Abortion capacity in Colorado could expand with advanced practice clinicians, more telehealth
As Colorado abortion rights activists prepare for a potential influx of patients coming into the state following the anticipated reversal of Roe v. Wade, they are strategizing about how to increase the pool of qualified abortion providers to meet demand and not compromise the care of Colorado residents.
“I don’t see any state that has secure abortion access being able to meet that demand with the current workforce. We are talking unbelievable numbers of reproductive-aged individuals who will live in states without abortion access,” Dr. Kristina Tocce, an OB-GYN and the vice president and medical director of Planned Parenthood of the Rocky Mountains, said.
“Every single state that has secure access is going to be called to serve an unmeetable need.”
A leaked draft opinion this month shows the U.S. Supreme Court is poised to overturn the landmark Roe v. Wade precedent, leaving abortion policy up to individual states. Since Colorado now has reproductive health care, including abortion rights, enshrined in state law, the state could become an island of abortion care access as surrounding states work to pass restrictions.
Wyoming and Utah both have so-called trigger laws on the books that will effectively ban abortion if Roe v. Wade is overturned. Oklahoma’s governor recently signed a six-week ban into law, following the lead of Texas’ controversial measure, S.B. 8, which went into effect last year.
The experience following Texas’ ban could foreshadow what Colorado can expect as surrounding states work to ban abortion.
“Our volume increased dramatically in the first month or so since S.B. 8 was implemented. We saw a huge spike in our requests from people, specifically from Texas. That volume continues to hold,” said Amanda Carlson, the abortion fund director for Cobalt, a nonprofit dedicated to abortion access in Colorado.
An increase of nonresident abortion patients, many of whom might be further along in their gestational period due to travel and logistical delays, could create a strain on the abortion provider network.
“We know if we experience a provider shortage in Colorado there will be impacts for both people who travel to Colorado and people who live in Colorado who need abortion care. I think the biggest concern for us, is that folks will inevitably be pushed much later into their pregnancies before being able to access the care they need. Generally, when someone can’t access abortion care when they want it and they are pushed later into their pregnancy, it can drive up financial costs and emotional burdens, significantly,” Gina Martínez Valentín, the director of Colorado Doula Project, said in an emailed statement. The organization provides practical, logistical and financial support to patients.
In 2021, 13.6% of the 11,580 people who received abortions in Colorado came from out of state, with high numbers from Texas and Wyoming, according to vital statistic records from the Colorado Department of Public Health and Environment. That share has steadily increased since 2017, when the earliest public data is available.“We are going to need more staff,” Carlson said. “We’re facing this national crisis of receiving states being flooded and not having staff capacity.”
“Just because abortion is legal somewhere does not mean it is accessible,” she said.
A May 9 meeting organized by Cobalt between abortion providers gave them a chance to connect and begin laying the necessary groundwork to meet the anticipated need.
Experts say a stream of out-of-state patients in a post-Roe world will take coordination and innovative problem-solving to address.
“One of our big focuses is how private providers can take some of the overflow and stress off of some of the larger organizations that are seeing a lot of the second trimester abortions for patients who are traveling out of state,” said Dr. Sarah Peterson, an OB-GYN who provides abortions in the Denver-metro area.
The clinic she works at is trying to block out time, for example, for patients who call at the last minute and need timely care. They are also working on communication strategies with larger organizations to let them know they are available to share the load. Right now, Peterson said she sees between two and 10 abortion patients per month.
Advanced practice clinicians an untapped group
One strategy for increasing the pool of providers in Colorado is recruiting more advanced practice clinicians — professionals such as nurse practitioners, certified nurse midwives and physician assistants — to begin practicing abortion care.
APCs already use skills and provide care that are extremely similar to what is needed in an abortion, such endometrial biopsies, ultrasounds and IUD insertion. Their scope of practice can also include miscarriage management.
“Essentially, miscarriage management and abortions are the same skill set. We are trained in that and have experience providing that care,” said Kate Coleman-Minahan, an assistant professor with University of Colorado’s College of Nursing and family nurse practitioner.
Colorado is one of a handful of states that does not have a law restricting abortion to physicians, meaning that APCs can provide them largely without restriction. Maryland is the most recent state to allow APCs to include abortions in their practice.
There is, however, low awareness among the group in Colorado of that opportunity.
In a 2020 survey from Coleman-Minahan and her colleagues, 12% of APCs were aware they could provide abortion in Colorado. Nearly 45%, however, were interested or possibly interested in medication abortion training. About 25% were interested or possibly interested in aspiration, or procedural, abortion training.
“This suggests that Colorado has the provider capacity to expand access to abortion,” Coleman-Minahan said. “We’re going to need that, as we’ve already seen an influx of patients leaving their states to receive essential health care in Colorado.”
She envisions a future where APCs who work at urgent care facilities or family medicine practices will be able to provide abortion care, expanding the provider pool and also the geographical footprint of where patients can access care.
There are specialized programs to train APCs on abortion care, such as the Training in Early Abortion for Comprehensive Healthcare, or TEACH, program in California and the Reproductive Health Access Project. There is no specific certificate required for an APC to begin practicing abortions, so they can also learn on the job.
“I think it’s definitely a strategy that should be utilized, especially given the current emerging scenario,” Peterson said. “Where do we have potential providers? How can we get them better equipped in terms of their comfort level and skill set?”
Planned Parenthood already employs APCs.
“Utilizing all hands on deck is definitely a strategy, and using advanced practice clinicians is definitely within that strategy plan,” Tocce said. “Absolutely, there is a very large interest through the abortion providing community to increase in any way possible and really call to action everyone who can contribute, and that includes advanced practice clinicians.”
Telehealth abortion care
Another strategy for increasing provider capacity is telehealth, which has grown in use and trustworthiness since the COVID-19 pandemic.
A growing number of national companies, such as carafem, Hey Jane and Choix operate in Colorado and ship abortion pills after a provider consultation. Just the Pill plans to expand to Colorado and operate mobile clinics starting in June, as reported by the New Yorker.
Colorado Doula Project is preparing to educate people on those self-managed abortions as they anticipate an increase in pregnant people seeking that option, Martínez Valentín said.
“Even if abortion were to become legally unsafe, it’s important that people know that they will still have access to safe abortion methods,” she wrote, highlighting the companies that mail FDA-approved abortion medication to people. “As an organization, we are preparing to be able to support clients locally and remotely who choose to self-manage their abortions.”
Telehealth for abortion care has its advantages: It is convenient, private and might provide space in clinics for patients who need a procedural abortion.
“Minimizing the amount of strain on clinics that only have so many appointment slots in a day is definitely something we are strategizing around,” Carlson said.
Using telehealth strategically for patients who can safely undergo abortion care without needing to come in person will “open up the availability in brick and mortar facilities for the patients who truly need that for their medical care,” Tocce said.
Planned Parenthood of the Rocky Mountains uses telehealth appointments for many of its services, including abortion care, and has offered it even before the COVID-19 pandemic. Like other medical providers, it expanded telehealth offerings over the past few years out of necessity.
“One silver lining of COVID is that we have this really robust network of telehealth now. That has been really such an advantage for patients seeking abortion care,” Tocce said. “We have utilized that tremendously and we have plans to increase that capacity.”
While telehealth can be convenient, it also comes with unique challenges, for both patients and providers. Petersen said she is open to telehealth abortion care, but the “logistical legwork” of getting it off the ground at her workplace is complicated. It could be a better strategy for larger organizations like Planned Parenthood and the online companies that have already developed best practices.
Patients also still need to get to a state where abortion is legal in order to access telehealth abortion care. Depending on the situation, they might need to stay overnight and could need assistance from an organization like Cobalt or another abortion fund for hotel and transportation costs.
Even as people in the abortion providing ecosystem think about the need to increase capacity and the workforce, it will take time. For now, abortion is still legal nationwide, until a final Supreme Court decision is issued this summer.
“Scaling up isn’t something that happens overnight,” Coleman-Minahan said. “There aren’t just trained and ready providers hanging out, waiting to jump in. It’s an opportunity, but it isn’t something that is going to happen instantly.”