By Amy J. Levi, PhD, CNM, WHNP-BC; Elizabeth Banks, FNP-C, MSN; Jessica Dieseldorff, FNP, MSN; and Victoria S. Tueros, FNP, MSN
Nurse practitioners (NPs) play an essential role in the prevention of unintended pregnancy through provision of contraceptive services and reproductive education and counseling. When unintended pregnancy does occur, NPs are there to provide options that include counseling, prenatal care, and/or needed referrals. Continuity of care and access to safe first-trimester abortion for women who decide to terminate an unintended pregnancy can be improved when NPs who choose to do so are also able to provide this service. In this article, the authors provide background information regarding the provision of abortion services by NPs, and three NPs share their experiences in this regard.
Unintended pregnancy remains a significant public health problem in the United States; current estimates identify 51% of pregnancies as unintended—that is, mistimed or unplanned.1 Of these unintended pregnancies, 27% are carried to term, 33% end in miscarriage, and 40% result in termination, by the use of either medication or uterine evacuation.1 Despite healthcare providers’ (HCPs’) and women’s best efforts to prevent unintended pregnancies, these events still occur, and many women choose termination as the best option for them. Termination of a pregnancy is a decision that women make within the complex reality of their own lives, and the decision to terminate a pregnancy, like all healthcare decisions, needs to be supported by NPs within the context of patient-centered care.2
The nurse practitioner role
Nurse practitioners have long been in the forefront of reproductive healthcare in the United States.3 The Patient Protection and Affordable Care Act requires that contraceptive care be included as part of preventive services for insured women without additional charge.4 Much of this contraceptive care is provided by NPs in primary care and reproductive health settings. Contraceptive care requires a wide range of skills, including patient education and counseling, as well as clinical expertise in intrauterine contraceptive (IUC) placement, contraceptive implant insertion, and unintended pregnancy management.5 As primary care providers, NPs are well positioned to take on responsibility for both unintended pregnancy prevention and management.6
The occurrence of unintended pregnancy continues despite the high rate of contraceptive use and the high efficacy rate for popular contraceptives. Up to 51% of unintended pregnancies occur in a cycle in which women have been using some form of contraception.7 Based on the perfect-use effectiveness rate for oral contraceptives, 3 pregnancies will still occur for every 1,000 women using this method alone.8 Therefore, the need for safe, accessible abortion will continue, and NPs represent a cadre of HCPs who can ensure continuity of care for unintended pregnancy, focusing on the needs of women who may already be their patients.
The number of abortion providers in the United States has declined steadily in the past decade; 89% of all counties in this country have no abortion provider at all.9 As a result, many women may need to travel to obtain abortion care, creating an increase in cost and possibly delaying an abortion past the first trimester, when terminations are safest. First-trimester abortions are among the safest gynecologic procedures available, and are part of a strategy to reduce the need for second-trimester abortions, which carry more risk of complications.10 An increase in the number of abortion providers, especially in counties lacking these providers or having too few of them, could make a safe procedure more accessible to more women. The contribution of NPs to this effort demonstrates the value of this previously underutilized workforce to address an important health problem for many women.
Provision of uterine vacuum aspiration is similar to many other clinical skills performed by NPs; this process includes dilating the cervical canal to enter the uterus in much the same way as is done for IUC placement or for intrauterine insemination. It involves instrumentation of the endometrium, as does endometrial biopsy. Many NPs are skilled in the use of ultrasonography (USG), another component of pregnancy termination skills. For NPs involved in reproductive healthcare, vacuum aspiration of the uterus for pregnancy termination can be easily added to the list of gynecologic services they provide.
Several recent studies support the safety of both medication and aspiration abortions provided by NPs and midwives.11 The largest of these studies compared complication rates for procedures performed by physicians with those performed by NPs, certified nurse-midwives (CNMs), and physician assistants (PAs).12 The results demonstrated that the risk difference for complications between the two groups was not clinically significant.
Despite these encouraging findings, NPs are restricted from providing abortions in many states. In fact, in 38 states, physicians are the only HCPs who can provide abortion services.13 In the remaining 12 states, NPs can prescribe medication abortions. In addition, in 6 of these 12 states—California, Montana, New Hampshire, New York, Oregon, and Vermont—NPs can provide aspiration abortions.
Three nurse practitioners speak
Nurse practitioners who choose to provide abortion services give varying reasons for doing so. A primary reason is the desire to provide continuity of care for women for whom they are already providing other reproductive healthcare services. NPs emphasize patient-centered care when a woman is diagnosed with an unplanned or mistimed pregnancy, and support her decision to parent, choose adoption, or terminate her pregnancy. Provision of an abortion, as chosen by the patient based on her needs, is simply part of the continuum of care. Three NPs describe their own journeys to becoming abortion providers.
My story started in a southeastern metropolitan area in the summer of 1992, when I had been hired as an educator for Planned Parenthood in a neighboring community. A friend called and asked if I would drive her to another city and hold her hand. She didn’t want to have her abortion in the town where we lived because she was afraid she would see people she knew, and she would be embarrassed and stigmatized. Despite all the reassurance I could give her about the sensitive and confidential care she would receive at our home clinic, we ended up on a road trip that changed her life and mine.
After witnessing my friend’s turning point, her taking control of her future, I felt called to be with other women making this profound and personal decision. I worked on call as a pre-abortion counselor. When I went to graduate school to become a nurse practitioner, I knew I wanted to come back to abortion care.
Over the 14 years during which I’ve been a women’s healthcare provider, my role in abortion care has slowly evolved. I have worked my way up from hand-holder and counselor to recovery room nurse, USG examiner, laminaria inserter, and medication abortion provider. For the past 3 years, I have been part of a research project training clinicians (NPs, PAs, and CNMs) to do in-clinic abortions up to 14 weeks. By participating in this research study, I hope that I will be enabling other advanced practice nurses (APNs) to become abortion providers and enabling more women to gain access to the early abortion services they need.
Having done almost 300 early abortions to date, I feel competent in the required skills, which are used in other procedures I do all the time (e.g., IUC insertion, colposcopy, biopsy). Every time I meet a woman on the day of her abortion, I remember the feeling I had 20 years ago. I’m honored when a woman trusts me to help her. Sometimes she wants to tell me her story and her reasons. I listen intently. Sometimes she just needs a quiet place to get through a harrowing day in her life. I am happy to witness her relief when I tell her the procedure is over.
I have been working in the field of reproductive health and abortion services for 30 years. My initial experience was as a clinician doing pre-operative assessments and counseling. Since then, my career has evolved to include colposcopy, medication abortion services, and now the direct provision of first-trimester aspiration abortions. Over the years, I have met hundreds of women, some with similar stories and some with unique ones. My most memorable patient story demonstrates perfectly why APNs should be able to add abortion to their list of skills in reproductive health.
One day our medical assistant came to me to say that our next patient was very nervous. She was sure of her decision and had good support at home, but she was “just so afraid of the pain that might be involved.” When I read her patient record, I immediately recognized her name—I had seen her in the past for dysplasia and cancer screening services. When I entered the room she smiled, let out a huge sigh of relief, and said, ”Oh my gosh, are you the person who is going to do my abortion? You did my colposcopy and you were so gentle. I’m so glad it’s you again.” I smiled back, feeling so appreciated—and grateful that I had been given the opportunity to help and support women in this way.
After providing abortions for more than 200 women, I feel that this procedure is just one more skill in which I have become proficient. As a nurse practitioner, I have been trained to look at the whole person and consider all her needs to optimize her health outcomes. I feel that I can now do this for women seeking abortions as well. I look forward to a time when all APNs who want to offer this service to their patients are able to do so.
Around 2005, two important factors converged to spur me to seek uterine aspiration training. I am of an age in which abortion has always been legal and I have taken it for granted that undergoing this procedure is a woman’s choice. However, in 2005, it seemed a real possibility that we might see a change in the composition of the Supreme Court and, as a result, the overturning of Roe v. Wade. The other motivating factor came in the form of the person who served as Director of Clinical Services where I worked. She was proactive and progressive, and believed that NPs could provide vacuum aspiration abortions because our state does not have a “physician-only” abortion law. My state also has a strong nurse practice act, which allows APNs to practice to the extent of their education. This person encouraged me to seek training in early aspiration abortion, which led to an opportunity to train with several physicians who all willingly shared their pearls of wisdom with me.
That was 7 years ago. I have participated in more than 3,000 aspiration abortions since then. My state does not restrict performance of abortion to physicians only; this procedure is treated like any other—performance of it is based on a clinician’s education and competency. I continue to feel privileged to assist women with this unique aspect of their healthcare, which I view as part of a continuum of their reproductive healthcare.
My journey continues to evolve as my patients share their stories with me. I believe more than ever that every aspect of abortion care is important and deserves careful attention. From the moment a woman discovers an unplanned pregnancy she faces new challenges. Even her first contact with clinic staff is an experience that she will remember. The process of assessing each patient when we first meet in the examination room, providing her USG, counseling her, and performing the aspiration abortion is incredibly inspiring as I see a woman transform from someone who may be anxious, angry, frightened, or all of the above to someone who is relieved and grateful for her care. I have come to appreciate the importance of how we NPs talk to patients, and of how our patience, kindness, and understanding help women get through very trying circumstances.
These stories demonstrate the power of nurse practitioners to provide care for women managing unintended pregnancy. NPs can support access to safe abortion care by increasing the number of providers for this much-needed clinical procedure and reducing the burden of obtaining access to care that many women need. The patient-centered care that is provided by NPs can be enhanced by adding this skill to their list of reproductive healthcare services.
Amy J. Levi is the Albers Professor of Midwifery at the University of New Mexico in Albuquerque. Elizabeth Banks is Director of Clinical Services at Planned Parenthood Columbia Willamette in Portland, Oregon. Jessica Dieseldorff is Quality Management Clinician/Clinician II at Planned Parenthood Mar Monte in San Jose, California. Victoria S. Tueros is a Family Nurse Practitioner in the Women’s Clinic at Family Health Centers Logan Heights in San Diego, California. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.
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