It has been a savage few months for reproductive rights, with 12 states passing 26 bills to ban abortion, including measures that ban abortion as early as six weeks into pregnancy, as well as attempting to outlaw safe methods of abortion. In the face of this extreme, unprecedented wave of attacks, several states pursued an alternative route, passing laws that expand the scope of abortion providers to include advanced practice clinicians such as nurse practitioners.
There are not enough physicians to provide abortions, however many states have antiquated “physician-only” laws that prohibit advanced practice clinicians, such as nurse practitioners, midwives, and physician assistants, from providing abortions. To remedy this shortage, lawsuits were filed by several advanced practice nurses, physicians, Planned Parenthood affiliates and other reproductive health groups in Arizona, Idaho, Maine, New York, Virginia, and Wisconsin this year to reverse these laws. The need for expanding the cadre of health professionals trained in abortion care was identified as a problem in 1990, and almost 30 years after that first call for eliminating physician-only laws, the presence of multiple legal challenges to overturn this legislation represents a rarely discussed bright spot in reproductive health and access this year.
Politically-motivated state restrictions not based in medicine are unnecessarily limiting the scope of services provided to people seeking abortions in states with physician-only laws. Numerous peer-reviewed research studies indicate first trimester abortions are safe when performed by advanced practice registered nurses and physician assistants. This expansion of services is also supported by the American College of Obstetricians and Gynecologists, the American Public Health Association, and the World Health Organization, among others. Not only are services provided by advanced practice clinicians safe, in a breakthrough 2018 study, the National Academies of Science, Engineering, and Medicine concluded that abortions in the United States are safe and effective, with complications being exceedingly rare.
Nurse practitioners, certified midwives, and physician assistants receive clinical training on the job, through university programs or with abortion-specific training programs alongside physicians, residents, and medical students. The training focuses on medical and surgical skills necessary for first-trimester abortions as well as pre and post-abortion care and counseling. An expanded cadre of trained advanced practice clinicians would respond to existing need and work to expand abortion care to places like primary care facilities, where these services are traditionally unavailable.
The majority of abortion procedures are performed in stand-alone abortion clinics, with only 1 percent of abortions occurring in primary care facilities. Most nurse practitioners work in primary care (89 percent) and are more likely than physicians to provide primary care in urban and rural community settings that serve Medicaid enrollees and vulnerable populations. This suggests an opportunity to expand services by utilizing nurse practitioners and midwives, making abortion care more accessible, particularly in rural communities, as part of comprehensive sexual health within a holistic, primary care setting.
Abortion services tend to be concentrated in urban communities creating challenges for people living in rural communities. In places like Wyoming and the Dakota’s, research shows that at least half of the those of reproductive age live more than 90 miles from a clinic. Maine’s Democratic Governor, Janet Mills, passed legislation (LD 1261) in June to permit nurse practitioners and physician assistants to perform medication and aspiration abortions in part because of a need to expand services and ensure unburdened access to care.
Recent deliberations about eliminating the physician-only law in Idaho focuses on the physician shortage in that state. Research indicates 90 percent of U.S. counties have no abortion clinics. Expanding the number of trained providers in both urban and rural communities is a core rationale for ensuring the constitutional right to abortion is met.
While divisive anti-abortion legislation continues to threaten access to abortion, the slow and steady expansion of states striking down physician-only laws is a notable and promising development in expanding access. Four cases introduced this year are pending — namely in Arizona, Idaho, Virginia, and Wisconsin — while Maine and New York struck down their physician-only laws earlier this year. These states join Alaska, California, Connecticut, Maryland, Montana, Massachusetts, New Jersey, New Mexico, Oregon, Rhode Island, and Vermont in expanding access to comprehensive family planning and reproductive health care through nurse practitioners and other advanced practice clinicians.
Vanessa Shields-Haas is a nurse.
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