by Holly Carpenter, RN, UCSF School of Nursing-CNM/WHNP Candidate 2014 (originally posted on the Nursing Students for Choice Blog)
Part I: Finding Full Spectrum Nurse-Midwifery
When I was choosing between various CNM (Certified Nurse Midwife) graduate programs in 2010, the faculty biographies at UCSF were the deciding factor. Every CNM on faculty was described as “Full Spectrum”, meaning they cared for patients through every reproductive health outcome, including abortion. My initial interpretation of this term was, “Wonderful! These midwives are providing abortions, and that means that I’ll be taught how to provide abortions.” As it turns out, while some UCSF CNM faculty provide medication abortions and place laminaria, CNMs in California do not typically perform first trimester “therapeutic abortions” or manual uterine aspiration procedures (MUAs).
This situation is not unique to California; CNMs and other advanced practice clinicians (APCs) are permitted to provide MUAs in only four states: Vermont, New Hampshire, Montana, and Oregon (Weitz et al., 2013). While the skills involved in first trimester MUAs are identical to those used in “miscarriage management” – a procedure that is legally within the APC scope of practice – many states have explicitly banned APCs from providing MUAs. Obviously, anti-choice politics play a major role in these bans, as evidenced by the recent rash of APCs-as-provider bans that have gone forward during the past two years of abortion limitation legislation. The impact of these bans is substantial, and connecting the dots is not difficult:
Under the Affordable Care Act, the proportion of the US population receiving primary care from APCs is expected to increase substantially (Taylor, et al., 2009).
NPs, CNMs, and PAs are …more likely than physicians to practice in medically underserved settings (Taylor, et al., 2009)
Abortion is one of the most commonly performed procedure for women (Boonstra, et al., 2006)
Limiting access to abortion is harmful to women (Foster, 2013)
The logical conclusion: banning the most accessible providers from performing a commonly demanded procedure is going to have a negative impact on medically underserved women.
However, progress is being made. In California, the Health Worker Pilot Program has been training APCs as first trimester MUA providers under a legal waiver from the CA State Legislature since 2005. The results of this project have been studied and published, and they offer proof that APCs are equal to MDs in safety, efficacy, and patient satisfaction (Weitz et al., 2013). The positive outcomes reported in this study have formed the basis for AB154, a CA bill which formally designates first trimester MUA procedures as within APC scope of practice. With the chances of passage of this bill looking promising, (it is currently on Governor Jerry Brown’s desk awaiting his signature), APCs in California are poised to address the important gap in abortion access that MD-only provider laws have created. There are millions of American women between the ages of 15-45, ⅓ of whom will seek an abortion at some point in their reproductive years (Weitz et al., 2013).
The first step in addressing this gap in access and care, however, starts with provider education at both the pre-licensure (RN) and APC levels. RNs play an important healthcare role by providing pregnancy options and contraceptive counseling in many clinical settings, and therefore need to meet competency standards in SRH care provision as well. In the next post in this blog series, the state of sexual and reproductive health in nursing education will be discussed, as well an innovative UCSF project: a student-led elective focused on abortion and family planning. Thanks for reading!
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Foster, D., (2013). The Turnaway Study. ANSIRH. Accessible at: http://www.ansirh.org/research/turnaway.php.
Weitz, T., Taylor, D., Desai, S., Upadhyay, U., Waldman, J., Battistelli, M., & Drey, E. (2013). Safety of Aspiration Abortion Performed by Nurse Practitioners, Certiﬁed Nurse Midwives, and Physician Assistants Under a California Legal Waiver. Accessible at: http://www.ansirh.org/_documents/library/weitz_AJPH2012.pdf
Boonstra, H., Benson Gold, R., Richards, C., & Finer, L. (2006). Abortion in Women’s Lives. Guttmacher Institute. Accessible at: http://www.guttmacher.org/pubs/2006/05/04/AiWL.pdf.
Taylor, D., Safriet, B., Dempsey, G., Kruse, B., & Jackson, C. (2009) Providing Abortion Care: a professional toolkit for Nurse-Midwives, Nurse Practitioners, and Physicians Assistants. University of California, San Francisco. Accessible at: http://www.apctoolkit.org/index.html.