Ethics, Abortion Access, and Emergency Care Post-Dobbs: The Gray Areas.

Clinical management of emergency pregnancy care, such as ectopic pregnancy or heavy bleeding with pregnancy of unknown location, includes upholding legal and ethical standards. For health care providers unwilling to provide evidence-based life-saving abortion care due to personal beliefs, clear guidance dictates disclosure of these limitations to the patient and colleagues, followed by immediate referral for appropriate care. However, this decision-making pathway may not be engaged due to a variety of factors: providers' beliefs preclude adherence to referral responsibilities, political discourse confuses patients as to their options and rights, and a constantly changing state and national legal landscape leads providers to question their ability to practice to their full scope of clinical care. Although this disruption of evidence-based standard of care existed pre-Dobbs, the moral disorder is now heightened. This Clinical Rounds highlights a patient vignette describing the risks of abortion restrictions for patients and providers alike, particularly when an individual provider's concerns for violating institutional guidelines sets a precedent for nursing response and forecloses on collaborative input or ethics consultation. The history of physician-only abortion exceptionalism and exclusion of nurses and midwives despite a significant history of nurses and midwives in abortion care grounds an argument for focusing on the impact of unethical and substandard care on the interprofessional care team leading to moral distress and negative patient outcomes. Patient-centered models of care, such as frameworks common in nursing and midwifery, offer opportunities to consider how all providers practicing to their full scope in interprofessional and collaborative ways, such as in emergency rooms and labor departments, might mitigate obstructions to abortion care that risk pregnant people's lives.

The Ethical Justification for Conscience Clauses in Nurse-Midwifery Practice: Context, Power, and a Changing Landscape.

In the last century, conscientious objection has moved from objection to conscripted military service to include health care providers who have moral concerns about participation in specific aspects of health care. Although guidance for the use of conscientious objection has developed in both nursing and midwifery, changes in the political landscape may be creating a source of conflict between providers and the use of conscientious objection. Particularly in aspects of sexual and reproductive care like abortion, contraception, and lesbian, gay, bisexual, transgender, or queer health care, the ethical requirement for prompt referral is becoming increasingly difficult to meet in many contexts. Changes to federal regulations protecting conscience clauses have tilted strongly in favor of the rights of providers in recent years; this challenges the delicate balance of patient and provider rights that has developed over the years. These may now represent an unavoidable conflict between different aspects of the ethical obligations of providers, in particular the obligation to seek justice, and bring into question whether the current status of conscientious objection is sustainable. In this article, we examine these conflicts in the context of the current political climate.

Training in aspiration abortion care: An observational cohort study of achieving procedural competence.

BACKGROUND: Studies in multiple countries have found that the provision of aspiration abortion care by trained nurses, midwives, and other front-line health care workers is safe and acceptable to women. In the United States, most state abortion laws restrict the provision of abortion to physicians; nurse practitioners, nurse-midwives, and physician assistants, can legally perform medication abortion in only twelve states and aspiration abortion in five. Expansion of abortion care by these providers, consistent with their scopes of practice, could help alleviate the increasing difficulty of accessing abortion care in many states. OBJECTIVES: This study used a competency-based training model to teach advanced practice clinicians to perform vacuum aspiration for the abortion care. Previous research reporting on the training of providers other than physicians primarily focused on numbers of procedures performed, without assessment of skill competency or clinician confidence. DESIGN: In this prospective, observational cohort study, advanced practice clinician trainees were recruited from 23 clinical sites across six partner organizations. Trainees participated in a standardized, competency-based didactic and clinical training program in uterine aspiration for first-trimester abortion. SETTINGS: Trainee clinicians needed to be employed by one of the six partner organizations and have an intention to remain in clinical practice following training. PARTICIPANTS: California-licensed advanced practice clinicians were eligible to participate in the training if they had at least 12 months of clinical experience, including at least three months of medication abortion provision, and certification in Basic Life Support. METHODS: A standardized, competency-based training program consisting of both didactic and clinical training in uterine aspiration for first-trimester abortion was completed by 46 advanced practice clinician participants. Outcomes related to procedural safety and to the learning process were measured between August 2007 and December 2013, and compared to those of resident physician trainees. RESULTS: Essentially identical odds of complications occurring from advanced practice clinician-performed procedures were not significantly different than the odds of complications occurring from resident-performed procedures (OR: 0.99; CI: 0.46-2.02; p > 0.05) after controlling for patient sociodemographic and medical history. The number of training days to foundational competence ranged from six to 10, and the number of procedures to competence for those who completed training ranged from 40 to 56 (median = 42.5). CONCLUSIONS: A standardized, competency-based trainingprogram can prepare advanced practice clinicians to safely provide first-trimester aspiration abortions. Access to safe abortion care can be enhanced by increasing the number of providers from cadres of clinicians other than physicians.

Premature or just small? Training Guatemalan birth attendants to weigh and assess gestational age of newborns: an analysis of outcomes.

We describe Guatemalan birth attendants' identification of vulnerable newborns, their evaluation of gestational age and anthropometry, and the validity of the Capurro and New Ballard newborn gestational age assessment methods. We interviewed 49 birth attendants and trained 10 of these women to assess 63 newborns. The Capurro and Ballard methods were correlated (Spearman rho = .75, p < .001) and showed agreement (Bland-Altman plot, difference and bias, -0.33 ± 1.3 weeks). Prematurity was estimated at 27% (Ballard) and 24% (Capurro); low birth weight (LBW) was 30%. Capurro provided a simplified, equivalent estimate of gestational age compared with New Ballard that could be used by birth attendants.

Midwives and abortion care: a model for achieving competency.

Throughout history, the care of women's reproductive health needs has included termination of unwanted pregnancy. Unfortunately, access to safe first-trimester abortion is restricted by a lack of skilled providers. In an effort to provide data-based evidence and increase access to first-trimester abortion care in California, the University of California, San Francisco, under the auspices of the Health Workforce Pilot Program, developed a competency-based training model to increase the number of certified nurse-midwives, nurse practitioners, and physician assistants who can provide uterine aspiration. This article describes the training program, which uses a curriculum comprising both self-directed didactic material and supervised clinical experience with a minimum of 40 procedures. Successful completion of the program requires passing a written examination and satisfactory achievement of a competency-based clinical assessment. Thirty-eight trainees have completed the training to date, achieving competency following an average of 6 training days. Competency development in the clinical area is monitored by both the trainer and the trainee, using daily and final competency assessments in 4 domains: patient comfort, procedural completeness, speed, and ability to identify problems. Analysis of complications is used to identify concerns about clinician safety. The availability of a competency-based training curriculum for uterine aspiration has the potential to increase the number of first-trimester abortion providers by making training available to experienced clinicians, including nurse-midwives, who would like to provide this care.

Midwifery data collection: options and opportunities.

Most midwives are aware of the need to collect clinical practice data and of its usefulness in supporting the care they provide, which contributes to healthy outcomes for mothers and babies. For the individual midwife, there is more than one easily accessible, standardized data collection instrument from which to choose. However, despite these choices, in an American College of Nurse-Midwives (ACNM) Division of Research (DOR) survey on midwifery clinical data collection (N = 263), the majority of member respondents (n = 135; 51%) reported using a self-designed data collection tool, and more than one-third did not know of the ACNM Nurse-Midwifery Clinical Data Sets (NMCDS). On a larger scale, the midwifery profession is also in need of an organized and consistent approach to data collection for the purpose of capturing midwifery practice and outcomes in order to provide data to support legislation, practice, and policy changes. However, the profession currently lacks a single common midwifery practice database. In order to facilitate data aggregation that captures a larger view of midwifery practice at the local, regional, and national levels, it is imperative that all midwives collect relevant data that are uniform and standardized, and that the midwifery professional organizations move forward with the development of a common electronic database. This article describes currently available data collection tools as well as their best uses, applications to practice, and future directions.