This article originally appeared in the August edition of the journal Contraception. It is co-authored by Tracy Weitz, Patricia Anderson, and Diana Taylor, all at the Bixby Center for GlobalReproductive Health at the
University of California, San Francisco (UCSF). Bios and photos for Anderson and Taylor can be found by clicking on their names.
declining availability of abortion care has been the topic of many studies,
commentaries, conferences and advocacy initiatives over the last 20 years.
One of the ideas suggested to ameliorate this problem is to increase the number
of physician assistants (PAs), nurse practitioners (NPs), and certified nurse
midwives (CNMs) who perform first-trimester abortion.
While addressing access through
this strategy holds great promise, it is not simply a matter of access that
calls for more clinicians to participate in abortion care. Rather, as health
professionals, we should expect that professional scope of practice
determinations are based upon whether the “profession can provide this proposed
service in a safe and effective manner” and not solely on the lack of physicians available to provide the
It is time to acknowledge that PAs, NPs and CNMs [collectively known
as advanced practice clinicians (APCs)] are capable and qualified to provide
abortion care services, but that current efforts to provide this care are
thwarted by both the politics of health care and the politics of abortion.
Outdated laws, restrictive
regulations, lack of clinical training opportunities, professional turf battles
and politically-motivated challenges impede APCs abilities to provide abortion
care. APCs, physicians, reproductive health and rights advocates and attorneys
must join together to promote the provision of abortion by APCs, thereby
protecting both women’s access to abortion care and practitioners’ rights to
provide essential care for their patients.
have a long history of providing comprehensive reproductive health services
within primary care and family planning settings. In 2004, APCs saw six times
as many women for publicly-funded family planning services as did physicians. Noteworthy is that APCs have been
providing abortions in some states since 1973 when abortion was nationally
legalized in the United States. There is a growing body of evidence that APCs are safe, efficacious
providers of abortion, via both medication and aspiration methods. Studies
published in 1986, 2004 and 2006, comparing abortions performed by physicians
to abortions performed by NPs and PAs found comparable rates of safety and
this evidence, many states have “physician-only” laws which prohibit the
performance of abortions by anyone other than licensed physicians. Some of
these laws were enacted around the time of Roe v. Wade in 1973 to protect women
from unsafe, unlicensed abortion providers. They predate the recognition of
APCs role in health care and the development of newer and simpler abortion
These laws were never meant to prohibit the future evolving scope
of practice by APCs, but their presence “on the books” is a de facto
restrictive legacy. In recent years, abortion rights opponents have used
physician-only laws in Arizona, Missouri, North Dakota and Tennessee
specifically as a strategy to reduce access to abortion services by limiting
who can provide such care.
allies in opposition to abortion restrictions, such as regional offices of the
American College of Obstetricians and Gynecologists, fail to aggressively fight
these proposed restrictions in part due to their overall support for using the
political process to control the scope of practice of other health
professionals. Professional nursing and other allied health professionals also
fail to engage in challenging these laws, although their motivations stem more
from the desire to avoid the messy contested world of abortion politics.
Consequently, abortion opponents often find little resistance to their efforts
to restrict access to abortion through limiting scope of practice. This
editorial seeks to provide health care professionals with the tools for
engaging in these debates.
How is scope of
practice normally determined for APCs?
of practice can be understood as the activities that an individual health care
practitioner is permitted to perform within a specific profession and is
uniquely defined by the congruence between law and appropriate practice. The boundaries of scope of
practice are determined by clinical competence and skill, knowledge and
training, professional and institutional standards and legal-regulatory
requirements. Scope of practice evolves and changes over time due to community
needs and technology advancements, as well as health professional practice and
education standards, institutional policies and state laws or regulations.
Advancing scope of practice
requires evidence that a new skill or technique will facilitate access to safe
and effective health care services and that professional and educational
standards and competencies are consistent with a new area of practice.
Interpreting abortion to be
outside the scope of practice of CNMs, NPs and PAs, regardless of their
documented competence, runs directly counter to the normal manner is which
scope of practice assessments are made.
the United States, there are approximately 200,000 licensed CNMs, NPs and PAs
who today perform primary health care services once provided only by licensed
physicians. APCs specializing in reproductive health have acquired numerous
advanced skills that are now considered common practice, such as administering
paracervical anesthesia, performing ultrasounds, inserting intrauterine
contraception and conducting colposcopy and biopsies [as reflected in the numerous
educational programs offered to APCs by the Association of Reproductive Health
Abortion care is a natural complement to these procedures
and practices. Integrating abortion into the care APCs provide holds the
potential to foster greater continuity of care, ensure earlier diagnosis and
termination of unintended pregnancy and promote women’s health and well-being.
Actions to support
including abortion in APC scope of practice
abortion care within APC scope of practice depends on collaboration among
multiple stakeholders. Individual APCs, APC educators and employers, physician
allies as well as reproductive health advocates, professional organizations and
state regulatory groups must be part of the solution. Professional
organizations play a critical part with state licensing boards and legislatures
in developing, maintaining and advancing professional practice. The following
strategies highlight a few ways for APCs to participate in his/her professional
organization and to work with others in bringing the professional voice to
scope of practice conversations at the state and national level:
- Become involved in your
professional organization and take leadership in developing, maintaining, and advancing professional standards and responsibilities. If the professions fail to provide leadership, the licensing boardspan and legislatures will take the lead.
- Become active in your national organization’s state chapters and practice committees; they play an important role in the implementation, review and revision of regulatory and credentialing documents.
- Build relationships with members of
your state professional association before there is a scope of practice debate rather than waiting to act until a crisis presents itself.
Read your state’s professional practice act and know how scope of practice is defined in statutes and regulations.
Understand regulatory board functions, as well as the roles of board members, when advocating for change.
- Check to see if your state regulatory
board has developed guidelines for advancing scope of practice and know the
- Get to know your nursing, medical
and/or healing arts boards.
- Volunteer to help your boards and
serve on committees. Develop a better understanding of the issues or
limitations that affect both the public and health professional groups.
- Learn about board processes and the
mechanisms used to regulate and advance scope of practice.
- Attend a board public meeting to observe the process in action and get to know board members and colleagues from
around the state.
- Obtain the minutes from public
meetings; in many states they are available online.
- If you are a clinician, develop a
professional portfolio that documents abortion care competencies and
- Describe your professional skills
and profile your major accomplishments. All health professionals — whether APCs
or physicians — are responsible for compiling essential documents and
credentials that authorize them to practice.
- As an educator or trainer, help develop
abortion care education and training programs.
- Serve as a resource to regulatory
boards, which look to NP, CNM and PA educators for reproductive health
standards and clinical competencies when assessing whether a procedure is
within APC scope of practice.
- Continue your dedication to
high-quality education by aligning educational curriculum and core competencies
in women’s and reproductive health with those for unintended pregnancy
prevention, including abortion care.
- Consider working closely with multi-disciplinary
professional organizations that support linkages in education between all
members of the health care team, such as the ARHP.
- Educate legislators and
policy-makers, testify before legislative committees and draft public
statements in support of abortion care as part of the scope of practice for all
health professionals who care for women at risk for unintended pregnancy.
APCs as abortion providers can make early abortion care more accessible, but their
practice in this arena is not simply a solution to the problem of access but a
natural advancement in scope of practice based on professional expertise. APCs,
their physician colleagues and reproductive health advocates need to actively
engage in the larger debates about scope of practice. Together we can ensure
that health policy decisions about who can provide abortions to whom and under
what circumstances are determined by evidence and not by the either the
politics of abortion or the politics of health care.
References used for this article include:
Abortion Federation. Who will provide abortions? Ensuring the availability of
qualified practitioners. Washington, DC: National Abortion Federation; 1991.
PD. Who will do the abortions?. Womens Health Issues. 1993; 3:
DA. Clinicians who provide abortions: the thinning ranks. Obstet Gynecol.
1992; 80: 719–723.
C, Yanow S. Advanced practice clinicians as abortion providers: current
developments in the United States. Reprod Health Matters. 2004; 12 (24
JB, Leslie N. The role of advanced practice clinicians in the availability of
abortion services in the United States. J Obstet Gynecol Neonatal Nurs.
2007; 36: 471–476.
B. Advanced practice clinicians and medical abortion: increasing access to
care. J Am Med Womens Assoc. 2000; 55 (3 Suppl): 167–168.
in Healthcare Professions’ Scope of Practice: Legislative Considerations.
[Accessed April 14, 2009]: The Association of Social Work Boards, The
Federation of State Boards of Physical Therapy, The Federation of State Medical
Boards, The National Association of Boards of Pharmacy, The National Board for
Certification in Occupational Therapy, The National Council of State Boards of
Nursing, Inc.; 2007.
D, Safriet B, Weitz T. When politics trumps evidence: legislative or regulatory
exclusion of abortion from advanced practice clinician scope of practice. J
Midwifery Womens Health. 2009; 54: 4–7.
JJ, Frohwirth L. Family Planning Annual Report: 2004 Summary Part 1. Report to
the Office of Population Affairs, U.S. Department of Health and Human Services.
Washington DC: The Alan Guttmacher Institute; 2005.
10. Donovan P. Vermont physician
assistants perform abortions, train residents. Fam Plann Perspec.
1992; 24: 225.
11. Freedman MA, Jillson DA, Coffin RR,
Novick LF. Comparison of complication rates in first trimester abortions
performed by physician assistants and physicians. Am J Publ Health.
1986; 76: 550–554.
12. Goldman MB, Occhiuto JS, Peterson
LE, Zapka JG, Palmer RH. Physician assistants as providers of surgically
induced abortion services. Am J Publ Health. 2004; 94: 1352–1357.
13. Warriner IK, Meirik O, Hoffman M,
et al. Rates of complication in first-trimester manual vacuum aspiration
abortion done by doctors and mid-level providers in South Africa and Vietnam: a
randomised controlled equivalence trial. Lancet. 2006; 368: 1965–1972.
14. Safriet BJ. Closing the gap between
can and may in health-care providers’ scopes of practice: A primer for
policymakers. Yale J Regul. 2002; 19: 301–334.
15. Milstead JA. Health policy and
politics: a nurse’s guide. 3rd ed. Sudbury, MA: Jones and Bartlett Publishers;
16. Schuiling KD, Slager J. Scope of
practice: freedom within limits. J Midwifery Womens Health. 2000; 45:
17. Taylor D, Safriet B, Dempsey G,
Kruse B, Jackson C. Providing abortion care: A professional toolkit for
nurse-midwives, nurse practitioners and physician assistants. San Francisco:
University of California, San Francisco; 2009.