There have long been important differences between Canada and the United States regarding access to, and regulation of, abortion care. During this time of crisis, these differences have become all the more glaring.
In March, Alabama, Iowa, Ohio, Oklahoma, Texas, and Kentucky all leapt to ban, or at least severely limit, access to abortion care during the current COVID-19 pandemic, with criminal consequences for violations. Reproductive rights and civil liberties organizations, notably the American Civil Liberties Union (ACLU), responded immediately – and largely successfully – with lawsuits to reverse these state actions.
In response to these news stories, some Canadians have wondered whether something similar might happen here. Fortunately, none of the provinces or territories have attempted to restrict access to abortion under their jurisdiction over health care, although the government of New Brunswick continues to refuse to pay for surgical abortions provided outside of hospital. The federal government has not attempted to restrict access under its jurisdiction over the criminal law; in fact, it has demanded New Brunswick expand access.
Leaders across Canada have affirmed that abortion is an essential service to be maintained throughout the pandemic. This is because abortion, unlike many other interventions, cannot reasonably be delayed. A delay of as little as a few weeks can make for significant changes in terms of the required supplies, techniques and facilities thereby seriously affecting the safety and availability of the service.
In Canada, most abortions occur in the first trimester. In a small number of cases, however, patients require care after that period. Later abortions are not available in all parts of the country. For example, no hospital in Atlantic Canada provides elective abortion care after 16 weeks. This fact emphasizes the importance of timely access to abortion during the pandemic, so that travel does not become necessary.
Despite provincial and territorial assurances concerning access to abortion care, certain populations will inevitably face greater challenges accessing this essential service at this time. Canada’s immense geography, limitations in the training available to clinicians, and gaps in public health insurance for people like international students remain barriers to timely and free care for all. These challenges are amplified for patients now facing COVID related job loss and mobility restrictions.
During the COVID-19 pandemic, the National Abortion Federation has advised that providers of abortion care need to take extra precautions, use appropriate personal protective equipment, practice physical distancing, and restrict the presence of support people while continuing to provide care. This means that members of the care team (nurses, nurse practitioners, physicians, social workers and others) will need to conduct most patient assessments by phone. They will need to coordinate care so that ultrasound, bloodwork and surgical procedures are completed in a single appointment. And, in those rare cases where travel is required, the health authorities will need to provide comprehensive and thoughtful guidance to patients and providers so that care can be offered while respecting public health protocols.
For medical abortions, prescribers will need to prescribe this over the phone, having confirmed the availability of Mifegymiso (the medication used to induce a miscarriage at home) with the patient’s local pharmacy. They will need to follow-up with patients by phone to see how they have managed the experience of medical abortion.
In addition to the direct provision of care, experienced providers of abortion care will need to mentor their peers to develop greater comfort with prescribing medical abortions, thereby increasing the pool of prescribers. They will need to teach abortion care concepts and procedures through Zoom and distance technologies. These sound changes in practice and mentoring will support patient comfort and safety.
COVID-19 itself may increase the demand for abortion care. There is limited access to sexual health services to support people seeking contraception and education. We should make better use of pharmacists’ ability to prescribe contraception, so that instead of going to primary care offices or acute care settings, patients can get their birth control pills at the pharmacy near their homes. As well, domestic violence is on the rise during this pandemic. Controlling partners and the demands of self-isolation increase the risk of sexual coercion and difficulty discretely accessing abortion care.
For now, and in anticipation of increased demand, we need to keep protecting access to abortion services. Doing so includes talking about abortion as a normal, common and essential part of reproductive health care. Even, and especially, in a pandemic.