BILL ANALYSIS Ó
AB 154
Page 1
Date of Hearing: April 23, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
AB 154 (Atkins) - As Amended: March 19, 2013
SUBJECT : Abortion.
SUMMARY : Authorizes a nurse practitioner (NP), certified nurse
midwife (CNM), and physician assistant (PA) to perform abortion
by medication or aspiration techniques in the first trimester of
pregnancy upon completion of training, as specified.
Specifically, this bill :
1)Makes it unprofessional conduct for any NP, CNM, or PA to
perform an abortion, as specified, without prior completion of
training and validation of clinical competency.
2)Provides that a person is not subject to the prohibition on
the unauthorized practice of medicine, as specified, if he or
she performs an abortion by medication or aspiration
techniques in the first trimester of pregnancy, and at the
time of so doing, has a valid, unrevoked, and unsuspended
license or certificate obtained in accordance with some other
provision of law, including but not limited to the Nursing
Practice Act or the Physician Assistant Practice Act, as
specified, that authorizes him or her to perform the functions
necessary for an abortion by medication or aspiration
techniques.
3)Deletes existing law which requires that a physician and
surgeon perform or assist in performing nonsurgical abortion.
4)Deletes existing law which defines nonsurgical abortion to
include termination of pregnancy through the use of
pharmacological agents. Deletes existing surgical and
nonsurgical abortion terms.
5)Deletes an existing provision which makes it unprofessional
conduct for a physician and surgeon to perform, assist,
procure or aid, abet, attempt, agree, or offer to procure an
illegal abortion under the Reproductive Privacy Act (RPA).
6)Requires a NP or CNM, in order to perform an abortion by
aspiration techniques, to complete training recognized by the
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Board of Registered Nursing (BRN). Requires, beginning
January 1, 2014 and until January 1, 2016, the
competency-based training protocols established by Health
Workforce Pilot Project (HWPP) No. 171 through the Office of
Statewide Health Planning and Development (OSHPD) to be used.
7)Authorizes a NP or CNM who has completed training and achieved
competency through HWPP No. 171 to perform abortions by
aspiration techniques.
8)Requires a PA, in order to receive authority from his or her
supervising physician and surgeon to perform an aspiration
abortion by aspiration techniques, to complete training either
through training programs approved by the Physician Assistant
Board (PAB) or by training to perform medical services which
augment his or her current areas of competency pursuant to
regulations, as specified. Requires, beginning January 1,
2014, and until January 1, 2016, the training and clinical
competency protocols established by HWPP No. 171 through OSHPD
to be used as training and clinical competency guidelines for
PAs.
9)Requires the training protocols established by HWPP No. 171 to
be deemed to meet the standards of the PAB. Authorizes a PA
who has completed training and achieved clinical competency
through HWPP No. 171 to perform abortions by aspiration
techniques.
10)Deletes provisions in the RPA which makes assisting in
performing abortion unauthorized if the health care provider
assisting in performing abortion is not an authorized
provider, as specified.
11)Makes other technical and conforming changes.
EXISTING LAW :
1)Establishes the RPA which provides that every individual
possesses a fundamental right of privacy with respect to
personal reproductive decisions. Provides that it is the
public policy of the state that:
a) Every individual has a fundamental right to choose or
refuse birth control;
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b) Every woman has the fundamental right to choose to bear
a child or to choose and to obtain an abortion, except as
specified; and,
c) Prohibits the state from denying or interfering with a
woman's fundamental right to choose to bear a child or to
choose to obtain an abortion, except as specified.
2)Indicates the following in the RPA:
a) The state may not deny or interfere with a woman's right
to choose or obtain an abortion prior to viability of the
fetus, or when the abortion is necessary to protect the
life or health of the woman; and,
b) The performance of an abortion is unauthorized if either
of the following is true:
i) The person performing or assisting in performing the
abortion is not a health care provider authorized to
perform or assist in performing an abortion, as
specified; or,
ii) The abortion is performed on a viable fetus, and
both of the following are established:
(1) In the good faith medical judgment of the
physician, the fetus was viable; and,
(2) In the good faith medical judgment of the
physician, continuation of the pregnancy posed no risk
to life or health of the pregnant woman.
3)Establishes the Medical Practice Act, administered by the
Medical Board of California, to regulate the practice of
medicine.
4)Provides the following under the Medical Practice Act:
a) The failure to comply with the RPA in performing,
assisting, procuring or aiding, abetting, attempting,
agreeing, or offering to procure an illegal abortion
constitutes unprofessional conduct;
b) A person is subject to the prohibition on the
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unauthorized practice of medicine if he or she performs or
assists in performing a surgical abortion, and at the time
of so doing, does not have a valid license to practice as a
physician and surgeon, or if he or she assists in
performing a surgical abortion and does not have a valid,
unrevoked, and unsuspended license or certificate to
perform the functions necessary to assist in performing a
surgical abortion;
c) A person is subject to the prohibition on the
unauthorized practice of medicine if he or she performs or
assists in performing a nonsurgical abortion, and at the
time of so doing, does not have a valid license to practice
as a physician and surgeon, or does not have a valid
license that authorizes him or her to perform or assist in
performing the functions necessary for a nonsurgical
abortion; and,
d) Defines nonsurgical abortion to include the termination
of pregnancy through the use of pharmacological agents.
5)Establishes the Nurse Practice Act, administered by the BRN,
to regulate the practice of nursing, including advance
practice registered nurses, which include NPs and CNMs.
6)Establishes the Physician Assistant Practice Act, administered
by the PAB, to regulate the practice of PAs.
7)Provides that any person who practices or attempts to
practice, or who advertises or holds himself or herself out as
practicing any system or mode of treating the sick or
afflicted in this state, or who diagnoses, treats, operates
for, or prescribes for any ailment, blemish, deformity,
disease, disfigurement, disorder, injury, or other physical or
mental condition of any person without a valid certificate to
practice medicine is guilty of a public offense, punishable by
a fine not exceeding $10,000, by imprisonment, as specified,
or both. Provides that any person who conspires with or aids
or abets another to commit this act is guilty of public
offense, subject to the same penalties.
FISCAL EFFECT : This bill has not yet been analyzed by a fiscal
committee.
COMMENTS :
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1)PURPOSE OF THIS BILL . The sponsors of this bill are: ACCESS
Women's Health Justice, American Civil Liberties Union of
California (ACLU), Black Women for Wellness, California
Latinas for Reproductive Justice, NARAL Pro-Choice California,
and, Planned Parenthood Affiliates of California (PPAC).
According to the author:
"The Guttmacher Institute indicates that 52% of California
counties lack an abortion provider. This lack of access
causes women to delay the termination of their pregnancies
into the second, or even third, trimesters. It also forces
rural women to travel long distances, in the case of some
rural areas, up to five hours; women have to raise money to
cover these travel costs, further delaying care. Even women
in urban areas face long wait-times to receive first trimester
abortion care. This bill will address this access shortage by
allowing advance practice clinicians (APCs) to perform this
procedure under the terms of their licenses. This bill helps
to ensure that women are getting safe and early care.
Furthermore, the bill will help provide comprehensive and
better coordinated reproductive health care in areas such as
miscarriage management, post-abortion follow-up, and
contraception. Women should be able to receive care from
clinicians they know and trust. When performed by physicians
as well as by APCs, first trimester aspiration abortion has
been proven to be effective, safe, and acceptable. A
multi-year study conducted by The University of California's
San Francisco's (UCSF) Bixby Center for Global Reproductive
Health, under a waiver from OSHPD, evaluated the safety,
effectiveness, and acceptability of APCs in providing
aspiration abortion. Over the five years of the study, HWPP
No. 171, almost 8,000 patients were provided care by an APC
and over 6,000 patients were provided care by a physician.
The results of the study show comparable rates of safety,
effectiveness and acceptability between the two categories of
providers.
2)BACKGROUND .
a) RPA . The RPA codified the constitutional principles of
Roe v. Wade (1973) 410 U.S. 959, 35 L.Ed.2d 694 ( Roe v.
Wade ) and replaced in its entirety the Therapeutic Abortion
Act. In 1967, Governor Ronald Reagan signed the
Therapeutic Abortion Act, which expanded legal abortion in
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California under very restrictive criteria. Most of those
restrictions were subsequently ruled unconstitutional in
the 1972 California Supreme Court case, People v. Barksdale
(1972) 8 Cal.3d 320, 105 Cal.Rptr 1 ( People v. Barksdale ).
The US Supreme Court issued its landmark Roe v. Wade and
Doe v. Bolton 410 U.S. 179 (1973), decisions in 1973, which
invalidated two of the three remaining provisions of the
Therapeutic Abortion Act.
Although Roe v. Wade and People v. Barksdale rendered much of
the Therapeutic Abortion Act obsolete, the Act itself was
not repealed by the Legislature until 2003, pursuant to SB
1301 (Kuehl), Chapter 385, Statutes of 2002, the
Reproductive Privacy Act. One rationale for the passage of
the Reproductive Privacy Act was the concern that the US
Supreme Court may overturn Roe v. Wade , and it would,
therefore, be important to have a state law which would
protect reproductive rights in California. In 2003, the
California Assembly passed AJR 2 (Jackson), Resolution
Chapter 63, Statutes of 2003, urging Congress and the
President to uphold the intent and substance for Roe v.
Wade and reiterated the elements of reproductive rights.
b) Aspiration Abortion . According to the UCSF Medical
Center, surgical abortion, also known as suction aspiration
abortion can be performed in a one-day procedure, usually
around three hours if less than 12 weeks pregnant or five
to six hours if 12 to 14 weeks pregnant. Suction is
created with either an electric pump or a manual pump.
Both methods use the same level of suction, and so can be
considered equivalent in terms of effectiveness and safety.
Vacuum or suction aspiration uses aspiration to remove
uterine contents through the cervix. It may be used as a
method of induced abortion, a therapeutic procedure used
after miscarriage, or a procedure to obtain a sample for
endometrial biopsy. Vacuum aspiration is most commonly
used for first-trimester abortions. The rate of infection
is lower than any other surgical abortion procedure at
0.5%. When used for uterine evacuation, vacuum aspiration
is 98% effective in removing all uterine contents.
Retained products of conception require a second aspiration
procedure. This is more common when the procedure is
performed very early in pregnancy, before six weeks
gestational age. Other complications occur at a rate of
less than one per 100 procedures and include excessive
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blood loss, injection injury to the cervix or uterus,
including perforation, and uterine adhesions.
c) Medication Abortion . Medication abortion, also referred
to as medical abortion is brought about by taking
medications that will end a pregnancy. Two medications,
mifepristone (RU-486) or methotrexate can be used for
medical abortion. Each of these medications is taken
together with another medication, misoprostol, to induce an
abortion.
d) OSHPD HWPP No. 171 . The HWPP No. 171at OSHPD permits
temporary legal waivers of certain practice restrictions or
educational requirements to test expanded roles and
accelerated training programs for health care
professionals. In March 2007, OSHPD approved HWPP No. 171
Access Through Primary Care Project Demonstrating the Role
of Advanced Practice Clinicians in Expanding Early
Pregnancy Care. The applicant/sponsor of HWPP No. 171 is
the Advancing New Standards in Reproductive Health (ANSIRH)
at UCSF. HWPP No. 171 sought to demonstrate and evaluate
the role of APCs in providing first trimester aspiration
abortion and miscarriage management as part of coordinated
early pregnancy care. The sponsor states that training
APCs in aspiration abortion as part of early pregnancy care
will address the critical shortage of abortion providers in
California. It will create providers in underserved areas
that need them most, assist them with better follow-up and
complication management, and integrate abortion services
into previously existing health care networks. Under HWPP
No. 171, there were 41 trainees and five training sites.
The total project cost was $3,943.00, funded by various
foundations.
Under HWPP No. 171, NPs, CNMs, and PAs from five partner
organizations (four Planned Parenthood affiliates and
Kaiser Permanente of Northern California) were trained to
competency in the provision of aspiration abortion. A
total of 28 NPs, five CNMs and seven PAs and 96 physicians
(trained in either family medicine or obstetrics and
gynecology) completed procedures during the duration of the
project. Physicians had a mean of 14 years of experience
providing abortions compared with a mean of 1.5 years among
NPs, CNMs, and PAs.
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e) Curriculum and Training Requirements for HWPP No. 171 .
Under HWPP No. 171, to conduct training, trainers are
experienced providers currently offering abortion services
at an institution participating in HWPP No. 171. All
physician trainers are required to have performed at least
200 procedures and to have an excellent safety record; and,
have received formal "train-the-trainer" instruction prior
to training advanced practice clinicians at their own
institution.
To participate in the project, NPs, CNMs, and PAs must have
at least 12 months successful clinical experience in a
health care facility and be licensed to practice in
California, demonstrate maintenance of Professional
Certification or equivalent credentialing, have at least
three months experience in the provision of early
medication abortion or equivalent experience, demonstrate
maintenance of certification of Basic Life Support, and
have a desire to work in the area of women's reproductive
health, including provision of early abortion care.
Additionally, each project participant must participate in
at least six days of simulated and hands on clinical
training to perform a minimum of 40 first trimester
abortions, participate in didactic teaching-learning in
core content: orientation and simulation lab, values
clarification and options counseling, complication
prevention and management, and post-procedure care and
contraception. Required readings included the ANSIRH
workbook and chapters relating to "Management of Unintended
and Abnormal Pregnancy." Each trainee must also
successfully complete all case-based exercises, achieve 90%
on final written exam, and complete all required evaluation
instruments. For clinical training, each trainee will
complete abortion training at one of the participating
health care facilities. The trainee will work one-on-one
with an experienced abortion provider and staff to practice
counseling, ultrasonography, pre-procedure assessment,
first trimester vacuum aspiration, and abortion aftercare.
During clinical training in early aspiration abortion care,
each trainee will:
i) Review the training program, meet training
faculty and staff, and receive an orientation to clinic
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policies and procedure for abortion care;
ii) Participate in values clarification around
pregnancy options, including practice in pre-abortion
counseling;
iii) Follow client(s) through an abortion visit from
counseling to recovery;
iv) Receive training in first trimester vacuum
aspiration abortion techniques: supervised practice
performing manual and electrical vacuum aspiration
using simulated model and "no touch" method; observe
faculty performing first trimester vacuum aspiration
abortions; and, under the direct supervision of
faculty, perform aspiration abortion procedures until
assessed as competent;
v) Perform tissue examinations until competent at
identifying pregnancy elements consistently and
accurately;
vi) Perform routine post-procedure and follow-up
care;
vii) Discuss case studies involving abortion-related
complications and manage complications when they occur;
viii) Complete evaluation instruments to assess
trainee knowledge and competence and to provide
feedback about the training program; and,
ix) Continue to participate in tracking of cases
with review of complicated cases by a supervising
physician during the post-procedure employment
utilization period.
f) Peer Review Study . In January 2013, the American
Journal of Public Health published "Safety of Aspiration
Abortion Performed by Nurse Practitioners, Certified Nurse
Midwives, and Physician Assistants Under a California Legal
Waiver." This study examined the impact on patient safety
if NPs, CNMs, and PAs were permitted to provide aspiration
abortions in California, as authorized by HWPP No. 171.
The study was designed to answer the following question:
"What would be the impact on patient safety if NPs, PAs,
and CNMs were permitted to provide aspiration abortions in
California?" The study compared complications of early
aspiration abortions completed by physicians and those
completed by newly trained NPs, CNMs, and PAs. According
to the study authors, a non-inferiority design was used
with a predetermined acceptable risk difference of 2%.
They indicate that unlike a superiority analysis, a
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non-inferiority study design determines whether the effect
of a new treatment is not worse than that of an active
control by more than a specified clinically acceptable
margin of difference. A non-inferiority design was
selected because the authors were not seeking to replace
physicians as abortion providers, or to determine whether
NPs, CNMs, and PAs were better than current providers of
care, but to identify additional, comparably safe providers
to supplement the provider pool.
Patients involved HWPP No. 171 were between the ages of 16
years (18 years for Planned Parenthood affiliates) and 40
years old, were seeking first trimester aspiration
abortion, and could speak English or Spanish. These
patients were enrolled at 22 clinical facilities between
August 2007 and August 2011. Patients were excluded if
general anesthesia was requested or did not meet specified
health-related criteria. The final sample size for the
project was 11,487, and of these procedures, 5,812 were
performed by physicians and 5,675 were performed by NPs,
CNMs or PAs. A sampling of the outcomes is as follows:
"Overall complications were rare. Out of 11,487 aspiration
abortions, 1.3% (152) resulted in a complication; 1.8% for
NP, CNM, and PA-performed aspirations while 0.9%
complications resulted from physician performed
aspirations. The majority of complications (146/152) were
minor and included cases of incomplete abortion (nine among
physicians and 24 among NPs, CNMs, and PAs); failed
abortion (seven among physicians and 11 among NPs, CNMs and
PAs); hematometra or collection of blood in the uterus
(three among physicians and 16 among NPs, CNMs, and PAs);
infection (seven among physicians and seven among NPs,
CNMs, and PAs); endocervical injury (two among physicians
and two among NPs, CNMs, and PAs); anesthesia-related
reactions (one among physicians and one among NPs, CNMs,
and PAs); and uncomplicated uterine perforation (three
among NPs, CNMs, and PAs). Complications without clear
etiology but accompanied by patient symptoms were
classified as symptomatic intrauterine material (16 among
physicians and 24 among NPs, CNMs, and PAs). Only six
major complications occurred (three in each provider
group), which included two uterine perforations, three
infections, and one hemorrhage." The study found that
there was no difference in risk of major complications
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between provider groups. The study concluded that abortion
complications were clinically equivalent between newly
trained NPs, CNMs, and PAs and physicians.
g) Legislative Counsel Opinion . In 2012, Senator Kehoe
asked Legislative Counsel whether existing law authorizes a
CNM, NP, or PA to perform an aspiration abortion. It is
the opinion of Legislative Counsel that existing law does
not authorize a NP, CNM, or PA to perform an aspiration
abortion. Legislative Counsel concluded that aspiration
abortion is a surgical abortion as that term is used in the
Medical Practice Act, and consequently, may be performed
only by a licensed physician and surgeon.
3)SUPPORT . The California Women's Health Alliance comprising of
30 organizations, including ACLU, ACCESS Women's Health
Justice, Black Women for Wellness, California Latinas for
Reproductive Justice, NARAL Pro-Choice California, and PPAC,
states that this bill will reduce barriers to care by
broadening the types of health professionals who can provide
early abortions and allows women to receive a wide spectrum of
reproductive health care including family planning, birth
control, miscarriage management, abortion, and post-abortion
follow-up from the same practitioner, allowing for continuity
of care.
The National Center for Youth Law, the Khmer Girls in Action,
the National Latina Institute for Reproductive Health, and the
California Latinas for Reproductive Justice state that despite
California's history of supporting comprehensive reproductive
health care, almost half of the counties do not have an
accessible abortion provider. This creates barriers to care
in both rural and urban areas; and in rural areas, some women
have to travel five hours by train or bus and also arrange for
child care and missed work. These barriers can force women to
delay abortions into advanced stages of pregnancy, which could
result in more complicated procedures.
4)OPPOSITION . The Concerned Women for American and the
California Catholic Conference state that this bill lowers the
standard of care for women and points out that upon review of
the peer review study, the data demonstrates that the
mid-level clinicians in the pilot project averaged twice the
complication rate as that of licensed physicians. In arguing
that this bill lowers the standard of care, the California
Nurses for Ethical Standards points out that standard of care
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means that the person performing the procedure must be trained
not only to simply perform the procedure, but also to deal
with complications that may arise. Serious complications such
as hemorrhage, infection, uterine perforation, cervical
injury, and shock can occur during surgical abortions. Even
specifically trained surgeons and OB/GYNs have a known
expected complication rate of 3% to 6% in these procedures.
When complications arise, a physician with a depth of training
and hospital privileges should be there to deal with them.
The proposed legislation does not require physician
supervision of non-physicians performing these surgical
procedures, even in remote areas.
The Coalition for Women and Children and the Pro-Life Mission:
International indicate that this bill contradicts Roe v. Wade
by authorizing non-physicians to perform first trimester
abortions in California.
5)RELATED LEGISLATION . SB 491 (Ed Hernandez) deletes the
requirement that NPs perform certain tasks, including
examination of patients and establishing a medical diagnosis,
pursuant to standardized procedures and/or consultation with a
physician or surgeon and authorizes a NP to perform those
tasks independently. Requires, after July 1, 2016, that NPs
possess a certificate from a national certifying body in order
to practice
6)PREVIOUS LEGISLATION .
a) SB 623 (Kehoe), Chapter 450, Statutes of 2012, extends
until January 1, 2014 HWPP No. 171 to evaluate the safety,
effectiveness, and acceptability of NP's, CNMs, and PAs in
providing aspiration abortions.
b) SB 1338 (Kehoe) of 2012 would have allowed NPs, CNMs,
and PAs who have completed training in under HWPP No. 171on
or before January 1, 2013 to continue to perform abortions
by aspiration techniques. SB 1338 died in Senate Business,
Professions and Economic Development Committee.
7)DOUBLE-REFERRED . This bill is double-referred. It passed out
of the Assembly Business, Professions and Consumer Protection
Committee on April 9, 2013 on a 9-4 vote.
8)AUTHOR'S AMENDMENTS . In an effort to address concerns raised
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by the California Medical Association, the author would like
to amend this bill to require that in order to perform
abortion by aspiration techniques, an NP, CNM or PA shall
adhere to standardized procedure or protocols that specify:
a) The extent of supervision by a physician and surgeon
with relevant training and expertise;
b) Procedures for transferring patients to the care of the
physician and surgeon or a hospital;
c) Procedures for obtaining assistance and consultation
from a physician and surgeon;
d) Procedures for providing emergency care until physician
assistance and consultation is available; and,
e) The method of periodic review of the provision of the
standardize procedure or protocols.
9)SUGGESTED AMENDMENTS . This bill makes it unprofessional
conduct for any NP, CNM, or PA to perform an abortion pursuant
to the Medical Practice Act (Section 2253 of the Business and
Professions Code (BPC)) without prior completion of training
and validation in clinical competency. However, BPC Section
2253 refers to abortion by medication or aspiration
techniques. Is it the author's intent to also require that
NPs, CNMs, or PAs also obtain training and validation in
clinical competency when performing abortion by medication?
It should be noted that CNMs, (see BPC Section 2746.51), and
NPs (see BPC Section 2836.1) are authorized to furnish or
order drugs or devices in accordance with standardized
procedures and protocols developed by these practitioners and
the supervising physician. Additionally, PAs may administer
or provide medication to a patient pursuant to a delegation
authority between the PA and the supervising physician (see
Section 3502.1).
Also, the unprofessional conduct provisions are included in the
general code section of the Business and Professions Code.
Since the practice of NPs, CNM, and PAs are governed by their
own Practice Acts, the author may wish to amend this bill to
place those provisions in those Practice Acts.
10)POLICY QUESTIONS . This bill requires the PAB to approve
training programs by regulations for PAs who want to perform
abortion by aspiration techniques. However, for purposes of
NPs and CNMs, the BRN is not required to approve such training
programs. In general, what is BRN's role in approving
training programs?
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REGISTERED SUPPORT / OPPOSITION :
Support
ACCESS Women's Health Justice (cosponsor)
American Civil Liberties Union of California (cosponsor)
Black Women for Wellness (cosponsor)
California Latinas for Reproductive Justice (cosponsor)
NARAL Pro-Choice California (cosponsor)
Planned Parenthood Affiliates of California (cosponsor)
ACT for Women and Girls
American Association of University Women
American College of Nurse-Midwives
American Nurses Association of California
Bay Area Communities for Health Education
Business and Professional Women of Nevada County
California Academy of Physician Assistants
California Association for Nurse Practitioners
California Church IMPACT
California Family Health Council
California Nurse-Midwives Association
California Women's Health Alliance
California Women's Law Center
Cardea Institute
Center on Reproductive Rights and Justice at UC Berkeley
Choice USA
Choice USA at California State University Long Beach
Choice USA at California State University Sacramento
Choice USA at Mills College
Choice USA at San Jose State
Choice USA at Scripps College
Forward Together
Fresno Barrios Unidos
Khmer Girls in Action
Law Students for Reproductive Justice
League of Women Voters of California
National Asian Pacific American Women's Forum
National Association for Youth Law
National Association of Social Workers, California Chapter
National Center for Lesbian Rights
National Center for Youth Law
National Council of Jewish Women California State Policy
Advocates
National Health Law Program
National Latina Institute for Reproductive Health
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National Network of Abortion Funds
Nevada County Citizens for Choice
Nursing Students for Choice at UCSF
Physicians for Reproductive Health
Planned Parenthood Mar Monte
Planned Parenthood of the Pacific Southwest
Reproductive Justice Coalition
Reproductive Justice Coalition of Los Angeles
Students for Reproductive Justice at Stanford University
Women's Community Clinic
Women's Health Specialists of California
Opposition
California Catholic Conference
California Nurses for Ethical Standards
California Right to Life Committee
Capitol Resource Center
Coalition for Women and Children
Concerned Citizens of California
Concerned Women for America
Life Legal Defense Foundation
Pregnancy Counseling Center
Pro-Life Mission: International
Several individuals
Analysis Prepared by : Rosielyn Pulmano / HEALTH / (916)
319-2097