Why is Citizens for Choice supporting a bill to increase non-physician abortion providers? Because of the need for this practical solution: train nurses and midwives to fill the gap.
These California nurse-midwives want to provide abortions.
They’re struggling to get trained
When Ariela Schnyer was choosing where to get trained as a nurse-midwife, California stood out for an important reason: The state would allow clinicians like her to provide abortions.
But three years later, after graduating from her nurse-midwifery program at UC San Francisco, Schnyer is not yet prepared to provide abortions that require hands-on care. After the news broke that Roe vs. Wade had been overturned — a shift that is expected to send more abortion patients to California — Schnyer was trying to find out whether she could get trained in Mexico City.
“It feels frustrating to have that theoretical training,” she said, “but not be able to jump into the gaps that are going to be here.”
As Texas, Mississippi and other states have clamped down on abortion, California leaders have vowed to make their state a haven for abortion patients. UCLA researchers have estimated that 8,000 to 16,000 more patients will head to California annually for abortions after the Supreme Court ruling.
But the limited availability of abortion training has constrained the number of clinicians who can provide the procedure, abortion rights advocates warn.
California lawmakers have laid the legal groundwork for a range of health providers to provide abortions, but certified nurse-midwives and other eligible health professionals say that scant opportunities for training have made it harder for them to do so. The obstacles to getting trained are steeper for abortions that involve a physical procedure than for medication abortions, which use pills to end a pregnancy.
When California changed its laws to allow more health professionals to provide early abortions, “many people came to California to become clinicians, thinking that they would be able to be abortion providers — and then there was no training available to them,” said Debbie Bamberger, a nurse practitioner and board member of Training in Early Abortion for Comprehensive Healthcare, a group focused on abortion training.
Obstetrician gynecologists are supposed to get access to abortion training in their medical residencies under accreditation requirements, although residents can choose to opt out. Other physicians can also become trained in abortion care, but such opportunities have been sparser.
Abortion access advocates estimate that in California, roughly a fifth of family medicine programs routinely offer “opt-out” abortion training under their residency programs; nationally, the estimated number is under 6%.
For physicians, if it isn’t covered in medical school, “you’re most likely going to enter residency with very little to no education in abortion,” said Flor Hunt, executive director of TEACH. “And then if your residency program doesn’t have a meaningful abortion rotation, your chances of then being able to get abortion training are very low.”
Then there are other health professionals including certified nurse-midwives: nurses who complete additional higher education in pregnancy and childbirth. California allows nurse practitioners, physician assistants and certified nurse-midwives to provide abortions using suction early in pregnancy — also known as aspiration abortions — if they get training and follow other requirements under a law passed in 2013.
But that training can also be hard to get. Kim Q. Dau, who directs a UC San Francisco nurse-midwifery education program, said that when that law passed, the program was quick to provide training through lectures and reading but has “struggled over many years to find the hands-on learning experience.”
Many of the local sites that can train her students are already teaching physicians, which limits their capacity to bring in more trainees. “To teach anything takes more time and energy” than simply doing it without training anyone at the same time, Dau said, and clinics are concerned about not being able to see as many patients as a result.
Schnyer, who recently graduated from the midwifery program, said she had gotten training on medication abortions and had a chance to practice with tools used in early abortions on a papaya. But she had limited chances to observe procedural abortions. Her midwifery program gave her an opportunity to assist with preparing patients for abortions, but not the actual procedure, she said.
“It is kind of frustrating to leave school without that skill under my belt, in terms of actual clinical training,” Schnyer said.
She hopes to find a job that will assist her in getting trained. In the meantime, Schnyer is looking into whether she might be able to continue her training at a Mexico City clinic.
Zoe Carrasco, another graduate from the UC San Francisco midwifery program, also said she had limited opportunities for hands-on training in abortion, which meant that “we only saw a small glimpse of what abortion management looks like.”
Carrasco had wanted to help provide access to abortion care as a Latina provider who speaks Spanish, but doesn’t feel prepared to do so with the amount of training she has received. Like Schnyer, she is hoping she might be able to get trained on the job, but knows that those opportunities are also rare.
That scarcity, she said, “is a reflection of how abortion is viewed in this country.”
The California law that paved the way for physician assistants, nurse-midwives and nurse practitioners to provide aspiration abortions does not mandate a specific number of hours of training, but says the required training must be recognized by state boards or, for physician assistants, other options outlined in state code.
In an analysis of training opportunities across the country, the reproductive rights advocacy and educational group Nurses for Sexual and Reproductive Health found that most abortion training is focused on medical doctors; it identified only one program across the country offering “clinical training” — hands-on education meant to build clinical skill — in abortion care for registered nurses. Two others accepted “advanced practice clinicians” such as nurse practitioners.
Nurse-midwifery programs are focused on preparing students to take a licensing exam, and unless abortion procedures are on that test, “it’s hard to get programs to really robustly incorporate that into education,” said Anna Brown, a registered nurse and director of education for Nurses for Sexual and Reproductive Health.
Tiffany Lundeen, a certified nurse-midwife who works in Contra Costa County, said that during her graduate school training at Yale University, “there were no opportunities for me to be trained in abortion care.” After she graduated, Lundeen went to work in federally qualified health centers — community clinics that provide primary care to poor and uninsured patients.
Lundeen sees abortion as something that should be part of primary care — “as fundamental to health and well-being as getting your screening tests for cancer.”
“What that means is I don’t have access to on-the-job training in abortion care,” Lundeen said. “I could never find another way to be trained.” Lundeen said she tried reaching out to nonprofits trying to fill that gap, but found that they had limited capacity.
Abortion training has been limited, in part, by the number and distribution of existing providers in California. Bamberger estimated that to become adept in procedural abortions takes being trained with an abortion provider on 20 to 50 procedures. Broad swaths of the state have no abortion providers at all.
“In order to provide training, we have to be able to do the abortions in the first place,” said Dr. Melissa Myo, a complex family planning fellow at L.A. County-USC Medical Center. “Even in places like California where it is legal, access is an issue” because many rural counties lack an abortion provider.
At Planned Parenthood Mar Monte, which covers dozens of health centers from Sutter County to Bakersfield, nurse practitioners and midwives can get hands-on training, but “it’s just one person at a time,” Bamberger said. Clinicians can get trained quicker in providing medication abortion but need added training to step in if complications occur, Bamberger said.
“There’s a vicious cycle with not enough providers and not enough training — which produces not enough providers,” said Ian Lague, curriculum and program manager with Reproductive Health Education in Family Medicine, a group seeking to integrate abortion training into residency programs for family physicians.
For that reason, the group has emphasized training in medication abortion, which is simpler to learn. “There is a deluge of people who want to help in this moment, and while it would be wonderful to get them trained in procedural abortion, this is the low-hanging fruit.”
Dr. Katrina Heyrana, a fellow in family planning at County-USC, said it has been refreshing to see doctors from all specialties being galvanized by the Supreme Court ruling. Physicians have asked her, “How can I become a mifepristone prescriber?” — one of the medications used to end a pregnancy.
California lawmakers are also trying to help: Under Assembly Bill 1918, one in a package of state bills aiming to expand and protect abortion access, the state would create the California Reproductive Health Service Corps to recruit a diverse workforce by offering scholarships, stipends and loan repayment for health professionals who get abortion training and agree to work three years in underserved areas of the state.
The recently enacted state budget includes $20 million for the health service corps and an additional $20 million for scholarships and loan repayment to healthcare providers who commit to providing reproductive healthcare services.
Health educators are also anticipating that more out-of-state physicians will come to California for training as abortion is criminalized in other states. Two years ago, 92% of OB-GYN residents reported that they had some access to abortion training; UCLA and UC San Francisco researchers estimated that number would fall to 56%— and possibly lower — after Roe was overturned.
Training out-of-state doctors is important, but “I definitely think there’s going to be a bottleneck,” said Heyrana, who will soon start a new job training medical residents in abortion care. “We need to train our residents to feel comfortable in providing this care — and now have the added burden of having to train residents in probably over half the country.”
Times staff writer Melody Gutierrez contributed to this report.
Thousands more patients are expected to head to California annually for abortions, but the limited availability of training has constrained the number of clinicians who can provide them.
CAFAB council Applauds CA Assembly’s Swift Passage
of Constitutional Amendment Legislation
FOR IMMEDIATE RELEASE June 27, 2022
CONTACT Information Below
California Future of Abortion Council Applauds CA Assembly’s Swift Passage of
Constitutional Amendment Legislation Protecting Abortion & Contraception
SCA 10 Heads to November Ballot to be Voted on by Californians
CALIFORNIA – The California Future of Abortion Council (CA FAB Council) Steering Committee organizations, comprised of ACCESS REPRODUCTIVE JUSTICE, Black Women for Wellness Action Project, Essential Access Health, NARAL Pro-Choice California, National Health Law Program, Planned Parenthood Affiliates of California, and Training in Early Abortion for Comprehensive Healthcare (TEACH), released the following statement celebrating the California Assembly for their swift passage and overwhelming support of Senate President pro Tempore Toni Atkins & Assembly Speaker Anthony Rendon’s Constitutional Amendment legislation (SCA 10), which seeks to amend the California State Constitution to explicitly affirm that Californians have the fundamental right to access abortion and contraception:
“With the Supreme Court taking away a constitutional right to abortion on Friday, this swift statewide response to protect abortion and contraception in our state’s constitution is crucial. California must continue to take every step possible to protect access to abortion, that includes this effort to explicitly protect abortion and contraception.”
“The comprehensive effort underway by California reproductive health, rights, and justice organizations in collaboration with California leaders, is the response needed by our state right now to meet this moment of national crisis.”
“We look forward to Californians once again reaffirming their belief in equitable access to essential health care, including abortion care, at the ballot this November.”
SCA 10 (Atkins & Rendon) now heads to the ballot, where it will be voted on by Californians. Polling has shown overwhelming support among Californians for abortion care and abortion rights, and found that abortion rights is a particularly motivating factor for Independent voters.
This swift and bold action follows the U.S. Supreme Court ruling on Friday in Dobbs v. Jackson Women’s Health Organization—which overturned nearly 50 years of precedent and eliminated the nationwide constitutional right to abortion.
According to the Guttmacher Institute, the impact overturning Roe will have on the country and on California will be enormous. Currently, extreme bans on abortion are in effect in nine states, and many more states across the country are likely to quickly enact severe limits or outright bans on abortion care. That would mean more than 33 million women of reproductive age would no longer have access to abortion services in their home state. Not to mention the implications for criminalization of pregnancy outcomes and the nation’s maternal mortality crisis. California could see an increase of nearly 3,000% in women of reproductive age who would find their nearest abortion provider in California.
Brandon Richards, Director of Communications
Planned Parenthood Affiliates of California
Elliott Kozuch, Senior Communications Strategist
NARAL Pro-Choice California
The “California Future of Abortion Council” (CA FAB Council) is comprised of reproductive freedom and sexual and reproductive health care allies, partners, and leaders. The CA FAB Council works in collaboration with policymakers, researchers, advocates, providers, patients, and key constituents to determine potential challenges in the state and recommend solutions that will continue to provide access and stability for both Californians and those who may seek services here from out of state. The CA FAB Council allows for those dedicated to protecting reproductive rights and expanding access to sexual and reproductive health care to come together. Learn more here.
Abortion restrictions: We have been here before,
and here is what we learned
As abortion restrictions proliferate, protesters around the country are making their voices heard. Photo by Fibonacci Blue from Minnesota, USA [CC BY 2.0].
Over the last several months, a plethora of states have passed onerous restrictions on abortion. Pundits have called this onslaught unprecedented. While it is certainly true that the number of states successfully passing anti-abortion bills within a short window of time is the worst we have ever seen, the tactics we are seeing today have been used repeatedly over the last several decades. These tactics include bans on abortion at particular stages of pregnancy, after there is a detectible cardiac activity, for example, or after 20 weeks of gestation; bans on abortions for particular reasons such as sex selection or fetal anomalies; or laws that ban particular types of abortion procedures, usually those used in the second trimester. The Alabama law, considered the most onerous of all time, prohibits all abortions except those necessary to save the life of the woman, an extremely rare occurrence. In the early 1990s, Utah, Louisiana, and Guam also banned nearly all abortions, and other states were considering such measures.
Other current legislative activity restricting access to abortion has its roots in earlier decades. Between 1988 and 1992, as now, state legislatures across the country considered and passed a host of restrictions intended to intimidate doctors or to make abortion more expensive for women or more difficult to obtain, particularly for poor women, young women, or rural women.
The flurry of activity in the 1990s and now were driven by the changing composition of the Supreme Court. Then as now, anti-abortion legislators believed that the Supreme Court was poised to overturn Roe v. Wade and wanted to push test cases to the Court to ensure review of the constitutional standards that protect legalized abortion.
In 1992, I represented the abortion providers of Pennsylvania who were challenging restrictions on abortion in the seminal case Planned Parenthood v. Casey. My co-counsel and I fully expected the Supreme Court to reverse Roe v. Wade in our case. In fact, the Court after oral argument voted to overrule Roeand permit states to recriminalize abortion. Any legislative restriction, so long as it was rational (and protection of fetal life was considered rational), would be permissible.
To our surprise, we got a reprieve. Justice Kennedy changed his vote and supported a joint ruling that preserved legal abortion up to viability and thereafter if necessary to protect women’s health. At the same time, the Court gave states additional latitude to restrict abortion. In the intervening 27 years, abortion has remained legal and available in every state, albeit with additional hurdles that adversely affect poorer and younger women.
When considering the constitutionality of these new laws, I start with the premise that the current Court is likely to use any abortion case, not just the bans on abortion, to give states the ability to recriminalize abortion. Why am I so pessimistic? First and foremost, the Supreme Court today is more conservative than in 1992 and Chief Justice Roberts, unlike Justice Kennedy, has shown his willingness to overturn precedent if five members of the Court disagree with the initial basis for the decision. Just this term, he joined the opinion of the Court in Franchise Tax Board of California v. Hyatt, in which the liberal dissenting justices cautioned that reversing “a well-reasoned decision that has caused no serious practical problems in four decades” caused them “to wonder which cases the Court will overrule next.” And the chief justice has sided with anti-abortion advocates, voting in 2007 to uphold a federal late-term procedure ban and dissenting in 2016 when the Court struck down onerous Texas provisions that targeted abortion providers and restricted access in that state. It is not clear when the Court might accept a case for review, as they may want to avoid the issue before the 2020 elections, but I am confident that the end of federal constitutional protection for abortion will happen.
Contrary to many pundits, I also believe that once states are given the green light to recriminalize abortion, many will do so and do so quickly. Five states already have trigger laws that may automatically ban abortion with only very limited exceptions, once Roe/Casey are overturned, and at least two other states are considering similar laws. As noted by The New York Times, for the first time in over 100 years, Republicans control the governor’s seat and both houses of the legislature in 21 states, and these legislative bodies are overwhelmingly opposed to abortion and indebted to the anti-choice lobby. State legislative gerrymandering and voter suppression in these states will make it very difficult to overturn this trifecta of power in many locales.
Third, I believe that those who oppose abortion will not stop when abortion is made illegal in some states. Anti-choice advocates will push to limit women’s rights in a wide range of circumstances, pushing for restrictions on birth control, limiting funding for Planned Parenthood and family planning services, expanding fetal rights, diminishing protections for survivors of domestic violence and sexual abuse and harassment, rolling back marriage equality, and more.
What did we learn from our experience in Planned Parenthood v. Casey? What can we do now to help preserve the constitutional liberties that generations of women have relied upon for nearly 50 years?
I learned from Casey that pro-choice Americans must prepare for the likelihood that Roe will be overturned, and work to ensure that as many women in the nation as possible understand that future access to necessary health services is in jeopardy. We cannot wait until rights are lost. We need to begin now to fight for their preservation. Almost everywhere I go, there is the hope that this will not happen, that Justice Roberts will go slowly, that women are being alarmist. We need to believe that our rights are in jeopardy and work to preserve them.
I also learned that public resistance makes a difference. Between 1988 and 1992, pro-choice Americans attended large-scale demonstrations in Washington and at state legislatures, joined political campaigns to elect a pro-choice president and Congress, and made their voices heard in the public arena. This public resistance helped increase public support for Roe v. Wade and made abortion a big issue in the 1992 presidential campaign.
As we recently saw, public resistance did not derail the appointment of Justice Kavanaugh to the Supreme Court. Nevertheless, it activated women across the nation to become politically active in the 2018 elections and to run for office in unprecedented numbers. The pictures of women sitting in the halls of the Senate, challenging the status quo, helped spread the message that the federal courts are now in the hands of conservative forces and that we will need to find protections in other venues.
But in addition to public resistance, those who care about reproductive justice must become politically active — not just on social media or in the voting booth, but in both federal and state-level campaigns. Canvassing, texting, phone calls, and postcarding, as well as fundraising for pro-choice candidates, while tedious, is the best way to win elections.
The strategy is simple: At the federal level, we need to win back the presidency and the U.S. Senate. Some of the 23 Democrats running for president or prominent Democrats sitting on the sidelines should run for the Senate so that we can relegate Mitch McConnell to minority leader.
Equally important, we need to break up the trifectas, in which Republicans control the governorship and both houses of the legislature in 21 states. Flipping gubernatorial seats, reducing the margins of control, and where possible flipping control in one or both houses should be our primary goals. There are currently only 18 states that are controlled by Democratic pro-choice lawmakers. Some of them have already moved to weave a patchwork of protections for reproductive choice for women in those states. We need to expand that number, and it can be done. For example, there are realistic chances of winning back one or both chambers in Virginia and Pennsylvania in 2020, and hard work at the state level will make a difference.
And of course, the election or appointment of state supreme court judges must be on our priority list. State courts have the ability to interpret their state constitutions in ways that protect women, even if that protection is not available at the federal level. The Kansas Supreme Court recently established a state right to abortion that will remain, even if Roe is overturned. The right wing has paid attention to state Supreme Courts and invested in running conservative candidates for the last decade. We need to do the same.
Lastly, we need to pay attention to voting rights, for voting rights is a women’s issue. Gerrymandering and voter suppression enable conservative minorities to preserve power, even in the face of public opposition. Expanding the electorate is a key way to win more support in states that are passing these draconian laws. The recent close election in Georgia is but one example of how voter suppression skewed the election, and there are many more.
My experience in Planned Parenthood v. Casey has taught me that there is no substitute for public resistance and political activism. Please share these lessons and get to work.
THE TURNAWAY STUDY
Presented by the Bixby Center for Global Reproductive Health, the University of California San Francisco (UCSF) and Advancing New Standards in Reproductive Health (ANSIRH).
It is estimated that more than 4,000 women are denied wanted abortions due to facilities gestational limits every year. As more states pass gestational limit laws, thousands more will be affected.
The Turnaway Study was the first study to rigorously examine the effects of receiving versus being denied a wanted abortion on women and their children. Nearly 1,000 women seeking abortion from 30 facilities around the country participated. Researchers conducted interviews over five years and compared the trajectories of the women who received a wanted abortion to those who were turned away because they were past the facility’s gestational age limit. As legislators pass more and more laws to restrict access to abortion care, it’s important to document what happens to women who are unable to obtain an abortion.
Abortion does not harm women. It does not increase women’s risk of having suicidal thoughts, or the chance of developing PTSD, depression, anxiety, low self-esteem, or lower life satisfaction. Abortion does not increase women’s use of alcohol, tobacco or drugs. 95% of women said abortion was the right decision for them. Women who received a wanted abortion were more likely to have a positive outlook on the future and achieve aspirational life plans within one year.
BEING DENIED AN ABORTION REDUCES WOMEN AND CHILDREN’S FINALCIAL SECURITY AND SAFETY.
Women denied an abortion had almost four times greater odds of a household income below the federal poverty level and three times greater odds of being unemployed. There was an increased likelihood that women didn’t have enough money to pay for basic family necessities like food, housing and transportation if they were denied an abortion. Women unable to terminate unwanted pregnancies were more likely to stay in contact with violent partners, putting them and their children at greater risk than if they had received the abortion. Continuing an unwanted pregnancy and giving birth is associated with more serious health problems than abortion.
WHEN WOMEN HAVE CONTROL OVER THE TIMING OF PREGNANCIES, CHILDREN BENEFIT
Existing children of women denied abortions were more than three times more likely to live in households below the federal poverty level and they were less likely to achieve developmental milestones than the existing children of women who received abortions. Nine percent of children born because an abortion was denied met the threshold for poor maternal bonding, compared to three percent of children born subsequently to women who received an abortion.
Out-of-pocket costs for women whose insurance or Medicaid did not cover abortion were $575. For more than half, out-of-pocket costs were equivalent to more than one-third of their monthly personal income. It cost closer to two-thirds of their monthly personal income for those receiving abortions after 20 weeks.
For more information about the Turnaway Study and detailed references, visit http://bit.ly/TurnawayStudy.
WHOEVER SAID NUMBERS DON’T LIE?
In 2017, the CDC was proud to announce that 26 states had met the 2000 target of 6.0 infant deaths per 1,000 live births. Time to celebrate? Unfortunately, a closer look at the data reveals a disturbing inequity. For non-Hispanic White mothers, the infant mortality rate was 4.9. For African-American mothers, the rate was 11.4. Geographically, infant mortality rates were highest among the southern states of Oklahoma, Arkansas, Tennessee, North Carolina, Mississippi, Alabama, and Georgia. Rates were also higher in the midwestern states of Indiana and Ohio. Clearly, culture is a factor, and the cumulative stress of racism and sexism inordinately undermines the health of African-American mothers and their offspring.
In light of this data, the Center for American Progress has called for policymakers to improve the quality of care for African-American mothers and their infants by taking these steps:
- Provide more and easier access to affordable health care
- Recruit a diverse, compassionate, and respectful workforce
- Screen for and address each mother’s mental health as well as physical health
- Continue to support both mother and child after birth through home visits and connections to community programs
Finally, federal policymakers have a responsibility to continue to collect and disseminate reliable, consistent data on maternal and infant mortality in order to identify data-driven solutions.