Ed. note: This is a guest post by Sarah Erdreich, the author of Generation Roe: Inside the Future of the Pro-Choice Movement. An Alabama native who grew up in Ann Arbor, Michigan, Sarah now lives in Washington, D.C. with her husband, baby girl, and elderly Shih-Tzu.
California governor Jerry Brown is currently considering a measure that would allow trained nurse practitioners, and certain other non-physicians, to provide first-trimester abortion care. This proposal was part of a larger push to expand what services nurse practitioners are allowed to provide in the state, which—like many around the country—suffers from a shortage of physicians to serve its residents. But while most of the larger proposal failed to move out of committee, the abortion provision has survived.
As of this writing, four states—Montana, New Hampshire, Oregon, and Vermont—allow non-physicians to perform both medication and aspiration abortions. California, along with a handful of other states, allows non-physicians to perform medication abortions only. If Brown allows nurse practitioners to expand their services to aspiration abortion provision, he would be approving a measure that could effect positive change beyond the state lines.
While California’s shortage of physicians is, unfortunately, not uncommon, this is also a situation that abortion providers have been familiar with for years. Between 1982 and 2000, the number of abortion providers in the U.S. declined from 2,900 to 1,800. As a result, women’s access to these services has been greatly affected: as of 2008, 87% of all U.S. counties didn’t have a provider.
A wealth of additional statistics can be found at the Guttmacher Institute and Medical Students for Choice, but two numbers in particular speak to the need for trained abortion providers. According to a 2011 study published in Obstetrics and Gynecology, 97% of practicing OB/GYNs will have a patient that needs an abortion. But only 14% perform them.
Allowing nurse practitioners to provide first-trimester terminations will greatly expand the ability of women to access trained, competent medical care. And while any expansion of providers is a positive development, it’s difficult not to wonder if doing so will make nurse training programs vulnerable to the same anti-choice politics that target medical and residency training programs.
Indeed, one of the more insidious aims of the anti-choice movement is to make abortion training so difficult to receive that women won’t be able to find reputable providers. The very fact that abortion is such a common procedure makes it even more shocking to see just how difficult it can be for medical students and residents to receive adequate training.
A 2005 study published in the American Journal of Obstetrics and Gynecology examined abortion education in medical schools, asking 78 clerkship directors of OB/GYN rotations at medical schools were asked about the abortion education available at their schools. Twenty-three percent said they didn’t know if any such education was given in the preclinical years, 44% said no formal education was provided, 19% responded that there was a lecture specifically given about abortion, and 11% had “a small group discussion of abortion and/or a clinical experience in abortion care.” When asked about education in the third year of medical school, 25% reported no formal abortion education, and 45% reported offering a clinical abortion experience.
The barriers to receiving abortion training extend further to residencies, which are potentially more troubling, given that this is the phase of a doctor’s training where they learn how to diagnose and treat actual patients in their specialty. In 1995, the Accreditation Council for Graduate Medical Education (ACGME) required that training in abortion provision be part of OB/GYN residency programs. However, it distinguished between spontaneous and induced abortion, mandating only that all residents learn how to manage spontaneous abortions. As an article in the Journal of the American Medical Association put it, “With respect to induced abortion, residency programs are required to provide ‘access to experience’ and residency programs and/or individual residents with religious or moral objections are allowed to opt out of induced abortion training. This ‘access’ can be provided as either an elective or a required rotation and, unlike other OB/GYN procedures, the mandate does not require that residents perform induced abortion procedures.” A survey conducted nine years later showed that only 51% of OB/GYN program directors reported routine training, 10% offered no training, and 39% said they offered elective training.
Despite these dismal numbers, anti-choice activists have increased their attacks on abortion training in recent years, attempting to prohibit medical residents at state schools from learning the skills and prohibiting state funds from paying residents’ salaries if they are trained in abortion provision. Such measures in Wisconsin and Kansas were taken up by their respective legislatures, even though neither the University of Wisconsin Hospital and Clinics nor the University of Kansas Medical Center actually perform abortions.
Attacking abortion provision at the education and residency levels doesn’t just have consequences for those medical professionals that know they want to provide abortion care. It also negatively impacts other doctors, and by extension their future patients.
Learning how to perform an abortion also has value in teaching doctors how to treat miscarriage, which can affect an estimated 10–20% of all pregnancies. Students and residents that receive abortion training gain a deeper understanding of how to examine a patient; even residents who opt out of the actual procedure training but still learn about managing complications have reported that this education has value: in addition to learning technical skills such as sizing the uterus, they also improve their skills in talking with and counseling patients.
And this hints at the less tangible but equally meaningful ways in which abortion training enhances the provider-patient relationship. The decision to have an abortion is personal, but many women value the input of medical professionals that they trust. Likewise, many women are making this decision at least in part due to outside stressors in their lives, and would benefit from having a trained, nonjudgmental person to talk with. Having a medical professional who is comfortable talking about such a personal and controversial subject may make a patient more likely to open up about other difficult subjects, and to feel more confident in their decisions and medical care.
It is encouraging that state legislators in California have recognized the benefits to expanding abortion provision in their state. Hopefully other state legislatures will follow in their footsteps.