BILL ANALYSIS Ó
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|Hearing Date:June 17, 2013 |Bill No: AB |
| |154 |
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SENATE COMMITTEE ON BUSINESS, PROFESSIONS
AND ECONOMIC DEVELOPMENT
Senator Ted W. Lieu, Chair
Bill No: AB 154Author:Atkins
As Amended:April 30, 2013 Fiscal:Yes
SUBJECT: Abortion.
SUMMARY: Permits a nurse practitioner (NP), certified nurse-midwife
(CNM) or physician assistant (PA), who complete specified training and
complies with specified standardized procedures or protocols, to
perform an abortion by aspiration techniques during the first
trimester of pregnancy.
Existing law, the Health and Safety Code (HSC):
1) Establishes the Reproductive Privacy Act (Act) which does the
following:
a) Makes legislative findings that every individual possesses a
fundamental right of privacy with respect to personal
reproductive decisions. Accordingly, specifies that it is the
public policy of the State of California that: (HSC § 123462)
i) Every individual has the fundamental right to choose or
refuse birth control.
ii) Every woman has the fundamental right to choose to
bear a child or to choose and to obtain an abortion, except as
specifically limited by this Act.
iii) The state shall not deny or interfere with a woman's
fundamental right to choose to bear a child or to choose to
obtain an abortion, except as specifically permitted by this
Act.
b) Includes the following definitions: (HSC § 123464)
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i) "Abortion" is any medical treatment intended to induce
the termination of a pregnancy except for the purpose of
producing a live birth.
ii) "Pregnancy" is the human reproductive process,
beginning with the implantation of an embryo.
iii) "State" is the State of California, and every
county, city, town and municipal corporation, and
quasi-municipal corporation in the state.
iv) "Viability" is the point in a pregnancy when, in the
good faith medical judgment of a physician, on the particular
facts of the case before that physician, there is a reasonable
likelihood of the fetus' sustained survival outside the uterus
without the application of extraordinary medical measures.
c) Provides that 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. (HSC § 123466)
d) Specifies that the performance of an abortion is
unauthorized if either of the following is true: (HSC § 123468)
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 pursuant to Section 2253
of the Business and Professions Code.
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.
(2) In the good faith medical judgment of the
physician, continuation of the pregnancy posed no risk to
the life or health of the pregnant woman.
Existing Law, the Business and Professions Code (BPC):
1) Provides that failure to comply with the Reproductive Privacy Act
in performing, assisting, procuring or aiding, abetting,
attempting, agreeing or offering to procure an illegal abortion
constitutes unprofessional conduct. (BPC § 2253 (a))
2) Makes it a public offense, punishable by a fine not exceeding
$10,000 or imprisonment, or both, for a person to perform or assist
in performing a surgical abortion , and at the time of so doing,
does not have a valid, unrevoked, and unsuspended license to
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practice as a physician and surgeon, or to assist in performing a
surgical abortion without a valid, unrevoked, and unsuspended
license or certificate obtained in accordance with some other
provision of law that authorizes him or her to perform the
functions necessary to assist in performing a surgical abortion.
(BPC § 2253 (b)(1))
3) Makes it a public offense, punishable by a fine not exceeding
$10,000 or imprisonment, or both, for a person to perform or assist
in performing a nonsurgical abortion if the person does not have a
valid, unrevoked, and unsuspended license to practice as a
physician and surgeon, or does not have a valid, unrevoked, and
unsuspended license or certificate obtained in accordance with some
other provision of law that authorizes him or her to perform or
assist in performing the functions necessary for a nonsurgical
abortion.
(BPC § 2253 (b)(2))
4) Provides that "nonsurgical abortion" includes the termination of
pregnancy through the use of pharmacological agents. (BPC § 2253
(c))
5) Establishes the Nursing Practice Act which provides for the
certification and regulation of RNs, NPs and advanced practice
nurses by the Board of Registered Nursing within the Department of
Consumer Affairs.
6) Provides that the practice of nursing includes direct and indirect
patient services, including but not limited to, the administration
of medications and therapeutic agents necessary to implement a
treatment, disease prevention or rehabilitative regimen ordered by
and within the scope of licensure of a physician, dentist,
podiatrist or clinical psychologist.
(BPC § 2735 (b)(2))
7) Provides that the practice of nursing may be performed under
"standardized procedures," as defined, for specified functions,
treatments and procedures. (BPC § 2725)
8) Authorizes a registered nurse to dispense specified drugs or
devices upon an order issued by a certified nurse-midwife, nurse
practitioner, or physician assistant if the nurse is functioning
within a specified clinic. (BPC § 2725.1)
9)Authorizes a registered nurse to dispense or administer hormonal
contraceptives in strict
adherence to specified standardized procedures. (BPC § 2725.2)
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10)Provides that a CNM may furnish or order drugs or devices,
including controlled substances, if furnished or ordered
incidentally to the provision of family planning services, routine
health care or perinatal care, or care rendered consistent with the
CNMs practice occurs under physician and surgeon supervision and is
in accordance with standardized procedures or protocols as
specified. (BPC § 2746.51)
11)Provides that a NP may furnish or order drugs or devices,
including controlled substances, if it is consistent with a nurse
practitioner's educational preparation or for which clinical
competency has been established and maintained; occurs under
physician and surgeon supervision and is in accordance with
standardized procedures or protocols as specified. (BPC § 2836.1)
12)Defines the furnishing or ordering of drugs or devices by NPs to
mean the act of making a pharmaceutical agent or agents available
to the patient in strict accordance with a standardized procedure.
(BPC § 2836.2)
13)Establishes the Physician Assistant Practice Act which provides
for the licensure of PAs by the Physician Assistant Board within
the Department of Consumer Affairs.
14)Provides that a PA may perform those medical services as set forth
by the regulations of the Medical Board of California when the
services are rendered under the supervision of a licensed physician
and surgeon, and provides that the PA and the supervising physician
and surgeon shall establish written guidelines or protocols, as
specified, for some or all of the tasks performed by the PA. (BPC
§ 3502)
15)Provides that a PA, while under the supervision of a physician and
surgeon, may administer or provide medication to a patient or
transmit orally or in writing a drug order under specified
conditions and protocols adopted by the supervising physician and
surgeon. (BPC § 3502.1)
This bill:
1) Declares that it is unprofessional conduct for any NP, CNM, or PA
to perform an abortion by medication or aspiration techniques in
the first trimester of pregnancy without completing training and
validation of clinical competency.
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2) Deletes obsolete references to "performing, assisting, procuring or
aiding, abetting, attempting, agreeing or offering to procure an
illegal abortion" in regards to what constitutes unprofessional
conduct for failure to comply with the Reproductive Privacy Act.
3) Deletes obsolete references to "surgical" and "nonsurgical"
abortions and replaces the terms as necessary with abortion by
"medication" or "aspiration techniques."
4) Deletes obsolete references to "assisting" in performing an
unauthorized abortion in regards to what constitutes a public
offense.
5) States that a person is not guilty of the public offense of
practicing medicine without the appropriate legal authorization if
he or she performs an abortion by aspiration techniques in the
first trimester of pregnancy while having a valid, unrevoked and
unsuspended license or certificate authorizing him or her to
perform an abortion by aspiration technique, as specified.
6) Requires a NP or CNM to complete training recognized by the Board
of Registered Nursing in order to perform an abortion by aspiration
techniques.
7) Requires the competency-based training protocols established by
Health Workforce Pilot Project No. 171 (HWPP #171) through the
Office of Statewide Health Planning and Development (OSHPD) to be
utilized from January 1, 2014, until January 1, 2016.
8) Authorizes NPs or CNMs who have completed the HWPP #171 training,
achieved clinical competency and adhere to specified standardized
procedures to perform abortions by aspiration techniques.
9) Requires a NP and CNM to adhere to standardized procedures in
order to perform an abortion by aspiration techniques that must
specify all of the following:
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
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assistance and consultation is available; and,
e) The method of periodic review of the provisions of the
standardized procedures.
10)Requires a PA 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, as specified, in order to receive authority from his or
her supervising physician and surgeon to perform an abortion by
aspiration techniques; further requires the training and clinical
competency protocols established by HWPP #171 through OSHPD to be
used as training and clinical competency guidelines to meet this
requirement from January 1, 2014, through January 1, 2016.
11)Deems the training protocols established by HWPP #171 to meet the
PAB standards.
12)Authorizes a PA who has completed the HWPP #171 training, achieved
clinical competency, received authority from his or her supervising
physician and surgeon, and acts according to specified protocols,
to perform abortions by aspiration techniques.
13)Requires a PA, in order to receive authority from his or her
supervising physician and surgeon to perform an abortion by
aspiration techniques, to comply with 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 protocols.
FISCAL EFFECT: This measure has been keyed "fiscal" by Legislative
Counsel. According to the Assembly Appropriations Committee analysis
dated May 15, 2013, this bill "?will result in unknown costs or
savings, potentially in excess of $150,000. For example, if the
number of Medi-Cal first trimester procedures increases by 350 per
year, Medi-Cal costs would increase by approximately $152,000. On the
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other hand, a similar reduction in second trimester procedures would
result in savings of approximately $212,000, based on data from 2009."
COMMENTS:
1. Purpose. The bill is sponsored by the following: ACCESS Women's
Health Justice, American Civil Liberties Union of California , Black
Women for Wellness , California Latinas for Reproductive Justice ,
NARAL Pro-Choice California and Planned Parenthood Affiliates of
California . According to the Author, "Early abortion access is a
critical public health issue. An estimated one in three women will
decide to terminate a pregnancy by age 45, yet many women often do
not have sufficient access to early abortions because of the
limited number of physicians providing the services in their
communities?By authorizing trained and qualified health
professionals to provide care, this measure would allow women to
receive timely care locally from advanced trained practitioners
they already know and trust through a more responsive health care
delivery system."
2. Background.
a) Reproductive Privacy Act. The Reproductive Privacy Act
codified the constitutional principles of 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 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. The
United States Supreme Court issued its landmark Roe v. Wade
(1973) 410 U.S. 959, 35 L.Ed.2d 694, and Doe v. Bolton, decisions
in 1973, which invalidated two of the three remaining provisions
of the Therapeutic Abortion Act.
Although Roe and 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 this Act was the concern that the United
States Supreme Court may overturn Roe v. Wade, and it would,
therefore, be important to have a state law which would protect
reproductive rights in the State of California. In 2003, the
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California Assembly passed
AJR 2 (Jackson, Chapter 63, filed with the Secretary of State June
19, 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 Technique and Procedure. History. Vacuuming as a
means of removing the uterine contents, rather than the previous
use of a hard metal curette, was pioneered in 1958 by Doctors Wu
Yuantai and Wu Xianzhen in China, but the results of their
research study were only translated into English on the fiftieth
anniversary of the study that "ultimately led to the technique
becoming the world's commonest and safest obstetric procedure."
Dorothea Kerslake introduced the method into the United Kingdom
in 1967, and published a study in the United States that further
spread the technique. Harvey Karman in the United States refined
the technique in the early 1970s with the development of the
Karman cannula, a soft, flexible cannula that avoided the need
for initial cervical dilatation and so reduced the risks of
puncturing the uterus.
Description . 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. The rate of infection is lower than any other surgical
abortion procedure at 0.5%. Some sources may use the terms
dilation and evacuation or "suction" dilation and curettage to
refer to vacuum aspiration, although those terms are normally
used to refer to distinct procedures.
Clinical Uses . Vacuum aspiration may be used as a method of
induced abortion, as a therapeutic procedure after miscarriage,
to aid in menstrual regulation and to obtain a sample for
endometrial biopsy. It is also used to terminate molar
(abnormal) pregnancy. When used as a miscarriage treatment or an
abortion method, vacuum aspiration may be used alone or with
cervical dilation anytime in the first trimester (up to 12 weeks
gestational age). For more advanced pregnancies, vacuum
aspiration may be used as one step in a dilation and evacuation
procedure. Vacuum aspiration is the procedure used for almost
all first-trimester abortions in many countries.
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Procedure . Vacuum aspiration is an outpatient procedure that
generally involves a clinic visit of several hours. The
procedure itself typically takes less than 15 minutes. Suction
is created with either an electric pump (electric vacuum
aspiration or EVA) or a manual pump (manual vacuum aspiration or
MVA). Both methods use the same level of suction, and so can be
considered equivalent in terms of effectiveness and safety. The
clinician may first use a local anesthetic to numb the cervix.
Then, the clinician may use instruments called "dilators" to open
the cervix, or sometimes medically induce dilation with drugs.
Finally, a sterile cannula is inserted into the uterus and
attached via tubing to the pump. The pump creates a vacuum which
empties uterine contents. After a procedure for abortion or
miscarriage treatment, the tissue removed from the uterus is
examined for completeness. Expected contents include the embryo
or fetus as well as the decidua, chorionic villi, amniotic fluid,
amniotic membrane and other tissue. Post-treatment care includes
brief observation in a recovery area and a follow-up appointment
approximately two weeks later.
Complications. 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 6 weeks gestational age. Other
complications occur at a rate of less than 1 per 100 procedures
and include excessive blood loss, infection, injury to the cervix
or uterus, including perforation, and uterine adhesions.
Advantages Over Dilation and Curettage. Dilation and curettage
(D&C), also known as sharp curettage, was once the standard of
care in situations requiring uterine evacuation. However, vacuum
aspiration has a number of advantages over D&C and has largely
replaced D&C in many settings. Vacuum aspiration may be used
earlier in pregnancy than D&C. Manual vacuum aspiration is the
only surgical abortion procedure available earlier than the 6th
week of pregnancy. Vacuum aspiration has lower rates of
complications when compared to D&C. Vacuum aspiration,
especially manual vacuum aspiration, is significantly less
expensive than D&C. The equipment needed for vacuum aspiration
costs less than a curette set. Unlike D&C, vacuum aspiration
does not require general anesthesia and so can be performed as an
outpatient procedure at a clinic rather than in a hospital
surgical setting. D&C is generally provided only by physicians.
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Manual vacuum aspiration does not require electricity and so can
be provided in locations that have unreliable electrical service
or none at all. Manual vacuum aspiration also has the advantage
of being quiet, without the noise of an electric vacuum pump.
c) Health Workforce Pilot Project Study #171. California's
Health Workforce Pilot Projects (HWPP) Program was established in
1972, and continues to be administered by the Office of Statewide
Health Planning and Development. The HWPP program offers an
opportunity to safely demonstrate and evaluate new approaches to
care delivery before changing laws and regulations. HWPP
demonstrations can allow health care workers to acquire new
skills; develop new health care occupations or accelerate
training in existing categories; or teach new roles to providers
with no prior training. The HWPP program has played a role in
the passage of pivotal legislation, such as the Nurse Practice
Act, Dental Practice Act, and Emergency Medical Services Act,
among many others.
According to the Center for the Health Professions at the
University of California, San Francisco (UCSF), which in 2010
conducted a review of HWPP Programs from 1973-2005, a total of
171 applications were made to HWPP, and of the 171 applications
121 were approved and more than 65 percent of the approved and
implemented projects affected some type of policy change. At the
same time, many pilot projects appear to have been run well with
exemplary results for the practitioners and patients in terms of
improved access, cost savings or health outcomes. UC System and
California State University-sponsored projects achieved some type
of regulatory or legal change in over 80 percent and 60 percent,
of their respective pilot applications. As an example of a
health care practitioner profession, nurses achieved some type of
policy change in more than 60 percent of their pilots.
Approximately 40 pilots were run which were designed to
demonstrate nurses' ability to function in expanded roles. Many
of these were coordinated efforts demonstrating the same
objectives at multiple locations. Other practitioner groups,
including EMTs and dental auxiliaries, followed the same model
with success.
In an effort to expand the pool of education, trained and skilled
California abortion providers, the Advancing New Standards in
Reproductive Health (ANSIRH) program at the UCSF Bixby Center for
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Global Reproductive Health sponsored HWPP #171 was initiated on
March 31, 2007. The purpose of the program was to evaluate the
safety, effectiveness and acceptability of NPs, CNMs, and PAs in
providing first-trimester aspiration abortion. Until September
2012, HWPP #171 operated under the auspices of California's
Office of Statewide Health Planning and Development (OSHPD) to
improve health care access. For the duration of the project,
OSHPD provided a mechanism to temporarily suspend laws and
regulations that might otherwise restrict NPs, CNMs and PAs from
performing aspiration abortion
Collaborating Organizations . UCSF collaborated with five Partner
Organizations, including Kaiser Permanente of Northern California
and four Planned Parenthood affiliates: Shasta Pacific, Mar
Monte, Los Angeles, and Pacific Southwest.
Results . The results of the HWPP #171 study were published in the
American Journal of Public Health (AJPH) on January 17, 2013.
The study analyzed 11,487 aspiration procedures performed on
patients in their first trimester of pregnancy. Physicians
performed 5,812 of the procedures and the remaining 5,675 were
performed by NPs, CNMs or PAs. Results showed that complications
were rare. The rate of complications from CNM, NP, and PA
performed aspirations was 1.8%, as compared to physicians' rate
of 0.9%. The study further noted that the majority of
complications were minor and "complication rates from aspiration
abortions performed by recently trained NPs, CNMs, and PAs were
statistically no worse than those performed by the more
experienced physician group." The study also noted that only 1
additional complication would occur for every 120 procedures as a
consequence of having a NP, CNM or PA perform the procedure.
d) Legislative Counsel's Opinion on Aspiration Abortion.
Legislative Counsel was recently asked whether existing law
authorizes a NP, CNM, or PA to perform an aspiration abortion.
On April 6, 2012, Counsel opined that existing law does not
authorize a NP, CNM or PA to perform an aspiration abortion.
Counsel reached the conclusion that an aspiration abortion is a
surgical abortion, as that term is used in BPC § 2253 (b)(1),
and, consequently may be performed only by a licensed physician
and surgeon.
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e) Waiver for HWPP #171. While the original HWPP #171
application stated that aspiration abortions are within the legal
authority of NPs, CNMs and PAs, the application was amended prior
to the pilot project approval to reflect the uncertainty of that
assertion and the need for suspending BPC § 2253. The approved
version of the application states in relevant part, "There is a
discrepancy of opinion among health care professionals, boards
and organizations as to whether advanced practice clinicians are
prohibited from performing aspiration abortion under BPC Section
2253. Because of this discrepancy in interpretation, ANSIRH
seeks a waiver of BPC Section 2253 for trainees participating in
the pilot project for the duration of the project." This
amendment in the application was in response to the disagreement
within the health professional community as to whether aspiration
abortion should be classified as surgical or nonsurgical
abortion, and, therefore, whether the identified health
professionals could legally perform aspiration abortion
procedures. The suspension of BPC § 2253, along with the Title
22 California Code of Regulations (CCR) § 75043 and Title 16 CCR
§ 1399.541, was deemed necessary for these clinicians to legally
provide aspiration abortions. A waiver of these provisions was
therefore granted by the Office of Statewide Health Planning and
Development with the approval of the HWPP #171 application on
March 31, 2007.
3. Clinical Training for Abortion Care. According to the Author,
many NP, CNM and PA programs provide instruction on unintended
pregnancy care including medication abortion. Some programs teach
uterine aspiration for treating common women's health conditions
such as uterine bleeding problems, miscarriage management, or for
gynecological cancer diagnosis. These training programs are
approved by national accreditation bodies as well as state
regulatory agencies.
There are also opportunities for NPs, CNMs and PAs to obtain
post-graduate continuing education for early abortion care. This
training is currently offered by national professional
organizations that are required to meet national accreditation
standards established by the Department of Education. Further,
these nationally accredited continuing education providers are
approved by the BRN and the PAB. For example, numerous published
abortion training curricula and guidelines exist through the
Association of Reproductive Health Professionals and the National
Abortion Federation which provide competency-based training in
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comprehensive early abortion care including medication/aspiration
abortion procedures.
4. Other States. Not all states limit the practice of aspiration
abortion to physicians and surgeons. Specifically, in Vermont,
New Hampshire, Montana and Oregon, NPs, CNMs and PAs have been
providing first trimester abortion care by medication or aspiration
procedure for decades, according to the Sponsors. These clinicians
follow evidence-based clinical standards and guidelines established
by organizations such as the National Abortion Federation, which is
registered with the National Guideline Clearinghouse, for the
provision of abortion care. Clinical facilities and clinicians use
these national standards as "protocols" in the provision of
medication or aspiration abortion.
5. Arguments in Support.
The California Women's Health Alliance which represents 33
different organizations, including the sponsors of this bill,
writes, "AB 154 is necessary. Despite California's history of
supporting comprehensive reproductive health care, over half of our
counties do not have an accessible abortion provider. This creates
barriers to care in both rural and urban areas; in rural areas,
some women have to travel five hours by train or bus and also
arrange for child care and missed work. In urban areas, many women
face long delays in getting medical appointments. These barriers
can force women to delay abortions into later stages of pregnancy,
which can result in a more complicated procedure."
Planned Parenthood Affiliates of California (Sponsor), Planned
Parenthood of Santa Barbara, Ventura and San Luis Obispo Counties,
Inc. , Planned Parenthood Mar Monte , Planned Parenthood Advocacy
Project of Los Angeles County, Planned Parenthood of the Pacific
Southwest and Planned Parenthood Shasta Pacific Action Fund all
write in support of the measure. In their letter they state, "AB
154 enacts the results and findings from a multi-year study
conducted by the University of California at San Francisco's Bixby
Center for Global Reproductive Health, under the auspices of the
Office of Statewide Health Planning and Development?The study
showed exceptionally low rates of complications by both the NPs,
CNMs and PAs and the physicians, affirming that aspiration abortion
is an extremely safe procedure overall and safe whether performed
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by the trained NPs, CNMs and Pas, or by the physicians. Access to
the full range of first trimester reproductive health services is
an important aspect of women's health. An estimated one in three
women will decide to terminate a pregnancy by age 45, yet many
women often do not have sufficient access to early, safe abortions
because of the limited number of physicians providing the services
in their communities."
The California Medical Association also supports the bill. In
their letter they note, "When any allied health professional seeks
to expand their authority or scope of practice, CMA prioritizes
patient safety. Physician supervision and appropriate training and
education are paramount factors in this determination. AB 154
addresses both."
The American Nurses Association of California states their support
of the bill when they write, "By expanding the types of trained and
qualified health professionals who can provide early abortions to
include Nurse Practitioners, Certified Nurse Midwives and Physician
Assistants, AB 154 removes a barrier in the law that prevents an
Advanced Practice Registered Nurse from functioning as the Nurse
Practice Act defines."
The California Association for Nurse Practitioners (CANP) supports
the bill. In their letter they write, "CANP acknowledges the
complex personal, political, religious and professional
sensitivities that surround the advancement of AB 154. First and
foremost, CANP is committed to furthering the practice of nurse
practitioners in California. Among CANP's core missions is the
promotion of expanding the scope of practice for licensed NPs?In
reaching a 'support' position, the association has concluded that
AB 154 is amenable to this mission. We believe that the
performance of these procedures is consistent with the education
and training held by nurse practitioners. Additionally, as fewer
physicians are willing or available to provide these services, it
becomes important for women to have access to all types of health
care services provided by non-physicians."
6. Arguments in Opposition. Concerned Women for America opposes the
bill. In their letter they state, "The bill's proponents hold that
increasing access to abortion in this manner is a 'critical public
health issue.' We contend that allowing non-physicians to
supervise medical abortions and perform aspiration abortions
presents a critical public health issue as well. Abortion carries
the potential for serious complications, including hemorrhage,
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uterine perforation, cervical injury and incomplete abortion.
There is no need to increase the risk to patients for an elective
procedure?especially in a state where, according to the Guttmacher
Institute, a mere one percent of women live in a county where there
is no abortion provider. The need for a very small number of women
to potentially have to travel across a county line in order to
obtain an elective procedure hardly seems worth the general risk to
women's safety."
The Coalition for Women and Children shares their concerns when
they write, "We must put the health and safety of women first,
rather than the profits of the abortion industry. The UCSF pilot
project's study was done under the most highly supervised,
specially selected, hygienic conditions and even then, women whose
abortions were done by non-physicians experienced complication
rates twice that of those women whose abortions were performed by
physicians. Proponents of this bill argue that these unsafe
non-physician providers will increase abortion access to women in
rural counties, yet the abortion industry's own Guttmacher
Institute lists California already as the #1 state in abortion
provider access and publicly funded support for abortion."
Shasta Lake City Councilman Greg Watkins writes in his letter, "I
strongly oppose AB 154. Women deserve the highest level of medical
care, but this bill would lower the standard of care for women in
California."
The University of Southern California Students for Life also
opposes the bill and they write in their letter, "It is surprising
that the Legislature would consider approving a lowered standard of
care for women. According to the UCSF pilot project's own study,
abortions performed by these non-physicians have complication rates
twice that of abortions performed by physicians."
The San Jose Students for Life and the John Paul the Great Catholic
University Students for Life both write in their opposition
letters, "We urge you to put the safety of women first and vote no
on AB 154."
The California Catholic Conference, Inc . argues, "The reality of a
'right' to health care, which we support, does not and should not
require the government to facilitate access by weakening health
standards or reclassifying medical practices?Decisions of this
import, made quickly and with no consideration of unintended
consequences for women's health, for future health policy,
insurance rate, or government subsidized payments, etc. will set a
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very poor precedent, particularly at a time when the government is
playing a more influential role in health care delivery through the
implementation of the Federal ACA."
The Traditional Values Coalition also opposes the bill. In their
letter they state, "Current California Business 4826 requires that
an animal abortion be performed only by a veterinary surgeon. Yet
AB 154 removes the current requirement that a human abortion be
performed only by a trained surgeon. Non-doctors could perform
surgical abortions in AB 154 is passed?Why compromise the health of
women? Why give animals a higher standard of care than human
beings?"
The Pro-Life Mission: International argue, "Women deserve the
highest level of medical care, but this bill would lower the
standard of care for women in California. Abortion is a dangerous
surgical medical procedure, often leading to hemorrhage,
perforation of the uterus and bowels, and sometimes death. It is
one of the least regulated industries in California and a further
diminution in the requirements as set out in AB 154 of those who
perform the procedure will only put more women at risk."
The Capitol Resource Family Impact contends, "Women, and certainly
young girls who are given access in this state to abortion at 12
years of age, are unaware of the complications that even a first
term pregnancy can bring. Pregnant women seeking abortions should
not be deceived into believing that the experience of a clinician
is equal to the training of a physician. This bill simply creates
an industry for non-physician abortionists, generating more revenue
for the Abortion Industry."
7. Related Legislation This Session. SB 491 (Hernandez, 2010) 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.
( Status : This measure passed this committee and is currently in
the Assembly Rules Committee.)
8. Prior Related Legislation. SB 623 (Kehoe, Chapter 450, Statutes of
2012) extended until January 1, 2014, HWPP #171 to evaluate the
safety, effectiveness and acceptability of Nurse Practitioner's,
Certified Nurse Midwives, and Physician Assistants in providing
aspiration abortions.
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SB 1338 (Kehoe, 2012) would have allowed NPs, CNMs, and PAs who
have completed training in under HWPP #171on or before January 1,
2013 to continue to perform abortions by aspiration techniques.
( Status : This bill failed passage in Senate Business, Professions
and Economic Development Committee.)
AB 2348 (Mitchell, Chapter 460, Statutes of 2012) authorized a
registered nurse to dispense specified drugs or devices upon an
order issued by a certified nurse-midwife, nurse practitioner or
physician assistant if the nurse is functioning within a specified
clinic. The bill also authorized a registered nurse to dispense or
administer hormonal contraceptives in strict adherence to specified
standardized procedures.
AB 1306 (Donnelly, 2011) would have required the person authorized
to perform the abortion to provide complete and full information on
the potential physiological and psychological impacts of an
abortion, in both verbal and written form, to any woman seeking an
abortion in order to obtain her informed consent to the abortion
during a counseling session where only verified immediate relatives
or legal guardians of the woman may join her in the counseling
room. ( Status : This measure failed passage in the Assembly Health
Committee.)
SB 1009 (Benoit, 2007) would have enacted the Unborn Child Pain
Awareness Act of 2008, to require, with an exemption for medical
emergency, the physician performing the abortion to offer to the
pregnant woman information and counseling on fetal pain. Also
required the Department of Public Health to develop a related
brochure and waiver form, for the Medical Board of California to
adopt regulations for revocation or suspension of medical licenses
for violation of this requirement, and authorized the Attorney
General and the woman or her family to bring civil action for
damages and penalties for violation of this requirement. ( Status :
This measure failed passage in the Assembly Health Committee.)
SB 1487 (Hollingsworth, 2006) would have prohibited a physician and
surgeon from performing an abortion unless he or she has obtained
the written assurance from the patient that she understands that
she may not be coerced into having an abortion, and that her
decision to have an abortion is voluntary. The bill would have
also required a form to be signed to that effect and to be placed
in the patient's chart. ( Status : This measure failed passage in
the Senate Health Committee.)
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AB 2512 (Sharon Runner, 2006) was similar to SB 1009 which would
have enacted the Unborn Child Pain Awareness Act of 2006. ( Status :
This measure failed passage in the Assembly Health Committee.)
SB 147 (Runner, 2005) was also similar to SB 1009 and AB 2512 which
would have enacted the Unborn Child Pain Awareness Act of 2005.
( Status : The hearing was cancelled by the Author in the Senate
Health Committee.)
AB 669 (La Suer, 2006) would have required a physician and surgeon
who performs an abortion to advise the patient that she should seek
follow-up medical care, as prescribed. ( Status : This measure
failed passage in this Committee.)
AB 1427 (Mountjoy, 2005) would have required a physician and
surgeon performing an abortion on a minor to retain sufficient
tissue of the aborted fetus to permit DNA testing for the purpose
of determining paternity and establishing the guilt or innocence of
the accused in any criminal action regarding sexual crimes relating
to the aborted pregnancy.
( Status : This measure failed passage in the Assembly Public Safety
Committee.)
AJR 3 (Cohn, Chapter 83, Filed with the Secretary of State July 18,
2005) relative to the
32nd anniversary of Roe v. Wade, urged Congress and the President
to uphold the intent and substance for Roe v. Wade and reiterated
the elements of reproductive rights.
AJR 2 (Jackson, Chapter 63, Filed with the Secretary of State June
19, 2003) urged Congress and the President to uphold the intent and
substance for Roe v. Wade and reiterated the elements of
reproductive rights.
SB 1050 (Figueroa, Chapter 1085, Statutes of 2002) repealed one of
the penalty provisions for the unlawful practice of medicine
(Section 2053 of the BPC) which was a felony and combined this
provision with another provision which provided for only
misdemeanor violations. The penalty provision for the unlawful
practice of medicine in now contained in Section 2052 of the BPC
and provides that a violation of this section shall be a public
offense, punishable by a fine or imprisonment, or both.
SB 1301 (Kuehl, Chapter 385, Statutes of 2002) deleted provisions
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of the Therapeutic Abortion Act and enacted the Reproductive
Privacy Act, which this analysis references and details on Page 1
and 5 above.
SB 370 (Burton, Chapter 692, Statutes of 2000) repealed Penal Code
provisions relating to an abortion and instead provided that
penalty provisions relating to the unlawful practice of medicine
shall apply, which could include a misdemeanor offense as well as a
felony offense, punishable by imprisonment in a county jail not
exceeding one year or in state prison.
9. Suggested Author's Amendment. In consideration of related
legislation this session, namely SB 491 (Hernandez, 2013), that may
affect the requirement for NPs to work under standardized
procedures and protocols, the Committee recommends the following
amendment to this measure. This amendment will ensure that the
standardized procedures and protocols mandated in this measure will
stay in effect regardless if SB 491 is or is not signed into law.
Page 3, Line 32, after "2725.4" and before "(a)" Insert:
"Notwithstanding any other provision of this chapter:"
That language will operate as a preamble to all provisions of each
of the subdivisions in Section 2725.4. "this chapter" refers to
Chapter 6 which covers nurse midwives and nurse practitioners.
NOTE : Double-referral to Health Committee second.
SUPPORT AND OPPOSITION:
Support:
California Women's Health Alliance:
ACCESS Women's Health Justice
ACLU of California
ACT for Women and Girls
American Nurses Association/California
Bay Area Communities for Health Education
Black Women for Wellness
Business and Professional Women of Nevada County
California Church IMPACT
California Family Health Council
California Latinas for Reproductive Justice
California Nurse Midwives Association
California Women's Law Center
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Cardea Institute
Center on Reproductive Rights and Justice at Berkeley Law
Choice USA
Forward Together
Fresno Barrios Unidos
Khmer Girls in Action
League of Women Voters of California
NARAL Pro-Choice California
National Asian Pacific American Women's Forum
National Center for Lesbian Rights
National Council of Jewish Women- California
National Health Law Program
National Latina Institute for Reproductive Health
National Network of Abortion Funds
Nevada County Citizens for Choice
Nursing Students for Choice- UCSF
Physicians for Reproductive Health
Planned Parenthood Affiliates of California
Reproductive Justice Coalition of Los Angeles
Women's Community Clinic
Women's Health Specialists of California
California Association for Nurse Practitioners
California Medical Association
Planned Parenthood Advocacy Project of Los Angeles County
Planned Parenthood Mar Monte
Planned Parenthood of Santa Barbara, Ventura and San Luis Obispo
Counties, Inc.
Planned Parenthood Shasta Pacific Action Fund
Planned Parenthood of the Pacific Southwest
Several individuals
Opposition:
California Catholic Conference
Coalition for Women and Children
Concerned Women for America
Greg Watkins, City Councilman, City of Shasta Lake
John Paul the Great Catholic University Students for Life
Pro-Life Mission: International
San Jose State Students for Life
Traditional Values Coalition
University of Southern California Students for Life
Capitol Resource Family Impact
Several individuals
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Consultant:Le Ondra Clark, Ph.D.