This article is based on the Imagining the Next Chapter for Abortion Care in Canada: Pathways to Access and Equity panel hosted by missINFORMED on May 2, 2024. We invited five leaders in reproductive health and abortion to provide their insights on the present and future of abortion care in Canada.
Systemic factors refer to the broader policies, practices and norms that shape what reproductive healthcare and abortion access look like in Canada. Unfortunately, there are many systemic barriers that prevent safe access to abortion care for many communities in Canada, including:
Geographical barriers: Abortion clinics are often located in urban centers. In some rural communities, there are no clinics or pharmacies within a reasonable distance that provide abortion care.
Lack of healthcare coverage: In Canada, we have a large number of international students, migrant workers, and other folks new to Canada who do not have healthcare coverage. Without coverage, the out-of-pocket cost of a medication abortion ranges from $300-$450 in Ontario (1). This cost can limit access to care.
Lack of Primary Care: Many folks in Canada do not have a primary care provider (e.g., family doctor). This presents challenges to access because primary care providers can help patients access abortion care through prescribing and referrals. It also makes follow-up care for folks who have had an abortion more challenging.
Stigma: Abortion is healthcare, but across Canada, there are protestors who use graphic anti-abortion images (e.g., images of fake fetuses) in the streets or in front of abortion clinics to depict abortion as something shameful. They actively try to shame people who have accessed or provided abortion care.
Misinformation: Protests not only stigmatize abortion care but can also spread misinformation to discourage people from seeking out abortions. Crisis Pregnancy Centers (CPCs) market themselves as healthcare providers for pregnant people, but instead, they are religiously-associated (i.e., funded or motivated by religious beliefs) clinics that promote misinformation to scare people out of having an abortion.
Impacts of colonialism: Abortion care has roots in the intergenerational reproductive health knowledge of Indigenous communities. Prior to colonization, medicinal herbs were used by Indigenous people to promote bodily autonomy and reproductive choice. However, stigma around abortion care was ingrained in Indigenous communities due to colonization and oppression by the church. Feelings of fear and shame around abortion can make it difficult for anyone to get care, but this is even harder in Indigenous communities due to a lack of anonymity. Indigenous communities are close-knit and people may worry about others in their community learning about their abortion. Accessing abortion care may require individuals to leave the safety of their Indigenous communities to access care, putting Indigenous people at risk.
Racism: Institutional and interpersonal racism are major issues in the Canadian healthcare system. Both forms of racism limit abortion access for racialized people, particularly Black and Indigenous people, and increase the risk to their safety when accessing abortion care outside of their communities.
Private member bills: There are continued attempts by politicians and policymakers to reduce abortion access through new laws and policies that limit who can provide or access abortions.
Conscientious objection: Physicians, pharmacists, and other providers may choose to opt out of care on the basis of a moral or religious objection. This means that a provider who does not believe in abortion as healthcare can choose not to provide care to a patient, further limiting the pool of available abortion providers.
In 2015, Canada made a landmark decision to approve Mifegymiso, making medication abortion available in the country for the first time (2). However, there were significant regulations that limited its accessibility. For example, the pills had to be given directly to the patient by the prescribing doctor, rather than allowing the patient to pick it up from a pharmacy (2). Since 2015, the regulatory limitations have decreased making Mifegymiso more accessible (2). We asked our panelists how the availability of medication abortion impacts specific communities:
Indigenous communities: Willow emphasized that there is no one unifying experience for Indigenous people accessing abortion. Based on the most recent research, broader access to medication abortions has improved its availability in rural locations with the resources (e.g., adequate supply of the medication) to provide it. But this also presents new challenges. While the majority of medication abortions are successful, complications can happen that require urgent medical attention. This can pose challenges for Indigenous people living in rural areas without immediate access to medical care.. Willow also discussed challenges around patient education. In some situations, a person may have the option to choose between a medication abortion or procedural abortion. The differences between these two types of abortions are not always explained so people may not feel adequately informed when choosing which form of care is best for them. Sometimes they may feel pushed towards one type of abortion over another and feel as if they do not have a choice.
Transgender, nonbinary and queer folks: A.J. highlighted that for many trans, nonbinary and queer folks, there may be general mistrust of the healthcare system. There is a desire for medication abortion because it allows a patient to receive care at home rather than going into a clinic or hospital where they may anticipate mistreatment or non-affirming care. A.J. describes this as a “constrained choice”, because their choices in care are limited based on what form of care is most likely to be affirming of their gender. There is a great need for inclusive and gender affirming spaces for abortion care to ensure that any decisions about the type of abortion people receive are not based on anticipated mistreatment.
People who are unhoused: The ability to receive medication abortion is constrained by the duration of pregnancy. Medication abortions are only available up to 10 weeks of pregnancy (in other words, 10 weeks after a person’s last menstrual period) (3). Nora emphasized that for people who are unhoused, malnutrition may delay the discovery of pregnancy, sometimes eliminating their ability to access medication abortion. They often lack access to material resources like period products, or a place to rest, which greatly affect their abortion experience.
The availability of Mifegymiso has also changed the practice landscape for providers and prescribers. We asked our panelists, what kinds of support are out there for providers and patients who use Mifegymiso?
Continuing education: Currently, there are no extra training requirements for a physician, nurse practitioner, or midwife to prescribe Mifegynmiso; but as Natasha pointed out, training can be very helpful for providers. National Abortion Federation and Society of Obstetricians and Gynecologists of Canada (SOGC) both offer additional elective training to providers interested in learning more about providing abortion care that can be accessed voluntarily.
Other like-minded providers: Natasha pointed out that abortion care can be isolating work for providers. There is value in connecting with other abortion providers not only to share knowledge but also to lean on others for support.
Emphasis on counseling: People are increasingly accessing abortion care via telemedicine, and having a medication abortion at home. Natasha and Willow both emphasized the need for comprehensive patient counseling prior to receiving their abortion to help set their expectations and establish support prior to taking the medication. As Natasha pointed out, good counseling is a huge part of determining the quality of someone’s abortion experience.
Abortion doulas: Nora shared her experience as an abortion doula and highlighted the critical role they play in supporting folks through their abortion experiences. Abortion doulas provide one-on-one care and support before, during, and after an abortion. Clark also highlighted Abortion Doula training offered by Abortion Support Services Atlantic.
Collaboration with community organizations: Many members of QTBIPOC communities hold great distrust in the medical system. As Clark pointed out, folks are more likely to turn to trusted community organizations for support when accessing abortion care. These community organizations may then take on the significant responsibility of supporting people through their abortion care journey, sometimes without adequate resources or training. Clark highlighted this as an opportunity for providers to collaborate with these community spaces in providing education and support to patients accessing abortion care.
Canada’s current state of abortion care is shaped both by recent advancements, including the introduction of Mifegymiso, as well as long-standing systemic barriers that limit access to care. Improving access to care requires making medication abortion and procedural abortion more easily available, while also making abortion care inclusive and safer for communities that face the most barriers to care, including Indigenous Peoples, Black and other racialized groups, and 2SLGBTQIA+ communities.
Want to learn more about what our panelists have to say? Watch the full panel webinar.
Acknowledgement: We at missINFORMED are incredibly grateful to all of our panelists for their dedication to reproductive justice and their willingness to participate in our panel discussion. Thank you to our panelists and to all who have engaged with our panel discussion.
References:
Only information that was not mentioned during the panel discussion is cited.
Action Canada for Sexual Health and Rights. FAQ: The Abortion Pill Mifegymiso. 2019 Apr 6. Available from: https://www.actioncanadashr.org/resources/factsheets-guidelines/2019-04-06-faq-abortion-pill-mifegymiso [Accessed 2024 Aug 4]
Action Canada for Sexual Health and Rights. The Politics of Mifegymiso in Canada: Key Dates and Milestones. 2018 Nov 5. Available from: https://www.actioncanadashr.org/resources/factsheets-guidelines/2018-11-05-politics-mifegymiso-canada-key-dates-and-milestones#:~:text=July%202015%3A%20Health%20Canada%20approves,the%20newly%20approved%20abortion%20pill [Accessed 2024 Aug 4]
Women’s College Hospital. Abortion Options Comparison. Available from: https://www.womenscollegehospital.ca/care-programs/the-bay-centre-sexual-health/abortion-options-comparison/ [Accessed 2024 Aug 4]
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