Certified nurse-midwives, nurse practitioners, and physician assistants are already involved in abortion care in every state. CFC seeks to ensure that these three professional groups are encouraged to practice to the full extent of their scope of practice. However, this scope differs from state to state as do laws affecting the provision of abortion care. Furthermore, the situation can change positively or negatively as laws are passed and power in the legislature, administration, and/or nursing boards shifts.
The approval of mifepristone and the increasing availability of medical abortion have prompted many to consider examining more closely the role of certified nurse-midwives, nurse practitioners, and physician assistants in the provision of medical abortion in their states. Unfortunately, the legal and regulatory situation controlling who may provide abortions is exceedingly complex and in most cases there is not a simple answer to the question of whether these clinicians can provide medical abortion services in any given state.
While the approved distribution system for Mifeprex®, the brand name under which Mifepristone is sold in the U.S., stipulates that Mifeprex® may only be ordered by a physician, the FDA specifically stated in its approval that non-physicians may provide Mifeprex® under the supervision of a physician, provided it is permitted under state law.
Many states have "physician-only” laws that prohibit anyone other than a licensed physician from performing an abortion. At the same time, state practice acts authorize specific health care providers, such as certified nurse-midwives, nurse practitioners, and physician assistants, to prescribe and/or dispense certain medications, and in most cases these state practice acts are more recent and more specific than physician-only laws. As a result, it is unclear in many instances to what degree a physician-only law limits certified nurse-midwives, nurse practitioners, and physician assistants ability to provide mifepristone.
Legislation in California, administrative rule changes in Rhode Island, and an attorney general opinion in Connecticut and Washington have specifically established the role of these clinicians in those states providing medical abortions. In the absence of such clarification, a physician-only law could limit the ability of certified nurse-midwives, nurse practitioners, and physician assistants to provide medical abortion care.
Through the CFC grassroots organizing project, NAF has always supported the participation of these qualified health care professionals in various aspects of providing abortion care for which they are trained, and as permitted by state regulations. CFC works in collaboration with partner organizations to explore different strategies for expanding scope of practice in states, depending upon the legal situation. If you have a question about a particular state, please email naf@prochoice.org. We can let you know what other work is taking place in your state so that efforts are not duplicated, and we can put you in touch with colleague organizations and CFC State Contacts working on these issues nationally.
In addition to NAF and CFC, there are several organizations that can provide guidance in evaluating the laws and regulations in your area:
Abortion Access Project
American Civil Liberties Union Reproductive Freedom Project
Center for Reproductive Rights
New York Civil Liberties Union Reproductive Rights Project
Planned Parenthood Federation of America
Further information on legal issues regarding certified nurse-midwives, nurse practitioners, and physician assistants and abortion care can be found in the NAF-sponsored August 2000 American Journal of Obstetrics and Gynecology supplement on medical abortion.
Read our symposium report, "The Role of Physician Assistants, Nurse Practitioners, and Nurse-midwives in Providing Abortions" (PDF file, 209K).
Order hard copies of this report and the report from the first symposium, "Who will Provide Abortions?: Ensuring the Availability of Qualified Practitioners.”
1973: Physician Assistants at the Planned Parenthood of Northern New England in Burlington, Vermont (formerly the Vermont Women's Health Center) have provided abortion care since its legalization in 1973. Currently physician assistants and nurse practitioners provide 1st and 2nd trimester abortion care in Vermont and New Hampshire.
1994: The New York Civil Liberties Union (NYCLU) obtained a Declaratory Ruling from the New York Department of Health (NYDH). The NYDH issued a Declaratory Ruling (December 20, 1994) stating that physician assistants can provide first-trimester abortions in New York under their practice act, despite the state's physician-only law. The ruling recognized that the intent of the physician-only requirement and the physician assistant legislation are the same - to provide access to safe medical care. This ruling paved the way for similar research in other states. (On file with New York Civil Liberties Union)
1999: Montana's prohibition against physician assistants providing abortion was struck down by the Montana Supreme Court in 1999 in Armstrong v. State. The court held that the statute violated the right to privacy, because the statute was a disguised attempt to limit patient access to abortion, and the legislation was not justified by a compelling state interest. (Armstrong v. State, 1999 MT 261.)
2000: Rhode Island Department of Health issued new regulations, which allow licensed health care practitioners to provide medical abortion.
2001: Connecticut's Attorney General issued an official opinion stating that Connecticut law permits advanced practice registered nurses, certified nurse-midwives, and physician assistants to provide medical abortions.
2002: California passed the Reproductive Privacy Act, which permits any authorized health-care professional to provide medical abortion. The passage of this law was a culmination of years of background preparation by Planned Parenthood Action Committee and California affiliates. This was the first state law to affirm the right of non-physicians in providing abortion care.
2004: Washington State Attorney General issued an official opinion stating that nothing in State law prohibits nurse practitioners from providing medical abortion.
2006: The Oregon State Board of Nursing determined that the performance of manual suction/aspiration abortions was not outside the scope of practice of a Family Nurse Practitioner given that she is both educationally prepared and clinically competent.
From January 1, 1981 to December 31, 1982, a comprehensive analysis of complication rates of 2,458 first-trimester abortions provided at Planned Parenthood of Northern New England in Burlington, Vermont compared the overall, immediate, and delayed complication rates of physicians and PAs providing early uterine evacuation and suction curettage. The study found that there is no difference in overall, immediate, or delayed complication rates between physicians and PAs providing abortion care. (Freeedman MA, Jillson DA, Coffin RR, Novick LF. Comparison of Complication Rates in First Trimester Abortions Performed by Physician Assistants and Physicians. American Journal of Public Health 1986; 76 (5): 550-554.)
A sixteen-month study from July 1996 until October 1997 of 1,505 women having a first-trimester surgical abortion compared the complication rates of PAs at PPNNE in Burlington, VT versus physicians at the Feminist Health Center of Portsmouth, New Hampshire. The study found that there is no difference in complication rates between physicians and PAs providing abortion care. (Goldman MB, Occhiuto JS, Peterson LE, Zapka JG, Palmer H. Physician Assistants as Providers of Surgically Induced Abortion Services. American Journal of Public Health 2004; 94 (8) 1352-1357.)
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