Study Backs NP, PA Prescriptions for Abortion Drugs

Medication abortion was just as safe and effective when provided by nurse practitioners (NPs) or physician assistants/associates (PAs) as compared to physicians, a retrospective cohort study suggested.

The estimated effectiveness of mifepristone (Mifeprex) and misoprostol was 92.9% for the advance practice clinicians, which met noninferiority criteria compared with the physicians in the study (90.1%), reported researchers led by Sarah Averbach, MD, MAS, of the University of California San Diego.

Abortion completion rates following prescriptions from NPs and PAs, which made up the bulk of the advance practice clinicians, were 92.8% and 93.2%, respectively. Emergency department visits (0.2%) and adverse events (0.1%) were rare and didn’t differ by clinician type, according to the research letter in JAMA Network Open.

“Our estimates of abortion completeness when provided by APCs [advance practice clinicians] are similar to published estimates provided with ultrasonography dating and follow-up to 70 days by a variety of clinicians (93.3%), and to 77 days when provided by physicians (88.4%),” the authors noted.

“These data affirm the safety and effectiveness of [medication abortions] provided by APCs,” Averbach and team concluded.

In 2016, the FDA changed the risk evaluation and mitigation strategy (REMS) program for mifepristone to allow advance practice clinicians — like NPs, PAs, and certified nurse midwives — to prescribe abortion drugs.

But “in the absence of sufficient data, 26 states have physician-only laws restricting APCs from providing medication abortion,” according to the study authors.

Most of the literature thus far has focused on the effectiveness and safety of advance practice clinicians providing procedural abortions, they noted, so Averbach and team set out to compare medication abortion effectiveness by advance practice clinicians and physicians.

They included all medication abortions for pregnancies under 77 days’ gestation provided at Planned Parenthood of the Pacific Southwest across three counties in California from December 2021 to December 2025.

Of the 59,150 medication abortions analyzed, 32,008 were provided by NPs, 23,012 by PAs, 2,553 by certified nurse midwives, and 618 by physicians; 59 medication abortions were missing data on practitioner type and were excluded from the final sample.

Mean patient age was 27 years, 62% paid with Medicaid, 22% paid with private insurance, and 16% self-paid. Four percent of patients traveled from out of state. About two-thirds of the abortions were for pregnancies at 49 days’ gestation or less.

Pregnancy was confirmed via ultrasound for all patients before mifepristone and misoprostol were dispensed. A week or two later, patients were seen again for transvaginal ultrasonography to see if they were still pregnant or retained products of conception, and were offered an additional dose of misoprostol or aspiration if needed.

In an adjusted model, the type of provider was not significantly associated with complete abortion. Estimated effectiveness was 92.9% for NPs, 93.1% for PAs, 91.9% for certified nurse midwives, and 91% for physicians.

There were 41 minor adverse events, of which 26 were hemorrhages and 15 were infections. All four severe adverse events were blood transfusions.

Of patients who visited the emergency department, 53 were for bleeding, 25 for pain, 39 for incomplete abortion or ongoing pregnancy, four for fainting or dizziness, four for allergic reaction, two for infection, one for hematometra, and two were unspecified.

As for limitations, the authors noted that group sizes were unbalanced and some patients were lost to follow-up.