Position

The American Academy of Nursing (Academy) supports equitable access to health care, including sexual and reproductive health (SRH) care, for all individuals.¹  This includes the full spectrum of SRH care under evidence-based clinical guidelines. As SRH services are being prohibited or unduly regulated, the Academy urges strong protections for the full spectrum of SRH services and care.

Although the term “women” is used throughout this statement, the Academy recognizes and affirms that some individuals who receive SRH services including abortion care may be transgender men or nonbinary people.

Background

The Academy has long supported policies that ensure access to safe high-quality SRH services. Members of the Academy are experts in facilitating the expansion of clinical knowledge and evidence-based preventive health services, especially related to preventing unintended pregnancies and advocating that all health care, including SRH services and policies that support those services, are grounded in scientific knowledge and evidence-based standards of care.^{1, 2}

Family Planning Services

SRH care decisions, including but not limited to the decision of whether to bear children, directly affect individuals’ health and well-being. These decisions are private and personal, and all individuals should have the ability to make decisions in partnership with health care professionals.

The Medicaid program serves as the primary payor of family planning services for low-income individuals in the United States.³ While family planning services are a mandatory benefit of the federal program, it is not defined, and this has allowed states to exclude qualified reproductive and family planning providers from participating in their Medicaid programs. At the federal level, the Title X Family Planning Program also provides a range of SRH services for low-income and uninsured individuals. Restricting the type of clinicians who can provide Title X services has had harmful effects on eligible individuals’ access to gender-sensitive SRH services (e.g., pregnancy diagnosis/counseling, contraceptive services, basic infertility services, sexually transmitted infections [STI] screening, and preconception health care) and is linked with increased pregnancy rates.^4,5 Restricting access to the breadth, range, or type of health care providers who can provide SRH services results in a serious lack of access for those who rely solely on these programs for their health care.

The Patient Protection and Affordable Care Act (ACA, Public Law No. 111-148, and implementing regulations) requires all new insurance plans to cover “all Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity” without cost-sharing requirements.⁶ This law was created to protect women’s health, ensure that women do not pay more for insurance coverage than men, and advance women’s equality and well-being.⁷ Under Section 1557 of the Affordable Care Act, 42 U.S.C. 18116, recipients of federal financial assistance, including Medicare and Medicaid payments, and pharmacies are prohibited from discriminating based on race, color, national origin, sex, age, and disability in their programs and activities, including access to prescription medications for reproductive health and other types of care.⁸ Without the protections for abortion care provided by the landmark case Roe v. Wade following the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization,⁹ increasing numbers of individuals, particularly those aged 18-30, are choosing permanent contraception options (tubal sterilization, vasectomy) to prevent the risks of unintended pregnancy.¹⁰ In 2023, the FDA approved the first daily oral contraceptive approved for use without a prescription. Over the counter (OTC) contraceptives have the potential to reduce barriers to access and could help reduce the number of unintended pregnancies. All individuals must continue to have access to all facets of contraceptive care as intended under the ACA.

Abortion is an essential component of family planning SRH services. The National Academies of Sciences, Engineering, and Medicine (NASEM) have reported that all legal methods for performing abortions in the Unites States are safe and effective.¹¹Moreover, NASEM found that barriers to abortion care, including mandatory waiting periods and the provision of inaccurate or misleading information about abortion, can negatively impact quality and safety.¹¹ Availability of abortion care is highly dependent on state and location factors, particularly in the wake of the Dobbs decision. The Hyde Amendment prohibits the use of federal funds for abortion care with few exceptions, which poses an immense challenge for individuals covered through Medicaid in states that restrict abortion.¹² Although several states use state funds to cover abortion care for Medicaid enrollees, access to abortion care for low-income and uninsured individuals remains a significant challenge.¹²

It is important to note that minoritized and historically marginalized racial and ethnic groups have uninsured rates disproportionate to other groups. Of women ages 18-49, 22% of American Indian and Alaska Native (AIAN) women; 21% of Hispanic women; 14% of Native Hawaiian or Pacific Islander (NHPI) women; and 11% of Black women are uninsured compared with 7% of white women.¹³ Furthermore, uninsured rates among women ages 18-49 are higher in states that have restricted abortion care compared to states that have maintained access to care.[13] With insurance coverage, of women ages 18-49, 37% of AIAN women; 33% of Black women; 32% of NHPI;  and 27% of Hispanic women are covered by Medicaid compared to 18% of white women.¹³ Without equitable access to abortion care, the already striking disparities in maternal health are likely to worsen. As an essential, safe, and effective component of family planning services, abortion care coverage should be expanded wherever possible.

Health Screenings

Under the Medicaid program’s “free choice of provider” provision, beneficiaries have the right to obtain care from any provider qualified to perform the service.¹⁴ Some states have excluded certain health centers and health care providers from providing SRH care in their programs. This in turn creates a severe lack of access to such services in certain communities. However, the consequence of states’ limiting the provision of SRH services perpetuates discrimination between those who can afford health services and those who cannot. Ultimately, limiting such services contributes to a wide range of health disparities. Numerous evidence-based studies have found a lack of access to care ultimately leads to not only higher health care costs overall, but also lower health outcomes.¹⁵

Telehealth Services for SRH Care

There is also a need to increase access to telehealth services for SRH care. Nearly one in five Americans live in rural areas that are becoming more diverse, exposing an increase in health disparities such as being at a higher risk of maternal morbidity and mortality. This further requires the need for growth of the health care workforce and access to quality health care.¹⁶

The Need to Protect Access to SRH Services

There is a heightened need to protect access to SRH services in light of recent and ongoing judicial consideration and Supreme Court cases involving the availability of SRH care. The Dobbs v. Jackson Women’s Health Organization¹⁷ decision significantly increased concerns for health equity and privacy. Research has demonstrated that individuals of low socio-economic status and individuals from some racial and ethnic groups are disproportionally affected when limitations have been placed on abortion access.¹⁸ Marginalized communities already experienced limited access or outright denial of services, and Dobbs has only exacerbated existing disparities. While more research is needed to measure outcomes over a longer time frame, a scoping review examined public health implications in the year after Dobbs and found that approximately 60% of reproductive age women now live in states that ban or restrict abortion care.¹⁹ Furthermore, among women ages 18-49, Black and AIAN women are more likely than other women to live in states with bans or restrictions on abortion care. Barriers such as needing to travel out of state to access care have become more impactful, as travel distances have expanded and many women, particularly women having low incomes, are not able to do so to receive the care they need. Women in states that have restricted abortion are more likely to have low incomes compared with women that live in states that do not have such restrictions.¹³ Historically marginalized and medically underserved populations, including Black, AIAN, Hispanic, and rural-residing women, are likely to face the most barriers to care, which has deep implications for disparities in maternal health.¹⁹

The Supreme Court will soon determine whether the Emergency Medical Treatment and Active Labor Act (EMTALA)²⁰ preempts state laws that restrict access to abortion care.²¹ EMTALA requires hospitals that participate in public health programs to provide all patients with screening, examination, stabilizing treatment, and transfer, if necessary, irrespective of any state laws or mandates that apply to specific procedures. Stabilizing treatment could include medical and/or surgical interventions, including abortion. Under EMTALA, patients are assured access to emergency medical care, including SRH care, and protects providers when offering legally mandated, life- or health-saving abortion services in emergency situations.²²

In FDA v. the Alliance for Hippocratic Medicine, the Supreme Court will determine if mifepristone, used in medicated abortion services, may be allowed to be mailed to patients and dispensed at pharmacies as its Food and Drug Administration (FDA) approval and regulation permits.²³ If dismantled, the Supreme Court would set the precedent of impairing the FDA’s scientific, independent medication approval and regulation processes for all future medications as well as create barriers for patients to access a medication essential to providing the full spectrum of SRH services.

As SRH services are increasingly under scrutiny, protecting a patient’s health information when seeking abortion services and other SRH care is essential.²⁴ Policies from The Federal Trade Commission²⁵ that protect the sharing of highly sensitive data, including location and health information contained in fertility and period tracking data, and the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule²⁶ to protect the privacy of individuals health information, including SRH care are required to ensure patients’ health information remains protected and private. The Academy stands in support of additional protections including the HIPAA Privacy Rule to Support Reproductive Health Care Privacy.²⁷ This rule strengthens protections for persons seeking, obtaining, providing, or facilitating reproductive health care that is lawful under the circumstances in which it is provided by prohibiting disclosures of protected health information (PHI) for criminal, civil, or administrative investigations or proceedings against individuals for such care.²⁸

Rights and Responsibilities of Individual Nurses

Nurses play a key role in educating patients on their health care treatment options. Nurses promote and advocate for the rights, health, and safety of the patient. The American Nurses Association’s (ANA) Code of Ethics for Nurses is “a nonnegotiable moral standard of nursing practice for all settings”.²⁹  According to the Code of Ethics, “Recipients of care have the moral and legal right to determine what will be done with and to their own person; to be given accurate, complete, and understandable information in a manner that facilitates an informed decision; and to be assisted with weighing the benefits, burdens, and available options in their treatment, including the choice of no treatment..”²⁹ The Academy recognizes there may be nurses who are uncomfortable providing the full spectrum of SRH services for moral or religious reasons and have the right to refuse to participate in SRH care based on ethical grounds. In these cases, patient safety must be assured, and alternative sources of timely care must be arranged for the individual seeking SRH care.³⁰

The Academy supports policies that protect the rights to and access of SRH services, including abortion. There is a strong need for legislative reform that addresses prevalent health disparities and realigns structures to enable the attainment of health equity.³¹

1. Require health insurance plans (both public and private) provide access to and coverage for the full spectrum of SRH care.

2. Increase funding for the Title X Family Planning Program.³²

3. Ensure that provider networks include SRH providers, including advanced practice registered nurses (APRNs), who specialize in these services and ensure they are able to practice at the top of their licensure.

4. Prohibit policies and legislation at all levels of government that interfere with the patient-provider relationship, including those that prevent nurses and other clinicians from discussing SRH services such as abortions, as well as legal actions against those who seek and provide reproductive care.

5. Protect individuals who travel to access abortion care from prosecution for criminal behavior. Clinicians who provide abortion care for these individuals should also be protected from prosecution.

6. Prohibit the illegal use and sharing of any sensitive patient health information, including patient identifiers revealing the patient’s location and health data, as intended by the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule²⁵  and other similar policies that protect the use of an individual’s data.

7. Require access to contraception care and coverage of prescribed and over the counter (OTC) contraception as well as medication abortion. This includes access for individuals who are prescribed the medications used in medication abortion for off-label use to treat health conditions unrelated to abortion.

8. Increase funding for community-based public health approaches for SRH care (including information and educational resources) for marginalized communities.

9. Enforce the Emergency Medical Treatment and Active Labor Act (EMTALA),which requires hospitals that participate in public health programs to provide all patients with screening, examination, stabilizing treatment, and transfer, if necessary, irrespective of any state laws or mandates that apply to specific procedures. Stabilizing treatment could include medical and/or surgical interventions, including abortion.

10. Increase access to SRH services and care through telehealth technologies.
    
    
    This position statement originated from the Academy’s Expert Panels on Bioethics, Health Equity, and Women’s Health. The Expert Panel on LGBTQ+ Health also reviewed this position statement. The Academy’s Expert Panels are the organization’s thought leadership bodies. Through the Expert Panels, Academy Fellows, with subject matter expertise, review the current trends, research, and issues within their field to make informed and evidence-based recommendations. It was approved by the Board of Directors on May 15, 2024. Updated March 13, 2025 to reflect the 2025 ANA Code of Ethics for Nurses as outlined on page 4 of this position statement.

[1] Olshansky, E., Taylor, D., Johnson-Mallard, V., Halloway, S., & Stokes, L. (2018). Sexual and Reproductive Health Rights, Access & Justice: Where Nursing Stands. Nursing Outlook, 66(4), 416–422.  https://doi.org/10.1016/j.outlook.2018.07.001

[2] American Academy of Nursing. (2022, June 24). Joint Statement from Maternal Health Specialists on Dobbs v. Jackson Women's Health Organization.

https://cdn.ymaws.com/aannet.org/resource/resmgr/policydocuments/positionstatements/joint_maternal_health_statem.pdf

[3]Medicaid Coverage of Family Planning Benefits: Findings from a 2021 State Survey. (2022, May 31). Kaiser Family Foundation.  https://www.kff.org/womens-health-policy/report/medicaid-coverage-of-family-planning-benefits-findings-from-a-2021-state-survey/

[4] White, K., Hopkins, K., Aiken, A. R. A., Stevenson, A., Hubert, C., Grossman, D., & Potter, J. E. (2015). The Impact of Reproductive Health Legislation on Family Planning Clinic Services in Texas. American Journal of Public Health, 105(5), 851–858. https://doi.org/10.2105/ajph.2014.302515

[5] Health Management Associates. (2017). Challenges to Underserved Women’s Access to Family Planning Services in Wisconsin 2016.  https://www.docdroid.net/Ny4AxrB/hma-report-ppfa-wi-jan2017-pdf

[6] H.R.3590 - 111th Congress (2009-2010): Patient Protection and Affordable Care Act. (2010, March 23).  http://www.congress.gov/

[7] 42 U.S.C. § 300gg-13(a)(4); 45 C.F.R. § 147.130 (2013) (a)(1)(iv)

[8] Office for Civil Rights. (2022, July 13). HHS issues guidance to the nation's retail pharmacies clarifying their obligations to ensure access to comprehensive reproductive health care services. HHS.gov. https://www.hhs.gov/about/news/2022/07/13/hhs-issues-guidance-nations-retail-pharmacies-clarifying-their-obligations-ensure-access-comprehensive-reproductive-health-care-services.html

[9]Dobbs v. Jackson Women's Health Organization , No. 19-1392, 597 U.S. (2022),

[10]  Ellison, J. E., Brown-Podgorski, B. L., & Morgan, J. R. (2024). Changes in permanent contraception procedures among young adults following the Dobbs decision. JAMA Health Forum, 5(4), e240424. https://doi.org/10.1001/jamahealthforum.2024.0424

[11]  National Academies of Sciences, Engineering, and Medicine. (2018.) The Safety and Quality of Abortion Care in the United States. Washington, DC: The National Academies Press. https://doi.org/10.17226/24950 .

[12]  Jung, C., Oviedo, J., & Nippita, S. (2023). Abortion care in the United States—Current evidence and future directions. NEJM Evidence, 2(4).  https://doi.org/10.1056/EVIDra2200300

[13]  Hill, L., Artiga, S., Ranji, U., Gomez, I., & Ndugga, N. (2024, April 24). What are the implications of the Dobbs ruling for racial disparities? KFF. https://www.kff.org/womens-health-policy/issue-brief/what-are-the-implications-of-the-dobbs-ruling-for-racial-disparities/

[14]  Section 1902(a)(23) of the Social Security Act.

[15]  Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, & Office of the Secretary. (2020, August 18). Access to Health Services - Healthy People 2030. https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/access-health-services

[16]  Office, A. S. P. A. P. (2022, August 8). HHS invests nearly $60 million to strengthen health care workforce and improve access to care in rural communities. HHS.gov. https://www.hhs.gov/about/news/2022/08/08/hhs-invests-nearly-60-million-to-strengthen-health-care-workforce-and-improve-access-to-care-in-rural-communities.html

[17] Dobbs v. Jackson Women's Health Organization, No. 19-1392, 597 U.S. (2022).

[18] Redd, S.K., Rice, W.S., Aswani, M.S. et al.Racial/ethnic and educational inequities in restrictive abortion policy variation and adverse birth outcomes in the United States. BMC Health Serv Res 21, 1139 (2021).  https://doi.org/10.1186/s12913-021-07165-x

[19]  Zhu, D. T., Zhao, L., Alzoubi, T., Shenin, N., Baskaran, T., Tikhonov, J., & Wang, C. (2024, March 29). Public health and clinical implications of Dobbs v. Jackson for patients and healthcare providers: A scoping review. PLOS ONE, 19(3), e0288947. https://doi.org/10.1371/journal.pone.0288947

[20]  Centers for Medicare and Medicaid Services. (2022, August 25). Emergency Medical Treatment Labor act (EMTALA). CMS. https://www.cms.gov/medicare/regulations-guidance/legislation/emergency-medical-treatment-labor-act   

[21]  Sobel, L., Salganicoff, A., & Felix, M. (2024, April 22). Abortion back at SCOTUS: Can states ban emergency abortion care for pregnant patients? KFF.  https://www.kff.org/womens-health-policy/issue-brief/abortion-back-at-scotus-can-states-ban-emergency-abortion-care-for-pregnant-patients/ .

[22]  Assistant Secretary for Public Affairs (ASPA). (2022, July 12). Following President Biden's executive order to protect access to reproductive health care, HHS announces guidance to clarify that emergency medical care includes abortion services. HHS.gov.  https://www.hhs.gov/about/news/2022/07/11/following-president-bidens-executive-order-protect-access-reproductive-health-care-hhs-announces-guidance-clarify-that-emergency-medical-care-includes-abortion-services.html

[23]  Sobel, L., Salganicoff, A., & Felix, M. (2024, March 21). What’s at stake for access to medication abortion and the FDA in the Supreme Court case FDA v. The alliance for Hippocratic medicine? KFF.  https://www.kff.org/womens-health-policy/issue-brief/medication-abortion-fda-supreme-court-alliance-hippocratic-medicine/

[24] Office for Civil Rights. (2022, June 29). HIPAA privacy rule and disclosures of information relating to Reproductive Health Care. HHS.gov. https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/phi-reproductive-health/index.html

[25] Cohen, K. (2022, July 11). Location, health, and other sensitive information: FTC committed to fully enforcing the law against illegal use and sharing of highly sensitive data. Federal Trade Commission. https://www.ftc.gov/business-guidance/blog/2022/07/location-health-and-other-sensitive-information-ftc-committed-fully-enforcing-law-against-illegal

[26] Office for Civil Rights. (2022, March 31). Privacy. HHS.gov.https://www.hhs.gov/hipaa/for-professionals/privacy/index.html

[27] American Academy of Nursing. (2023, June 16). American Academy of Nursing Comments Regarding HIPAA Privacy Rule to Support Reproductive Health Care Privacy.  https://aannet.org/resource/resmgr/policydocuments/2023_policy_actions/AAN_HIPAA_Privacy_Rule_Lette.pdf

[28]  HIPAA Privacy Rule to Support Reproductive Health Care Privacy. (2024, April 22). 45 CFR Parts 160 and 164. RIN 0945-AA20.

[29] Code of Ethics for Nurses with Interpretative Statements.  (2015).American Nurses Association. https://www.nursingworld.org/coe-view-only

[30] Sexual and Reproductive Health. (2022, March 7). American Nurses Association.  https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/reproductive-health/

[31]  American Academy of Nursing. (2020, August 4). The American Academy of Nursing and the American Nurses Association Call for Social Justice to Address Racism and Health Equity in Communities of Color.   https://cdn.ymaws.com/aannet.org/resource/resmgr/pressreleases-newsitems/oldwebsite/Academy_ANA_Joint_Statement_.pdf

[32]  U.S. Department of Health and Human Services. (n.d.). Title X statutes, regulations, and legislative mandates: HHS Office of Population Affairs. OASH Office of Population Affairs.  https://opa.hhs.gov/grant-programs/title-x-service-grants/title-x-statutes-regulations-and-legislative-mandates