Roe v Wade, California abortion law, HWPP #171, and the future of access
January 22, 2013 marks the 40th anniversary of the Roe v. Wade Supreme Court decision that legalized abortion nationwide. While abortion in California had been legal under more limited circumstances since 1967, Roe did have an effect on our law. It eliminated the need for a psychiatrist to approve a woman’s abortion, negated the requirement that abortions be performed in hospitals, and extended when a woman could have an abortion. But the law on the books didn’t change.
It wasn’t until 2000, when the FDA was poised to approve mifepristone (the “abortion pill”), that advocates considered asking the legislature to modernize the abortion law. Legal research in California confirmed that the state’s physician-only law would prohibit nurse practitioners (NPs), certified nurse midwives (CNMs), and physician assistants (PAs) from being able to offer women the abortion pill, thereby limiting the benefit of this new abortion option. Although they knew it wouldn’t be easy, advocates took on the challenge of reforming California’s abortion law. A lot of hard work paid off, and on January 1, 2003, California enacted a contemporary abortion law. Known as the Reproductive Privacy Act, SB1301 codified the Roe v. Wade standards and affirmed the legal right of NPs, CNMs, and PAs to perform abortions using medications.
One of the unsettled parts of the discussion over SB1301 was whether non-physician clinicians should be allowed to offer other types of low-risk abortion procedures. At the time, there were two published studies on the provision of aspiration abortion by PAs in Vermont and New Hampshire. While the authors found no difference in safety, the studies included both a small number of patients and only a few clinicians. For many stakeholders, the evidence was insufficient to give them comfort opening up California’s law in this way. What was needed was a more comprehensive study of the safety of aspiration abortion provision by NPs, CNMs, and PAs.
This is where UCSF entered the picture
After a few years of research design and fundraising, ANSIRH researchers were prepared to study the safety and competency of NPs, CNMs, and PAs performing aspiration abortions. In order to conduct the study, we utilized the Health Workforce Pilot Project (HWPP) mechanism within the Office of Statewide Health Planning and Development (OSHPD), which provides legal waivers for demonstration projects to test and evaluate new or expanded roles for health care professionals to improve access to health care and encourage workforce development. In 2007, UCSF obtained a legal waiver from the State and the HWPP #171 study began.
HWPP #171 was designed to answer two questions:
- Can NPs, CNMs, and PAs be trained to competence in aspiration abortion?
- Can they perform those procedures with outcomes comparable to those of their physician colleagues?
There were three principal investigators on the application to the state: Tracy A. Weitz, PhD, MPA; Diana Taylor, PhD, FNP, and Philip Darney, MD, MSc. There is also a principal investigator for each of the five partner organizations where clinicians were trained and offered services (four Planned Parenthood affiliates and Kaiser Permanente of Northern California).
The study results are relatively simple. A total of 5,675 women had their abortions performed by an NP, CNM, or PA and 5,812 by a licensed physician. The first major conclusion is that abortion is incredibly safe no matter who performed it. Fewer than 2% of all patients required any additional care after the initial abortion; only 6 patients (less than .05%) needed any hospital-based care (3 of those patients were seen by physicians and 3 by an NP, CNM, or PA); and all of those women recovered without any long-term physical harm.
The study was designed to assess the equivalence between the two groups of providers. The goal of the study was not to show that one group was better than the other, rather to see if they are the same. To do this, we set a margin of difference of 2%. In the physician group, 0.9% of women had a complication, compared to 1.8% of women in the NP/CNM/PA group. This slightly higher number among newly trained providers was expected and is not clinically significant. The risk difference for complications between the two groups fell within the predetermined margin of non-inferiority. As a result, we conclude that NPs, CNMs, and PAs can perform aspiration abortions as safely as their physician colleagues.
So why does all this matter?
Nationally, 92% of abortions take place in the first trimester—but black, uninsured, rural, and low-income women continue to have less access to this care. In California, 13% of women using state Medicaid insurance obtain abortions after the first trimester. Because the average cost of a second-trimester abortion is substantially higher than a first-trimester procedure and abortion complications increase as the pregnancy advances, shifting the population distribution of abortions to earlier gestations would result in safer, less costly care.
In addition, NPs, CNMs, and PAs provide the majority of well-woman care in primary care settings and are key health access points for low-income and rural women. Allowing a larger group of health care professionals to offer early aspiration abortion care is one way to reduce this health care disparity and increase continuity of care. The evidence to support this policy option is now in hand.
In 2013, policy advocates in Sacramento will once again work with the California legislature to modernize California’s abortion law and allow NPs, CNMs, and PAs to perform early aspiration abortions. By utilizing these skilled health care professionals, perhaps many more California women will have their reproductive health care needs met in their local communities by health care providers they know and trust.