CA expands abortion access and nurse practitioner authority at once

This January, what would have been fifty years of Roe v. Wade met fifty years of scope of practice debate in California.

Following the June 2022 Dobbs v. Jackson decision, California lawmakers passed a large number of bills to protect the right to legal abortion. Part of that expansion included amending the state’s complex scope of practice laws.

The legislative solution was Senator Toni Atkins’ Senate Bill 1375, which allows nurse practitioners and certified nurse midwives to perform first-trimester abortions without the oversight of a doctor, upon completion of additional training in the procedure.

Atkins’ bill is intended to augment her earlier measure (AB 154 Atkins, 2013) which had first allowed nurse practitioners to perform first-trimester abortions under doctor supervision. Now nurse practitioners will be able to practice as they have been without that oversight. It is a significant change given that physicians have long represented the strongest opponents to expansion of practice authority for nurse practitioners, citing concerns over quality of care.

The scope of practice issue has been a constant point of contention in California since the seventies, but it took the overturn of Roe for truly significant change to occur in regard to nurse practitioners and abortion.

Scope of practice in medicine refers to what different medical professionals can and cannot legally do. It also draws the distinction between who needs what kind of guidance; doctors need little oversight, nurses always need oversight, and nurse practitioners tend to operate in a gray area, with different states giving them varying levels of autonomy in their practice.

According to the National Conference of State Legislatures, 32 states require that abortions be performed by licensed physicians, but allowing trained professionals such as nurse practitioners and certified nurse midwives to do so is becoming more common as a way to expand access.

California is one of 11 states that currently have some form of restricted practice authority for nurse practitioners, though that could also be changing. While the American Association of Nurse Practitioners California still considers California a restricted authority state, a bill signed into law last year (AB 890) has created a three-year pathway to full practice authority for nurse practitioners.

The scope of practice issue has been a constant point of contention in California since the seventies, but it took the overturn of Roe for some kind of change to occur in regard to nurse practitioners and abortion.

Former California Secretary of Health and Human Services Diana Dooley has witnessed the tug of war over both abortion and scope of practice for the entirety of her long career in both the public and private sectors. In retirement, Dooley has a sharp perspective on the issue.

“It’s about power and money,” she said, describing the inflexibility of nurse practitioners’ limited authority in the state. “We all make financial decisions in addition to professional ones.”

Abortion is certainly not the only driver in the evolution of scope of practice allowances. The pandemic also forced the elimination of many long held restrictions in telehealth. While much of the loosening of those rules was temporary, many of the changes have since become permanent in California and across the country.

But legality is one thing; access is another.

Of California’s counties, 40 percent do not have a single abortion provider, and nine do not have a single OB-GYN.

There is also a significant shortage of doctors in the United States, per the Association of American Medical Colleges, and little projected growth in the field. With that in mind, Dooley says giving more power to nurse practitioners allows for “more care for less cost.”

In California, nurse practitioners have been able to prescribe medication abortions since they were first introduced in 2000. Prescribing and administering medication is well within their scope of practice, and the newly FDA-approved abortion medication was considered no different from any other medicine administration they would do.

Of California’s 58 counties, 22 (roughly 40 percent) do not have a single abortion provider, and nine do not have a single OB-GYN.

Getting that mentality applied to procedural abortion was a different story entirely.

AB 154 itself came about after a UC San Francisco study found that nurse practitioners had no higher complication rates with the procedure than physicians, but the push to allow them to do it without oversight was still almost ten years away.

Much like the impact it had on the 2022 midterms, the Dobbs decision gave that effort urgency.

“To get an expansion of scope requires a political fight,” said Dooley. “The desire to provide more access in California created the political environment to expand the scope of practice at the nurse practitioner level.”

Claire McCarville is an intern with Capitol Weekly. She is a junior at Arizona State University.