Roe vs. Wade, the landmark Supreme Court decision from January 22, 1973, invalidated all state laws in the United States that previously restricted elective abortion in the first trimester (Roe, 1973). By 1965, all 50 states in the United States had banned elective abortions; however, many states had exemptions for the health of the mother, fetal anomalies, and cases of rape and/or incest (Joffe, 2010). Immediately prior to the passage of Roe v. Wade, nurse epidemiologists collected abortion surveillance data for the Center for Population Research, a division of the National Institutes of Health (Bourne, Kahn, Conger, & Tyler, 1972). These studies were conducted to understand the numbers of abortions by state and to examine factors associated with women who had abortions.
In 1972, Bourne and colleagues published the manuscript, “Surveillance of Legal Abortions in the United States, 1970,” in the Journal of Obstetric, Gynecologic, & Neonatal Nursing (JOGNN). At that time, 15% of pregnancies ended in abortion, and the abortion rate was 189 for every 1,000 live births (Bourne et al., 1972). These statistics did not reflect the number of illegal abortions that occurred at this time. Current data indicate that unintended pregnancy accounts for one half of all pregnancies in the United States, and 4 in 10 of these pregnancies end in abortion (Guttmacher Institute, 2010). Nine out of 10 of these abortions occur in the first trimester (Guttmacher Institute).
Today, comprehensive quantitative abortion data in the United States are compiled by the Centers for Disease Control and Prevention (CDC) and entities such as the Guttmacher Institute (2010) and the National Abortion Federation ([NAF]; 2010). The rate of abortions, abortion-associated morbidity, mortality, and other demographic data are collected from abortion providers and clinics across the United States and sent to these entities. These data are similar to the data collected by Bourne and colleagues (1972).
As part of JOGNN's anniversary “Then & Now” series, we reviewed the literature specific to nurses and the care of women seeking abortions from 1971 to 2010. The purpose of this article is to highlight the historical and current information for nurses who provide abortion care, the attitudes and perceptions of nurses toward abortion, the ethical and legal issues surrounding abortion, and the role of advanced practice clinicians (APCs) in the provision of abortion services.
We searched articles in PubMed with keywords including nurses and abortion care, abortion, abortion care, and care of women undergoing elective abortions. The initial search criteria yielded more than 340 articles, many of which covered topics such as miscarriage, pregnancy loss, stillbirth, molar and ectopic pregnancy, and fetal death. Therefore, search term limits were used for these terms, which reduced the overall number of articles to 219.
An article met the inclusion criteria if it was available in English, if the study was conducted in the United States or the United Kingdom, and it was published between 1971 and 2010. The United Kingdom was included in this review because abortion was legalized there in 1967, and many seminal studies examining nurses and abortion have been conducted in the United Kingdom.
Articles were excluded if patients from abortion clinics were sampled for research questions not specific to abortion care (e.g., sexually transmitted infection incidence studies, contraception studies, intimate partner violence prevalence). No distinction was made for medication or medical abortion versus surgical or aspiration abortion. Articles describing surgical techniques similar to those used for abortion for other medical conditions (e.g., uterine aspiration as treatment for fibroids or dysfunctional uterine bleeding) were also excluded. Abstracts were reviewed, and 59 articles met the inclusion criteria.
Articles were grouped by similarities in subject area, and several themes emerged: (a) legal and ethical responsibilities of nurses; (b) attitudes and perceptions of nurses toward abortion care (nurses providing this care and those who did not); (c) nonphysician providers or APCs providing abortion care; (d) education and counseling needs of women seeking abortions; and (e) articles specific to the physical provision of abortion care.
The 59 articles included in this review were read and reviewed for these themes. Articles may have included several themes, but the major theme determined the overall group in which the article was placed. For each theme, the total number of articles in each group is provided as well as a summary for each theme.
Legal and Ethical Responsibilities of Nurses
Seventeen articles categorized under the theme legal and ethical aspects of abortion care or 29% were consistent with this heading (Char & McDermott, 1972; Davis, 1980; Dickens, 2003; Finch, 1981, 1983; Freda, 1994; Fromer, 1982; Heima, 1972; Horsley, 1992; Hurry, 1997; Kane, 2009; McHale, 2009; Rae, 1981; Schorr, 1972; Silva, 1974; Taylor, Safriet, & Weitz, 2009; Ventura, 1999). Five of the articles grouped under this theme are from the United Kingdom: (Kane; McHale; Hurry; Finch; Rae). All of the articles included under this theme address the role of the legal system and ethics in abortion care.
Three subthemes emerged: (a) respecting the right of nurses to determine their own moral and ethical participation (or not) in providing care to women seeking abortion (Char & McDermott, 1972; Dickens, 2003; Finch, 1981, 1983; Fromer, 1982; Horsley, 1992; Hurry, 1997; Kane, 2009; McHale, 2009; Rae, 1981; Taylor et al., 2009; Ventura, 1999); (b) explanation of current abortion law (Dickens; Finch; Heiman, 1972; Horsley; Rae); and (c) workplace issues caused by the provision of abortion care (Kane; Ventura; Silva, 1974; Char & McDermott).
The current legal responsibility of the nurse in abortion care is relatively straightforward. Abortion remains legal in the United States and the United Kingdom, and nurses can choose to provide care for patients or invoke conscientious objector clauses and decline to care for patients seeking abortion services. Workplace law does not mandate the provision of abortion, therefore, hospitals and clinics are free to choose to provide abortion services or not. However, controversy remains regarding the rights of fetuses and the definition of personhood (Kane, 2009), the conflicting rights of patients and nurses (Davis, 1980; Dickens, 2003; Fromer, 1982; Hurry, 1997; Kane, 2009; McHale, 2009), issues of fetal viability (Freda, 1994; McHale), the use of selective reduction for multiple gestations (Dommergues, Cahen, Garel, Mahieu-Caputo, & Dumez, 2003; Kane), and the use of feticidal agents (Dickens; Dommergues et al.; McKee & Adams, 1994; Muller, 1991).
Nurses’ Attitudes and Perceptions Toward Abortion Care
Fourteen articles categorized under nurses’ attitudes and perceptions toward abortion care or 24% were consistent with this heading (Baluk & O'Neill, 1980; Fischer, 1979; Gallagher, Porock, & Edgley, 2010; Hudson-Rosen, Werley, Ager, & Shea, 1974; Kaltreider, Goldsmith, & Margolis, 1979; Likis, 2009; Lipp, 2008; Marek, 2004; Marshall, Gould, & Roberts, 1994; McKee & Adams, 1994; Neustatter, 1980; Sandroff, 1980; Swenson, Swanson, & Oakley, 1994; Webb, 1985). The articles grouped under this theme include attitudes of staff nurses (Hendershot & Grimm, 1974; Kaltreider et al.; Marek; Marshall et al.; Neustatter; Sandroff; Swenson et al.; Webb), nurse-midwives (Glenn, 1996; Likis; Lipp; McKee & Adams), and other health care professionals with nurses included (Baluk; Fischer; Hudson-Rosen et al.).
Several subthemes emerged among these articles, particularly concerning the distinction between positive and negative attitudes toward abortion care. Generally, nurses in the United States and United Kingdom do not have extreme views regarding abortion, and their views mirror general public statistics (Lipp, 2008). However, nurses have distinct views about their personal participation in abortion care in their role as nurses that are framed by religious belief, the patient's stated reason for abortion, and the possible financial impact of unintended pregnancy.
First, religion has a large influence in how nurses, nurse-midwives, and other health care providers develop their attitudes toward abortion and abortion care. Belief in any of the major religions (e.g., Christianity, Judaism, Islam) is a strong modifier of beliefs concerning the provision of abortion services (Lipp, 2008; Marshall et al., 1994). Overall, 13% of nurses cite religion as the primary reason for negative attitudes toward abortion (Fischer, 1979; Hudson-Rosen et al., 1974; Lipp; Marek, 2004; Marshall; McKee et al., 1994; Sandroff, 1980).
Second, the reasons women have abortions, also called termination criteria, affect nurses’ attitudes and perceptions regarding the care of women seeking abortion. Several factors constitute termination criteria, including gestational age of the fetus (Gallagher et al., 2010; Lipp, 2008), rape or incest (Fischer, 1979; Lipp; Marek, 2004; Marshall et al., 1994), failed contraception (Lipp; Marek; Sandroff, 1980), physician or clinician advice (Swenson et al., 1994), and health of the mother (Baluk & O'Neill, 1980; Fischer; Hudson-Rosen et al., 1974; Lipp; Marek; Neustatter, 1980; Swenson et al.; Webb, 1985). Nurses report being comfortable with providing abortion services or perceiving abortion services as positive using these termination criteria. However, two factors draw negative attitudes toward abortion in surveys of nurses and other health care providers. These two factors are abortion as contraception and abortion for sex or gender selection (Lipp; Marek; Marshall; Sandroff; Webb).
Third, financial reasons for seeking an abortion were cited in two distinct categories: inability to pay for additional children and whether federal dollars were the primary financial source for the provision of abortion service. Most of the nurses surveyed cited inadequate socioeconomic resources as a legitimate and/or positive reason for abortion; however, the data are divided regarding the use of federal dollars for the provision of abortion services. Nurses surveyed in three of the articles strongly disapproved of the use of federal dollars for abortion services and viewed this as a negative practice (Fischer, 1979; Sandroff, 1980; Swenson et al., 1994).
Nonphysician Clinicians Providing Abortion Care
Fourteen articles categorized under nonphysician clinicians providing abortion care or 24% were consistent with this heading (Abbott, Renovitch, & Barker, 1973; Berer, 2009; Bewley, 1993; Donovan, 1992; Foster et al., 2006; Hord & Delano, 1994; Hwang, Koyama, Taylor, Henderson, & Miller, 2005; Joffe & Yanow, 2010; Kowalczyk, 1993; Kruse, 2000; Narrigan, 1998; Samora & Leslie, 2007; Summers, 1992; Weitz, Anderson, & Taylor, 2009; Yarnall, Swica, & Winikoff, 2009). Several state laws identifying the provider of care have changed since Roe vs. Wade legalized abortion across the United States. An abortion provider shortage was identified in the early 1980s due to the aging of the current providers and a lack of physicians in the education pipeline available to keep up with clinical demand (Guttmacher Institute, 2010; Joffe, 2004). As early as 1971, APCs, that is advanced practice nurses, nurse-midwives, and physician's assistants, began addressing their roles in the provision of abortion care. Certified nurse-midwives (CNMs) began to examine their role in 1971 (Abbott et al.; Summers); at the same time, physician assistants (PAs) were already providing first-trimester abortions for healthy women (Donovan, 1992).
The role definition of CNMs as determined by the American College of Nurse Midwives (ACNM) is addressed in 11 of the 14 articles (Abbott et al., 1973; Berer, 2009; Bewley, 1993; Foster et al., 2006; Hord & Delano, 1994; Joffe & Yanow, 2010; Kowalczyk, 1993; Summers, 1992; Kruse, 2000; Narrigan, 1998; Yarnall et al., 2009). In 1971 a consensus statement published by the ACNM prohibited CNMs from performing abortions; it was updated without change in 1990 (Summers). This document was not changed until 1991, when the ACNM rescinded the statement and allowed practicing CNMs to determine their own participation in abortion services.
Advanced practice clinicians perform abortions in 14 states in the United States, and as of 2004 only California has passed statewide legislation supporting APCs in independent roles in the provision of medication abortion (Joffe & Yanow, 2010). Other states use local or regional bodies such as the Department of Health or Boards of Nursing to regulate APC abortion practice. Advanced practice clinicians have been shown to be well educated (Abbott et al., 1973; Foster et al., 2006; Yarnall et al., 2009), safe practitioners (Berer, 2009; Joffe & Yanow, 2010; NAF, 2010; Samora & Leslie, 2007; Weitz et al., 2009; Yarnall), and cost effective abortion providers (Berer; Kowalczyk, 1993; Joffe & Yanow; NAF; Samora et al.).
Nursing Role in Patient Option Counseling and Education in Abortion Care
Four articles categorized under nursing role in patient options counseling and education in abortion care or 7% were consistent with this heading (Aruda, Waddicor, Frese, Cole, & Burke, 2010; Newton, Iddenden, & Newton, 1979; Simmonds & Likis, 2005, Zahourek & Tower, 1971). All four articles highlighted the need for nursing assessment of emotional response, coping skills, and social resources when an unintended pregnancy is diagnosed. Additionally, these articles stressed the need for contraception (Aruda et al.; Simmonds & Likis) and sexually transmitted infection screening (Aruda et al.; Simmonds & Likis; Newton et al.).
Specific to abortion, all four articles confirm a woman's three choices: abortion (either medical or aspiration), continuing pregnancy with the goal of adoption, and continuing pregnancy with the goal of parenthood. These articles stressed the need for values clarification of the nursing staff to support women in making the best decisions for themselves and their families. This approach emphasizes that decision making is the purview of the patient, and that the actual decision making is not the role of the nurse. The goal of these articles was to provide nurses with tools and case studies for providing women with the information they need to determine their personal decisions. Finally, all of these articles highlighted the education and training necessary for nurses to provide unbiased options counseling.
Physiologic Care of Women Undergoing Abortion
Nine articles categorized under physiologic (knowledge-based) care of women undergoing abortion or 15% were consistent with this heading (Aby-Nielsen, 1979; Dommergues et al., 2003; Hughes, 2003; Huntington, 2002; Kwast, 1992; Lipp, 2007; Mackenzie & Yeo, 1997; Mueller, 1992; Murphy, Jordan, & Jones, 2000). Four of these articles originated in the United Kingdom (Dommergues et al.; Huntington; Lipp; Murphy et al.). These articles can be divided into four subcategories: first-trimester abortion (Hughes; Lipp; Murphy et al.), midtrimester abortion (Aby-Nielsen; Dommergues et al.; Huntington; Lipp; Mueller), late-term abortion (Aby-Nielsen; Dommergues et al.; Kwast), and medical abortion (Mackenzie & Yeo; Murphy et al.). All articles covering midtrimester and late surgical abortion reviewed termination of pregnancy by induction of labor.
These articles described in detail surgical techniques, medications, nurses’ training and educational needs, cost, efficacy, and safety. The nursing role was clearly defined, and these technical articles reflected the most current practice at the time of publication.
Abortion care and the role of nurses have evolved since 1971 when Bourne and colleagues first published their data in JOGNN. Several key areas of investigation necessary for the safe provision of abortion care remain, including the safest and most effective medication regimes for pain management postabortion; an anesthesia standard for second-trimester and late-term abortions; the appropriate educational standards and competencies required for nurses regarding abortion care; educational standards and competencies required for nurses who provide abortion services to women; appropriate settings for abortion care (e.g., inpatient units, outpatient clinics, labor and delivery suites); comprehensive contraceptive options for women with or without complex medical histories; and continued efforts at preventing unintended pregnancy.
Since the legalization of abortion in the United States, nurses have been involved in the education, counseling, and care of women seeking abortion services. The sensitive and controversial nature of abortion decisions and the emotional, spiritual, and psychological effects these decisions have on women, their social support systems, and health care professionals who care for them must be managed by well-trained nurses and other staff. Nurses’ personal values and decisions concerning participating in abortion care must be respected by coworkers, supervisors, and institutions.