BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 154
AUTHOR: Atkins
AMENDED: June 24, 2013
HEARING DATE: July 3, 2013
CONSULTANT: Moreno
SUBJECT : Abortion.
SUMMARY : Permits nurse practitioners, certified nurse midwives,
and physician assistants, who have completed training and
achieved clinical competency through the Health Workforce Pilot
Project No. 171 or who have completed training recognized by the
Board of Registered Nursing or the California Medical Board, to
perform abortions by aspiration techniques, in adherence to
standardized procedures and training.
Existing law:
1.Provides for the licensing and regulation of nurse
practitioners (NPs), certified nurse midwives (CNMs) by the
Board of Registered Nursing (BRN) and of physician assistants
(PAs) by the Medical Board of California (MBC).
2.Establishes the Reproductive Privacy Act (RPA), which
prohibits the state from denying or interfering with a women'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. Defines "abortion," for purposes
of the RPA, as any medical treatment intended to induce the
termination of a pregnancy except for the purpose of producing
a live birth.
3.Specifies that 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.
4.Establishes the Medical Practice Act, administered by the MBC,
to regulate the practice of medicine by physicians. Makes it a
violation of the Medical Practice Act if a person performs or
assists in performing surgical or nonsurgical abortion, and at
the time of so doing, does not have a valid license to
practice as a physician, or if he or she assists in performing
an abortion and does not have a license or certificate to
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AB 154 | Page 2
perform the necessary functions.
5.Defines "nonsurgical abortion" to include termination of
pregnancy through the use of pharmacological agents. Permits
NPs, CNMs, and PAs to perform a nonsurgical abortion that
includes termination of pregnancy through the use of
pharmacological agents.
6.Establishes the Health Workforce Pilot Project (HWPP) program
within the Office of Statewide Health Planning and Development
(OSHPD) to designate experimental health workforce projects as
approved projects sponsored by community hospitals or clinics,
non-profit educational institutions, or government agencies
engaged in health or education activities. Establishes,
through regulations, the definitions and criteria for
administering the HWPP.
7.Permits a trainee in an approved project, notwithstanding any
other provision of law, to perform health care services under
the supervision of a supervisor where the general scope of the
services has been approved by OSHPD.
8.Prohibits OSHPD from approving a project for a period lasting
more than two training cycles plus a preceptorship of more
than 24 months, unless it determines that the project is
likely to contribute substantially to the availability of
high-quality health services in the state or a region of the
state.
9.Requires OSHPD to extend the duration of the health workforce
project known as HWPP No. 171 until January 1, 2014.
This bill:
1. Permits NPs, CNM, and PAs, who have completed training
and achieved clinical competency through the HWPP No. 171
or who have completed training recognized by the BRN or
MBC, to perform abortions by aspiration techniques, in
adherence to standardized procedures and training described
below.
2.Requires an NP or a CNM, in order to perform an abortion by
aspiration techniques to:
a. Complete training recognized by the Board of Registered
Nursing. Requires, until January 1, 2016, the
competency-based training protocols established HWPP No.
AB 154 | Page
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171 to be used for this purpose; and,
b. Adhere to standardized procedures developed in
compliance with existing law for the practice of nursing
and that specify all of the following:
i. The extent of supervision by a physician with
relevant training and expertise;
ii. Procedures for transferring patients to the care of
the physician or a hospital;
iii. Procedures for obtaining assistance and
consultation from a physician;
iv. Procedures for providing emergency care until
physician assistance and consultation is available; and,
v. The method of periodic review of the provisions of
the standardized procedures.
3.Requires a PA, in order to receive authority from his or her
supervising physician and surgeon to perform an abortion by
aspiration techniques, to complete training either through
training programs, as specified, or by training to perform
medical services which augment his or her current areas of
competency, as specified. Requires, from January 1, 2014 to
January 1, 2016, the training and clinical competency
protocols established by HWPP No. 171 to be used as training
and clinical competency guidelines to meet this requirement.
4.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 physician 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 or a hospital;
c. Procedures for obtaining assistance and consultation
from a physician;
d. Procedures for providing emergency care until physician
assistance and consultation is available; and,
e. The method of periodic review of the provisions of the
protocols.
5.Requires the training protocols established by HWPP No. 171 to
be deemed to meet the standards of the MBC.
AB 154 | Page 4
6.Makes it unprofessional conduct for an NP, CNM, or PA to
perform an abortion by aspiration techniques without prior
completion of training and validation of clinical competency.
7.Makes technical, clarifying changes to existing law related to
the provision of abortions, including deleting references to
"surgical abortion" and "nonsurgical abortion."
FISCAL EFFECT : According to the Assembly Appropriations
Committee, 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 other hand, a
similar reduction in second trimester procedures would result in
savings of approximately $212,000, based on data from 2009.
PRIOR VOTES :
Assembly Business, Professions and Consumer Protections:9- 4
Assembly Health: 13- 6
Assembly Appropriations: 12- 5
Assembly Floor: 50- 25
COMMENTS :
1.Author's statement. Fifty-two percent of California counties
lack an accessible 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. AB 154 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 NPs, CNM, and PAs, first trimester
aspiration abortion has been proven to be effective, safe and
acceptable. A multi-year study conducted by The University of
California San Francisco (UCSF) Bixby Center for Global
Reproductive Health evaluated the safety, effectiveness and
acceptability of these professionals in providing aspiration
abortion. Over the five years of the study, HWPP No. 171,
almost 8,000 patients were provided care by a NP, CNM, or a PA
and over 6,000 patients were provided care by a physician. The
AB 154 | Page
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results of the study show comparable rates of safety,
effectiveness and acceptability between the two categories of
providers.
2.Medication abortions and aspiration abortions. The
descriptions below were compiled using information from UCSF
Medical Center's website, as well as Planned Parenthood's
website. Both medication and aspiration abortions are
first-trimester abortions. Second trimester abortions (those
taking place 15 to 23 weeks after the last menstrual period)
use a different procedure, known as dilation and evacuation.
Medication abortion: Medication abortion, also known as
non-surgical abortion, is a way to terminate early pregnancy
using medications. A medication abortion can be performed
from the time a woman confirms she is pregnant up until nine
weeks from her last menstrual period. Medications typically
include a combination of two drugs: Mifepristone, also known
as Mifeprex or "RU-486," blocks the action of the hormone
progesterone on the uterus. This causes the lining of the
uterus to shed, as it does during a period, and stops the
growth of the pregnancy. The second medication, Misoprostol,
also known as Cytotec, causes the uterus to contract and
initiates bleeding and cramping. A medical abortion involves
at least two visits to a doctor's office or clinic: the first
visit includes an exam and counseling, and then the woman is
given the first medication, and told to take the second
medication within the next few days while at home. The woman
returns to the clinic or doctor's office within the next week
or two to ensure the abortion is complete.
Aspiration abortion: Suction aspiration abortion, also known as
surgical abortion, or suction curettage abortion, can be
performed from about six weeks after the woman's last
menstrual period up until about 14 weeks after the last
period. The procedure involves dilating the cervix, often
using a series of increasingly thick rods. The provider may
inject a numbing medication into or near the cervix for this
dilation procedure. Once the cervix is dilated, a tube is
inserted through the cervix into the uterus, and either a
mechanical or electric suction device gently empties the
uterus. Sometimes, an instrument called a curette is used to
remove any remaining tissue that lines the uterus, or to check
that the uterus is empty. When a curette is used, people often
call the abortion a D&C, or dilation and curettage.
AB 154 | Page 6
3.HWPP No. 171. According to the project application submitted
to OSHPD for HWPP No. 171, the Advancing New Standards in
Reproductive Health (ANSIRH) program at UCSF sponsors the
Access through Primary Care (APC) Project. The project seeks
to demonstrate and evaluate the role of advanced practice
clinicians in providing first-trimester aspiration abortion
and miscarriage management as part of coordinated early
pregnancy care. Training advanced practice clinicians 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 the most, assist with better follow-up and
complication management, and integrate abortion services into
previously existing health care networks. The project seeks
to:
a. Increase access to early abortion services,
particularly in rural and underserved areas;
b. Improve patient safety by allowing early diagnosis and
management of unintended pregnancy;
c. Improve patient and clinical satisfaction by
integrating abortion services in existing women's primary
care; and
d. Improve overall women's health care delivery by
coordinating early pregnancy care and thereby reducing
costs associated with such care and referrals.
4.Curriculum and Training Requirements for HWPP No. 171. In
order 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). Each trainee must also successfully complete
all case-based exercises, achieve 90 percent on the final
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written exam, and complete all required evaluation
instruments. For clinical training, each trainee completes
abortion training at one of the participating health care
facilities, where he or she works 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:
a. Reviews the training program, meets training faculty and
staff, and receives an orientation to clinic policies and
procedure for abortion care;
b. Participates in values clarification around pregnancy
options, including practice in pre-abortion counseling;
c. Follows client(s) through an abortion visit from
counseling to recovery;
d. Receives 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;
e. Performs tissue examinations until competent at
identifying pregnancy elements consistently and accurately;
f. Performs routine post-procedure and follow-up care;
g. Discusses case studies involving abortion-related
complications and manage complications when they occur;
h. Completes evaluation instruments to assess trainee
knowledge and competence and to provide feedback about the
training program; and,
i. Continues to participate in tracking of cases with
review of complicated cases by a supervising physician
during the post-procedure employment utilization period.
5.AJPH 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." 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, (rather than a superiority analysis) to
identify additional, comparably safe providers to supplement
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the provider pool (rather than determine whether NPs, CNMs,
and PAs were better than current providers of care).
Patients treated under 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.
There were 11,487 procedures included in the study (5,812
procedures performed by physicians and 5,675 performed by NPs,
CNMs or PAs). According to the study:
"Overall complications were rare. Out of 11,487 aspiration
abortions, 1.3 percent (152) resulted in a complication;
1.8 percent for NP, CNM, and PA-performed aspirations while
0.9 percent 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 between provider groups and concluded that
abortion complications were clinically equivalent between
newly trained NPs, CNMs, and PAs and physicians.
6.Double referral. This bill was heard in the Senate Business
and Professions Committee on June 17, 2013, and passed with an
8-2 vote.
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7.Related legislation. AB 980 (Pan) requires the California
Building Standards Commission to adopt emergency regulations
to delete a provision of the 2013 California Building
Standards Code that establishes building standards for primary
care clinics that provide abortion services, and prohibit the
Commission from adopting any building code standards for
clinics providing medication or aspiration abortion services
that differ from construction standards applicable to other
primary care clinics. AB 980 is set to be heard in this
Committee on July 3, 2013.
8.Prior legislation. 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.
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 the Senate Business, Professions
and Economic Development Committee.
9.Support. The California Women's Health Alliance writes that
despite California's history of supporting comprehensive
reproductive health care, over half of our counties do not
have an accessible abortion provider, which 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.
Planned Parenthood Affiliates of California (PPAC) and several
affiliates write that 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. PPAC states that this bill enacts the
results and findings from a multi-year study conducted by the
UCSF Bixby Center for Global Reproductive Health, under the
auspices of OSHPD. According to PPAC the study showed
exceptionally low rates of complications by all types of
providers, affirming that aspiration abortion is an extremely
safe procedure overall and safe whether performed by the
trained NPs, CNMs and PAs, or by the physicians. The American
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Nurses Association of California writes that 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, this bill
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) states that the performance of these
procedures is consistent with the education and training held
by NPs and 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.
10.Opposition. Concerned Women for America states abortion
carries the potential for serious complications, including
hemorrhage, uterine perforation, cervical injury and
incomplete abortion and there is no need to increase the risk
to patients for an elective procedure in a state where a mere
one percent of women live in a county where there is no
abortion provider. The Coalition for Women and Children
writes that we must put the health and safety of women first,
rather than the profits of the abortion industry. Shasta Lake
City Councilman Greg Watkins writes that 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 states that 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 California Catholic Conference,
Inc. states that 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. The Traditional Values
Coalition asserts that current law 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. The Pro-Life Mission:
International contend that women deserve the highest level of
medical care, but this bill would lower the standard of care
for women in California, which is already one of the least
regulated industries in the state; a further diminution in the
requirements of those who perform the procedure will only put
more women at risk. The Capitol Resource Family Impact
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contends that this bill simply creates an industry for
non-physician abortionists, generating more revenue for the
Abortion Industry.
SUPPORT AND OPPOSITION :
Support: ACCESS Women's Health Justice
ACLU of California
ACT for Women and Girls
American Association of University Women
American Civil Liberties Union of California
American Nurses Association
Black Women for Wellness
Business and Professional Women of Nevada County
California Association of Nurse Practitioners
California Bay Area Communities for Health Education
California Church IMPACT
California Family Health Council
California Latinas for Reproductive Justice
California Nurse-Midwives Association
California Women's Law Center
Capital Resource Family Impact
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 Abortion Federation
National Asian Pacific American Women's Forum
National Association of Social Workers, California
Chapter
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
Planned Parenthood of the Pacific Southwest
Reproductive Justice Coalition of Los Angeles
AB 154 | Page 12
Six Rivers Planned Parenthood
Women's Community Clinic
Women's Health Specialists of California
59 Individuals
Oppose: California Catholic Conference
California Federation of Republican Women
California Right to Life Committee, Inc.
Capital Resource Family Impact
Coalition for Women and Children
Concerned Women for America
Traditional Values Coalition
8 individuals
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