Nurse practitioners and certified nurse midwives play an integral role in all facets of reproductive healthcare. They provide full-spectrum pregnancy care, contraception care, and counseling about pregnancy options, including abortion care. Advanced practice nurses (APNs) are first-line practitioners in the prevention and management of unintended pregnancy—a major public health issue. This commentary presents narratives from four APNs who sought and obtained clinical training in abortion care while they were APN students, training that is not currently integrated into APN educational programs.
Throughout the world, 40% of all pregnancies are unintended.1 In the United States, nearly half of pregnancies are unplanned; 40% of these pregnancies are terminated legally by abortion.2 The percentage of women seeking to terminate an unintended pregnancy in countries where abortion is illegal is similar to that in the U.S.; what varies is the rate of complications from illegal and unsanctioned abortions.3 In 2008, the incidence of unsafe abortion was 1/1,000 women aged 15-44 years in developed countries versus 16/1,000 women of the same age in developing countries.4 Women die as a result of illegal abortions; the number of abortion-related deaths due to unsafe abortion in 2008 was 90 in developed regions versus 47,000 in developing regions.4 Although abortion is a legal option in the U.S., access varies from state to state and region to region. Eighty-nine percent of all counties in this country have no abortion provider, and the number of abortion clinics declined from 851 to 839 from 2008 to 2011.2
Early aspiration abortion is an in-clinic procedure that involves dilating the cervix, inserting a sterile cannula into the uterus, and applying gentle suction to remove pregnancy tissue. Medication abortion can be done through various regimens; in the U.S., it involves sequential administration of two drugs, mifepristone and misoprostol, to halt embryonic development and induce uterine contractions so the patient may pass the pregnancy at home. Numerous recent studies have shown that advanced practice nurses (APNs) can provide both aspiration and medication abortion procedures with the same safety and quality outcomes as their physician colleagues.5 Despite the evidence, only a dozen states permit APNs to provide medication abortion and fewer than half of these states allow APNs to perform aspiration abortion.5,6
Although evidence shows that APNs can safely provide aspiration and medication abortions, obtaining training to perform these procedures presents a challenge. Foster et al7 investigated the status of abortion education in accredited nurse practitioner (NP), certified nurse midwife (CNM), and physician assistant programs, and found educational opportunities to be deficient. These authors concluded that didactic and clinical training in abortion care should be included in routine curricula. Unfortunately, not much has changed since the publication of their report 10 years ago.
In this commentary, we present narratives from three NPs and one CNM who sought abortion training as APN students. All four of them completed the same program in Mexico City and learned the essential skills to perform an aspiration abortion: bimanual examination for gestational age assessment, basic ultrasonographic evaluation, paracervical block administration, cervical dilation, uterine aspiration, and identification of the products of conception. Their experience differs from those of medical residents who have in-country access to training in abortion procedures through their academic institutions.8 APN students lack access to such training in this country. The objective of this commentary is to describe why four APN students sought training to become abortion providers, how they achieved their goal, and how they are using their abortion training experience to best serve patients in their current clinical practice.
Narrative One
My post-college plan was to become a midwife. I moved to Texas to train as an apprentice and interned in Mexico with traditional midwives. I learned about pregnancy care and experienced the joy of birth. What left a lasting impression, though, was when a woman presented with an unintended pregnancy and was sent away to a whispered location. I decided to become a nurse practitioner and enrolled in a program that I hoped would prepare me to offer full-scope reproductive care within the context of primary care. As an NP student, I sought abortion training in the U.S., but the opportunity fell through.
I reached out to a midwife I met in Mexico to discuss my dilemma. She told me about an organization that trained physicians and midwives in manual vacuum aspiration (MVA). After some persistence, I was invited to participate in their 6-week Integrated Medical Model of Aspiration Procedures for Unintended Pregnancies training. The program entailed long days and many hours of studying. I learned more hands-on skills in 6 weeks than in a year of clinical rotations at school. I performed 30 MVA procedures, including 16 solo procedures, and several post-procedure intrauterine device (IUD) insertions, all while expanding my Spanish-speaking and gynecologic skills.
Today, I work at a community clinic in the South Bronx—a marginalized area with a long list of health challenges, including unplanned pregnancy. Although I do not perform abortions here, my training experience in Mexico shaped me as a provider. The patient-centered care model and the hands-on skills I acquired there prepared me for performing procedures such as endometrial biopsy and IUD insertion. The experience equipped me with counseling tools that I use to discuss all pregnancy options with patients who present with an unintended pregnancy. I hope that abortion training will be offered to all interested APN students here in the U.S. so that safe abortion will be easily accessible to anyone who needs it.
Narrative Two
When I began my NP program, I knew I wanted to focus on sexual and reproductive healthcare; I liked the idea of caring for patients’ most sensitive needs and helping them understand their bodies in a nonjudgmental space. I had always supported a person’s right to choose, but I hadn’t felt strongly about becoming an abortion provider myself. When I started my graduate studies, I wasn’t even aware that NPs could provide abortions. That all changed when I attended my first National Abortion Federation (NAF) conference.
Prior to the conference, I had learned nothing about abortion in my NP program. At NAF, I learned that NPs could legally provide abortions in some states. I attended a lecture by another APN student who had trained in Mexico City. She spoke about the complexities of working in a country where abortion is legal only up to 12 weeks’ gestation and only in the capital city. She discussed how these restrictions forced women to carry undesired pregnancies to term, undergo unsafe abortions, or travel long distances to receive care. She addressed the fact that when abortion access is restricted or denied—as is increasingly the case in the U.S.—patients suffer. These realizations made the proverbial light bulb go off in my head: I needed to become an abortion provider in order to fully meet the needs of my patients by providing all reproductive care options.
There was nowhere in the U.S. for me to train. In the summer before my final year of APN school, I traveled to Mexico City to become an abortion provider. Over an intensive 6 weeks, I studied, trained, and completed 28 MVA abortion procedures.
In my current clinical work in California, I provide comprehensive reproductive healthcare, including medication abortion. I will soon offer MVA because I live in a state where APNs can legally provide aspiration procedures. My training in Mexico City laid the groundwork for me to become a full-scope abortion provider.
Narrative Three
Abortion care has always been a passion of mine, so I decided to pursue a career in midwifery and women’s healthcare. A classmate once commented that I care about contraception and abortion in “the same way other midwives feel about birth.” Prior to nursing school, I worked as a family planning and abortion counselor. I became aware that the experience of ending a pregnancy can be as transformative as giving birth, and that supporting a woman through this experience is a privilege. To me, abortion care is a natural extension of midwifery care; if the meaning of the word midwife is “with woman,” then midwives should provide the same holistic care for women undergoing abortion they do for those undergoing pregnancy and childbirth.
Having exhausted all options for training in the U.S., I attended the program in Mexico City as a nurse midwife student. I am so grateful for the unique learning opportunity it afforded me. The doctors in the clinic were excellent teachers. After 5 weeks of training, I felt confident in my MVA skills and in my ability to manage abortion complications. I improved in my physical assessment techniques and I felt more selfassured with IUD insertions. I finished the program better able to counsel patients in either English or Spanish regarding all pregnancy options.
I now work as a CNM in Massachusetts. NPs and CNMs are restricted from providing aspiration abortion in this state, but I am involved with advocacy groups to advance efforts to include all aspects of abortion care as part of our scope of practice. My patients know they can come to me for patient-centered midwifery, including abortion care.
Narrative Four
When I began nursing school, I had a strong desire to make meaningful change in the world. In pursuit of this goal, I planned to become an NP and provide individualized care. After meeting abortion providers during clinical rotations, I learned how common abortion is and saw first-hand the value of a provider who offers whole-hearted support while discussing all the options that a pregnant patient has. I learned that abortion is simple and safe. It became important to me that abortion care be a part of my future practice as a clinician. The experience of providing abortion care is summed up well in Virginia Henderson’s definition of nursing: “It is a service, which, at its best, is emotionally and intellectually rewarding to those who give it, and highly-prized by those who receive it.”9
After unsuccessful attempts to find training in the U.S., I heard about the program in Mexico City. I was mentored and strategically trained in aspiration abortion by doctors to whom I am forever grateful. As a clinician, I support my patients to become their most complete and healthy selves. If becoming a parent, carrying a pregnancy to term, or choosing adoption does not make sense for a given patient, I am honored to support her in her decision to have an abortion. Working in outpatient healthcare settings does not often allow a provider to see patients “cured” in one visit. Seeing a woman enter the clinic with an unwanted pregnancy and leave feeling cared for and respected is extremely satisfying for both patient and clinician.
Today, I work in California, a state that recognizes my ability to provide effective and safe aspiration and medication abortions. At my place of employment, I am receiving continued aspiration abortion training by a physician and performing the procedure independently.
Conclusion
In her treatise on the concept of nursing, Virginia Henderson stated, “The most successful preparation of nurses will always include whatever gives them the broadest possible understanding of humanity and the world in which they live.”9 Henderson proposed that all nursing students have an opportunity to participate in learning in a variety of healthcare settings in order to gain broad knowledge of the world, humanity, and the multifaceted needs of the patients they serve.
These narratives demonstrate how abortion training helped prepare four APNs for clinical practice. They also reveal the lack of access to abortion training for APN students in this country. With motivation and resourcefulness, these students were able to receive the education they desired. These narratives validate the favorable impact that abortion training has on the development of both clinical skills and confidence as an APN.
Advanced practice nursing students should not need to leave the U.S. to acquire clinical skills that they are legally permitted to apply in several states. Expansion of training opportunities in full-scope reproductive care, including abortion care, via both didactic and clinical experience, should be included in nursing curricula in this country. This training will be essential in preparing the next generation of APNs to meet the needs of all our patients by providing fullscope, patient-centered reproductive care.
Annelle Taylor is a women’s health and adult primary care NP at a family-centered community health clinic in the South Bronx, New York. Alison Hathaway is a women’s health and adult NP at Planned Parenthood Mar Monte in San Jose, California. Michelle Luneau is a women’s health and adult NP in clinical practice at Planned Parenthood of the Pacific Southwest in San Diego, California. Fedelma McKenna is a CNM working in full-spectrum women’s health in a community hospital and birth center in Cambridge, Massachusetts. Joyce D. Cappiello is Assistant Professor of Nursing at the University of New Hampshire in Durham. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.
References
1. Sedgh G, Singh S, Hussain R. Intended and unintended pregnancies worldwide in 2012 and recent trends. Stud Fam Plann. 2014;54(3):301-314.
2. Guttmacher Institute. Induced Abortion in the United States. May 2016.
3. Guttmacher Institute. Induced Abortion Worldwide. Global Incidence and Trends. May 2016.
4. World Health Organization. Unsafe Abortion Incidence and Mortality. Global and Regional Levels in 2008 and Trends During 1990-2008.
5. Guttmacher Institute. State Laws and Policies: Medication Abortion. August 2016.
6. 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. Am J Public Health. 2013;103(3):454-461.
7. Foster AM, Polis C, Allee MK, et al. Abortion education in nurse practitioner, physician assistant and certified nurse-midwifery programs: a national survey. Contraception. 2006;73(4):408-414.
8. Singer J, Fiascone S, Huber WJ 3rd, et al. Four residents’ narratives on abortion training: a residency climate of reflection, support, and mutual respect. Obstet Gynecol. 2015;126(1):56-60.
9. Henderson V. The concept of nursing. J Adv Nurs. 2006;53(1):21-31.