focus on nurse leaders who have continued and extended the work of the Reproductive Options Education in Nursing (ROE) Consortium (described in Part I, RhN April Blog)
- Policy and advocacy resources for nurses, including scope of practice laws for nurses providing abortion.
- Evidence-based research and scholarship by nurses and for nurses on topics related to sexual and reproductive health and abortion care and clinical practice
- Nursing educator tools to incorporate SRH and abortion care into teaching and curriculum.
These self-guided nursing education modules are designed for students to improve their understanding, clarify their values, and learn of ways to integrate best practices in unintended pregnancy prevention and care into clinic settings. Through a national Delphi study, Essential Competencies in Unintended Pregnancy Prevention and Care for Nursing Education,5 85 nursing experts in unintended pregnancy prevention and care reached consensus on 27 core educational competencies for nursing education, which provide a framework for curricular development in an important area of nursing education. Each module is based on several of these UPPC Essential Competencies to help students improve competency and hone their skills in these defined areas.
Patient scenarios are presented that require in-depth analysis to resolve the issues that are presented and provide the highest quality of patient care. An orientation tool must be completed prior to working through each module and a self-assessment tool can be used to test the learner’s knowledge and competence after completing the module. Each module includes faculty guides and teaching tips.
- Hwang AC, Koyama A, Taylor D, Henderson JT, and Miller S, Advanced practice clinicians’ interest in providing medical abortion: Results of a California survey. Perspectives on Sexual and Reproductive Health, 2005, 37(2), 92–97. ↵
- Ranieri D, Training in ethics consultation: a model for Physician Assistant programs, Journal on Physician Assistant Education, 2015, 26(4):212-4. ↵
- United Nations, 1995 ↵
- University of Illinois-Chicago Nurse Midwifery and Patient’s Health Nurse Practitioner Program, 2003 ↵
- Hewitt C, and Cappiello J, Essential competencies in nursing education for prevention and care related to unintended pregnancy, Journal of Obstetric, Gynecologic, and Neonatal Nursing, 2015, 44:69-76. ↵