Expanding the abortion workforce and improving access to care in California

Between 2010 and 2016, states passed 338 new abortion restrictions. California was one of the only states during that time to pass laws that both protected and expanded abortion access. In 2014, California passed AB 154 to become the 5th and largest state to allow nurse practitioners (NPs), certified nurse-midwives (CNMs) and physician assistants (PAs) to provide aspiration abortion. While California doesn’t have the same scarcity as other states, 43% of counties have no abortion provider. New research from ANSIRH is the first study to look at how organizations have used the new law and if it’s meeting its goals to expand access to abortion care.

In interviews with administrators of five organizations that employ NP, CNM and PA providers for aspiration abortion care, there was broad agreement that the change in California law added value to patient services. They identified major improvements:

  • Increased access to abortion care. In some cases, having NP, CNM and PA aspiration abortion providers made the provision of abortion services possible at more remote clinics. It also allowed some clinics to reduce wait times and improve patient satisfaction.
  • Better management of complications from miscarriage or abortion. Before the law went into effect, some clinics had to send patients with an incomplete miscarriage or abortion to a hospital emergency room or a clinic in another city. Now those patients are seen right away in the same clinic.
  • Improved skills and job satisfaction. NPs, CNMs, and PAs found that the skills they learned for aspiration abortion care transferred to other services like IUD insertion. They were also more satisfied in their jobs and felt more effective on a daily basis.

Despite these advances, the administrators identified obstacles to taking full advantage of the law:

  • Balancing workload with physicians. Clinics rely on physicians to comply with clinical supervision regulations and other administrative responsibilities and cannot risk cutting too many physician hours and still keep their contracts competitive. Some clinics need physicians to perform later abortions and it didn’t make sense to have multiple abortion providers on staff.
  • Declining demand for abortion services. Overall demand for abortion services has gone down, which has decreased the need for additional providers, especially in cities with more trained providers. However, providers are still not spread enough throughout the state to meet need in rural areas.
  • Financial constraints. Some clinics had to prioritize other services just to stay afloat since California offers a low Medicaid reimbursement rate for abortion services.

Researchers found that what made the biggest difference in the success of the rollout was having a strong champion in management of an organization, and having a critical gap in the care that needed to be filled.

These results indicate that the California law is achieving many of its goals, having a positive impact on care and helping the clinics that most needed more available abortion providers. While the identified obstacles must be addressed to fully realize the benefits, this law provides a model that could significantly increase access to care around the country.