Fact sheets summarizing the HWPP aims and background, study methods and findings, and policy strategy for durable change
Prepared by HWPP Study faculty and staff: Diana Taylor PhD, RNP, Molly Battistelli, MPH, and Patricia Anderson; UCSF Advancing New Standards in Reproductive Health (ANSIRH) Program with funding from RhN/Anonymous Donor
There is widespread consensus that abortions are safest when provided in the first trimester.1–5 Additionally, receiving abortion care as part of a comprehensive continuum of sexual and reproductive healthcare (SRH) by familiar practitioners in convenient local settings further reduces complications and improves outcomes.3,6–10 With the passage of Assembly Bill 154 (AB154)11 and Assembly Bill 980 (AB980)12 in 2013, California took important steps in improving access to abortion services for the most vulnerable women in the state by increasing access to abortion under the conditions when it is safest – in the first trimester and closest to home.
This policy change was based on findings from the six-year HWPP #171 study conducted by UCSF ANSIRH that provided conclusive evidence for removing restrictions on the clinical provision of abortions by qualified nurse practitioners (NPs), certified nurse midwives (CNMs), and physician assistants (PAs) while also lifting unnecessary restrictions on the facilities in which they are performed, thereby allowing abortion care to be provided by trained providers in a variety of safe and appropriate clinical settings.3,13 We have prepared four fact sheets that describe the HWPP Project from background to empirical study methods and findings to evidence for durable policy change.
Background: Nurses’ Role in Unintended Pregnancy Prevention: Nurses as abortion care providers
Registered nurses (RNs) as well as advanced practice registered nurses (APRNs)—have a long tradition of participating in SRH care and reproductive rights, including preconception care, management of planned and unintended pregnancies, and promotion of sexual health.14–16 In the provider-patient relationship established when a woman seeks care related to an unintended pregnancy, nurses provide essential services that have the potential to influence health in profound and meaningful ways. Nurse scholars and practitioners have contributed to the literature across the SRH continuum from the historical role of nurses in SRH and emerging scientific findings15,17,18 to the framing of a public health model for primary, secondary, and tertiary prevention of unintended pregnancy;19–23 including strategies for aligning practice and education for all health professionals providing care for populations at risk for unintended pregnancy.24 This first fact sheet provides a summary of what we know about nurses and the provision of abortion care, situated within secondary prevention of unintended pregnancy. The fact sheet’s primary focus is on NPs/CNMs, though there is also reference to the role of RNs as coordinating and assisting with abortion provision.
HWPP #171 Study: Aims, Methods & Findings
The California Health Workforce Pilot Project #171 (HWPP-171) was a California-based, multi-site, six-year study of CNMs, NPs, and PAs as providers of early aspiration abortion care in community-based clinics. This study was designed to address several aims and questions related to the acceptability, safety, and effectiveness of abortion care provided by NPs, CNMs, and PAs; the training standards and competency-based curriculum needed to prepare primary care professionals including NPs, CNMs, and PAs to provide safe and competent abortion care; and the development and validation of a taxonomy and monitoring framework to define and classify abortion-related incidents. The second fact sheet describes the HWPP-171 study design, questions, methods and findings and demonstrates the positive impact of expanding the abortion care workforce on increasing access to abortion while reducing abortion-related complications.
Evidence for Policy Change: Safety, acceptability and utilization of NP/CNMs as abortion providers
Between 2007 and 2013, HWPP #171 collected data from almost 20,000 patients and trained nearly 50 CNMs, NPs, and PAs to competency in aspiration abortion care. In 2013, California lawmakers passed legislation (AB 154)11 that expanded the pool of clinicians available to perform first-trimester abortions, a legislative change that was grounded in the findings of HWPP-171, which provided conclusive evidence that abortion is very safe, whether it is provided by a nurse practitioner (NP), a certified nurse midwife (CNM), a physician assistant (PA), or a physician.3 Additionally, more than 2,500 patients surveyed at 25 separate facilities across the state of California rated the abortion care they received in this study as being extremely positive (9.4/10), regardless of whether the care had been provided by a NP, CNM, PA, or MD/DO.3,25 The findings of HWPP-171 support the adoption of policies that increase access to abortion by increasing the number of health professionals qualified to perform first-trimester abortions. Study findings also affirm the acceptability of NPs, CNMs, and PAs as abortion care providers, thereby supporting their potential to expand the abortion care workforce. This third fact sheet details the ways in which the findings from the HWPP-171 study were used to make legislative and policy change in California and offers suggestions as to how the findings can inform policy change in other states to improve access to comprehensive sexual and reproductive health care services, including community-based early abortion care.
Legislative & Regulatory Implementation: What NPs/CNMs/PAs need to know/do to provide abortion care in California
The passage of AB 154 and AB 980 expanded access to community-based early abortion care (medication and aspiration abortion) for women in California by allowing NPs, CNMs, and PAs to maximize their practice and training and by establishing parity for all primary care clinics including those providing abortion care. This fourth fact sheet discusses the provisions contained in AB 154 and details the professional and legal requirements for NPs, CNMs and PAs providing early abortion care in California.
- Bartlett L, Berg C, Shulman H, et al. Risk factors for legal induced abortion-related mortality in the United States. Obstet Gynecol. 2004;103(4):729-737.
- Bennett IM, Baylson M, Kalkstein K, Gillespie G, Bellamy SL, Fleischman J. Early abortion in family medicine: clinical outcomes. Ann Fam Med. 2009;7(6):527-533. doi:10.1370/afm.1051.
- 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. doi:10.2105/AJPH.2012.301159.
- Taylor D, Safriet B, Weitz T. When Politics Trumps Evidence: Legislative or Regulatory Exclusion of Abortion From Advanced Practice Clinician Scope of Practice. J Midwifery Women’s Heal. 2009;54(1):4-7. doi:10.1016/j.jmwh.2008.09.003.
- Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obs Gynecol. 2015;125(1):5-12. doi:10.1097/AOG.0000000000000564.
- McLemore MR, Desai S, Freedman L, James EA, Taylor D. Women Know Best—Findings from a Thematic Analysis of 5,214 Surveys of Abortion Care Experience. Women’s Heal Issues. 2014;24(6):594-599. doi:10.1016/j.whi.2014.07.001.
- Grumbach K, Hart LG, Mertz E, Coffman J, Palazzo L. Who is caring for the underserved? A comparison of primary care physicians and nonphysician clinicians in California and Washington. Ann Fam Med. 2003;1(2):97-104. doi:10.1370/afm.49.
- Taylor D, Safriet B, Dempsey G, Kruse B, Jackson C. Providing Abortion Care: A Professional Toolkit for Nurse-Midwives, Nurse Practitioners, and Physician Assistants. APC Toolkit. http://apctoolkit.org/wp-content/themes/apctoolkit/index.html. Published 2009.
- Taylor D, Upadhyay U, Fjerstad M, Battistelli M, Weitz T, Paul M. Standardizing the classification of abortion incidents: The Procedural Abortion Incident Reporting and Surveillance (PAIRS) Framework. Contraception. 2017. doi:10.1016/j.contraception.2017.05.004.
- Auerbach DI, Pearson ML, Taylor D, et al. Nurse Practitioners and Sexual and Reproductive Health Services: An Analysis of Supply and Demand. Rand Heal Q. 2012;2(3):3. http://www.ncbi.nlm.nih.gov/pubmed/28083262. Accessed March 12, 2017.
- Assembly Bill No. 154. California General Assembly; 2013.
- Wood AM. ASSEMBLY BILL No. 980. 2017;(980):3-5.
- Weitz TA, Taylor D, Upadhyay UD, Desai S, Battistelli M. Research informs abortion care policy change in California. Am J Public Health. 2014;104(10):e3-e4. doi:10.2105/AJPH.2014.302212.
- McLemore MR, Levi AJ, James EA. Recruitment and retentio strategies for expert nurses in abortion care provision. Contraception. 2015;91(6):474-479. doi:10.1016/j.contraception.2015.02.007.
- Levi AJ, Simmonds KE, Taylor D. The Role of Nursing in the Management of Unintended Pregnancy. Nurs Clin North Am. 2009;44(3):301-314. doi:10.1016/j.cnur.2009.06.007.
- Berg JA, Olshansky E, Shaver J, Taylor D, Woods NF. Women’s health in jeopardy: Failure to curb unintended pregnancies. A statement from the AAN Women’s Health Expert Panel. Nurs Outlook. 2012;60(3):163-164.e1. doi:10.1016/j.outlook.2012.03.001.
- Aztlan-James EA, Mclemore M, Taylor D. Multiple Unintended Pregnancies in U.S. Women: A Systematic Review. Women’s Heal Issues. 2017:1-7. doi:10.1016/j.whi.2017.02.002.
- Levi A, Dau KQ. Meeting the National Health Goal to Reduce Unintended Pregnancy. JOGNN – J Obstet Gynecol Neonatal Nurs. 2011;40(6):775-781. doi:10.1111/j.1552-6909.2011.01292.x.
- Taylor D, James EA. An evidence-based guideline for unintended pregnancy prevention. J Obstet Gynecol Neonatal Nurs. 2011;40(6):782-793. doi:10.1111/j.1552-6909.2011.01296.x.
- Simmonds K, Likis FE. Caring for women with unintended pregnancies. J Obstet Gynecol neonatal Nurs JOGNN. 2011;40(6):794-807. doi:10.1111/j.1552-6909.2011.01293.x.
- Hewitt C, Cappiello J. Essential competencies in nursing education for prevention and care related to unintended pregnancy. JOGNN – J Obstet Gynecol Neonatal Nurs. 2015;44(1):69-76. doi:10.1111/1552-6909.12525.
- Cappiello J, Levi A, Nothnagle M. Core competencies in sexual and reproductive health for the interprofessional primary care team. 2016;93(5):438-445. doi:10.1016/j.contraception.2015.12.013.
- Cappiello J, Levi AJ, Gorwodo J. The Updated, Annual, Gynecologic Examination. 2015:77-86. doi:10.1111/1552-6909.12580.
- Taylor D, Johnson-Mallard V, Berg J, et al. A response from the Women’s Health Expert Panel (WHEP) of the American Academy of Nursing (AAN). J Am Assoc Nurse Pract. 2014;26(6):290-291. doi:10.1002/2327-6924.12128_2.
- Taylor D, Postlethwaite D, Desai S, et al. Multiple Determinants of the Abortion Care Experience: From the Patient’s Perspective. Am J Med Qual. 2013;28(6):510-518. doi:10.1177/1062860613484295.