On a recent weekday, a nurse midwife and an advanced practice registered nurse at Planned Parenthood of Southern New England sat hunched over two papayas on a medical table.
The APRN slid a long silver tool into one papaya. Nearby, Dr. Nancy Stanwood, the chief medical officer, observed the nurse’s technique.
“That’s 12 millimeters, so that should work,” Stanwood said. “Most of the kits here, that is the biggest dilator.”
The nurse removed the instrument and inserted a manual vacuum aspirator, a syringe-like device. Stanwood placed her hands on the papaya to hold it steady.
“Remember, put your fingers through the loop,” Stanwood instructed. The nurse wrapped her fingers around the device’s looped handle and pulled back, creating suction.
The two trainees were learning how to perform a vacuum aspiration abortion. Connecticut’s General Assembly passed legislation in April allowing certain medical practitioners other than doctors to perform the procedure, a move meant to expand the abortion provider workforce.
The newly authorized providers include nurse midwives, physician assistants and advanced practice registered nurses. Gov. Ned Lamont signed the bill into law in May, and it took effect July 1.
At least 14 other states, including Oregon, Delaware, Maryland and Washington, allow advanced practice clinicians to perform abortions.
In Connecticut, people are waiting an average of two weeks to receive an aspiration abortion. Proponents of the bill said they hope the additional providers will help reduce that wait time.
“With such a time-sensitive procedure, two weeks is too long,” said Rep. Jillian Gilchrest, D-West Hartford, a key supporter of the legislation. “My hope would be [that people could have the abortion] same day or next day. When someone is ready to have the procedure, it’d be great if they could get in and get it.”
An aspiration abortion, also known as a suction abortion, uses suction to empty the uterus. It is usually performed during the first trimester and sometimes during the first couple of weeks of the second trimester (up until about 14 to 16 weeks after a person’s last period). It is the most common type of in-clinic abortion, officials at Planned Parenthood said.
Data show that people overwhelmingly seek abortions in the earliest weeks of pregnancy. In 2019, abortions at nine weeks or less accounted for over 80% of abortions in Connecticut.
The new law took effect just days after the Supreme Court overturned Roe v. Wade, ending the constitutional right to an abortion after almost 50 years. Abortion remains legal in Connecticut because of legislation passed in 1990 codifying Roe v. Wade into state statute.
In addition to helping reduce wait times for an abortion, supporters say the new law will broaden the workforce at a time when more people from out of state could be traveling to Connecticut for the procedure.
“We do anticipate more folks seeking aspiration abortion in the state of Connecticut from outside of the state,” Gilchrest said. “I think anything we can do to reduce that wait time, and make it so aspiration abortion is more readily available, is important.”
The two employees at Planned Parenthood practicing on papayas are part of the first wave of advanced practitioners in Connecticut now learning to perform aspiration abortions. Planned Parenthood of Southern New England will train two providers to begin with; officials there expect to educate more employees on the procedure in the coming months.
“I can’t necessarily say how many people we need to train. My goal is for us to have a robust workforce of physicians and clinicians who are ready, willing and able to provide care for people who need an aspiration abortion,” Stanwood said. “If I trained 60, and each of them only did a few procedures a year, that’s not a way to maintain skills. We don’t want to over-train. But my goal is to have the workforce that we need, so patients don’t have the current wait time that they do, which is really a pain point for us.”
Stanwood hopes to reduce wait times to less than a week.
When officials at the organization put out a call for trainees, they received a wide response.
“We had many of our advanced practice clinicians raise their hand, and say, ‘Yes, sign me up,’” Stanwood said.
Planned Parenthood is using a training curriculum from the University of California, San Francisco. The instruction requires time in a classroom and in the clinic. The trainees typically perform the procedure 30 to 40 times with Stanwood nearby before continuing on their own.
Patients can choose if they want to be part of the training.
“We are being very clear with patients that we are doing training, explaining what it’s all about, and how safe it is. We’re also giving them the opportunity and a safe space to say, ‘You know, I don’t think I want to be in the training,’” Stanwood said.
The organization has received inquiries from APRNs, nurse midwives and physician assistants outside of Planned Parenthood, asking whether it will also run training programs for people who don’t work there. For now, Stanwood said, she’s focused on educating Planned Parenthood workers.
“We have had interest from people who don’t work for us at Planned Parenthood, who work somewhere else and say, ‘Hey, can I sign up for this training?,’” she said. “We’re not holding an open school for people who don’t work for us. Right now we are focusing on training our clinicians … who will be an immediate part of our workforce.”
Polly Moran, a nurse midwife with S.H.E Medical Associates, said she plans to train in aspiration abortions. Creating robust training programs for all of the advanced clinicians who want to learn the procedure should be a priority, she said.
Ongoing education programs could play a role.
“As midwives, we have a professional organization that meets four times a year. So that will be up for discussion: How do we access that training?” Moran said. “In for-profit ongoing educational programs, I think we’ll begin to see that built in.
“Sometimes in an ongoing educational conference, there will be colposcopy training. You can go two days prior to the other larger workshops and just pay to learn how to do a colposcopy. I could see that being utilized for aspiration abortion.”
Officials at Hartford GYN Center in Bloomfield, the only independent abortion provider in Connecticut, are planning to offer training not only to their own workers but also to advanced practice clinicians outside of their organization. They expect to begin training their own employees by the end of the summer and then broaden the program.
“We would like to position ourselves to do that for our internal providers and also to be a resource to build the abortion provider workforce,” said Roxanne Sutocky, director of Community Engagement at The Women’s Centers, which includes Hartford GYN. “It’s something we know is increasingly necessary, especially as states are going dark and abortion providers are having to close their doors. We’re seeing an uptick in requests for training … from advanced practice clinicians.”
Some medical groups have raised concerns about providers other than doctors performing abortions. The Connecticut State Medical Society, testifying on the bill during the legislative session, said there could be “unintended consequences” to the measure.
“We head down the slippery slope to allowing those procedures that are in fact surgical to be done by mid-level providers, creating patient safety concerns and significant scope of practice issues,” the organization testified.
But abortion providers maintain that it’s safe for advanced practice clinicians to perform the procedure.
“If the doctor who is there hasn’t had the training, they wouldn’t be the right person to do it. Whereas if the advanced practice clinician who is there has all of the training, then they are the right person to do it,” Stanwood said. “Just because you’re a doctor doesn’t mean you know how to do this procedure. It’s really not about what letters come after your name. It’s about what training you’ve had. And our clinicians are going to get excellent training. We won’t graduate them until they really are ready.”
Proponents of the legislation say that allowing APRNs, nurse midwives and physician assistants to perform abortions will help with continuity of care. Patients who already see these providers will soon be able to have that same person perform an abortion if need be, rather than going to someone they’ve never met.
“I had a medication abortion and I went to my routine provider at Planned Parenthood to get that care. I found a lot of comfort in knowing that I already had this relationship with my provider,” said Liz Gustafson, state director of Pro-Choice Connecticut. “I think if anything, this [new law] will allow more providers to meet their patients where they’re at and offer them the same quality, compassionate care.”
Connecticut has not yet seen a crush of patients traveling from other states seeking abortions, in part because it does not border a state that recently banned the procedure, providers said. But officials hope to expand the workforce in time to meet what they expect will be a growing need in the coming months.
“I imagine it like a rock that gets dropped in a pond. There are going to be ripples,” Stanwood said. “We’re not right next to where the rock got dropped. But we’re definitely going to see ripple effects. So this will help us prepare for that.”