Martha Paynter contrasts Newfoundland and Labrador and New Brunswick to describe how abortion should be part of the continuum of a rationally organized health care service delivery system for reproductive health in Atlantic Canada.
Last week Chrissy Teigen and John Legend shared their experience of pregnancy loss publicly and received an “outpouring of support” and applause for their de-stigmatizing approach. Despite the frequency of miscarriage (15% of pregnancies) and abortion (18%), public acknowledgement of these experiences is anomalous and courageous. Normalizing these very normal experiences would support the emotional health of the people who experience them, and our approach to health service provision has a role to play in that normalization.
As a registered nurse in abortion care in Nova Scotia, I spent this week in St John’s, Newfoundland and Labrador to learn about the practices there. The people of this province grapple with the greatest geographical challenges to abortion access in Atlantic Canada. It is 1600 km and a $1000 flight from Happy Valley-Goose Bay in Labrador to St. John’s, where most of the abortion care is provided. Such distances create incredible challenges to anonymity, religious norms, cultural safety, financial security, and continuity of care. Despite these challenges, the abortion care providers in Newfoundland and Labrador have developed progressive approaches that centre patients and optimize resources by harmonizing reproductive health care services.
Approximately 95% of the elective abortion care in Newfoundland is provided by the Athena Clinic, a one-day-a-week clinic embedded in a family practice in downtown St. John’s. That same practice offers maternity care all the other days in the week. When a wanted pregnancy results in spontaneous abortion, also called a miscarriage, the family practice can support patients in that experience as well, through watching and waiting, medicine, or a suction procedure. Similarly, the hospital-based practitioners (obstetricians and nurses) who provide the remaining 5% of elective abortion care in the province also support patients with pregnancy loss and births. A patient may go to a care provider in early pregnancy and truly be supported in all of the pregnancy’s potential outcomes.
Reproductive health experiences including contraception, pregnancy, abortion, pregnancy loss, and birth are part of a continuum. People with a uterus will go through periods of pregnancy prevention, pregnancy management, and many seek care to become pregnant. Care silos are unintuitive, and may cause unnecessary delay, confusion, and trauma for patients. In many settings across Canada, different providers and facilities offer specific reproductive health services. One clinic may offer contraception (e.g. a walk-in clinic), another long-acting reversible contraception including the IUD or Nexplanon implant (e.g. a sexual health clinic), while another offers early prenatal care (e.g. a regular family practitioner). Yet another clinic may offer later prenatal care in the form of a primary care provider who attends births, while another offers elective abortion at an abortion clinic. Still another clinic may offer abortion for maternal health concerns or fetal anomaly (e.g. a hospital operating room). An emergency department might offer treatment for suspected miscarriage, while there is yet another place to go to give birth, such as a maternity hospital. Birth is the most common reason for hospitalization in Canada, and yet the pathway for reproductive care is extraordinarily complex.
This complex web is exhausting. Harmonizing services normalizes the very common experiences of pregnancy prevention, pregnancy, miscarriage and abortion. While of course we cannot all offer the same clinical care, planners and policymakers in reproductive health should prioritize the development of models that integrate services.
To give an example of poor planning, consider the Higgs Conservative provincial government in New Brunswick. Clinic 554 in Fredericton, facing imminent closure, was a model very much like the care available in St. John’s, but went further. It was a family practice that not only offered abortion, but some of the only trans health services rooted in primary care in the country. Despite stand-alone abortion clinics like Athena operating across Canada, and receiving provincial funding for the services they provide, the Higgs’ government has concocted a misleading narrative that remunerating Clinic 554 for abortion services amounts to “privatization”, weaponizing the language of progressives to silence demands for rational and equitable service delivery.
The “private” clinic services at Clinic 554 are only private because the Higgs government refuses to provide public funding for them. Further, the need for the clinic’s abortion care is due to inadequate abortion services in the province. Despite miscarriage management being available at Fredericton’s hospital, which requires the same clinical skill set as elective abortion (use of misoprostol medication or suction procedures), elective abortion is excluded from that hospital’s services.
These exclusions are unnecessary, but they are not arbitrary: this is a conscious decision to stigmatize, mystify, and deny abortion services from the continuum of reproductive health care. Abortion is normal, common and safe, and should be proudly supported by all of us working in reproductive health and paid for by our governments as necessary care.