Notes From a Full Spectrum Nurse­Midwifery Student, Part I

Guest Post: Holly Carpenter, RN, CNM Candidate, UCSF

When I was choosing between various CNM (certified nurse midwifery) Master’s 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 surgical 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 this most recent period of abortion restricting legislation. The impact of these bans is substantial, and connecting the dots is not difficult:

  1. Abortion is one of the most commonly performed procedure for women (Boonstra, Benson Gold, Richards, & Finer, 2006)
  2. “As primary care providers APCs are an obvious entry point to the health care system for women facing unintended pregnancies”(APC toolkit)
  3. In 2004, APCs saw six times as many women for publicly funded family planning services as did physicians (Frost & Frohwirth, 2005).
  4. Under the affordable care act, the proportion of the US population receiving primary care from APCs is expected to increase substantially (NPs, CNMs, and PAs offer a competent source of women’s primary care and often practice in medically underserved settings – Institute of Medicine Committee on the Future of Primary Care & Donaldson, 1996).
  5. Limiting access to abortion is harmful to women (Lang, 2013)
  6. Therefore, 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). What was clear to me in 2010 is becoming clear to the rest of the state through this project, and APCs in California are poised to address the gap in services that MD-only provider laws create. (Weitz et al, 2013).

We still face several major hurdles in terms of training and education. A 2005 survey of APC programs demonstrated that only 53% of schools in the US offer didactic instruction in medication or aspiration abortion, and a mere 21% offer clinical training in these procedures (Foster et al, 2005). Even at UCSF, where CNMs are taught to provide comprehensive options counseling (two hours of instruction), contraceptive methods (one quarter of a pharmacology-focused class), and medication abortions (one hour of instruction), we are not taught how to provide first-trimester MUAs. In conversations with other UCSF nursing and medical students, I found that my sentiment of disappointment was shared, and that students were eager for more training and education in sexual and reproductive health – specifically focused on abortion.

In the next blog post in this series, I’ll describe my review of the currently available curricular resources and our initial effort to bring more RH teaching into the curriculum at UCSF.  I’ll also discuss my current collaboration with an incredible group of nursing educators and innovators in the creation of a nationally applicable curriculum, and our plans to disseminate it through Nursing Students for Choice and pilots at UCSF, Oregon Health and Sciences University, Yale University, San Francisco State University, the University of New Mexico, and other schools of nursing. Please direct your feedback and comments to