The role of CNMs in abortion care

cayenne06, MSN, CNM · Mar 17, 2011

I understand what you're saying - and appreciate that complications are the issue - but fortunately any CNM who would be performing such a procedure *would* have years of training; they would have a BSN, plus a MSN - plus, most probably, additional training since very few MSN programs include training on the provision of abortions. That is to say nothing of the fact that more and more CNMs will probably have doctorates as the DNP moves forward (not to get into a debate about that issue here :)).
CNMs regularly face the prospect of serious and sudden complications when helping women give birth, including maternal hemorrhage, retained placenta, cord prolapse, shoulder dystocia, neonates that need resuscitating, etc...again, fortunately CNMs are trained to manage complications, and transfer to a physician when necessary. I don't see why CNMs performing certain kinds of abortions would be any different.

I know this is an old thread, but I absolutely agree with this post. 1st trimester abortion (medical and surgical) clearly falls under "well woman care" and I honestly think the only reason most states disallow CNMs and NPs from providing it is because of anti-abortion bias, NOT because midwives aren't trained and competent to provide the service. The fact that it is a "surgical" procedure is a red herring. We are talking about a low risk, routine procedure that carries a FAR lower risk of complications than a full term delivery.

I think second tri abortion is less clear cut, and I do not have a set opinion on it.

TLAandy · Mar 17, 2011

It varies state by state. It also depends on the physician you are working with. A great resource on something like this is ACNM website, they actually address issues like this in their "Standards for Practice of Midwifery" document. The last section:

STANDARD VIII

MIDWIFERY PRACTICE MAY BE EXPANDED BEYOND THE ACNM CORE COMPETENCIES TO INCORPORATE NEW PROCEDURES THAT IMPROVE CARE FOR WOMEN AND THEIR FAMILIES. The midwife:

1. Identifies the need for a new procedure taking into consideration consumer demand, standards for safe practice, and availability of other qualified personnel.

2. Ensures that there are no institutional, state, or federal statutes, regulations, or bylaws that would constrain the midwife from incorporation of the procedure into practice.

3. Demonstrates knowledge and competency, including: a) Knowledge of risks, benefits, and client selection criteria. b) Process for acquisition of required skills. c) Identification and management of complications. d) Process to evaluate outcomes and maintain competency.

4. Identifies a mechanism for obtaining medical consultation, collaboration, and referral related to this procedure.

5. Maintains documentation of the process used to achieve the necessary knowledge, skills and ongoing competency of the expanded or new procedures.

Reference:

http://www.midwife.org/siteFiles/descriptive/Standards_for_Practice_of_Midwifery_12_09_001.pdf

Source: Division of Standards and Practice Approved: ACNM Board of Directors, March 8, 2003; Revised and Approved: ACNM Board of Directors, December 4, 2009

(Supersedes the ACNM's Functions, Standards and Qualifications, 1983 and Standards for the Practice of Nurse-Midwifery 1987, 1993. Standard VIII has been adapted from the ACNM's Guidelines for the Incorporation of New Procedures into Nurse-Midwifery Practice)

LookingAhead · Mar 19, 2011

I'm actually still wondering if anyone has answers to the OP's original question: does anyone known of any schools where abortion provision is included in the CNM curriculum?

elkpark · Mar 19, 2011

I'm actually still wondering if anyone has answers to the OP's original question: does anyone known of any schools where abortion provision is included in the CNM curriculum?

I don't know, but I would guess it's unlikely -- I have read that most med schools have dropped it from their standard curricula, because it's so controversial, and students/residents who are interested have to specially seek out additional training on their own.

TLAandy · Mar 23, 2011

I don't know, but I would guess it's unlikely -- I have read that most med schools have dropped it from their standard curricula, because it's so controversial, and students/residents who are interested have to specially seek out additional training on their own.

That is correct, it is not in any of the curriculum's I know of for CNM's. My cousin is in Medical School and he said the same thing. It is not part of the curriculum, (to actually do one) they do go over care of the status-post abortion female. But it is available for MD's, but is not required. For OB/GYN's knowing how to do the procedure is required, but they can opt out of actually doing one. They have many interactive/computer modules that can walk them through the procedure.

CNM's that are practicing in the expanded role usually have a surgeon in house. CNM's will routinely close on C-sections by themselves, but have back up if needed. Early trimester abortions are not as medically significant as later trimester abortions, which even for OB/GYN's require certain circumstances. Early abortions are so medically insignificant women's bodies do most of them.

TLAandy · Mar 23, 2011

I am glad we are having this conversation and no one is arguing about the issue. That is good, usually someone assumes someone is taking "this or that" position and totally hijacks the conversation.

cega · Aug 26, 2011

I know I'm responding incredibly late to this, but I asked Dr. Carhart about this when I met him, and he recommended checking into the programs at UCSF and Oregon State Health Sciences University. I still haven't actually asked them - I'm a little nervous about asking before I even apply - but I thought I'd pass along his suggestion.

NewYorkMidwife · Sep 5, 2011

Medical abortions are taught in school. Most CNM's who do surgical abortion as well, are usually trained in the job, widening the scope of their practice. There are of different degrees of surgical abortions.

LookingAhead · Sep 5, 2011

Does that mean that CNM students would generally receive didactic and clinical education in medical abortions? If so, that's really good to know.

If CNMs are already being trained on the job to do surgical abortions it would be interesting if there were degree programs that integrated this into their curriculum. The Abortion Access Project (http://www.abortionaccess.org/advance-practice-clinicians) says this under their FAQs for Advanced Practice Clinicians:

"How can I be trained?

While currently there are no national training centers for APCs, local opportunities exist depending on your state and interest. AAP works with individual APCs on a case by case basis, providing tailored support and training where possible, and may be able to connect you with a training opportunity in your area. If you are a clinician within the Planned Parenthood network, there are often opportunities for training available through your affiliate. AAP also works with state-level partners to create sustainable training opportunities for APCs with other clinical affiliations.

What resources would be helpful to me?

AAP offers specific resources for physician's assistants, nurse practitioners and certified nurse-midwives. For more information about abortion care in your profession, please log in, free of charge, to our network member site. Also, please check out our APC Toolkit (http://www.apctoolkit.org/) for APCs who would like to advance their existing practice, as well as for those who are experienced in abortion care."

Section V of the APC Toolkit referenced, BECOMING CLINICALLY COMPETENT AND DOCUMENTING COMPETENCY IN ABORTION CARE (http://www.apctoolkit.org/section5a.html) mentions some of the ways in which abortion care provided by APCs in being integrated into select educational programs, including at UCSF.

Babayaga88345 · Sep 12, 2011

The surgical evacuation of the uterus is within our practice in every state provided it is to MANAGE AMISCARRIAGE. Oregon, Washington, new Mexico and several other jurisdictions allow us to do surgical abortions. NAF has the ceu didactic and will help you arrange clinical time to get your technique down. I strongly suggest that all CNMs who are able to cope with the concept learn the technique for the sake of managing miscarriages and, if it suits your practice ethics, providing first trimester abortions to selected patients. NAF = National Abortion Federation.

Baba Yaga, formerly of Portland Feminist Women's Health.

MountainHeather · Nov 12, 2011

I am a Nurse-midwifery student at UCSF and we do not have opportunities to learn aspiration (aka surgical) abortions. We have learned in class how to do medical abortions. It is not possible for us to learn aspiration abortions as students because California law does not yet permit Advanced Practice Nurses nor Physicians Assistants to do aspiration abortions. The only non-physician providers who can do aspiration abortions in California right now are those who are enrolled in the ANSIRH study and those participants are providers who already have their license. I do not know whether OHSU or other Nurse-midwifery programs offer training in aspiration abortions.

LookingAhead · Nov 12, 2011

Thanks for the info, Heather.

Out of curiosity, is this a subject that gets much discussion among your classmates? Does there seem to be interest in including more training on abortion provision and widening CNM/NPs' scope of practice to include aspiration abortions?