Nurse Practitioners Can Offer More Abortion Care in Underserved Areas

A conversation with Sarah McNeil, family medicine doctor and family planning specialist focused on expanding health care access

Illustration of medical scrubs and lab coat hanging up
Illustration: Dan Page

Nurse practitioners (NPs) play a key role in providing primary health care at clinics and in rural areas, among other historically underresourced settings.

AB 890 was enacted by California lawmakers in 2020 as one way to address the workforce shortage of providers. The law creates a pathway for nurse practitioners to treat patients independently, without supervision of a physician.

I recently spoke via Zoom to Sarah McNeil, MD, a family medicine physician and family planning specialist who has devoted her career to providing health care in underserved communities. She believes nurse practitioners are vital when it comes to expanding health care access.

McNeil has been an attending physician and faculty member at the Contra Costa Family Medicine Residency Program in Martinez since completing her residency there in 2013. The residency allowed her to obtain abortion and obstetrical training. She was the first fellow of the TEACH (Training in Early Abortion for Comprehensive Healthcare) program in the Bay Area. The program provided the curriculum basis for the Health Workforce Pilot Projects Program. McNeil is also a contractor and trainer at Planned Parenthood of Northern California. She provides labor and delivery, urgent care, and primary care primarily to Medi-Cal patients at the county hospital in Martinez, where she teaches residents. Until 2021, she traveled to Texas monthly to provide abortion care at an independent clinic.

Our conversation has been edited for length and clarity.

Q: How do you work with nurse practitioners in the context of providing abortions, and what’s your impression of their skills?

A: Without the workforce of nurse practitioners, there’s no way the patients would be able to access care in underresourced settings. Access is already a huge problem for all my patients. I feel strongly that, without any compromises in quality of care, the nurse practitioners allow for systemic improvements in access. NPs help with reviewing charts, doing ultrasounds, and dispensing medications, and they could do so much more if they were working at the top of their scope of practice.

Q: Do you have an example to illustrate the role that they play in underresourced settings?

A: Cynthia is a great example. She provides sexual and reproductive health care including first-trimester abortions at a clinic in Richmond, a historically Black neighborhood. If a patient desires ongoing prenatal care, Cynthia can provide that. If that patient desires a first-trimester abortion, it can be done that same day and without asking the patient to drive all the way to Walnut Creek, where most in-clinic abortions are done by Planned Parenthood Northern California. Being able to offer abortion services in Richmond is remarkable. It is physically and emotionally a completely different experience. It is not financially feasible for a doctor to be available to provide abortions five days a week in Richmond, so a nurse practitioners really helps at a systemic level to directly improve access for patients.

Q: What kind of access issues do you anticipate as a consequence of the Supreme Court ruling?

A: Because of the decision, a lot of doctors are saying, “I want to get trained in first-trimester abortion and integrate procedural abortion into primary care.” Even though they graduate residency with complete competence in first-trimester abortion, only half the physicians interested in integrating abortion services into their practice are able to do so. We need to work harder to make that possible — for people to get trained and to have the supports they need to deliver care so that we can fill gaps and provide much needed access to care. This includes MDs and NPs. TEACH has been advocating for two decades around the importance of integrating abortion services into primary care to decrease stigma, to normalize abortion, and to ensure that abortion is a normal part of health care. We believe that everybody should be incorporating medical, abortion, and miscarriage management into their clinics. If nurse practitioners across the entire country were incorporating abortion services into their care, that would improve access.

Q: Within California, a state that strongly supports abortion, are we seeing access issues related to the court decision?

A: There are different levels of access in California. Three months ago, a friend from out of state called me and said, “My stepdaughter just found out she’s pregnant. She’s in San Diego and she’s flying back in two days, so she needs an abortion tomorrow. We’ve called Planned Parenthood, but there’s nothing available.” The only way she was able to get an appointment is that I’m friends with the medical director of one of the Planned Parenthoods, who spoke to somebody at the appointment unit. Even in California, access is a huge problem. Ideally, somebody should be able to call, get an appointment, and go in the next day to have the abortion. That should be the standard. By training more people, including nurse practitioners, across the state of California, we could make improvements in our access.

Q: As a physician, what is your view of NPs working independently, without physician supervision?

A: The studies have all shown that nurse practitioners are able to work independently in parallel with other providers in safe ways. My own primary care provider was a nurse practitioner for many years. I chose her to take care of me. I recommend nurse practitioners to provide care for my loved ones and my patients. I feel confident in their ability to provide exceptional care.

Q: What does the future look like for nurse practitioners in California?

A: Nurse practitioners are a hugely important part of the workforce in California for underserved patients and beyond. I am always focused on the most vulnerable. In our underserved communities, the nurse practitioners play an even more important role. Statistically, the nurse practitioners are the ones who are willing to go to the underserved communities; they’re the ones who are moving to rural areas.

Q: You’ve made it a priority in your career to serve underresourced communities. Those are the very communities that a lot of people worry about when it comes to abortion access.

A: I chose to go into primary care. I chose to do abortion work. And I chose to work at the county hospital. Many NPs come to this work for those same reasons, which is why it’s important that we ensure that nurse practitioners are able to integrate abortion care into their practices. We have to ask ourselves, How are we going to continue to make sure that more vulnerable people are able to obtain access to care — historically, women and other people with uteruses, trans folks, poor folks, rural folks, people of color, and non-English-speaking people? Those are all deeply intertwined issues.

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