Leave it to California to buck a national trend. As states across the U.S. enact new laws restricting abortion, Golden State lawmakers are on the cusp of passing legislation that could greatly expand access to the procedure by allowing nurse practitioners, physicians’ assistants and certified nurse midwives to perform first-trimester abortions. The bill passed the state senate Monday and is expected to be approved by the California assembly this week.
Pro-life groups say the new law could put women’s health at risk, though a recently published study found abortions administered by these professionals, known as advanced-practice clinicians, are as safe as those performed by physicians. Supporters used that study, conducted by researchers at the University of California, San Francisco, to help secure the bill’s passage. (Four other states — Oregon, Montana, Vermont and New Hampshire — already allow advance-practice clinicians to provide abortions or do not explicitly ban them from doing so.) Pro-choice groups, meanwhile, are heralding advancement of the California bill as an increasingly rare victory in the effort to make abortion easier to access.
The state would seem to have little need to broaden abortion access. California has more than 500 abortion providers, according to the reproductive-rights organization the Guttmacher Institute and nearly 30% of all abortion providers in the U.S. were located there in 2008, the most recent year for which data is available. The abortion rate in the state that year was 27.6 abortions per 1,000 women ages 15 to 44, 40% higher than the national average.
But those statistics don’t accurately reflect access to abortion in California, says Tracy Weitz, director of UCSF’s Advancing New Standards in Reproductive Health program and lead author of the nonphysician abortion study. About half of all abortion providers in the state are hospitals that only offer the procedure in cases where fetuses have abnormalities or a mother’s health or life is at risk. Excluding these facilities, nearly half of the state’s counties currently have no abortion provider.
If the places where advanced-practice clinicians legally provide abortions are any guide, California’s legislation could increase abortion access for low-income women in rural areas. Montana has allowed the practice since 1999, when the state supreme court struck down a state law limiting the procedure to physicians. Letting such clinicians provide abortions is “very important, especially in Montana,” says Annie Hansen, director of the Blue Mountain Clinic in Missoula, which has a physician’s assistant on staff who performs abortions. “We’re so rural. There’s really about only four places doing this service and we’re all really spread out.”
The California legislation reflects another trend: the growing abortion access gap among states. Proposals to make abortions easier to get typically emerge in states where laws already favor widespread availability. Similar measures are rarely proposed, let alone passed, in states like North Dakota and Mississippi, which have a single abortion provider each.
New York State, like California, has relatively unfettered access to abortion. Yet, Governor Andrew Cuomo recently pushed for a law affirming a woman’s right to an abortion after 24 weeks if her health is threatened. Current state law permits abortions in the third trimester only if a woman’s life is in danger. But Roe v. Wade holds that such late-term abortions are legal to protect the life and health of mothers, so Cuomo’s proposal, which did not pass, would have simply codified this into state law. And the procedures that would have been affected are extremely rare: nationwide, less than 2% of abortions take place after 21 weeks.
If California legislators pass the bill to allow advanced-practice clinicians to perform first-trimester abortions, many are poised to step in. Some already have. In order to conduct the study on the safety of nonphysician abortions, Weitz and her fellow researchers were granted a waiver from the state allowing clinicians to perform the procedures. Working at Planned Parenthood locations and facilities in the Kaiser Permanente health system in Northern California, the clinicians were trained to provide abortions and the researchers designed a study to measure complication rates.
Of the 11,487 abortions provided between 2007 and 2011 included in the study, which was published in January in the American Journal of Public Health, 1.3% had complications. The rate of complication for advanced-practice clinicians was 1.8%; for physicians, it was 0.9%, which the study authors wrote was “clinically equivalent.” (Just six abortions in the entire study had complications that required hospital-based care.)