摘要：Objectives. We examined the impact on patient safety if nurse practitioners (NPs), certified nurse midwives (CNMs), and physician assistants (PAs) were permitted to provide aspiration abortions in California. Methods. In a prospective, observational study, we evaluated the outcomes of 11 487 early aspiration abortions completed by physicians (n = 5812) and newly trained NPs, CNMs, and PAs (n = 5675) from 4 Planned Parenthood affiliates and Kaiser Permanente of Northern California, by using a noninferiority design with a predetermined acceptable risk difference of 2%. All complications up to 4 weeks after the abortion were included. Results. Of the 11 487 aspiration abortions analyzed, 1.3% (n = 152) resulted in a complication: 1.8% for NP-, CNM-, and PA-performed aspirations and 0.9% for physician-performed aspirations. The unadjusted risk difference for total complications between NP–CNM–PA and physician groups was 0.87 (95% confidence interval [CI] = 0.45, 1.29) and 0.83 (95% CI = 0.33, 1.33) in a propensity score–matched sample. Conclusions. Abortion complications were clinically equivalent between newly trained NPs, CNMs, and PAs and physicians, supporting the adoption of policies to allow these providers to perform early aspirations to expand access to abortion care. Increased access to early abortion is a pressing public health need. By 2005, the number of abortion care facilities in the United States had decreased 38% from its peak in 1982. 1 Although the number has since remained stable, the proportion of US counties with no facility remains high at 87%; more than one third of women aged 15 to 44 years live in these counties. 2 Additionally, a large proportion of US facilities are hospitals that perform abortions only in cases of serious medical and fetal indications or facilities that offer medical abortions only up to 9 weeks of pregnancy. 2 Many women face difficulties finding a facility, resulting in delayed care. 3 Increasing access is critical because abortions at later gestations are associated with a higher risk of complications 4 and higher costs. 2 Research has also found that many women would prefer to obtain their abortions earlier 5 Finally, traditionally underserved populations experience the greatest barriers to abortion care, resulting in higher rates of procedures after the first trimester. 6,7 In California, more than half of the 58 counties lack a facility that provides 400 or more abortions (R. K. Jones, PhD, Guttmacher Institute, written communication, November 2011). Low-income and minority women are most likely to be served by public health departments or community health centers, 8 most of which do not provide abortions. These women are also more likely to be cared for by nurse practitioners (NPs) and physician assistants (PAs) than by obstetricians and gynecologists. 9 One potential solution to improve access is to increase the number and types of health care professionals who offer early abortion care. 10–12 Increased emphasis has been placed on task sharing to better meet women’s health needs in the context of health care workforce shortages. 13 In the United States, health professions are regulated through a patchwork of state regulations 14,15 that determine who can perform abortions, a power reaffirmed by several US Supreme Court decisions. 16–18 Currently, nonphysician clinicians can perform aspiration abortions legally in only 4 states—Montana, Oregon, New Hampshire, and Vermont. Two additional states (Kansas and West Virginia) do not limit the performance of abortions to physicians, but nonphysician clinicians have never tried to provide abortion care. Of the remaining 44 states ( Figure 1 ), some allow nonphysician clinicians to perform medical (but not aspiration) abortions under decisions by attorneys general or health departments, and 1 state—California—passed statutory authority for that care. As part of a larger effort to limit abortion access, several states have recently promulgated laws that specifically prohibit nonphysician clinicians from performing abortions. 19 For example, a 2009 Arizona law (HB 2564 and SB 1175) that precluded NPs from providing abortions resulted in the discontinuation of abortion care at several facilities that had previously been staffed exclusively by NPs. 20 Open in a separate window FIGURE 1— Landscape of health professional regulation of abortion provision in the United States. Note . CNM = certified nurse midwife; NP = nurse practitioner; PA = physician assistant. Limited clinical evidence is available to inform policymakers about whether physician-only legal restrictions on abortion are evidence-based. 21–24 Our study was designed to provide this evidence to policymakers; it answers the question “What would be the impact on patient safety if NPs, PAs, and certified nurse midwives (CNMs) were permitted to provide aspiration abortions in California?” (We use the term aspiration abortion to refer to what is commonly called surgical abortion because the technique does not meet the technical definition of surgery. 25 ) We used a noninferiority design to compare the incidence of abortion-related complications between groups because we anticipated a slightly higher number of complications among newly trained NPs, CNMs, and PAs than among the experienced physicians.
