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Paper for the conference "Expanding Access; Advancing the Roles of Midlevel Providers in Menstrual Regulation and Elective Abortion Care" South Africa 2 - 6 December 2001.

The paper in pdf-format


The Role of Midlevel Providers in Abortion Care in the United States

Beth Kruse, MS, CNM, ARNP

Rivka Gordon, PA-C, MHS

Jini Tanenhaus, PA-C, MA

Special Acknowledgement to Susan Yanow, Lindsay Mize, and Mary Fjerstad

Country Profile on Abortion Services: USA

Section 1.

The population of the United States according to the 2000 census was over 278 million people. The U.S. has a population density of 76 people per square mile. The population growth rate is estimated at 0.9%. For women, life expectancy at birth is 79.5 while life expectancy for men is 73.8.

1.1 Summary of reproductive health and abortion statistic

Birth rates and maternal mortality

The annual number of births in the U.S. in 2000 was 3,959,417 with a fertility rate of 2.1. Maternal morbidity for 1991-1997 was 11.5 per 100,000 live births. The maternal mortality rate, broken down by race and ethnicity, is as follows:

  • Black women 29.6/100,000 live births
  • American Indian/Alaska Native 12.2
  • Asian/Pacific Islander 11.3
  • Hispanic 10.3
  • Non-Hispanic White 7.3

Abortion rates and abortion related mortality

In the U.S. 49% of pregnancies are unintended and approximately half of these pregnancies will by terminated by abortion. It is estimated that 43% of American women will have at least one abortion by the time they are 45 years old.

Table 1.1 Incidence of abortion by age. (1999)


Abortion rate per 1000 women













Abortion related mortality decreased by 90% following the legalization of abortion in 1973. The average rate of abortion related mortality is 0.3:100,000. This can be broken down by gestation with the mortality rate for up to 8 weeks gestation being 1:530,000 and 16-20 weeks gestations having a rate of 1:17,000.

1.2 Laws and Policies

In the United States, as elsewhere around the world, women’s reproductive health care is often determined by politics and ideology rather than by primary health care needs. The first anti-abortion law in the US was passed in 1845 and was followed by many other laws aimed at restricting midwives in immigrant communities from performing abortions. By the early 1960s, 41 states permitted abortion only if the woman’s life was in danger.

In 1973, the United States Supreme Court, in Roe v. Wade, determined that the right of privacy, which is protected by the fourteenth amendment of the US constitution, includes the right of a woman to terminate a pregnancy prior to fetal viability. Planned Parenthood clinics, feminist women’s health centers, and some private physicians, primarily in urban and suburban settings, promptly began to offer abortion services across the United States.

Almost immediately, women’s access to abortion became the target of religious and political conservatives. Politicians came under intense pressure to remove or erode abortion rights. In 1976, the US Congress passed legislation that prohibited federal Medicaid funds (health insurance for low-income Americans) from being used for abortion except in cases of life endangerment, rape and/or incest.

The right to have an abortion was seriously challenged at the level of the Supreme Court in 1992. With the decision, Planned Parenthood v. Casey, the basic right to abortion was upheld, but states were given the right to superimpose restrictions on abortion access, as long as these conditions are not seen to present an "undue burden" for women. This legal setback has resulted in states enacting policies that include mandatory waiting periods or counseling (24 states), parental involvement for minors requesting abortion services (32 states) and federal felony penalties for anyone other than a parent transporting a minor across state lines for the purpose of seeking an abortion.

Other state-specific barriers:

Forty-five states allow medical personnel, facilities and/or institutions to refuse to participate in abortion on the basis of religious or moral beliefs (so-called "conscience clauses"); 15 states prohibit state employees from counseling or referring women for abortions; 8 states prohibit the use of public facilities for abortion in certain cases; and one state prohibits public employees from participating in abortion services.16 states will pay for abortions to Medicaid recipients out of their own funds, but restrictive qualifications in 36 states effectively eliminate public funding for abortion. State monies pay for only 14% of abortions in the US. Currently, many private insurance policies will pay for all or part of abortion care.

In 1970, a federal program (Title X) was enacted to make free or low-cost contraceptive supplies and services available to women who are eligible for funding assistance. Within the statutes of the program, using funds for abortion is explicitly prohibited, but the counseling offered to all pregnant clients must include the option to terminate the pregnancy.

In 1994, federal legislation was enacted that made it a felony crime to engage in threatening, violent, obstructive or destructive acts in order to injure, intimidate or interfere with persons seeking abortion services.

Of particular relevance to this report, forty-three states and the District of Columbia mandate that only a physician may perform an abortion. This language may allow for some interpretation to be discussed later in this report.

Pro-choice groups such as the National Abortion Rights Action League (NARAL) and the Planned Parenthood Federation of America (PPFA) have mobilized large committed constituencies to advocate for women’s reproductive rights. Legal experts, through groups such as the Center for Reproductive Law and Policy (CRLP) and the American Civil Liberties Union (ACLU), have been crucial in influencing pro-choice legislation and legal opinions. In spite of the attention anti-choice forces command, the majority of voters in the US continue to be pro-choice.

1.3. Provider profile

Training in surgical abortion is not universally incorporated in physician training. Ob/Gyn residents are all trained to surgically evacuate the uterus. In a survey conducted in the early 1990s, only 12% of Ob/Gyn residency programs required routine abortion training, and only 6% of residents in those programs had performed an abortion. Only 7% of Ob/Gyn programs required residents to be trained in second-trimester procedures. In 1995, 29% of family practice residency programs offered first-trimester abortion training, but only 15% of chief residents had ever actually performed an abortion. 65% of family practice residents said they would not provide abortions, and 65% felt that such training should be optional in residency programs. However, many residency programs permit residents to invoke a "conscience clause" and opt out of performing elective abortion.

Between 1992-1996, the number of abortion providers decreased by 14%. And by the end of 1996, only 14% of US counties had an identified abortion provider (meaning a site where abortions are performed). (3)

Table 1.3 Providers of abortion services

Type of provider

Total years of pre-

professional education

Duration of professional medical training

Duration of pre-service training in abortion service delivery *

Duration of in-service training in abortion


Duration of apprenticeship / on the job training


Training in clinical abortion procedures

Training in abortion counseling

Training in clinical abortion procedures

Training in abortion counseling

Training in clinical abortion procedures

Training in abortion counseling











Education for midlevels described in section 2





















* Training in abortion procedures is not universally taught (see above paragraph)
**Varies according to organizational/institutional guidelines
***Varies from site to site

1.4 Organization of Abortion Care

Sites and services:

Table 1.4a: Organization of Abortion Services

** More than 50% of women will be less than 9 weeks gestation

In 1997, the cost of a surgical abortion, with a gestation of 13 weeks or less, ranged from $150 to $1535 with the average amount paid being $316. At non-hospital facilities that offered surgical and medical abortions, medical abortions ranged from $100 to $1250 with the average being $401. (6) Only 19 states cover abortion for Medicaid recipients with their own public funds. 29 states specifically exclude abortion coverage in their medical assistance programs, except in the event of rape, incest or life endangerment; 16 of these require that the rape or incest be reported to the police in order for women to receive funding. 2 states will fund abortions only if the woman’s life is endangered. 7 states insist that women carrying private insurance be required to pay a higher premium if they want abortion coverage in their plan. 9 in 10 managed care plans routinely either cover, or provide limited coverage for abortion; certain states specify that such coverage is not considered mandatory for insurance carriers. (6,8)


National data on abortion are collected and disseminated by the Alan Guttmacher Institute (AGI), a not-for-profit reproductive health research organization. Abortion data in the United States are collected by 44 state health departments and compiled annually by a federal agency, the Centers for Disease Control (CDC), but reporting is voluntary in some states, and many do not receive reports from all providers. The AGI utilizes CDC statistics, but also collects information from local experts and analyzes other published and unpublished reports.

Public and Private Sector Services

In 1973, the year the Roe v. Wade decision overturned states’ prohibitions on abortion, 81% of all abortion providers were hospitals. By 1996, only 18% of private hospitals, excluding Catholic hospitals, and 10% of public hospitals offered abortion. Currently, the majority of abortions are performed in private, for-profit or non-profit specialty abortion clinics in which abortion services comprise >50% of the clinic visits. In 1996, 70% of abortions were performed in specialty clinics. The majority of these clinics are in urban or suburban areas, and, in 1996, 95% of nonmetropolitan areas had no acknowledged abortion services. In addition, abortion services are effectively unavailable in 1/3 of US cities. The number of providers has been decreasing since 1982, in all census divisions and in all but 6 states. (3)

Quality assurance follows the guidelines of the US Agency for Health Care Policy and Research, the American Institute of Medicine, and other professional medical organizations’ standards for establishing safe, high-quality health care. The National Abortion Federation (NAF), a non-profit organization whose members primarily are independent abortion providers and clinics that provide abortion services, published the first abortion care standards in 1978, and (since 1996) have annually updated their Clinical Policy Guidelines. NAF has established a credentialing committee that conducts site visits and evaluates clinic’s adherence to NAF standards and guidelines. NAF also offers both an annual meeting and an additional "risk-management" seminar for continuing education and practice development.

Integration with Other Sexual and Reproductive Health Services

Because abortion services are often provided in specialty abortion clinics, abortion is seldom integrated into the continuum of care that most primary care providers offer to women wishing to avoid or delay pregnancy. Many clinics that provide abortion care will offer a full range of reproductive health services.

Often, women receive reproductive health services from a private provider, a managed care organization (sometimes referred to as a health maintenance organization, or HMO), or a state, county or community health center.

Low-income women without health insurance (approximately 12 million between 15-44 years of age) (13) may qualify for lower-cost contraceptive health services. In 1997, publicly funded clinics provided contraceptive services to 2 out of every 5 women estimated to need such services: a total of 6.6 million women. Of these clinics, 40% were run by local health departments, 13% by Planned Parenthood affiliates and 26% by other agencies, including hospitals.

For women with health insurance, only 13 states require full coverage for comprehensive contraceptive care. 30 states have at least one contraceptive-specific, "conscience-based" exemption law, and 11 of these explicitly allow providers to deny information and counseling about abortion. State employee health plans in 44 states have some degree of contraceptive coverage; however, recent federal legislation has weakened the requirement to fully cover contraception. (8) Alan Guttmacher Institute (AGI) research suggests that without current publicly funded family planning services, an additional 1.3 million unplanned pregnancies would occur annually, resulting in over 600,000 abortions, or a 40% increase in incidence.

Policies and Services that Focus on Special Populations

The United States has a greater adolescent pregnancy rate and birthrate than almost any other developed country. Following the documentation of a 24% increase in teen pregnancy between 1986-1991, a variety of public and private programs were initiated in an attempt to reverse this trend. Many programs (particularly those which receive religious or public funds) focus on abstinence and do not discuss any other form of contraception; these programs typically do not cover methods of preventing HIV-AIDS or other sexually transmitted infections.

Between 1991-1996 there was a 14% decrease in the pregnancy rate and a 12% decrease in the birthrate for teens, with an accompanying decrease in the abortion rate. Although no single program has been able to prove generalizable effect on teen’s sexual practice, it is thought that these trends are due to a concurrent decrease in sexual intercourse and an increase in contraceptive use, particularly contraceptive use at first intercourse. Long-term contraceptive methods such as Depo-Provera have also become much more popular with adolescents.

47 states have laws that protect a minor’s (under age 18) right to access confidential contraceptive services. However, in most states, this does not include abortion.

1.5 Knowledge and perception of abortion services

Public information about abortion services has primarily been disseminated through advertising campaigns organized by the major reproductive health advocacy groups, such as NARAL (National Abortion Rights Action League) NAF (National Abortion Federation) and PPFA, (Planned Parenthood Federation of America) as well as by individual clinics. The approval of mifepristone in the fall of 2000 has led to a dramatic increase in the print and visual media coverage of abortion. In addressing medical abortion, responsible journalists find themselves obliged to cover the broader scope of abortion, and public awareness has increased accordingly.

Rural areas are much less likely to have access to information unless it is from a syndicated source of national news. Local churches and school boards have a significant influence on the content of education for sexuality, contraception and abortion.

Although a woman’s right to choose abortion in early pregnancy is supported by the majority of the voting population, the issue is beset by myth, misunderstanding, and violence. Although surgical abortion is the most common elective surgical procedure in the U.S., health care professionals may invoke a "conscience clause" and refuse to participate in a patient’s care.

Between 1977 and 1997 there were 2100 reported incidents of violence against abortion providers, including 6 murders and 15 attempted murders. Domestic terrorism in the United States has until very recently been primarily directed against abortion clinics (which continue to be the most common targets for arson, bombing and other forms of property destruction), and their personnel, who live and work under the threat of intimidation, injury and death from these attacks.

A family practice physician quoted in Family Practice News of 2/2001 opined: "Unless the current climate surrounding abortion changes, which is unlikely, it won’t be prudent for a physician to advertise openly that he or she provides mifepristone." (10)

Section 2: Midlevel Providers and Abortion Services

2.1. Description of Midlevel Providers

Midlevel providers in the United States include the disciplines of: certified nurse-midwife (CNM), nurse practitioner (NP)/registered nurse clinician (RNC), and physician assistant (PA). These groups are sometimes collectively referred to as advanced practice clinicians (APC) or midlevel providers or practitioners (MLPs).

Certified nurse-midwives (CNM) are baccalaureate or master’s degree prepared registered nurses who have completed additional training in obstetrics and gynecology and have passed a comprehensive examination administered by the national certifying body, the American College of Nurse Midwives. Nurse-midwifery was established in the 1920’s and until 1965, the scope of practice was limited to the maternity cycle. CNMs have prescriptive authority in most states, and the right to practice independently (without physician supervision) in many states. In 1999, there were approximately 6,000 practicing members of the ACNM.

Licensed and/or lay midwives (sometimes known as "direct-entry" midwives) practice legally in 30 states. They may have no formalized medical education, and state laws regulating their practice are generally very restrictive outside of home birth/birth home deliveries. They have not historically been acknowledged within the usual "midlevel" or "APC" categories, professions that are all based in a formal allopathic tradition. However, the category of "certified midwife" has recently been included by the American College of Nurse Midwives to denote a direct-entry midwife who has passed the same national certifying examination as the nursing-prepared midwife.

Nurse practitioners and nurse clinicians are all registered nurses who may be baccalaureate or masters degree prepared. They practice in every medical specialty, but when their specialty area is obstetrics and gynecology, their preparation is similar to that of a nurse midwife. No single national certifying body represents all nurse practitioners, although some states require NPs to pass a certifying examination. Like nurse midwives, they are also usually licensed to prescribe medications, and, in many states, may conduct practice independently. Each state’s Board of Nursing usually governs their practice. In 1996, there were over 63,000 NPs in the US; of these, 10,000 hold a certification in a women’s health specialty.

Physician assistants, by definition, practice under the supervision of a licensed physician, although this supervision may be remote. This category of medical providers is unique to the United States. The first PA training programs granted certificates and some PAs were apprentice-trained. Now, the requirements for certification are graduation from an accredited PA Program (most of which are baccalaureate or masters degree level) and successful completion of a National Certifying Examination. State medical boards generally govern their practice. Their scope of practice includes any medical act that is approved by their supervising physician, with the exception of those that are prohibited by legislation, in particular, in most states, abortion. Physician Assistants have prescriptive authority in most states. In 1996, there were 29,000 practicing PAs in the US. Approximately 5% have specialty training in OB/GYN.

Pre-service training in reproductive health:

Training in the areas of reproductive anatomy and physiology, diagnosis and treatment of common ob/gyn medical problems, and management of sexually transmitted infections and contraceptive options is considered standard in any advanced practice program that focuses on primary care or women’s health care. Counseling and referral guidelines for unplanned pregnancy are almost always addressed, but abortion care is not routinely covered.

Midlevel providers who offer abortion service

Surgical Abortion

Surgical abortions are only provided by midlevel clinicians in 5 states (Vermont, New Hampshire, New York, Montana, and Arizona), and in very limited numbers. There are approximately 20 midlevel providers providing surgical abortions in these 5 states, all of who are PAs or NPs. There are no CNMs currently providing abortion services in the US. A significantly greater number of MLPs have been trained through a variety of programs, but are not currently performing procedures. Surgical abortion training (including counseling) for midlevel providers is typically done either by the employing institution or through a 2-4 week internship available through three centers (U. of Rochester: "Reproductive Health Training Program", Vermont Women’s Health Center/Planned Parenthood of Northern New England: "Training Program for Abortion and Related Services" and Planned Parenthood of New York City: "Surgical Abortion Education Program"). The PPNYC Program is focused clinical training, including a counseling component, with a minimum of 50 cases. (The program is typically extended over a period of several months to accommodate working providers’ schedules.)

Because the skill of vacuum aspiration is well within the scope of practice of many midlevel practitioners, it is hoped that they will be increasingly involved in surgical management of incomplete abortions. The laws restricting midlevel practice specifically refer to "performing abortions" and do not specify management of other conditions including complications related to abortion.

Medical Abortion:

Advanced practice clinicians are often involved with medical abortions. Some states prohibit midlevel providers from dispensing mifepristone (interpreting this as ‘performing an abortion’) but midlevel providers typically are responsible for ultrasonography, counseling, on-call support, and follow-up. Much of the data-collection and clinical care for the research on both methotrexate and mifepristone regimens has been conducted by advanced practice clinicians working at the investigative sites. (11) Training in medical abortion is typically provided by the employing institution and/or through the "Early Options" education outreach program launched by NAF, the Planned Parenthood Consortium of Abortion Providers (CAPS) and Danco, the US manufacturer of mifepristone. These trainings range from a one-hour overview to a two-day workshop, addressing various components of medical abortion service delivery.

Abortion counseling:

Because most abortions in the US are provided in a specialized outpatient setting, abortion counseling itself has become a specialty area. In abortion clinics, counseling is usually conducted by a trained abortion educator rather than by a licensed medical professional. A recent survey showed that most abortion counselors are baccalaureate-prepared, with a significant minority having earned a master’s degree. About 2/3 were trained at their employing institution, and 2/3 report additional off-site training. 98% of counselors discuss contraception as part of their client encounters. (12)

2.2 History of midlevel providers offering abortion services

In two states, Vermont and Montana, midlevel providers have been performing surgical abortions for decades. As early as 1973, a clinic in Vermont began to train PAs to perform abortions. A landmark study in 1986, which has recently been replicated, showed that there was no difference in complication rates between women in Vermont who had abortions performed by a PA and those who had abortions performed by a physician. (14,15) PAs and NPs provide approximately 40% of all the abortions in that state, and have been training physicians in the techniques of abortion care for over 20 years. In Montana, in 1977, one PA began providing abortion care along with her supervising physician. In a case specifically directed against this PA and with a goal of preventing other PAs from performing abortions in Montana, the state courts ruled to prohibit PA abortion practice. Pro-choice lawyers attempted to have the case heard by the U.S. Supreme Court in the hope that a favorable decision would legalize midlevel practice throughout the U.S. However, the U.S. Supreme Court refused to hear the case, referring jurisdiction back to the state. The Montana Supreme Court heard the case and decided in favor of the PA, allowing her to resume practice and permitting PAs in Montana to perform all medical acts for which they are appropriately trained and supervised.

Ironically, the major obstacle in most of the other states accompanied the legalization of abortion in 1973. Realizing that there could be a potentially unsafe proliferation of abortion providers, most state legislatures and regulatory bodies instituted language limiting the practice of abortion to licensed physicians. At this time, the categories of physician assistant and nurse practitioner were relatively new fields and their actual and potential scope of practice was unfamiliar to many decision-makers (This unfortunately continues to be the case, even today.)

In 1990, because of the progressive decline in the numbers of physicians trained and willing to provide abortion services, and the corresponding implications for public health, a national symposium was called to explore solutions to the lack of access to services. An important recommendation of this meeting was that midlevel clinicians should be trained to provide first trimester abortion. However, states did not follow with enabling legislation. (16)

By 1996, it was evident that the provider situation was not improving. Another symposium was convened by NAF and the American College of Obstetricians and Gynecologists (ACOG) to explore the barriers further and to design strategies for their resolution. Those attending the meeting agreed that midlevel clinicians’ training curricula must be amended to include principles of abortion care, but also that actions toward these goals must be carefully planned and conducted on a state-by-state basis in order to overcome the tangle of political, legal, and regulatory barriers to midlevel provision of services. (17) Progress towards this goal has been very slow and setbacks are common.

The advent of medical abortion in the United States has drawn attention to the potential for midlevel practice because midlevel clinicians are licensed to administer and/or prescribe medications. When decisions are made preventing midlevel providers from administering a safe and legal medication, it becomes clear that such prohibitions are based on ideology rather than on concerns for public health and safety.

Activists have requested, and received, statements and resolutions from many professional medical, legal, public health, and policy organizations supporting the provision of abortion by midlevel providers. Legal advisors with the NY-ACLU and the Northwest Women’s Law Center (NWWLC) are conducting state-by-state research to develop a strategy that may ultimately result in acceptance of midlevel practice. The ACLU-Reproductive Freedom Project, the CRLP, and NAF have been involved in research and have pursued specific litigation. Because of this work, explicit language has been applied by licensing and/or regulatory bodies in 3 states with "physician only" laws to specify that medical abortion is indeed within the scope of practice of midlevel providers. Hawaii’s "physician-only" law defines abortion as "an operation", and therefore it too would only apply to surgical abortion.

2.3 Midlevel Practice in the Public and Private Sector

There are no midlevel providers who perform abortion in the public sector in the US. However, government employees do provide post abortion care, including contraceptive counseling and services. Federal Medicaid only covers contraceptive services for 2 months following the resolution of a pregnancy, although states may apply for a waiver extending coverage through state Medicaid budgets. 2/3 of women receiving publicly funded contraceptive care are clients of federally funded clinics. In these clinics, nurse practitioners provide approximately 80% of services. (13)

2.4 Scope of abortion practice of midlevel providers

Note: Scope of practice is meant to be broadly defined and flexible to allow for changes in health care practices over time. As has been made plain by legal restrictions on abortion practice, what a

profession views as within its scope and what is permitted by laws and institutions may not be the

same. The following discussion places abortion services within the scope of practice of a midlevel clinician who has had formal didactic and clinical training with experienced preceptors for the specific techniques and skills involved.

Physician supervision requirements vary by discipline and by state regulation. In some states NPs and CNMs are able to practice independently, usually with arrangements for physician consultation and referral. Therefore, requirements for "on-site" supervision will vary according to discipline, state regulation, and institutional policy.

Table 2.4 Midlevel provider scope of practice

Type of procedure

Offered by this level of provider (Y/N)? If "yes" specify method.

Method(s) of pain management used

Type of supervision required when performing the procedure




Not practiced in US as such


Medical abortion (specify different regimens used)

Yes – methotrexate alone or with misoprostol; mifepristone with misoprostol

Prescriptions or over the counter oral analgesics, possibly narcotics

MD supervision varies from state to state

Same as on-site

1st trimester surgical

Yes – Outpatient services offered by midlevels in 4 states; aspiration evacuation (manual or electric) with or without final curettage

Paracervical block,

oral and/or parenteral analgesia; general anaesthesia offered at some sites



2nd trimester surgical

Outpatient procedures up to 16 weeks offered by midlevels in 1 state

Pain management as for 1st trimester

MD supervision


Emergency treatment of abortion complication


Yes – for minor and major complications

Similar pain management modalities as for abortion



Uterine evacuation

Yes – for minor complications only; major complications would be referred to a hospital

Similar pain management modalities as for abortion



Management of spontaneous abortion


Yes- Under same circumstances as treatment of minor complications




Uterine evacuation

Yes- Under same circumstances as treatment of minor complications




Postabortion contraception


Yes -





Yes –limited number of clinicians offer placement of IUDs and implants





2.5 Incentives and Barriers to Midlevel Provision of Abortion Services

Laws, regulations and policies

The legal factors affecting midlevel provision of services are myriad, contradictory and subject to varying interpretations. Each state has its own regulations and policies for the practice of each of the health care professions as well as legislation specific to abortion. In some states the Board of Medicine may oversee all health care regulations; in other states Boards of Nursing will have the authority to regulate NPs and CNMs; or these duties may fall to the Department of Public Health. 43 states and the District of Columbia have either specific legislation or regulations that limit abortion procedures to licensed physicians; in other states the restrictions may be found in regulatory language governing the provision of health care. In New York, which has a "physician-only" law, the definition regulating the scope of practice of a physician assistant has been interpreted by the Board of Health to mean that an appropriately trained PA is able to provide the same services as his or her supervising physician. Likewise, in Montana, the "physician-only" law has been permanently enjoined by the State Supreme Court in order to allow for the provision of abortion by appropriately trained and supervised PAs.

As previously discussed, 3 states have recently issued opinions permitting the provision of medical abortion by midlevel providers: one opinion by the Board of Nursing, for NPs in Massachusetts; one by the Board of Health, for all midlevels in Rhode Island; and one by an Attorney General, for midlevels in Connecticut. It can be argued that at least in some states, "physician-only" laws cannot be held to apply to medical abortion without either unreasonably limiting women’s access to abortion or contradicting dispensing and prescribing authority held by midlevel providers. In some states, it may be possible to amend these restrictive laws to allow for the provision of early abortion, whether medical or surgical. (18)

From a societal and public health standpoint, there is widespread recognition that replenishing the diminished pool of abortion providers is essential to protecting the health and well being of women of reproductive age. Many medical professional organizations have supported inclusion of midlevel providers in abortion care. Within the disciplines, even clinicians who are not interested in providing abortions have recognized that limitations on their scope of practice based on outside political agendas must not be tolerated.

Those who are currently providing abortion care must have the legal ambiguities surrounding their services clarified. This includes appropriate insurance reimbursement. Women’s reproductive rights will be advanced when abortion care is properly placed within the realm of normal services offered by patients’ usual providers.

Barriers to change are found both within and without the pro-choice community. Internally, barriers may be based on fear that drawing attention to the inclusion of midlevel providers will lead to a backlash of anti-choice activity. In the current conservative political climate, there is fear that legislative regulatory changes will be enacted that will be more prohibitive and difficult to reverse than the current laws. Externally, of course, the anti-choice platform is clearly committed to restricting women’s access to abortion in every arena.

Health authorities, physicians and other personnel:

For health authorities, incentives for midlevel provision would include a significant reduction in the public health problems associated with unwanted pregnancy and birth. The societal cost of abortion care would be reduced. Increased access to early abortion would decrease the morbidity associated with abortion at more advanced gestational ages. From an economic standpoint, the direct costs of early abortion are lower; and midlevel clinicians are compensated at a lower rate than physicians. Barriers might include concerns about an increase in the need for monitoring, reporting and quality assurance oversight.

For physicians including midlevel providers in abortion, services would increase the capacity of the practice to provide services. Working conditions would improve by expanding the number of clinicians available to provide after hours coverage. Clinicians who do not provide abortions would have an increase in the referral pool of qualified clinicians available to their patients.

Barriers might include an increase in marketplace competition, professional "turf" infringement and a perceived loss of specialty status. Physicians may be concerned about the potential of increased call for their intervention in abortion-related complications, with a corresponding increase in acuity of care and its malpractice/insurance costs.

In addition, if the addition of a midlevel practitioner allows new abortion services to be initiated in a practice, there may be resistance from staff who are not comfortable with participation in abortion care. Changes in staffing, administration and clinic flow, as well as security issues and the need for learning new skills in values clarification, counseling, phone triage and other aspects of care may be overwhelming for some staff members.

Service providers:

On some levels, administrators of services will be relieved when the pool of abortion providers begins to expand. Clients will not have to be referred out or asked to wait for services, and salaries for midlevels will be lower than for physicians. However, marketplace competition will become a more pressing concern when numbers of providers are adequate. Clinics not already providing abortion will need to address malpractice insurance, clinic security and terrorism issues, quality assurance, staff training needs and continuing education.

Working conditions and salaries:

Currently, many midlevels that are providing medical abortions and/or minor office procedures (such as uterine aspiration) are not being compensated at a higher rate. In some Planned Parenthood affiliates, midlevels working in the abortion care clinics are paid at a slightly higher rate, based on an increased level of acuity of care, and in some clinics, surgical abortion providers are paid a small stipend for each procedure.

Compensation aside, professional and personal rewards are significant. On the other hand, abortion care is a stressful field. Clients are sometimes in crisis, often in distress, and the provider is usually responsible for causing some degree of pain or discomfort. Antiabortion attitudes from staff and clients may be subtle or blatant. There is the potential for psychological "burnout", or "compassion fatigue", as well as for the purely physical manifestations of repetitive stress injury. The threat of violence is inescapable; bulletproof vests and security entrances to clinics are commonplace and recommended safety measures. No matter how supportive one’s own community, anti-choice terrorists are a real and present danger.


Table 2.6 Professional Organizations for Midlevel Providers

Organization Name


Issued statements supporting their members rights and qualifications to provide "full reproductive health care"

American Academy of Physician Assistants



American Association of Nurse Practitioners



American College of Nurse Midwives



American College of Nurse Practitioners



Association of Physician Assistants in Obstetrics and Gynecology



National Association of Nurse Practitioners in Women’s Health



* These organizations have also endorsed the recommendations of NAF’s 1997 symposium report: "Appropriately trained midlevel clinicians possess the skills and expertise to perform this safe and routine elective procedure."

Only NANPWH has an internally generated resolution that specifically states that NPs are qualified to perform abortion. The ACNM has invited presentations on abortion for its annual meetings, and has requested a Clinical Bulletin for the provision of medical abortion (which will be an official College document for clinical practice); several articles on abortion have been published in the peer-reviewed Journal of Nurse-Midwifery. AAPA has also invited presentations on abortion for its annual meeting.

2.7 Advocating Abortion Service Provision by Midlevel Providers

Pro-choice advocacy and provider groups such as NAF, PPFA, ACLU, NARAL, AAP and others, have been fundamentally important in promoting the role of the midlevel provider to the medical establishment. The American Public Health Association, the American Medical Women’s Association, Physicians for Reproductive Choice and Health, and the American College of Obstetricians and Gynecologist have issued statements supporting midlevel abortion practice.

Clinicians for Choice

Clinicians for Choice (CFC) is an organization of pro-choice midlevel practitioners which originated within and is supported by NAF, and has grown to a membership of over 4000 midlevel clinicians in 4 years, with 63 chapters nationwide. Members are active in education and outreach within professional organizations, and work with medical, PA, and nursing schools in developing and presenting abortion care curricula. They also staff informational tables and exhibits at professional meetings nationwide. In the 6 New England states, the Abortion Access Project (AAP), in collaboration with Ipas, has developed an ongoing educational series for midlevel and primary care providers on abortion-related issues, and has embarked on a project with the NW Women’s Law Center to replicate this work in the Northwestern region of the U.S.

Most promotion is still being conducted within the health professions’ environment. Women in the general population are often unclear about the distinctions between different categories of midlevel providers, and may not even be aware of the common "physician-only" stipulations. Because of the politically sensitive nature of the goals of the movement, advocates for midlevel providers rarely reach out to the general population.

Section 3. Lessons learned related to access to safe abortion services

In the US, one can never ignore the political volatility surrounding the issue of abortion. In many ways, this has inhibited providers and advocates from confidently going forward to influence changes in law and practice. However, with the introduction of mifepristone in September 2000, abortion has entered a new place in the public discourse. Danco, the manufacturer of the drug, and NAF have placed advertisements in popular magazines and professional journals. Magazine and newspaper articles are raising the issue in a new and more positive way. This exposure helps to demystify abortion and makes it more difficult to demonize the procedure and the providers.

This presents an opportunity for midlevel providers to emphasize their logical role as abortion providers. Abortion practice, both medical and surgical, is well within midlevel provider’s scope of practice. Clinical trials have demonstrated that PA provision of surgical abortion is as safe as physician provision. Therefore, all training programs must be encouraged to include content on abortion in their reproductive health curricula. Midlevel providers who specialize in women’s health, as well as those trained in primary care, must see abortion as part of the services and/or referrals they routinely offer their patients.

As advocates, we must take opportunities at professional conferences, in training program presentations, with midlevel and other medical professional organizations and through workshops to clearly articulate the role of midlevel providers in abortion care. The goal is to expand the cadre of support beyond those already dedicated to the issue. We must be prepared to address opposition that emanates from deeply held beliefs; not to engage in ideological arguments, but to be ready to discuss abortion as one aspect of the continuum of reproductive health services to which women have a right, in the US and in every nation around the world.

Many members of the medical community are very interested being more informed about international issues and ways they can be involved in international work. Drawing on international experience and making the connection with practice and access issues in the US is very relevant and affords an entry point of discussion. We must take advantage of opportunities that arise to discuss our global experience and draw the analogies to US issues.

Section 4. Further development


  • Barriers to training (access, supervision, support, etc)
  • Legal and professional practice barriers
  • Developing a body of peer-reviewed literature documenting the safety and efficacy of midlevel practice in abortion care.
  • Half of US current abortion providers are at the age of retirement, further underscoring the need to train and incorporate the next generation of providers in abortion care.
  • Threats to person, property, and professional practice
  • Stigma to abortion practice (personal, professional, societal)
  • Lack of recognition by the medical and pharmaceutical establishments, policymakers, and general public of the scope of practice, skills and qualifications of midlevel providers
  • Administrative/institutional hesitancy to "rock the boat" by introducing abortion and by employing midlevel providers in abortion care
  • Hesitancy on the part of busy (overworked) clinicians to
    a) develop and pursue political action
    b) develop and offer new services which are associated with additional risks beyond the clinical sphere


  • Increased awareness and interest in abortion provision within the midlevel professions; rapid growth of network for clinicians and supporters
  • Strong support from highly-respected national and international health care policy, medical, and legal organizations
  • Regulatory recognition specific to midlevel provision of medical abortion in 3 states
  • Regulatory recognition for PA provision of medical and/or surgical abortion in 2 states and NP provision in one state
  • Dedicated legal research in the New England and Northwestern states, and development of a guide for such research for the rest of the states (AAP, NY-ACLU, NWWLC)
  • Increased willingness of professional organizations to sponsor abortion-related education
  • Development of CD-ROM/PowerPoint curricula on abortion care for undergraduate as well as graduate-level nursing programs (AAP)
  • Development of the New Abortion Provider Training Initiative and Organizing Guide
  • Increasing involvement in international networks, and the inspiration of a global movement!


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Updated 19 June 2002