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Radical or routine? Nurse practitioners, nurse-midwives, and physician assistants as abortion providers.

In 2013, one state in the United States (US) made a highly significant policy change based on evidence that nurse practitioners (NPs), certified nurse-midwives (CNMs), and physician assistants (PAs) can safely and competently provide early aspiration abortion, with training. NPs, CNMs, and PAs (henceforth referred to as "clinicians") in the US have graduate level training and provide direct care to patients independently and/or in partnership with physicians. California legalized the provision of early aspiration abortion by these health care professionals, thereby expanding the pool of available abortion care providers. The passage of California's new law (CA AB154), (1) was made possible by a strong coalition of patient advocates, health care providers, and researchers. This coalition worked with the state's health professional boards and members of the state legislature for over two years to enact this evidence-based change.

The safety and acceptability of clinicians (or comparable professionals) as providers of early abortion care has been demonstrated for vacuum aspiration abortion (2) and medical abortion (3) in both developed and developing countries. (4) In Europe, such providers are responsible for the administration and supervision of the majority of medical abortion in three countries: France, Great Britain, and Sweden. (5) Additionally, in the US as of 2015, 12 states allow for NP, CNM, and/or PA provision of medical abortion. (6) In Bangladesh, Cambodia, Mozambique, Nepal, South Africa, and Vietnam, such providers are able to provide both manual vacuum aspiration (MVA) abortions and medical abortion in the first trimester--allowing for greatly expanded access to safe abortion services for women. (4,7,8) The 2012 revised Safe Abortion: Technical and Policy Guidance for Health Systems (9) from the World Health Organization now acknowledges that abortions can be safely performed by such providers and, where abortion is legal, recommends the training of midwives, nurse practitioners, clinical officers, physician assistants, family welfare visitors, and others in abortion provision in order to ensure access to safe abortion for all women.

California's new law, (1) which followed this long established international standard, was particularly meaningful in the American context because it was the only abortion policy that expanded abortion access, in a sea of policies designed to restrict abortion passed that year. (10) State legislatures and courtrooms have been the primary battleground of abortion rights in the US for about two decades, with exponentially increased activity since 2011.10 Given that policies restricting abortion are increasingly common, California's AB154 was a radical departure.

But how radical was it really?

It wasn't radical for patient safety. Actually, a large study conducted between 2007 and 2013 demonstrated no difference between the complication rates of physician and clinician abortion providers. (11) The study, entitled the Health Workforce Pilot Project (HWPP) #171 was led by investigators at the University of California, San Francisco (UCSF), in collaboration with Planned Parenthood affiliates and Kaiser Permanente of Northern California. In total, 16,998 patients received aspiration abortions in the study, 53% performed by clinician providers and 47% by physician providers. The study showed that clinicians and physicians had comparable rates of complications, which were extremely low--lower than most existing published rates. During the study, experienced clinicians were trained in aspiration abortion provision according to a competency-based UCSF didactic and clinical protocol. To comply with sponsor requirements, the training included a minimum of 40 procedures performed under the direct supervision of a physician trainer and required all trainees to pass a didactic exam. This proved to be more than ample training for most clinicians. Like their physician colleagues (who were not trained as part of this study), clinicians frequently cite experience with aspiration abortion and related procedures, as well as the frequency of provision, as key components of developing confidence in their competence. The new California law advises following the same training protocol for experienced clinicians until 2016. Multiple publications detail the evidence generated by the study, including the safety of clinician provided aspiration abortion care, (11) multiple aspects of confidence development among clinicians while learning this skill, (12) patients' positive experience of early abortion care, (13,14) and the effective use of research to inform policy change. (15)

It wasn't radical as far as the patients were concerned either. Over the six-year study period, 81% of patients agreed to have their abortion procedure provided by a clinician, demonstrating that the large majority of women are likely to accept clinicians as their abortion care providers. (13) In surveys of patients during the study, the patients reported high satisfaction with their abortion care experience, regardless of who provided the abortion. (13,14) Rather, patients identified several factors that influenced how they ranked their care experience, including interventions to decrease shame and/or stigma, their experiences of pain and pain management, the clinical environment, and waiting times associated with their appointment. (14) These findings found no association with the type of professional (clinician or physician) who delivered the abortion care, and reflect systemic issues common in diverse health care settings.

It wasn't radical to the clinicians themselves either. They were largely already well-trained, reproductive health care specialists providing family planning and, since 2001 in California, medical abortion care. (16,17) In interviews conducted as a sub-study of the main study, clinicians regarded aspiration abortion as the natural next step in their skill building. (12) Many were already doing closely related procedures, such as inserting intrauterine devices (IUDs), performing biopsies and colposcopies, placing laminaria and more; they had, as their trainers noted in qualitative interviews, sophisticated hand skills and competence with ultrasound, uterine sizing, and Pap smears. The experienced clinicians who were trained as part of the study grasped the skill of aspiration abortion quite seamlessly.

As such, training clinicians as abortion providers is not a radical notion. But it is unfortunately not routine yet either. With the promise of dramatically improving abortion access, time will show if other US states will follow suit with this policy change.

Doi: 10.1016/j.rhm.2015.06.002

References

(1.) Atkins AMT. AB154: California State Legislature. http:// leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_ id=201320140AB154 2013.

(2.) 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(9551):1965-1972.

(3.) Warriner IK, Wang D, Huong NT, et al. Can midlevel health-care providers administer early medical abortion as safely and effectively as doctors? A randomised controlled equivalence trial in Nepal Lancet 2011;377(9772):1155-1161.

(4.) Berer M. Provision of abortion by mid-level providers: international policy, practice and perspectives. Bulletin of World Health Organization 2009;87(1):58-63.

(5.) Jones RK, Henshaw SK. Mifepristone for early medical abortion: experiences in France, Great Britain and Sweden. Perspectives on Sexual and Reproductive Health 2002:154-161.

(6.) Guttmacher Institute. State Policies in Brief: Medication Abortion. New York: Guttmacher Institute, 2015 (February 1, 2015).

(7.) Yarnall J, Swica Y, Winikoff B. Non-physician clinicians can safely provide first trimester medical abortion. Reproductive Health Matters 2009;17(33):61-69.

(8.) Limbombo A, Usta MB. Mozambique abortion situation: country report. In: Expanding access: midlevel providers in menstrual regulation and elective abortion care. Johannesburg: IHCAR-Ipas conference report, 2001 December.

(9.) World Health Organization. Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva: WHO, 2012.

(10.) Boonstra HD, Nash E. A surge of state abortion restrictions puts providers--and the women they serve--in the crosshairs. Guttmacher Policy Review 2014;17(1).

(11.) Weitz TA, Taylor D, Desai S, et al. Safety of aspiration abortion performed by nurse practitioners, certified nurse midwives, and physician assistants under a California legal waiver. American Journal of Public Health 2013;103(3):454-461.

(12.) Freedman L, Levi A. How clinicians develop confidence in their competence in performing aspiration abortion. Qualitative Health Research 2014;24(1):78-89.

(13.) Taylor D, Postlethwaite D, Desai S, et al. Multiple determinants of the abortion care experience: from the patient's perspective. American Journal of Medical Quality 2013;28(6):510-518.

(14.) McLemore MR, Desai S, Freedman L, et al. Women know best--findings from a thematic analysis of 5,214 surveys of abortion care experience. Women's Health Issues 2014; 24(6):594-599.

(15.) Weitz TA, Taylor D, Upadhyay UD, et al. Research informs abortion care policy change in California. American Journal of Public Health 2014;104(10):e3-e4.

(16.) Henshaw SK, Finer LB. The accessibility of abortion services in the United States, 2001. Perspectives on Sexual and Reproductive Health 2003;35(1):16-24.

(17.) Kruse B. Advanced practice clinicians and medical abortion: increasing access to care. Journal of the American Medical Women's Association 2000;55(3 Suppl.):167-168.

Lori Freedman, (a) Molly Frances Battistelli, (b) Caitlin Gerdts, (c) Monica McLemore (d)

(a) Medical Sociologist, Advancing New Standards in Reproductive Health (ANSIRH) Program, Bixby Center for Global Reproductive Health, University of California, San Francisco (UCSF), Oakland, CA, USA

(b) Project Director, ANSIRH Program, Bixby Center for Global Reproductive Health, UCSF, Oakland, CA, USA.

Correspondence: molly.battistelli@ucsf.edu

(c) Epidemiologist, ANSIRH Program, Bixby Center for Global Reproductive Health, UCSF, Oakland, CA, USA

(d) Clinician-Scientist, ANSIRH Program, Bixby Center for Global Reproductive Health, UCSF, Oakland, CA, USA
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Title Annotation:ISSUES IN CURRENT POLICY
Author:Freedman, Lori; Battistelli, Molly Frances; Gerdts, Caitlin; McLemore, Monica
Publication:Reproductive Health Matters
Geographic Code:1USA
Date:May 1, 2015
Words:1522
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