Strategies for Expanding Abortion Access

THE ROLE OF PHYSICIAN ASSISTANTS,NURSE PRACTITIONERS, AND NURSE-MIDWIVES

IN PROVIDING ABORTIONS

Recommendations from a National SymposiumAtlanta, Georgia • December 13 - 14, 1996

NATIONAL ABORTION FEDERATION

SYMPOSIUM PARTICIPANTS

Symposium ChairRachel Atkins, PA, MPH;

Vermont Women’sHealth Center,Burlington, VT

Publication ConsultantMartha Ann Overland;Washington, DC

James Armstrong, Jr. MD;Kalispell, MT

Louise Bateman, RNC, MPH;Planned Parenthood of Houston,Houston, TX

Susan Cahill, PA-C, MSW;Kallispell, MT

Ward Cates, MD, MPH;Family Health International,Research Triangle Park, NC

Suzanne Delbanco;Kaiser Family Foundation,Menlo Park, CA

Susan Dudley, PhD;National Abortion Federation,Washington, DC

Nichole Gara, MA;American Academy ofPhysician Assistants,Alexandria, VA

Cheryl Gibson, NP, MD;Women’s Choice,Burlington, VT

Marlene Goldman, ScD;Harvard School of Public Health,Boston, MA

Simon Heller, Esq;Center for ReproductiveLaw & Policy;New York, NY

Debbie Jalbert, MBA, PA-C;University of TexasSouthwestern Medical Center,Dallas, TX

Carole Joffe, PhD;University of California at Davis,Davis, CA

Chris Knutson, MN, ARNP;Center for Health Training;Seattle, WA

Lisa Landau, Esq;American Civil Liberties UnionReproductive Freedom Project,New York, NY

Donna Lieberman, Esq;New York Civil Liberties UnionReproductive Rights Project,New York, NY

Trent MacKay, MD, MPH;Centers for DiseaseControl & Prevention,Atlanta, GA

Ellen Martin, CNM;American College ofNurse-Midwives,Atlanta, GA

Stephanie Mueller;National Abortion Federation,Washington, DC

Deborah Narrigan, MSN,CNM;Nashville, TN

Cate Nicholas, MS, PA;Vermont Women’s Health Center,Burlington, VT

Maureen Paul, MD, MPH;Memorial Hospital,Worcester, MA

Barbara Safret, Esq;Yale Law School,New Haven, CT

Vicki Saporta;National Abortion Federation,Washington, DC

Janet Singer, CNM;Cambridge, MA

Jeanne Stotler, NP;Planned Parenthood of theRocky Mountains,Denver, CO

David Studdert, Esq;Harvard School of Public Health,Boston, MA

Lisa Summers, CNM;Silver Spring, MD

Susan Wysocki, RNC, NP;National Association ofNurse Practitioners inReproductive Health,Washington, DC

Susan Yanow, LICSW;Abortion Access Project,Cambridge, MA

Affiliations are provided foridentification purposes only.

Recommendations from a National Symposium

Atlanta, Georgia • December 13 - 14, 1996

In December 1996, the National Abortion

Federation (NAF), convened a national

symposium to explore how physician

assistants, nurse practitioners,

and nurse-midwives might increase

their participation in abortion service

delivery. The symposium’s key

findings and recommendations are

summarized in this report.

Strategies for Expanding Abortion Access

Copyright © National Abortion Federation, 1997.

All rights reserved.

THE ROLE OF PHYSICIAN ASSISTANTS,NURSE PRACTITIONERS, AND NURSE-MIDWIVES

IN PROVIDING ABORTIONS

Letter from NAF . . . . . . . . . . . . 5

A Note on Terminology . . . . . . 6

Summary . . . . . . . . . . . . . . . . . 8

Introduction . . . . . . . . . . . . . . 10

Finding I . . . . . . . . . . . . . . . . 12

Finding II . . . . . . . . . . . . . . . . 15

Finding III . . . . . . . . . . . . . . . 19

Conclusion . . . . . . . . . . . . . . . 21

Appendix . . . . . . . . . . . . . . . . 22

References Cited . . . . . . . . . . . 24

CONTENTS

LETTER FROM NAF

Nearly seven years ago a national symposium was held to examine the shortage of physicians pro-viding abortions in the U.S. The symposium participants found that the number of doctors provid-

ing abortions was dwindling, due to, among other things, anti-abortion violence and harassment, pro-fessional marginalization and the “graying” of providers. At the same time, obstetrics and gynecologyresidency programs were falling short of their responsibility to train new doctors inabortion services.

One of the key findings of that first symposium was that physician assistants, nurse practitioners, andnurse-midwives could be trained to perform first trimester abortions. In fact, in two states, physicianassistants had already established a long history of providing such services. The symposium participantsconcluded that midlevel providers offered one of the most promising ways to expand abortion access.

Since the 1990 symposium, the issue of access has become even more pressing. The number ofdoctors providing abortion services continues to shrink. Violence against doctors and clinic workershas escalated. The involvement of midlevel clinicians is now more critical, and, recent surveys suggestthat there is growing interest among these professional groups in participating in and providing firsttrimester abortion services.

During this time we have also seen the advent of medical abortion in this country, by which veryearly pregnancies can be ended with a combination of prescribed pills or injections. Management ofunwanted pregnancy through the administration of medications, with appropriate follow-up, is wellwithin the expertise and experience of physician assistants, nurse practitioners, and nurse-midwives.One of the biggest challenges ahead of us is ensuring that midlevel practitioners will be able todispense mifepristone (RU-486) and methotrexate as they would other drugs.

In December 1996, the National Abortion Federation, with funding from the Kaiser FamilyFoundation convened a national symposium to explore these issues. The symposium participantsagreed that there are several barriers to midlevel clinicians who want to become more involved inabortion service delivery. A common assumption shared by many clinicians and the public is thatfirst trimester abortion can be safely provided only by physicians, a view reinforced in most statesby outdated laws. But there is no reason to assume that such obstacles are insurmountable. Midlevelclinicians have a long history of responding to changes in health care, meeting the health care needsof underserved populations, and providing medical services that were once the sole domain of physi-cians. In most states, PAs, NPs, and CNMs routinely prescribe medications, and some perform surgery.The public has come to appreciate non-physician clinicians as trusted professionals. As attitudes havechanged, so too have the regulations governing their practice.

There is no reason why laws and attitudes shouldn’t change to permit midlevel providers to per-form first trimester abortions. The fact is, abortion is the most common elective surgical procedurein the country. It is also one of the safest, whether performed by a doctor or a physician assistant.If women are to continue to have access to this crucial component of reproductive health care,then physician assistants, nurse practitioners, and nurse-midwives must be part of the solution.This symposium was held to develop strategies to help make this possible.

Rachel Atkins, PA; Symposium ChairExecutive Director of Vermont Women’s Health CenterOctober 1, 1997

A NOTE ON TERMINOLOGY

Unfortunately, forour purposes,

there is no singleterm that adequatelyor accurately encom-passes all three ofthe professions thatthe symposiumaddressed: physicianassistants, nursepractitioners, andnurse-midwives. Theterm “non-physician”is not helpful, for itonly describes whothey are not, ratherthan who they are.“Physician-extender”implies that theseprofessionals areappendages to doc-tors. “Midlevel clini-cian” seemed, tomost of the sympo-sium participants,to be less objection-able, even with itsunfortunate empha-sis on hierarchy inhealth care.

Despite our efforts to agree ona single collective term, the sym-posium participants fully agreedthat the three professions are dis-tinct, and that they fill differentroles in the health care mosaic.But those who attended alsofound that the professions sharemuch in common, and that theircommon interests, in the contextof abortion service delivery, out-weigh their differences. Physicianassistants, nurse practitioners,and nurse-midwives are united intheir desire to provide the bestpossible patient care. They sharemany professional goals, andthey have all contributed to abroadened definition of thehealth care provider, leading toexpanded services for otherwiseunderserved populations. It isimportant to all three groupsto ensure that their scopes ofpractice are not limited byarbitrary, politically motivated,non-medical considerations.

Below is a brief descriptionof each of the professionalgroups the symposiumaddressed, and their scopesof practice:

Physician Assistant (PA)

PAs practice under the supervi-sion of licensed physicians,providing patients with servicesranging from primary medicineto very specialized surgical

care. They perform approxi-mately 80 percent of the dutiescommonly done by primarycare physicians and have pre-scriptive authority in moststates. Most PAs are graduatesof specially designated under-graduate physician assistantprograms located at medicalschools. States require PAs topass a national certifying exam-ination or to comply with statestatutes, rules, and regulationsset up to govern their practice.There are currently 29,000 prac-ticing physician assistants in theUnited States.

Nurse Practitioner (NP)

An NP is a registered nursewho has advanced education(typically a masters degree)and extensive clinical trainingin at least one health care spe-ciality area. NPs often serve asprimary health care providersfor children and adults. Theydiagnose and treat commonhealth problems, order andinterpret diagnostic tests, andprescribe and administer med-ications. Some states requireNPs to pass a national certify-ing examination. There aremore than 63,000 nurse practi-tioners in the United States.

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Certified Nurse-Midwife(CNM)

A CNM is a registered nursewith advanced education andclinical training in obstetricsand gynecology, who has alsopassed a national certificationexamination. The CNM prac-tices in collaboration withother health care providers asindicated by the health statusof the client. CNMs attendwomen during labor anddelivery and are trained andexperienced in prenatal,postpartum and newborncare, and in routine familyplanning and gynecologicalcare. Nurse-midwives haveprescriptive authority in moststates. There are approximate-ly 4,000 practicing CNMs inthe United States. (In additionto certified nurse-midwives,there are also lay midwives.These midwives are notusually registered nurses,and they have not necessarilytaken a national certifyingexam. This group practiceslegally in 30 states, butwas not represented atthe symposium.)

Advanced Practice Nurses(APN)

This term refers to nurseswith advanced educationand/or clinical training. Inthe context of this report,this includes nurse practition-ers and certified nurse-midwives. It does not includephysician assistants.

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SUMMARY

In December 1996,the National

Abortion Federation(NAF), with fundingfrom the KaiserFamily Foundation,convened a nationalsymposium toexplore how physi-cian assistants, nursepractitioners, and cer-tified nurse-midwivescould be encouragedto participate morefully in abortion ser-vice delivery nation-wide. We invited agroup of 30 partici-pants, each withspecialized expertisein issues related toabortion care, whomet together to dis-cuss and formulatestrategies to advancethis goal. The sympo-sium’s key findingsand recommenda-tions, which aresummarized in thisreport, represent theconsensus of opinionexpressed by theparticipants duringthe course of thistwo-day meeting.

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In light of the shortage ofphysicians currently performingabortions, and based on the find-ings of the 1990 symposium onthe shortage of abortionproviders, those attending thesymposium agree that one of themost effective ways to increasethe number of providers is topermit appropriately trainedphysician assistants, nurse practi-tioners, and certified nurse-midwives to provide firsttrimester abortions.

FINDING IThe symposium participantsfind that one of the greatestimpediments to expanding thepool of abortion providers isthe notion that first trimesterabortion is a dangerous proce-dure that only physicians canperform safely. Appropriatelytrained midlevel clinicianspossess the skills and expertise toperform this safe and routineelective procedure.

RECOMMENDATIONS1. Better educate the medical

community about the skillsand abilities of PAs, NPs, andCNMs and their potential asabortion providers.

2. Better educate health careconsumers about the safety offirst trimester abortion and theexpertise of midlevel practi-tioners in performing them.

3. Encourage PAs, NPs, andCNMs to pursue abortiontraining through better educa-tion about the positive publichealth impact of safe abortion.

4. Recognize and emphasize thatPAs’, NPs’, and CNMs’ contri-butions to abortion accesscomplement, rather than com-pete with physicians.Collaborative relationshipsbetween providers promotegood patient care.

FINDING IIThose attending the symposiumfind that a very carefullyplanned state-by-state effort willbe needed to overcome the cur-rent legal restrictions limitingmidlevel clinicians’ participa-tion in abortion service delivery.The complex manner in whichthe statutes and regulations areconstructed, as well as the politi-cal context in which they exist,require state-specific strategiesfor change.

RECOMMENDATIONS 1. Recognizing that neither med-

ical technologies nor laws arestatic, ensure that PAs, NPs,and CNMs have the appropri-ate skills so that they are notexcluded from opportunities toparticipate in the delivery ofmedical abortions, nor to learnsurgical abortion techniques.

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2. Pursue legal efforts to ease“physician-only” restrictionsonly after careful, state-specific background researchand with secured politicalsupport, since unfavorablerulings can be very difficultto overcome.

3. Provide multifaceted profes-sional support for PAs, NPs,and CNMs who elect to par-ticipate in abortion servicedelivery, including legaladvice, mentoring programs,and support networks.

FINDING IIIEducation and understandingof all aspects of abortion care,including counseling, pre-and post-abortion care, andabortion techniques must beexpanded. The symposiumparticipants find that it iscrucial to integrate principlesof abortion care into midlevelclinicians’ curricula.

RECOMMENDATIONS1. Even in states with “physician-

only” laws, or where it isunclear whether other practi-tioners can legally performabortions, incorporate didactictraining in abortion into thePAs’, NPs’, and CNMs’ educa-tion. Also include clinicalexperience in options coun-seling and abortion aftercare.

2. Establish abortion trainingcurricula that include allaspects of abortion care, anddevelop creative strategies toensure that abortion trainingcan be integrated into thelarger curriculum.

3. Develop appropriatemechanisms to supportmidlevel providers whowant to expand theirpractices to include firsttrimester abortion.

4. Provide support forabortion training sites tohelp ensure sufficienttraining opportunities.

INTRODUCTIONTHE ROLE OF PHYSICIAN ASSISTANTS, NURSE PRACTITIONERS,AND CERTIFIED NURSE-MIDWIVES IN EXPANDING THE POOL OF ABORTION PROVIDERS

In the 1970s, whenthe Supreme Court

struck down statelaws prohibitingabortion, there wasan immediate anddramatic reductionin the morbidity andmortality that hadbeen associated withillegal abortion. Firsttrimester abortionwas soon establishedas one of medicine’ssafest procedures.However, since the1980’s, a steadydecline in the numberof doctors providingabortion services hasbeen documented.

Physicians who practicedbefore the 1970s and witnessedfirsthand the public health disas-ters associated with black marketabortions are retiring; youngerphysicians are leaving the fieldafter enduring anti-abortion vio-lence and harassment; and otherscomplain of inadequate financialand professional rewards. At thesame time, alarmingly few med-ical residents are being trainedin the procedure. In 1991, only12 percent of ob/gyn trainingprograms routinely providedfirst trimester abortion trainingto their residents. (MacKay &MacKay, 1995)

The cumulative effect of thesedevelopments has been that 84percent of U.S. counties had noidentifiable abortion provider by1988. (Henshaw & Van Vort,1994) So difficult is it to find anabortion provider in some areasof the country that the AmericanMedical Association stated thatthe shortage of providers has the“potential to threaten the safetyof induced abortion.” (AMA, 1992)

To increase the number of clini-cians willing to perform abortions,and to appropriately place abor-tion services within the contextof other gynecological serviceswomen need, the pool ofproviders must be expanded.Physician assistants, nurse practi-tioners, and nurse-midwives,with appropriate training, repre-sent one potential solution to thispublic health problem.

THE ROLE OF PHYSICIANASSISTANTS, NURSEPRACTITIONERS, ANDNURSE-MIDWIVES

The dramatic change in theway health care is administeredmeans PAs, NPs, and CNMs havea greater role in patient care thanever before. With the emergenceof managed care, there is anexploding demand for the cost-effective services of these profes-sionals, whose training qualifiesthem to provide many of thesame services as physicians.Accordingly, regulatory and statu-tory requirements have beenadjusted to accommodate thenew health care environment.Depending upon the state, PAs,NPs, and CNMs can diagnose andtreat a variety of medical condi-tions, prescribe and administermedications, perform diagnostictests, do biopsies, suture wounds,and deliver babies.

With the increased visibility ofphysician assistants, nurse practi-tioners, and nurse-midwives,health care consumers are learn-ing to accept these professionalsin their expanded roles. At theVermont Women’s Health Center,for example, PAs are integratedinto all aspects of gynecologicalcare, with both PAs and physi-cians providing services. Patientsthere are free to request carefrom a specific provider. However,according to one survey, fewerthan five percent of the clinic’s

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patients expressed a preference.(Freedman, et al., 1986)

More and more physiciansand health care provider groupsare recognizing the value ofPAs, NPs, and CNMs in theirown practices. Again, at theVermont Women’s HealthCenter, PAs provide outpatientprocedures including abortioncare and the management ofgynecological disorders. As aresult, physicians at the Centerare free to manage more com-plicated outpatient problemsand to provide inpatient medicaland surgical care.

SUPPORT AMONGNURSING PROFESSIONALS FOR EXPANSION INTOABORTION SERVICES

While physician assistantshave been the first of the profes-sions with a documented recordin providing first trimester abor-tion services, they are not alonein recognizing that their profes-sion has a role to play. Nursepractitioners and nurse-midwiveshave traditionally providedpatient care appropriate to theirskill and training, and they havestepped forward to providehealth care in underserved areas.

Just as they have done in otherareas, midlevel professionalsrecognize the need to includeabortion services in their scopeof practice in order to fill thevoid in abortion services. In 1991,the National Association of NursePractitioners in ReproductiveHealth (NANPRH) adopted aresolution that states that nursepractitioners, with appropriatetraining, are qualified to performfirst trimester abortions. Thatsame year, the American Collegeof Nurse-Midwives (ACNM)

voted to rescind its 1971 state-ment that had prohibited CNMsfrom performing abortions, thusclearing the way for individualCNMs who chose to includefirst trimester abortion service intheir practices to do so.

A survey of ACNM membersconducted in 1991 found strongsupport within the professionfor expanding practice toinclude providing abortion care.(McKee & Adams, 1994)Seventy-nine percent of the1,208 respondents consideredthemselves “pro-choice.”Fifty-two percent said thatcertified nurse-midwives shouldbe permitted to perform abor-tions, and 19 percent said theymight be willing to provide sur-gical abortions themselves. Afull 57 percent said they wouldwant prescriptive authority forthe abortion-inducing drug,mifepristone (RU-486).

One State’s Experience:PAs Providing Abortions

in Vermont

Physician assistants at theVermont Women’s HealthCenter have been performingabortions since 1973. Currently,PAs provide nearly all of theapproximately 500 first trimesterabortions at the Center eachyear, which is about one-fourthof all abortions performed inthe state. Moreover, since the1980s, the University ofVermont has relied upon PAsat Vermont Women’s HealthCenter to provide training fortheir residents in out-patientgynecological services, includ-ing abortion. Physician assis-tants and nurse practitionersalso provide first trimester abor-tions at the Planned Parenthoodof Northern New England affili-ate in Vermont.

A comprehensive analysis ofcomplication rates in 2,458 firsttrimester abortions done at theVermont Women’s HealthCenter between 1981 and 1982established that the abortioncare provided by PAs was safe.Publishing in the AmericanJournal of Public Health, theresearchers found that “…therewere no differences in compli-cation rates between thosewomen who had abortions per-formed by a physician assistantand those who had the proce-dure performed by a physi-cian.” Freedman, et al., 1986.

A new study by researchersat the Harvard School ofPublic Health, to examine1996-97 complication rates,is currently underway.

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“The experience ofadvanced practicenursing suggeststhat a pattern of

access exists for thecreation of newnursing roles.

Advanced practicenurses tend to

expand into areasof health care in

which a vacancy inservices exists…”

— McKee and Adamsin the Journal of

Nurse-Midwifery, 1994

FINDING I

OVERCOMING“PHYSICIAN-ONLY”THINKINGThe symposium par-ticipants find thatone of the greatestimpediments toexpanding thepool of abortionproviders is thenotion that firsttrimester abortionis a dangerousprocedure that onlyphysicians canperform safely.Appropriatelytrained midlevelclinicians possessthe skills and exper-tise to perform thissafe and routineelective procedure.

BACKGROUND“Physician-only” thinking on

the part of both health careproviders and patients is perva-sive. Among patients, and evenamong some midlevel providers,first trimester abortion is mistak-enly seen as a dangerous proce-dure. This fear can be traced tothe high morbidity and mortalitystatistics from the years whenproviders of most illegal abor-tions had no medical training.However, since 1973, when theSupreme Court struck down statelaws banning abortion, medicaladvances and training have madefirst trimester abortion one of thesafest and most common surgicalprocedures, with complication ratesfar lower than those associatedwith carrying a pregnancy to term.

Despite the straightforwardnature of first trimester abortions,few doctors have considered del-egating them to other providers.Yet many midlevel providers reg-ularly manage complications ofchildbirth and perform proce-dures such as cryosurgery andcervical or endometrial biopsies.Some of these services requireskills similar to those needed infirst trimester abortion proceduresand carry greater morbidity risks.

Attitudes are beginning tochange. As more and more physi-cians gain firsthand exposure tothe skills of PAs, NPs and CNMs,many are aware of the midlevelprovider’s significant potential tooffer expanded services.

Indeed, in 1994, the AmericanCollege of Obstetricians andGynecologists (ACOG), as part oftheir effort to address the short-age of first trimester abortionproviders, endorsed “programsto train physicians and otherlicensed health care professionalsto provide abortion services incollaborative settings.” [emphasisadded] Similarly, as early as 1976,the American Public HealthAssociation (APHA) urged mid-wifery and physician assistantprograms to include abortionprocedures as part of theircurricula. (See Appendix)

RECOMMENDATIONS1. Better educate the medical

community about the skillsand abilities of PAs, NPs,and CNMs and their poten-tial as abortion providers.

The symposium participantsfind that it is crucial that physi-cians and others in the healthcare community recognize thatappropriately trained PAs, NPs,and CNMs have the skills toperform first trimester abor-tions. They should be educat-ed about the low complicationrates associated with firsttrimester abortions, whetherperformed by a physician oranother practitioner.

To achieve these goals it willbe important to:

• publicize the successes of themidlevel clinicians who havealready established them-selves as providers of firsttrimester abortion, along with

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relevant case studiesin professional journals,in newsletters, and at profes-sional conferences;

• highlight the comprehensiverange of services thatmidlevel practitionersalready provide, andpromote recognition ofthese skills to both physi-cian and midlevel profes-sional groups;

• encourage midlevel practi-tioners to participate inclinical training with resi-dents and physicians sotheir competency is demon-strated firsthand;

• promote the skills of PAs,NPs, and CNMs to managedcare (HMOs) and insurancegroups; and

• create advocacy and sup-port networks within eachprofession through groupslike Midwives for Choice,Nurse Practitioners forChoice, and PhysicianAssistants for Choice, withthe goal of ensuring thatthere is support for thosewho choose to provide firsttrimester abortion services.

2. Better educate health careconsumers about the safetyof first trimester abortionand the expertise ofmidlevel practitioners inperforming them.

To ensure that women arecomfortable with the idea thatnon-physicians are perform-ing their abortion procedures,it is imperative that the publicbe educated about the safetyof first trimester abortions andabout PAs’, NPs’, and CNMs’

training, skill levels, and abili-ty to perform abortions.

The Vermont (See box,page 11) and Montana(See box, page 14) modelsdemonstrate important successstories, and the fact that PAshave been performing abor-tions for two decades in eachcase should be as widely pub-licized as possible. Articlesin the popular press andwomen’s magazines areone way to pursue this goal.At a more personal level,physicians in joint practicescan also validate services pro-vided by PAs, NPs, and CNMsin the course of their normalcommunications with patients.Large medical settings, such asHMOs, are especially well-positioned to offer this levelof patient education.

“There is no doubtthat midlevel clini-cians can do this

procedure. It’s purelyand unfortunatelya political problemthat again affects

women andchildren’s healthcare…. I do thinkat some point this

will fly and we willbe able to do this.”

— Susan Cahill, PA-C,symposium participant

3. Encourage PAs, NPs, andCNMs to pursue abortiontraining through bettereducation about the posi-tive public health impactof safe abortion.

Because an estimated 43%of all women in the U.S. willhave an abortion by the timethey reach age 45, (AlanGuttmacher Institute, 1997)it is important for all healthcare professionals who treatwomen of reproductive ageto be knowledgeable aboutoptions counseling, appropri-ate referrals, and pre- andpost-abortion care; and tohave access to opportunitiesto be trained to perform firsttrimester abortions. As an inte-gral part of the comprehensivecare that women may need, itis important that all PAs, NPs,and CNMs, even those whodo not perform abortionsthemselves, are supportive ofthe efforts of clinicians withintheir professions who do so.

4. Recognize and emphasizethat PAs’, NPs’, and CNMs’contributions to abortionaccess complement ratherthan compete with those ofphysicians. Collaborativerelationships betweenproviders promote goodpatient care.

Efforts to integrate midlevelprofessionals into firsttrimester abortion servicedelivery should not be con-strued as an attempt by theseclinicians to compete withphysicians or replace them,but rather to enhance themedical community’s ability to

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meet the reproductive healthcare needs of their patients.

In order to accept a new poolof providers in the delivery ofabortion care, the medicalcommunity will need tounderstand and recognize thatthere are great benefits tohaving additional practitionersproviding first trimester abor-tions, especially where unmetpatient needs exist.

PAs, NPs, and CNMs cannotreplace physicians. Instead,doctors in collaborative rela-tionships with them can bet-ter ensure that all aspects ofreproductive health care areavailable to their patients. Thesymposium participants feelstrongly that collaborativerelationships between doc-tors, PAs, and APNs need tobe continually encouraged.

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Family Practice: The Partnership of a Physicianand a Physician Assistant in Montana

When Susan Cahill, a physician assistant who performs abortions inMontana, went through the PA program at the State University ofNew York at Stonybrook in the 1970’s, abortion training was anintegral part of her education. In fact, all medical students at SUNYlearned to do abortions, unless they opted out of the training forpersonal reasons.

After Cahill completed her studies in 1976 she moved to Montana todo an apprenticeship under Dr. Jim Armstrong, who has served as apreceptor for many PAs and NPs over the years. Armstrong, a familypractice doctor, eventually hired Cahill to work with him because hewanted someone skilled in providing abortions. Armstrong says that asa young doctor in a New York hospital before Roe v. Wade, “I used tosee 20 women a day who’d had botched abortions, some of themdied.” He was committed to offering abortion services, believing thatthe procedure should be part of any family practice.

Cahill’s skills have allowed Armstrong to live up to his commitmentto provide abortions. As a solo practitioner today, he says his officeoverhead is so high that he would not be able to offer abortions —which do not generate substantial income — without someone else inhis practice skilled in the procedure. “So from a practical standpointhaving her here has made it possible to provide a family practice andprovide abortions.”

When Armstrong hired Cahill in 1977, there were no laws dictatingwhat a PA could or could not do. Physicians were permitted to dele-gate patient care to their personnel, as long as they worked under adoctor’s supervision, which Cahill does. Even though not a singlecomplaint has been lodged against Cahill in nearly 20 years ofpractice, in 1995 the state attempted to stop her from performingabortions. Cahill’s current legal status is discussed in Finding II:Overcoming Legal Obstacles.

FINDING II

OVERCOMING LEGALOBSTACLESThose attending thesymposium find thata very carefullyplanned state-by-stateeffort will be neededto overcome the cur-rent legal restrictionslimiting midlevel clin-icians’ participationin abortion servicedelivery. The com-plex manner inwhich the statutesand regulations areconstructed, as wellas the political con-text in which theyexist, require state-specific strategiesfor change.

BACKGROUNDAfter the 1973 Supreme Court

decision in Roe v. Wade (410U.S. 113, 1973), most statesamended their laws to legalizeabortion. In doing so, they gen-erally legalized abortion onlywhen performed by a physician.These “physician-only” provisionswere largely designed to ensuresafe abortion services, rather thanas a vehicle to exclude otherlicensed health care providerswith the skill and training toperform abortions safely.

Today, the majority of stateshave “physician-only” provisionsin their abortion laws. These pro-visions may or may not be inter-preted to prohibit midlevel prac-titioners from performing abor-tions. In New York, for example,the state’s Department of Healthhas concluded that the “physi-cian-only” language of the stateabortion law, read in light ofother statutes, does not, in fact,ban physician assistants fromperforming abortions. (See box,page 16). In Montana, prior to the1995 enactment of a statute thatexpressly prohibited physicianassistants from performingabortions, PAs were permitted toperform abortions in that state,despite a “physician-only” provi-sion in the state abortion law.(See box, page 17).

Six states — AZ, KS, OR, VT,WV, and NH — have no “physi-cian-only” restriction. In four ofthose states — AZ, VT, WV andNH — broad, unconstitutionalpre-Roe abortion bans were

either struck down in court orare unenforceable. In the remain-ing states, the law is unclear.

LAWS GOVERNING PHYSICIANASSISTANTS, NURSE PRACTI-TIONERS AND NURSE-MIDWIVES

The laws and regulations thatcontrol PA, NP, and CNM practiceare not simple ones. Each groupis separately regulated by each ofthe 50 states, which means thatthe legislative/regulatory statusof the individual professionalgroups varies from state-to-state, and may involve restric-tions and rules adopted by statelegislatures, health departments,medical boards, boards of mid-wifery, and/or boards of nursing.This makes it nearly impossibleto develop a uniform nationalstrategy that would open oppor-tunities to midlevel providerswith respect to abortion services.However, strategies effective inone place may be helpful else-where. (See Pearson, 1996 for astate-by-state analysis of legisla-tion that affects NPs and CNMs.)

The legal ambiguity that exist-ed in New York state was clari-fied in 1994, when the New YorkState Department of Health, in aDeclaratory Ruling, found thatstate law “permits PAs to performabortions, provided they other-wise comply with their licensureand practice requirements.”

“Physician-only” laws, however,continue to confuse and intimidatemedical communities around thecountry. The U.S. Supreme Courthas recently confirmed states’

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Resolving the LegalAmbiguities Affecting

PAs in New York

In New York, a state that hasa “physician-only” law, but alsogrants PAs the authority to per-form medical procedures, theDepartment of Health hasissued an opinion that PAs canperform first trimester abortionsjust as they would any othermedical procedure for whichthey are trained.

In the early 1990’s DonnaLieberman, Esq., and AnitaLalwani, Esq., of theReproductive Rights Project ofthe New York Civil LibertiesUnion, reasoned that despitethe perceived conflict betweenNew York’s “physician-only”and PA statutes, properlytrained PAs can legally performfirst trimester abortions.

“It is true that, prior to enact-ment of the [New York] PAstatute, abortion was legal onlyif performed by a physician.But the qualifying clause intro-ducing the subsequently enact-ed PA statute, which expresslystates that ‘notwithstanding anyother provision of the law[emphasis added], a physicianassistant may perform medicalservices…when under thesupervision of a physician,’trumps the penal law.”

— Lieberman and Lalwani, 1994

authority to restrict abortion prac-tice to physicians. (See box,page 17). However, as the NewYork experience demonstrates,“physician-only” laws may notnecessarily exclude appropriatelytrained midlevel providers fromproviding first trimester abortions.

THE EMERGENCE OFMEDICAL ABORTION

The advent of pharmaceutically-induced medical abortions (non-surgical abortions) presents aunique opportunity to incorpo-rate midlevel clinicians into directabortion service delivery, sincethese providers have the authori-ty to prescribe and administerdrugs in most states. Many PAs,NPs, and CNMs already prescribeother reproductive health relatedmedications, including oralcontraceptives, emergency contra-ception, and treatments for STDinfections. In addition, many rou-tinely perform comprehensivehealth assessments and providepost-abortion care, includingre-aspirations after incompleteabortions, a key element ofprimary abortion services.

Nevertheless, medical abortioncannot be considered indepen-dently of the “physician-only”restrictions that apply in moststates. As in the case of surgicalabortion, these limitations mustbe analyzed in the context ofthe broader statutory schemeregulating midlevel practice.Most states permit midlevelclinicians to prescribe and/oradminister medications. In theabsence of superseding legalrestrictions, this prescription-writing authority should beadequate to permit midlevelclinicians to prescribe andadminister abortifacients.

It must also be noted that lawson the books in roughly a dozenstates specifically prohibit theuse, sale, or distribution of abor-tion drugs, although five of thesestates (CO, ID, IL, IA, MI) makeexceptions for physicians. Inmany cases, these laws areunconstitutional and unenforce-able vestiges from the late1800’s, when the states were try-ing to protect consumers fromdangerous elixirs, herbs, andother folk remedies. Abortifacientrestrictions of more recent vin-tage, however, may apply onlyto non-physicians and may posea more significant obstacle tomidlevel practitioners.

RECOMMENDATIONS1. Recognizing that neither

medical technologies norlaws are static, ensure thatPAs, NPs, and CNMs have theappropriate skills so thatthey are not excluded fromopportunities to participatein the delivery of medicalabortion, nor to learn surgi-cal abortion techniques.

Medical technology is rapidlychanging. With the advent ofnon-surgical abortion, PAs,NPs, and CNMs might naturallyexpect to be able to administerthe medications and performthe necessary health examsrequired by this early abortiontechnique, because they arealready well-qualified to per-form such services. PAs, NPs,and CNMs must ensure thatthey have the counseling andmedical follow-up skills so asnot to be excluded from partic-ipating in delivery of servicesthat may increase patients’access to safe and effectivehealth care.

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U.S. Supreme CourtRuling: A Postscript onthe Montana PA CaseIn Montana, Susan Cahill,

PA-C, has been performing firsttrimester abortions under thesupervision of a family practicephysician since 1977. She is theonly PA in Montana performingabortions. The state legislaturehas made numerous attemptsto limit Cahill’s practice, and in1995 passed a law preventingPAs from doing abortions.

Cahill’s legal counsel, SimonHeller of the Center forReproductive Law & Policy, suc-cessfully argued to a districtjudge that the law restricted awoman’s right to abortion. Thestate appealed, and the caseeventually went to the U.S.Supreme Court (Mazurek v.Armstrong). On June 16, 1997,without hearing oral arguments,the Court decided by a 6 to 3vote that the Montana bill didnot impose an undue burden onwomen, and let the law stand.

Responding to the ruling,Heller said, “The Supreme Courtdecision makes it very unlikelythat we will be able to strikedown laws specifically barringphysician assistants, nurse practi-tioners, and nurse-midwivesfrom performing abortions. Butonly Montana has such a law.We can continue to argue, aswas successfully done in NewYork, that existing laws requiringthat abortions be performed bya physician do not prevent otherqualified health care profession-als acting under the direction ofa physician (like PAs) from per-forming abortions.”

Heller plans to return to fed-eral court to argue that the billis an illegal “bill of attainder”— i.e. that it is a law affectingonly one person or one group.

Changes are to be expectedwithin the medical professionas well as within the midlevelproviders’ professions. PAswere not even legally recog-nized to practice until the1970’s; now they can performsurgery. The legislatures andthe courts have adapted tothe expanding expertise ofPAs, NPs, and CNMs, and itmakes sense they will contin-ue to do so in the future.

2. Pursue legal efforts to ease“physician-only” restric-tions only after careful,state-specific backgroundresearch and with securedpolitical support, sinceunfavorable rulings can bevery difficult to overcome.

To affect change in existinglaw, not only a state’s statuto-ry profile, but also the politi-cal climate must be right. Thismeans that there must be 1) ademonstrated critical shortageof abortion providers, 2) sup-port of state regulatory boardsand professional associations,and 3) support among mem-bers of the legislature and thepublic. The risk of politicalbacklash or of a negative rul-ing needs careful assessment.

In states where abortionservice shortfall can bedemonstrated, and wheremidlevel providers are avail-able to meet those firsttrimester abortion care needs,the political as well as statu-tory obstacles should beexhaustively studied. Beforeany effort to challenge thelaws begins, there should beextensive research into theconstruction of the state’s

“physician-only” restrictions,as well as investigation intohow they originally cameabout. It is also crucial toassess other practice regula-tions that apply to midlevelpractitioners in the state.

Obviously, overhauling theseoutdated “physician-only” lawswill take a great deal of timeand resources. But it will alsorequire a politically sophisticat-ed strategy. Developing andtapping grassroots supportwithin the various segments ofthe health care community iscrucial, because the notion ofnon-physicians performing firsttrimester abortions may be anew one to many people.Lawyers and lobbyists must beespecially sensitive to this asthey address legislatures, med-ical associations, and the pub-lic. Those states that alreadygive wide latitude to midlevelclinicians to practice unfetteredby other non-medical limita-tions may be more receptive toexpanding their options forabortion service delivery.

3. Provide multifaceted pro-fessional support forPAs, NPs, and CNMs whoelect to participate inabortion service delivery,including legal advice,mentoring programs,and support networks.

To encourage midlevel clin-icians to provide abortions,there must be ample supportfor the pioneers. PAs, NPs,and CNMs who wish to per-form abortions must receivesupport from their peers,as well as the medical andlegal communities.

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18

The following should bemade available:

• state-specific legal advice;

• support from appropriateprofessional associations;

• mentoring programsand networkingopportunities so no oneis forced to practice inisolation from supportivecolleagues; and

• resources for evaluationof and advice aboutsecurity issues.

“We couldn’t havemade the arguments

we made in NewYork and done what

we did in NewYork…in terms of

opening up the prac-tice without know-

ing New York historybackward and for-ward and knowingNew York politicsbackward and for-

ward. And we didn’tdo it until we wereextremely confidentthat we were goingto win. Now maybe

we were over-cautious, but we got

the right result.”

— Donna Lieberman, Esq.,symposium participant

FINDING III

OVERCOMING TRAININGOBSTACLESEducation andunderstanding of allaspects of abortioncare, including coun-seling, pre- andpost-abortion care,and abortion tech-niques must beexpanded. The sym-posium participantsfind that it is crucialto integrate princi-ples of abortion careinto midlevel clini-cians’ curricula.

BACKGROUNDWhile there are limited opportu-

nities for medical residents to getclinical training in abortion, thereare virtually none for PAs, NPs,and CNMs. One of the few facili-ties currently offering first trimesterabortion training to midlevel clini-cians is the Vermont Women’sHealth Center. As of 1996, thecenter had trained 14 PAs.

The symposium participantsnoted that midlevel clinicianshave often had to practicebeyond their mandate in orderto rise above antiquated laws.To gain professional legitimacy,PAs, NPs, and CNMs have some-times taken on certain new ser-vices, demonstrated their abilityto perform them safely, gainedacceptance as legitimateproviders of these services, andthen sought recognition by certi-fying, regulatory, or licensingboards. The history of their pro-fessions is full of many exampleswhere midlevel clinicians estab-lished themselves legally byfirst working illegally.

Those who attended the sym-posium do not suggest that PAs,NPs, or CNMs provide abortionswhere it is not legal to do so.Rather, they stress that only whenrelevant abortion education isbuilt into the curricula, will gov-erning bodies, physicians, andhealth care consumers be con-vinced that this is a reasonablearea in which PAs, NPs, andCNMs may practice.

Above all, abortion educationfor midlevel clinicians must

emphasize that abortion is a fun-damental part of women’s com-prehensive health care, regardlessof the legal restrictions.

RECOMMENDATIONS1. Even in states with

“physician-only” laws, orwhere it is unclear whetherother practitioners canlegally perform abortions,incorporate didactic trainingin abortion into the PAs’,NPs’, and CNMs’ education.Also include clinical experi-ence in options counselingand abortion aftercare.

If abortion care is not part ofthe basic competency for PAs,NPs, and CNMs, and is notrecognized as part of theirscope of practice, then legisla-tors and regulatory boards willbe hesitant to grant midlevelclinicians new practiceoptions. Therefore, it shouldbe a priority of the midlevelclinicians’ professional organi-zations to require their mem-bers to have at least someexposure to the basics of abor-tion care in their curricula.

2. Establish training curriculathat include all aspects ofabortion care, and developcreative strategies to ensurethat abortion trainingcan be integrated into thelarger curriculum.

All PA, NP, and CNM stu-dents should have “curricularexposure” to abortion, thoughnot necessarily clinical expo-

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sure. Didactic training is notonly legal but can help toemphasize to students thatabortion is part of compre-hensive gynecological care.To achieve this, the sympo-sium attendees recommenddevelopment of profession-appropriate training objectiveswhich include options coun-seling, abortion techniques,and follow-up care. Thesecurriculum guidelines shouldbe made available not only toPA, NP, and CNM programs,but to nursing and medicalschools as well.

All students should beexposed to:

• pregnancy options counsel-ing techniques that empha-size unbiased and non-judgmental assistance,including values clarificationand referral information;

• the management of unwant-ed pregnancy, the abortionprocedure, and recom-mended follow-up care; and

• the historical and publichealth aspects of abortiondelivery services.

In order to convince facul-ty to include abortion edu-cation in their curriculum,it is imperative to:

• reach out to faculty whobelieve abortion shouldbe part of their school’scurriculum;

• lobby professional associa-tions to require abortioneducation as part oftraining; and

• ask agencies that administernational/state tests toinclude abortion questionson exams.

Those who attended thesymposium understand thatthere are educational prob-lems unique to abortion. Dueto the highly charged politicalenvironment, there is a poten-tial for abortion education tobe marginalized. In addition,because so few midlevel clini-cians have been trained toperform abortions, it maybe difficult initially to findenough people even to teachthe procedure.

To deal most effectivelywith potential educationalproblems it is important to:

• develop a “train-the-trainers”program to make up for theshortfall of medical person-nel who can teach abortion;

• integrate abortion educationinto the total curriculum,rather than isolating it in aseparate course; and

• provide legal support andadvice for PA, NP, and CNMstudents who want to beginclinical training.

3. Develop appropriatemechanisms to supportmidlevel providers whowant to expand theirpractices to includefirst trimester abortion.

Every effort should be madeto make it as simple aspossible for PAs, NPs, andCNMs to pursue clinicalabortion training. Suchefforts should include:

• publicizing abortion train-ing opportunities in PA, NP,and CNM newsletters;

• assisting students by offeringscholarships and grants forclinical training in abortion;

• offering guidance withlicensing or certificationprocesses;

• evaluating security concernsand needs, and offeringsecurity consultations; and

• establishing “Studentsfor Choice” groups oncampuses to providementors and networkingoptions for students.

The symposium participantsexpressed concern that mid-career professionals not beignored. PAs, NPs and CNMswho have already receivedtheir training/certificationsshould have the opportunityto learn first trimester abortiontechniques, whether throughformal continuing educationprograms or special sessionsat professional conferences.

4. Provide support for abor-tion training sites to helpensure sufficient trainingopportunities.

As new students developinterest in abortion, additionaltraining opportunities will haveto be developed. It will benecessary to:

• ensure that training centershave security support;

• find ways to provide appro-priate financial compensa-tion at sites where trainingactivities are offered;

• increase training opportuni-ties so that PAs, NPs, andCNMs do not have to com-pete with residents fortraining; and

• identify facilities that arecenters of excellence.

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“This expansion of the provider pool makessense because abortion will be an empty right

if there is no one to provide it. But it alsomakes sense because it is sensible.Why not

allow professionals to provide a medical servicefor which they are qualified?”

— Anna Quindlen, New York Times, April 21, 1993

CONCLUSION

Women may havewon the right to

safe, legal abortion,but it is a right thatmeans little unlessaccess to these ser-vices is preserved.The solution thoseattending the sympo-sium offer — trainingphysician assistants,nurse practitioners,and nurse-midwivesin abortion — shouldbe viewed as apromising opportuni-ty for these midlevelclinicians and theirpatients. The poten-tial of these newgroups of health careprofessionals toprovide high qualityabortion care is sig-nificant, and worthyof serious effortstoward implementa-tion. The symposiumparticipants believethat these recommen-dations will result inbetter patterns ofpatient care.

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ASSOCIATION OF PHYSICIAN ASSISTANTSIN OBSTETRICS AND GYNECOLOGY

“In 1992, the Board of Directors of theAssociation of Physician Assistants in Obstetricsand Gynecology (APAOG) voted to supportthe policies of the American Academy ofPhysician Assistants (AAPA) regarding repro-ductive health.”

— Statement of the Association of PhysicianAssistants in Obstetrics and Gynecology,September 9, 1997

NATIONAL ASSOCIATION OF NURSEPRACTITIONERS IN REPRODUCTIVE HEALTH

“Whereas, the purpose of the NationalAssociation of Nurse Practitioners inReproductive Health (NANPRH) is to ‘assurequality reproductive health services whichguarantee reproductive freedom and toprotect and promote the delivery of theseservices by nurse practitioners’;

“Let it be resolved that NANPRH believes thatnurse practitioners, with appropriate prepara-tion and medical collaboration, are qualifiedto perform abortions.”

— Resolution on Nurse Practitioners asAbortion Providers, October 1991

AMERICAN ACADEMY OFPHYSICIAN ASSISTANTS

“The AAPA affirms a patient’s right of access toany legal medical treatment or procedure madewith the advice and guidance of their healthcare provider and performed in a licensedhospital or appropriate medical facility.

“The AAPA supports the free exchange ofinformation between the patient and providerand opposes any intrusion into the provider/patient relationship through restrictiveinformed consent laws, biased patient educa-tion or information, or restrictive governmentrequirements of medical facilities.

“The AAPA opposes attempts to restrict theavailability of reproductive health care.”

— Policy Adopted by the AAPA House ofDelegates, May 1992

“The AAPA is committed to the principle thata physician assistant should be allowed toperform any medical task, including abortion,delegated by a physician under whose super-vision the task will be performed.”

— Deposition statement in defense of achallenge to Montana’s “physician-only”abortion law, (Doe v. Esch), 1993

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APPENDIX:ORGANIZATIONAL STATEMENTS ON MIDLEVEL PROVIDERS AND ABORTION

AMERICAN COLLEGE OF OBSTETRICIANSAND GYNECOLOGISTS

“That to address the shortage of health careproviders who perform abortions, the Collegeencourages programs to train physicians andother licensed health care professionals to pro-vide abortion services in collaborative settings.”

— Statement of ACOG’s Executive Board,January 1994

AMERICAN PUBLIC HEALTH ASSOCIATION“Urges medical, nursing and public healthschools, residency training programs, andmidwifery and physician assistant programsto develop and incorporate materials on themedical need, procedures, and technology,as well as the history and public healthaspects of abortion into current curricula.”

— APHA Resolution No. 7626, 1976

AMERICAN COLLEGE OF NURSE-MIDWIVESThe ACNM has adopted thefollowing positions:

• that every woman has the right to makereproductive choices;

• that every woman has the right to access tofactual, unbiased information about reproduc-tive choices, in order to make an informeddecision; and

• that women with limited means shouldhave access to financial resources for theirreproductive choices.

— Approved by the Board of Directors,February 3, 1991

In 1991, the ACNM asked its membershipwhether it wanted to rescind a 1971 statementprohibiting members from performing abor-tions. Members voted to remove the prohibi-tion. The ACNM leadership wrote in theassociation’s newsletter Quickening that thevote did not mean the ACNM has gone onrecord for or against abortion. The vote meantthat individual CNMs now have the option tobecome involved in abortion service provision.

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Alan Guttmacher Institute. (1997). Facts in Brief: Induced Abortion.

American Medical Association (Council on Scientific Affairs). (1992). Induced termination of pregnancy: Trends in themortality and morbidity of women. JAMA, 268:3231-3239.

Freedman, M.A, et al. (1986). Comparison of complication rates in first trimester abortions performed by physician assistantsand physicians. American Journal of Public Health, 76:550-554.

Henshaw, S. & Van Vort, J. (1994). Abortion services in the United States, 1991 and 1992. Family Planning Perspectives,26:100-112.

Lieberman, D. & Lalwani, A. (1994). Physician-only and physician assistant statutes: A case of perceived but unfoundedconflict. Journal of the American Medical Women’s Association, 49:146-149.

MacKay, T. & MacKay A. (1995). Abortion training in obstetrics and gynecology residency programs in the United States,1991-1992. Family Planning Perspectives, 27:112-115.

McKee, K. & Adams, E. (1994). Nurse-midwives’ attitudes toward abortion performance and related procedures. Journal ofNurse-Midwifery, 39:300-311.

Pearson, L. (1996). Annual update of how each state stands on legislative issues affecting advanced nursing practice.The Nurse Practitioner: The American Journal of Primary Health Care, 21:10-70.

Quindlen, A. (1993). Beyond doctors. Op-Ed, New York Times (April 23).

Summers, L. (1992). The genesis of the ACNM 1971 statement on abortion. Journal of Nurse-Midwifery, 37:168-174.

Vermont physician assistants perform abortions, train residents. (1992). Family Planning Perspectives. 24:225.

Who will provide abortions? Ensuring the availability of qualified practitioners. (1990). Washington, D.C.:National Abortion Federation.

REFERENCES CITED

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National Associationof Nurse Practitionersin Reproductive Health(NANPRH)

The mission of the NationalAssociation of NursePractitioners in ReproductiveHealth (NANPRH) is “to assurequality reproductive healthservices which guaranteereproductive freedom, and topromote and protect the deliv-ery of these services by nursepractitioners.” In keeping withits mission, NANPRH supportsthe delivery of abortion ser-vices by nurse practitionerswho are qualified by advancedpreparation and who haveappropriate medical collabora-tion. We strongly endorse therecommendations containedin this report.

American Academy ofPhysician Assistants (AAPA)

As indicated in this report,abortion services have beenprovided by some physicianassistants for a number ofyears. The American Academyof Physician Assistants (AAPA)believes that PA practiceshould not be arbitrarilylimited by political considera-tions, but rather should bedetermined by patient needs,physician delegation, and thePA’s training, experience, skills,and choice. To the extent thatabortion services meet thesecriteria, the AAPA concurswith the basic statements inthis report.

American College of NurseMidwives (ACNM)

The American College ofNurse-Midwives (ACNM)recognizes the importanceof the recommendationscontained in this report interms of ensuring accessto safe, humane, and individu-alized services. ACNM furtherrecognizes that where statelicensure permits, someof our members may seektraining in this service as anadvanced practice procedurewhich goes beyond thecore competencies, andappropriate guidelines shouldbe utilized therefore.

ENDORSEMENTS

NATIONAL ABORTION FEDERATION1755 Massachusetts Avenue, NW, Suite 600

Washington, DC 20036

(202) 667-5881

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