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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)
Record-Keeping
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 The AGI utilizes CDC statistics, but also collects information from local experts and analyzes other published and unpublished reports.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.
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