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Tracy A. Weitz, University of California-San Francisco
As sociologists, we aim to make a difference in the “real world.” This is particularly true for scholars like me who study the socially contested issue of abortion, a health care service to which access increasingly reflects broader social inequalities. More than 10 years ago, I embarked on a project to reduce inequalities in access by using empirical research to make policy change. I encountered many unexpected obstacles as well as more than a few happy surprises. My experience offers lessons to social scientists who want to use their research to make social change through policy.
More than one million American women have abortions every year, making it one of the most common health care interventions for women of reproductive age. Women of all races, religions, social classes, and citizenship statuses seek abortion care, yet where they can access care is not evenly distributed. For a range of reasons, including efficiencies of size and more liberal social climates, abortion providers are clustered in urban centers leaving 97 percent of non-metropolitan areas—largely lower-income areas—without a local abortion provider. This means that, women with the fewest means often must travel great distances to access abortion.
Although these underserved areas may be lacking in physician-providers, they do have nurse practitioners (NP), certified nurse midwives (CNM), and physician assistants (PA), who are already routine providers of reproductive health care and whose scopes of practice include procedures similar to first-trimester abortion. In 2002, some colleagues and I noted that these clinicians had the skills to provide first-trimester abortions, but the law was fuzzy on whether they were legally allowed to. We set out to study this possibility, with the explicit goal of policy change in order to expand access to early abortion care in California.
California liberalized its abortion law in 1967, but still had many outdated or unconstitutional requirements on the books. One of those limitations was the requirement that all abortions be performed by a licensed physician. In 2002, abortion rights advocates successfully modernized the law to allow NPs, CNMs, and PAs to prescribe medication abortion (i.e., the abortion pill), but they were still officially precluded from performing a first-trimester aspiration abortion (often erroneously referred to as “surgical abortion,” despite not resembling surgery). To change this aspect of the law, we had to demonstrate to professional and political stakeholders that such a change would not risk the public’s health.
First, we had to identify a location to conduct the study. Four states (New Hampshire, Vermont, Oregon, and Montana) did not limit aspiration abortion provision to physicians, but collectively they had low numbers of women having abortions and few sites of care from which to conduct research. Then, we discovered a little know mechanism in the California bureaucracy: the Health Workforce Pilot Project (HWPP) program, wherein investigators could apply for a legal waiver to test the provision of health care services by a new classification of clinicians where current law limited provision. After a multi-year negotiation over the clinical protocol, University of California-San Francisco (UCSF) received a waiver for HWPP #171 and we commenced our research project. Because we wanted to be sure that the project resulted in real social change, we sought to design a study that would result both in legislative change and in the actual expansion of services and that required negotiating competing research and policy change frameworks.
In research, a core value is containment of findings until the research is complete. In the policy arena, transparency is a core value. Working in the public domain we were required to release data every three months, thus risking that premature conclusions would be drawn from the data. Additionally, in research, parsimony of sample size and independent variables is prized. In policy-relevant research, the sample size needs to feel sufficient to stakeholders and multiple types of environmental factors need to be assessed. Balancing these competing agendas was challenging and meant allowing a larger group of stakeholders to be involved in study design as well as some concessions from what would be standard research protocol.
In the end, we successfully balanced these competing needs, training 47 NPs, CNMs, and PAs, and enrolling more than 20,000 patients, to demonstrate that these clinicians had safety outcomes equivalent to physicians performing abortion care—fewer than 2 percent of patients needed any additional care and only nine patients needed any hospital-based care (what is defined as a major complication in abortion care).
It turned out that conducting the research study was the easy part—the hard part was making the policy change. In the course of the policy process, we were subject to personal attacks and accused of having an ideological agenda of promoting abortion. Opponents of abortion rights repeatedly tried to halt our study, introducing a bill to restrict the HWPP mechanism such that our study would be excluded and using a public records act to demand the names of the clinician trainees and the physician trainers. Luckily, neither effort was successful. In testimony before the state legislature and in lobbying efforts, they challenged the research design and findings, necessitating our ongoing involvement during the policy process in translating the research for legislators.
Not all the opposition came from those against abortion rights. Changes in scope of practice are high stakes for health professionals of all kinds, regardless of what our research evidence showed. The first effort to pass legislation to remove the physician-only restriction for aspiration abortion failed to even make it out of the first committee because a key lobbying constituency refused to support the bill, worried it would hamper other legislative goals of their group. This experience abruptly taught us how much groundwork was required with the broad range of professional groups, or stakeholders, who were implicated in the legislation policy change. A year later, with the support of a much broader coalition of community, legal, and professional groups, abortion rights advocates introduced a bill supported by our research evidence that was sensitive to the various stakeholder needs. This bill, AB154, won the approval of the California legislature and was signed into law by the governor in October 2013.
What are the lessons from this experience? First, that it’s not enough to conduct rigorous scientific research; if you want to make actual policy change, you have to be willing to stay in the policy process until it is done. Second, along the way, you have to pay attention to the quality and rigor of your science, while simultaneously balancing the needs of stakeholders who exist in the “real world.” Third, and perhaps most importantly, you have to realize you can’t do this from the security of the ivory tower. I made more than 50 trips to the state capital to testify before the legislature and to more informally discuss the study and its findings. This is on-the-ground work, above and beyond data collection, analysis, and interpretation. When all was said and done, I couldn’t be more proud. Women in California—regardless of income or location—now have greater access to safe abortion care, and I helped make that happen through my sociological research.
Tracy A. Weitz is an Associate Professor in the Department of Obstetrics, Gynecology and Reproductive Sciences and a research sociologist in the Advancing New Standards in Reproductive Health (ANSIRH) program or the Bixby Center at the University of California, San Francisco.