Joanna Erdman singles out medical abortion in answer to place-based access barriers in Canada.
Access to abortion depends on more than its legal status. We’ve known this to be true in Canada for decades.
Canada is one of few countries worldwide with no criminal abortion offence on the books – following judicial decriminalization in R v. Morgentaler (1988). Since this landmark decision, provincial governments under the power to regulate health care financing and delivery have both protected and restricted access to abortion services. While some provincial restrictions remain – notably in public funding – the primary access barrier to abortion in Canada is not directly legal. As recent studies suggest the critical access barrier today is that of place – invoked through dimensions of time, travel, cost and regional disparity.
In some ways, place-based barriers are not a new aspect of the problem. Former criminal abortion laws, for example, relied on a distinction between hospital and clinic services. After decriminalization, both Nova Scotia and New Brunswick prohibited the performance of abortions outside of hospitals, a prohibition later struck down by the Supreme Court as unconstitutional. Other provinces restricted public funding of abortion services based on the location where services were provided.
Since 1977, there has been a steady decline in public sector hospitals performing abortions. In fact, a lack of hospital-based therapeutic abortion committees to authorize terminations was named as a dysfunction of the old criminal regime. An increasing proportion of abortions today are performed in single-purpose clinics limited to large urban centers. This shift to clinic-based services may also explain the decline in the number of rural abortion providers. A recent study in British Columbia revealed an estimated 60% decrease in the proportion of abortions performed in rural or community hospitals between 1995 and 2005.
Both trends in abortion service availability have led to increasing distances between women and abortion service providers, with many women travelling across provincial borders to access services. In their research on spatial disparities in abortion access in Canada, Sethna and Doull reported on substantial access gaps for women living in Atlantic, Northern and coastal communities, as well as First Nations and Métis women living in rural and remote communities, and the burdens of travel, cost, and delay they face in accessing services. 73% of women travelling to the New Brunswick clinic had travelled more than 100 km to access the services. Women who self-identified as First Nations or Metis were almost three times more likely to report travelling over 100 km to access a clinic.
Place-based access barriers and their inequities offer yet one more reason to promote the availability of medical abortion in Canada. In medical abortion, drugs rather than surgery are used to terminate a pregnancy. Canadian women, however, cannot benefit from this innovation. Although registered in 57 other countries, the drug mifepristone has yet to be approved and distributed in this country. When used with misoprostol, mifepristone is a safe and effective method of abortion, preferred by many women. Moreover, a great promise of medical abortion is that it may be provided safely earlier in pregnancy by a more diverse set of providers in a broader range of facilities.
When mifepristone is approved for use in Canada, the legal task will be to ensure that legal regulation designed for safe surgical services does not impede its promise of access. The regulatory goal will be to ensure that with the introduction of medical abortion, services will become more widely available in health facilities beyond hospitals and specialized clinics, and that health practitioners beyond physicians (including nurse practitioners and midwives) will be trained and authorized to administer the drugs. To overcome, place-based barriers to access, we must welcome the abortion providers, facilities and methods of the future, unburdened by antiquated regulation of the past.
Joanna Erdman is the MacBain Chair in Health Law and Policy, Assistant Professor of Law, at Dalhousie University, Halifax, Canada