From Scope to Births: APRN Full Practice Authority and Fertility

• In Event: Evaluating Policies to Improve Access to Contraception in the US

Abstract

Background:
Provider shortages remain an important constraint on reproductive health access, particularly in underserved areas. This paper examines whether expanding Advanced Practice Registered Nurse scope of practice through Full Practice Authority alters downstream fertility outcomes by changing access to care. We exploit staggered state adoption of FPA laws between 2004 and 2023 to estimate effects on county-level fertility, measured as live births per 1,000 women ages 15–44.
Research Objective:
The central question is whether regulatory liberalization changes reproductive behavior through a supply-side channel: by reducing physician supervision requirements, FPA may expand provider availability, improve patient access, and alter the effective margin on which reproductive decisions are made.
Methods: 
The paper links fertility outcomes to provider supply and contraceptive prescribing in order to distinguish between competing mechanisms.The empirical strategy uses modern staggered-adoption difference-in-differences estimators, with Borusyak-Jaravel-Spiess as the principal specification and event-study models used to assess dynamic effects and pre-treatment patterns. The primary outcome is county-level fertility. Mechanism analyses pair the fertility specifications with county-level provider supply from the Area Health Resource Files and contraceptive prescription measures from Medicaid State Drug Utilization Data.
Results:
Preliminary first-stage evidence is suggestive: separate provider-supply analyses indicate strong growth in the nurse practitioner workforce over the past decade, with especially large increases in NP-to-physician ratios in counties with low baseline physician density, consistent with reallocation toward underserved markets.Preliminary downstream fertility results are more inconclusive, but the ambiguity is itself informative. A priori, FPA may operate through offsetting channels. On one margin, expanded contraceptive access could reduce fertility by lowering barriers to counseling, prescribing, and method continuation. On another, improved access to healthcare more generally, including primary, prenatal, and reproductive care, could increase fertility by lowering the expected health and logistical costs of pregnancy and childbirth. Consistent with these competing forces, preliminary event-study estimates do not yet show a sharply estimated post-adoption decline in fertility. Complementary Medicaid prescription analyses are also not yet decisive in baseline fixed-effects models, which reinforces the need for richer mechanism testing. The next step is to use prescription claims and related utilization measures to determine whether FPA primarily shifts contraceptive access, broader healthcare access, or both.
Conclusions:
The study contributes not only to the occupational licensing literature, but also to a broader policy question: whether supply-side healthcare reforms change fertility through contraception, through improved care access, or through offsetting combinations of the two.

Author

• Moiz Bhai, University of Arkansas
  Presenting Author