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 slipped a long silver tool into a papaya. Nearby, Dr. Nancy Stanwood, the chief physician, observed the nurse’s technique.
“That’s 12 millimeters, so it should work,” Stanwood said. “Most of the kits here, this is the biggest dilator.”
The nurse removed the instrument and inserted a manual vacuum aspirator, a syringe-like device. Stanwood put his hands on the papaya to steady it.
“Remember, put your fingers through the loop,” Stanwood said. The nurse wrapped her fingers around the handle of the device and pulled back, creating suction.
The two trainees were learning to perform a vacuum aspiration abortion. It passed the Connecticut General Assembly legislation in April, it allowed certain doctors other than doctors to perform the procedure, a move aimed at expanding the workforce of abortion providers.
Newly licensed providers include nurse midwives, physician assistants and advanced practice registered nurses. Governor Ned Lamont signed the bill it took effect in May and went into effect on July 1.
At least 14 other statesincluding Oregon, Delaware, Maryland and Washington, allow advanced practice doctors to perform abortions.
In Connecticut, people are waiting an average of two weeks to receive an aspiration abortion. Advocates 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 proponent of the legislation. “My hope would be [that people could have the abortion] same day or the next day. When someone is ready to do the procedure, it would be great if they could come in and get it.”
An aspiration abortion, also known as a suction abortion, uses suction to empty the uterus. Is usually performed during the first term and sometimes during the first two weeks of the second trimester (up to about 14 to 16 weeks after a person’s last period). It is the most common type of abortion at the clinic, according to officials said Planned Parenthood.
Data shows that most people seek abortion in the first few weeks of pregnancy. In 2019, abortions at nine weeks or less accounted for more than 80% of abortions in Connecticut.
The new law went into effect just days after the Supreme Court overturned Roe v. Wade, ending the constitutional right to abortion after nearly 50 years. Abortion remains legal in Connecticut due to legislation passed in 1990 codifying Roe v. Wade in the state statute.
In addition to helping reduce wait times for an abortion, supporters say the new law will expand the labor force at a time when more out-of-state people could travel to Connecticut for the procedure.
“We anticipate more people seeking aspiration abortion in the state of Connecticut from out of state,” Gilchrest said. “I think anything we can do to reduce that wait time and make aspiration abortion more available is important.”
The two Planned Parenthood employees who practice with papayas are among the first wave of advanced practitioners in Connecticut who are now learning to perform aspiration abortions. Planned Parenthood of Southern New England will train two providers to start; officials hope to educate more employees about the procedure in the coming months.
“I can’t necessarily say how many people we have to train. My goal is for us to have a strong workforce of doctors and physicians who are ready, willing and able to provide care to people who need an aspiration abortion,” Stanwood said. “If I trained 60, and each of “they only did a few procedures a year, that’s no way to maintain skills. We don’t want to overtrain. But my goal is to have the manpower we need, so patients don’t have the time to ‘current wait they have, which is really a pain point for us.’
Stanwood hopes to reduce wait times to less than a week.
When the organization’s officials put out a call for fellows, they received a wide response.
“We had a lot of our advanced practice doctors raise their hand and say, ‘Yes, sign me up,'” Stanwood said.
Planned Parenthood uses a training curriculum from the University of California, San Francisco. Instruction requires time in the classroom and in the clinic. Students typically perform the procedure 30 to 40 times with Stanwood nearby before continuing on their own.
Patients can choose whether they want to be part of the training.
“We’re being very clear with patients that we’re 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 training Stanwood said.
The organization has received inquiries from APRNs, nurse-midwives and physician assistants outside of Planned Parenthood, wondering if it will also host training programs for people who don’t work there. For now, Stanwood said, he’s focused on educating Planned Parenthood workers.
“We’ve 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 don’t run an open school for people who don’t work for us. Right now we’re focusing on training our doctors … who will be an immediate part of our workforce.”
Polly Moran, a nurse midwife at SHE Medical Associates, said she plans to train in aspiration abortions. Creating strong training programs for all advanced doctors who want to learn the procedure should be a priority, he said.
Ongoing education programs may play a role.
“As midwives, we have a professional organization that meets four times a year. So it will be discussed: How do we access this training? Moran said. “In ongoing for-profit educational programs, I think we’ll start to see that incorporated.
“Sometimes at an ongoing educational conference, there will be colposcopy training. You can go two days before the other bigger workshops and just pay to learn how to do a colposcopy. I saw it being used for aspiration abortion.”
Officials at Hartford GYN Center in Bloomfield, Connecticut’s only independent abortion provider, they plan to offer training not only to their own workers, but also to advanced practice physicians outside their organization. They hope to begin training their own employees by the end of the summer and then expand the program.
“We would like to position ourselves to do that for our internal providers and also to be a resource for building the workforce of abortion providers,” said Roxanne Sutocky, Director of Community Engagement for The Women’s Centers, which includes Hartford GYN. “It’s something we know is increasingly needed, especially as states are going dark and abortion providers are having to close their doors. We’re seeing an increase in requests for training… of advanced practice doctors”.
Some medical groups have raised concerns about providers other than doctors performing abortions. The Connecticut State Medical Society, witnessing the invoice during the legislative session, said there could be “unintended consequences” to the measure.
“We are headed down the slippery slope of allowing those procedures that are in fact surgical to be performed by mid-level providers, creating patient safety issues and significant scope-of-practice issues,” the organization testified.
But abortion providers maintain that it is safe for advanced practice doctors to perform the procedure.
“If the doctor there has not had the training, he would not be the right person to do it. Whereas if the advanced practice doctor that’s there has all the training, then he’s the right person to do it,” Stanwood said. “Just because you’re a doctor doesn’t mean you know how to do that procedure. It’s not really about what letters come after your name. It’s about the training you’ve had. And our doctors will receive excellent training. We’re not going to graduate them until they’re really ready.”
Supporters of the legislation say 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 the same person perform an abortion if needed, rather than going to someone they’ve never met.
“I had a medication abortion and went to my routine provider at Planned Parenthood to get that care. I found so much comfort in knowing that I already had that relationship with my provider,” said Liz Gustafson, state director of Pro- Choice Connecticut. “I think if anything, that [new law] will allow more providers to meet their patients where they are and deliver the same quality and compassionate care.”
Connecticut has yet to see a pool 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 falling into a pond. There will be ripples,” Stanwood said. “We’re not right next to where the rock fell. But we’re definitely going to see ripple effects. So this will help us prepare for that.”