Parts I and II were posted previously on the NSFC website, all three parts are posted here:
Part I: Finding Full Spectrum Nurse-Midwifery
When I was choosing between various CNM (Certified Nurse Midwife) graduate programs in 2010, the faculty biographies at UCSF were the deciding factor. Every CNM on faculty was described as “Full Spectrum”, meaning they cared for patients through every reproductive health outcome, including abortion. My initial interpretation of this term was, “Wonderful! These midwives are providing abortions, and that means that I’ll be taught how to provide abortions.” As it turns out, while some UCSF CNM faculty provide medication abortions and place laminaria, CNMs in California do not typically perform first trimester “therapeutic abortions” or manual uterine aspiration procedures (MUAs).
This situation is not unique to California; CNMs and other advanced practice clinicians (APCs) are permitted to provide MUAs in only four states: Vermont, New Hampshire, Montana, and Oregon (Weitz et al., 2013). While the skills involved in first trimester MUAs are identical to those used in “miscarriage management” – a procedure that is legally within the APC scope of practice – many states have explicitly banned APCs from providing MUAs. Obviously, anti-choice politics play a major role in these bans, as evidenced by the recent rash of APCs-as-provider bans that have gone forward during the past two years of abortion limitation legislation. The impact of these bans is substantial, and connecting the dots is not difficult:
- Under the Affordable Care Act, the proportion of the US population receiving primary care from APCs is expected to increase substantially. (Taylor, et al., 2009).
- “NPs, CNMs, and PAs are …more likely than physicians to practice in medically underserved settings.” (Taylor, et al., 2009)
- Abortion is one of the most commonly performed procedure for women. (Boonstra, et al., 2006)
- Limiting access to abortion is harmful to women. (Foster, 2013)
- The logical conclusion: banning the most accessible providers from performing a commonly demanded procedure is going to have a negative impact on medically underserved women.
However, progress is being made. In California, the Health Worker Pilot Program has been training APCs as first trimester MUA providers under a legal waiver from the CA State Legislature since 2005. The results of this project have been studied and published, and they offer proof that APCs are equal to MDs in safety, efficacy, and patient satisfaction (Weitz et al., 2013). The positive outcomes reported in this study have formed the basis for AB154, a CA bill which formally designates first trimester MUA procedures as within APC scope of practice. With the chances of passage of this bill looking promising, (it is currently on Governor Jerry Brown’s desk awaiting his signature), APCs in California are poised to address the important gap in abortion access that MD-only provider laws have created. They will finally be able to provide truly full spectrum care for American women between the ages of 15-45, ⅓ of whom will seek an abortion at some point in their reproductive years (Weitz et al., 2013).
The first step in addressing this gap in access and care, however, starts with provider education at both the pre-licensure (RN) and APC levels. RNs play an important healthcare role by providing pregnancy options and contraceptive counseling in many clinical settings, and therefore need to meet competency standards in SRH care provision as well. In the next post in this blog series, the state of sexual and reproductive health content in nursing education will be discussed, as well an innovative project at the University of California, San Francisco: a student-led elective focused on abortion and family planning. Thanks for reading!
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Part II: What are we being taught? What do we *want* to learn?
In the previous post in this series, I introduced the big picture of nursing education in sexual and reproductive health care. This section discusses the extent of training that currently exists within nursing education programs in U.S., including a student-led elective that was piloted at UCSF this past year.
Both APC and pre-licensure nursing students still face a fairly bleak picture in terms of standard SRH training and education. In a preliminary review of existing curriculum and educational programs, the results demonstrate a significant need for further study and development of curriculum. Most importantly, we have zero baseline data regarding the content in RN (or “pre-licensure”) programs in terms of sexual and reproductive health. Without this information, we can only operate on assumptions to make the case for improvement or plans for curricular change.
The sole national survey of APC programs (conducted in 2001 and not updated since) demonstrated that only 53% of schools in the U.S. offer didactic instruction in medication or aspiration abortion, and a mere 21% offer clinical training in these procedures (Foster et al. 2006). This is all despite the fact that “professional associations and accreditation bodies have repeatedly identified the need to include reproductive health in the standard curricula” including The American Association of Colleges of Nursing (AACN), the National Organization of Nurse Practitioner Faculties (NONPF), the AAPA, and the American College of Nurse Midwives (ACNM), all of whom have “…developed guidelines that recognize the need for their graduates to possess competence in providing care related to sexual and reproductive health” (Taylor et al., 2009). Even at UCSF, with the passage of AB154 a firm reality, CNMs only receive two hours of comprehensive options counseling training, and two didactic hours of instruction on medication and aspiration abortion*. Contraception is a very basic, pharmacology-focused online course.
In conversations with other nursing and medical students at UCSF, I have found a shared sentiment of disappointment in this educational gap. Nursing students at all levels are eager for more training and education in sexual and reproductive health – specifically focused on abortion. To meet these demands, a first year medical student and I designed a noontime interprofessional elective entitled “Family Planning and Reproductive Choice”, to which we invited guest speakers who covered options counseling, adoption, values clarification, clinical and public health aspects of abortion, and IUD insertion, among other SRH-related topics. As UCSF students, we were incredibly lucky to have access to the top SRH/abortion researchers and providers in the world, which made the task of selecting speakers very enjoyable. Dr. Tracy Weitz gave an electrifying introductory session on the state of abortion in the U.S., and Dr. Eleanor Drey followed with a comprehensive overview of clinical abortion provision. Residents and Family Planning Fellows taught our IUD and MVA papaya workshop, and Exhale (After Abortion Talkline) hosted a personal experience panel.
Student reception was overwhelmingly positive, and we had packed classrooms throughout the quarter. After presenting on this experience at the National Abortion Federation conference in 2013 and meeting with nursing students from around the country at the conference, it was clear to me that nursing students’ desire to be taught SRH curriculum is a national phenomenon. Anecdotally, their reasons included a desire to achieve competency in patient care provision, desire to increase abortion access in underserved and underinsured populations, and competitiveness in the job market, among others. In collaboration with an incredible, interdisciplinary group of nursing educators and innovators, I’m currently in the process of creating and disseminated the elective as a nationally applicable curriculum. We are planning to implement the first pilots at Oregon Health and Sciences University, Yale University, the University of New Mexico, and the University of Pennsylvania, among others. The elective materials and curricular resources will be added to the Nursing Students for Choice website as well. Through the efforts of dedicated grassroots nursing student activists at these campuses, we hope to demonstrate to faculty and administrators that we strongly believe this content needs to be included in our standard curriculum, not just to satisfy our own interests, but to prepare us to be competitive entrants to the nursing workforce, provide access to high quality sexual and reproductive health care to our patients, and normalize abortion care within the full spectrum of nursing scope of practice.
The final post in this series will review resources and opportunities that exist to build and improve SRH curriculum in U.S. nursing programs at both the pre-licensure and advanced practice levels.
*Due to the admirable efforts of several dedicated faculty, instruction in first trimester MUA is set to be implemented in 2014.
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Part III: Conclusion
To start, an update on the Sexual and Reproductive Health elective pilot project: IRB approval has been granted, the electives are wrapping up, and the student surveys are starting to filter in. We have had great response rates from student participants, due in large part to the incredible efforts of the student leaders at Yale, University of Pennsylvania, Columbia, UCSF, University of Illinois at Chicago and University of New Mexico. We are also in the process of conducting qualitative interviews with the student leaders, discussing their experience of running the elective, what it meant to their direction as leaders in sexual and reproductive health, and suggestions for improvement.
Emily Wolfe-Roubatis (a fellow APC student at Univ. of Pennsylvania) and I have been accepted to the Association of Reproductive Health Professional’s conference in October to present a poster on these results. This summer will be devoted to data collection, synthesis, and publication (not to mention our continued work as full time students and part-time working RNs). We are also looking forward to conducting a workshop and panel discussion of the elective project at the Nursing Students for Choice Summit in October, where student leaders will have a chance to talk about their experiences and participants will have a facilitated discussion on how to implement the elective at their school in the coming year.
In the last blog post, I mentioned that I would “review resources and opportunities that exist to build and improve SRH curriculum in U.S. nursing programs at both the pre-licensure and advanced practice levels” – a task that consumed a great deal of time over the past winter/spring, and involved an entire team of dedicated NSFC folks. You can see the results here: NSFC Abortion Education Resources. Not only are curricular resources and clinical opportunities reviewed and presented in detail, we have also posted the entirety of the elective curriculum, startup guide, and suggested materials for students to implement on their campus. Please take a sec to peruse if you’re interested or know a student who might be! Although it is targeted towards advanced practice nursing students, there is ample material that pertains to PA, MD, and RN students as well.
On a personal note, I’m headed in a new direction as my thesis, comprehensive exams, and graduation are all past. I’m currently completing an integration (mini-residency) at a birth center in Boise, Idaho, and doing some major soul searching as I figure out my next steps. Midwifery school has been as steep learning curve, and I’m very much looking forward to putting my education to use. While finding a work environment that accords with my ideals is important, I’m also facing pressure to pay back educational loans and develop my basic CNM/WHNP skills to the fullest extent possible. This push/pull is particularly challenging in my specific area of interest, which is full-spectrum midwifery practice in a non-metropolitan area. I am specifically looking in Montana, Colorado, northern California, and Idaho, none of which are particularly choice-friendly parts of the country.
From conversations with APC new grads and fourth year medical students, I know that finding a full-spectrum practice is a ubiquitous challenge. We have to navigate the opinions of administrators, political climates of conservative communities, and the increasing predominance of hospitals and clinics that do not provide abortions for religious reasons. However, an important resource exists in the work of Medical Students for Choice and Nursing Students for Choice – they both provide mentorship resources, from the paid externships with MSFC to the clinician mentor network currently being formed by NSFC. My plea to current MD and APC providers: if you are a clinician who provides abortions please consider mentoring the next generation! Hopefully, as we develop choice-friendly networks of MDs and APCs, the concept of full-spectrum practice will become more mainstream and provide wider opportunities for eager, energetic new grads.
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Foster, D., (2013). The Turnaway Study. ANSIRH. Accessible at: http://www.ansirh.org/research/turnaway.php.
Weitz, T., Taylor, D., Desai, S., Upadhyay, U., Waldman, J., Battistelli, M., & Drey, E. (2013). Safety of Aspiration Abortion Performed by Nurse Practitioners, Certiﬁed Nurse Midwives, and Physician Assistants Under a California Legal Waiver. Accessible at: http://www.ansirh.org/_documents/library/weitz_AJPH2012.pdf
Boonstra, H., Benson Gold, R., Richards, C., & Finer, L. (2006). Abortion in Women’s Lives. Guttmacher Institute. Accessible at: http://www.guttmacher.org/pubs/2006/05/04/AiWL.pdf.
Taylor, D., Safriet, B., Dempsey, G., Kruse, B., & Jackson, C. (2009) Providing Abortion Care: a professional toolkit for Nurse-Midwives, Nurse Practitioners, and Physicians Assistants. University of California, San Francisco. Accessible at: http://www.apctoolkit.org/index.html.
Foster, A., Polis, C., Allee, M., Simmonds, K., Zurek, M., Brown, A. (2006). Abortion education in nurse practitioner, physician assistant and certified nurse–midwifery programs: a national survey. Contraception 73 (2006) 408–414.
Cross-posted at Innovating Education in Reproductive Health