Care for Women Choosing Medication Abortion

Nurse Practitioner, Oct 2004 by Taylor, Diana, Hwang, Ann C, Stewart, Felicia H

Unintended pregnancy is a common problem for many women during their reproductive years. Nearly half of all pregnancies in the United States are unintended, and nearly half of these end in abortion.1,2 Approximately 43% of American women have had an abortion by the age of 45.1

Mifepristone was approved by the Food and Drug Administration (FDA) in September 2000, giving women a new option for early pregnancy termination. Since receiving FDA approval, mifepristone has proven to be even safer and more effective than previously demonstrated. Of the approximate 80,000 U.S. women who chose mifepristone abortion in the first year after its approval, there were 139 reported adverse events: a rate of 0.17%.3 Adverse events included allergic reactions such as hives, need for uterine aspiration due to bleeding or treatment failure, blood transfusion, ectopic pregnancy, and one death from a ruptured ectopic pregnancy. In addition to the growing use in the U.S., mifepristone is approved in 27 countries and has already been used for well over a decade in Europe and China. As providers and patients become more familiar with mifepristone, it is likely to become an even more popular choice for pregnancy termination in the U.S.

Nurse practitioners (NPs) play a vital role in providing women's primary care and reproductive healthcare. Medication abortion offers NPs a new opportunity to become involved in abortion care, providing patients with another safe and effective method for early pregnancy termination. Whether or not you plan to provide medication abortion, becoming familiar with the procedure is part of the standard of care for women's health providers and essential for abortion-related counseling and care.

This article uses clinical vignettes to outline the essentials of clinical care for women choosing medication abortion and to discuss medication abortion procedures and pharmacology, clinical care guidelines, and professional practice issues for NPs.

* NPs and Medication Abortion

In January 2003, a new California state law clarified the authority of appropriately licensed healthcare personnel to provide medication abortion. The new law applies to a variety of advanced practice clinicians (APCs): NPs, nurse-midwives, and physician assistants. Recent surveys of NPs by the Abortion Access Project in Massachusetts and Oregon found that a large majority of respondents believe that medication abortion should or might fall into their scope of practice.

Advocates for expanding the role of NPs and other APCs note that APCs working in reproductive health are well-qualified in the clinical skills required for medication abortion: performing a history and physical exam, confirming and dating pregnancies, counseling patients, and managing complications through referrals, supervisory arrangements with physicians, or comanagement plans. Furthermore, clinical practice standards for advanced practice nurses in general and women's health NPs specifically have been developed by national professional organizations (such as the National Association of Nurse Practitioners in Women's Health, the Association of Women's Health, Obstetric and Neonatal Nurses, and the American Nurses Association) to recognize the independent scope of nursing practice in the provision of women's primary care throughout the lifespan.

More recently, the U.S. Health Resources and Services Administration published primary care NP competencies with specialty competencies in women's, family, adult, pediatrics, and geriatrics care (available at http://www.nonpf. com). These competencies, expected of all entry-level NPs, specifically refer to the role of the women's health NP to perform primary care procedures such as intrauterine device (IUD) insertions and endometrial biopsies, as well as to provide pregnancy-related evaluation and care.

In some states, there is a well-established precedent of APCs, especially physician assistants, providing abortion. In Vermont, for example, physician assistants have been providing aspiration abortions safely for 30 years. But in other states, physician-only laws prevent APCs from independently providing abortions.

Because it involves medication rather than a procedure, medication abortion is a particularly appropriate treatment to integrate into primary care practices. Providing abortion care in the context of primary care has several advantages. As women's primary care providers, NPs are likely to have continuing relationships with their patients who have made the decision to terminate an unintended pregnancy. Primary care providers have more opportunities to follow-up with patients, and can encourage effective, consistent contraceptive use. Providers have noted how much their patients appreciate the opportunity to obtain abortion care in a familiar, comfortable setting by a provider who knows them well.4 Also, consider that there is a tremendous shortage of abortion providers in the U.S., with underserved populations suffering the most; and recent research shows NPs are more likely than physicians to care for underserved populations.5