Three University of Washington reproductive health experts had already dreamed up parts of a plan that would expand access to abortion training in Washington state. But things had been slow moving.
Then, last June, the U.S. Supreme Court eliminated Americans’ constitutional right to abortion.
“We just looked at each other and said, ‘Well, I guess we’re moving on this,’” said Molly Altman, a UW assistant nursing professor and 18-year nurse-midwife.
Less than a year later, she, Monica McLemore and Meghan Eagen-Torkko are nearly ready to unveil a unique program that will offer a clinical opportunity for advanced practice clinicians throughout the U.S. to learn how to provide abortions and other sexual and reproductive health care.
The group hopes to bridge a gap in the country’s abortion training landscape, which has historically excluded advanced practice clinicians like nurse practitioners and midwives. More hands-on learning opportunities are available for physicians and medical students, though even those options are still limited — especially now that medical residencies in states where the procedure is outlawed are questioning whether or not to keep their programs.
Now, Washington is positioned to serve as a national leader in expanded abortion training, the UW’s nurse experts say. The state not only continues to protect legal abortion, but also allows more types of providers to offer abortion care and houses a major educational research institution that’s willing to devote resources. Few other states offer similar benefits.
“It’s kind of a perfect storm of opportunities,” said Eagen-Torkko, longtime nurse-midwife and UW Bothell’s director of nursing.
Last summer, as the country grappled with how to respond to the Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision, it became apparent the case also marked a subtle, but significant, shift for advanced practice clinicians.
“Dobbs leveled the playing field in a very interesting way,” said McLemore, who founded the original research-based version of the program at the University of California, San Francisco.
Before the Supreme Court overturned Roe v. Wade, 32 states had “physicians-only” laws that allowed only doctors to provide abortions, McLemore said. Recent years brought gradual expansions for nurse practitioners, but now that states with physicians-only laws have largely banned abortions altogether, the incentive to only focus on physician training has disappeared, she said.
“As long as [physicians-only laws] were in place, physicians were the only people that have been prioritized in workforce development,” McLemore said.
Washington has seen an increase in patients seeking abortions from Southeastern states and other parts of the country since the Dobbs decision, said Kate Cole, a volunteer with the Northwest Abortion Access Fund, which helps people pay for abortion care in Washington, Oregon, Idaho and Alaska. The fund received more than 1,500 requests between July 2022 and last month, Cole said, up from about 1,170 requests in the same period a year earlier.
At the same time, there is a growing pool of health care workers who could be trained to help meet that demand: Washington’s number of licensed advanced registered nurse practitioners and nurse-midwives has jumped almost 60% in the last five years, according to the state’s nursing care quality assurance commission.
“We know we’re going to be a ‘surge state,’ where we’re going to see an influx of patients,” McLemore said. “So we want to make sure we have a workforce that can match the need.”
Who can provide abortions?
In Washington, the first state to vote to legalize abortion, licensed doctors, advanced registered nurse practitioners and physician assistants are allowed to provide abortions.
Physician-provided abortion in the first four months of pregnancy was legalized in 1970, three years before the Supreme Court decided Roe v. Wade. In 1991, Washington went further by codifying Roe and establishing a right to abortion up to the point of fetal viability.
Nurse practitioners and physician assistants were granted further eligibility in 2004 and 2019, when the state Attorney General’s Office published opinions in support of allowing advanced registered nurse practitioners (and later also physician assistants) to provide early surgical and medication abortions. Medication abortions involve taking pills to halt a first-trimester pregnancy, while surgical abortions, also known as aspiration or suction abortions, occur when a doctor uses a vacuum to remove the fetus.
Just last year, the Legislature voted to make the expansion official in statute. Those who spoke in opposition to the bill, including representatives from anti-abortion and religious groups, worried it would lower standards of care and said nonphysicians “lack the training to manage emergencies,” though several OB-GYN experts and abortion providers testified in support of the bill.
Not all providers and hospitals offer abortion care — including any owned by a Catholic-based health care system, like Providence — but patients can ask for referrals to nearby clinics. In the Puget Sound region, Planned Parenthood or Cedar River Clinics, a Renton-based abortion clinic with locations in Seattle, Tacoma and Yakima, offer some options. Cedar River also specializes in contraception, screenings for sexually transmitted infections and gender-affirming care.
But despite legal protections and opportunities for care in more populous parts of the state, there isn’t a comprehensive workforce plan yet to address the growing number of abortion requests here and in other parts of the U.S. where they remain legal, the UW’s nurse experts say.
“This all stems from a clear and distinct need for advanced practice clinicians and nurses to be able to provide abortion care as soon as possible,” Altman said.
Spots in the UW’s program, called UW ACTIONS (Abortion Care Training Incubator for Outstanding Nurse Scholars), will be open to any licensed clinician or advanced practice nursing student interested in abortion care or other aspects of reproductive health, including birth, contraception, sexuality and parenting.
Curriculum will include four online courses, covering practical guidance on how to start an abortion practice or incorporate their training into an existing practice. It will also delve into topics like the country’s abortion history and politics. Students will then be placed at clinics in the area for direct experience.
While the specific locations are still being finalized, the UW does have relationships with existing abortion providers in the area, such as Cedar River, where some of the school’s OB-GYN residents train.
Similar to many medical procedures, there aren’t abortion-specific credentialing or training requirements at a national level for licensed providers. Eagen-Torkko of UW Bothell said that down the line, one of the goals of the new program would be to build out a credentialing system that can show a provider is considered clinically competent.
The program will also be open to out-of-state clinicians and students. Classes can be taken online, and the UW team is in touch with abortion centers and health care clinics across the country that could help students fulfill their clinical requirements without traveling to Washington.
There is some concern, however, about possible backlash directed at abortion providers, Altman said. State lawmakers are in the process of considering legislation that aims to increase protections for Washington providers, one of which would restrict out-of-state courts and law enforcement agencies from enforcing subpoenas, warrants and other orders here based on abortion care.
“This is a tricky situation, and it’s always in flux,” Altman said. “States are changing their laws as we speak.”
Program leaders are aware that there might always be people who prefer a doctor to a nurse practitioner or midwife, and vice versa, and are hoping the initiative will give patients as many choices as possible in the long term, Altman said.
“OB-GYNs are almost certainly going to have more surgical experience than an [advanced practice clinician],” said Dr. Sarah Prager, a UW OB-GYN professor and director of the school’s complex family planning program and fellowship. But anyone appropriately trained can provide routine abortion care, Prager said.
Because Washington has so few obstetric hospitals in rural areas, Prager said, rural residents are also more likely to find accessible sexual and reproductive health care from advanced practice clinicians, who can also work in homes and birth centers, unlike OB-GYNs.
In addition, about 44% of OB-GYN residents nationwide are receiving training in a state where they can’t legally learn how to provide abortions, she said.
“The number of OB-GYN providers who are going to graduate from a residency program confident and competent to do abortion and miscarriage care is going to go down,” said Prager, who also cares for patients at Cedar River. “Ramping up that training for lots of different kinds of providers in the states and the spaces where that can happen, I think, is a really key strategy.”
The program is still awaiting the UW’s final approval, expected later this month, but the team expects to hit the ground running with a 15-person cohort in the fall after receiving nearly $300,000 in anonymous donations last year.
Other colleges and universities could soon follow suit.
“We are so happy to support them in building their programs,” Altman said. “I am not seeing this as a monopoly, and I’m hopeful that we’re not going to be the only school offering this in two years.”