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Access to Abortion Services in Ontario

Contents

I Background
II Key Messages about Abortion Services in Ontario
III Collaborating to Improve Abortion Services in Ontario
IV Ongoing efforts to support accessibility
V Conclusions

--submitted by Simone Kaptein

I Background

Abortion is considered a safe, legal, insured and funded service in Canada; however, abortion is funded under provincial and territorial health plans, and coverage varies by region. Currently, abortion services are easier to get in larger urban centres; that means that some women will have to travel outside their communities to access abortion services. [1, 2] The vast majority of abortions performed in Ontario were before 16 weeks gestation and complication rates were low. [1, 3] Abortion rates are highest among women aged 20 – 24 and those living in the lowest-income neighbourhoods. [3]

Over the last 15 years, more abortions are being performed outside of hospitals and fewer in hospitals. [1, 3] Tracking of abortion rates has usually been done by examining hospital and abortion clinic data; these data indicate decreasing abortion rates in the province. [1] However, Statistics Canada data has limitations because procedures being performed at clinics not funded by the Ministry of Health and Long-Term Care (MOHLTC), in private doctors’ offices, as well as those paid by women themselves are not reported to Statistics Canada. [1] This means that the number of abortions being performed in the province is currently underestimated.
 
II Key Messages about Abortion Services in Ontario

  1. Abortion is a safe procedure in Ontario. [1, 3] Abortion procedures performed at lower gestational age lowers the complication rate, making timely access to abortion services essential.
  2. Research shows that high quality abortion services must be readily available to support women’s reproductive health. [4 – 7] When women are able to make safe choices regarding their sexual and reproductive health, they are more likely to participate equally in social, political and economic life. [7]
  3. The Ontario abortion system is fragile. Abortion services are shifting from a model that relied on hospitals to one that relies on specialized clinics and private physician offices (PPOs). The current abortion system is poorly understood and is dependent upon a relatively small group of providers.  Hospitals must remain core providers in the system and provide back-up support to the clinics and PPOs.
  4. Access to abortion services can be difficult and access is not equitable across Ontario, primarily due to a complex and fragmented system.  A centralized source of information regarding how to access services that support women’s choices needs to be available.
  5. Health care professionals have a duty to operate in alignment with legal and ethical frameworks that identify obligations regarding confidentiality, respectful behaviour and full disclosure of pregnancy options and choices to their patients. When women are not referred to abortion service providers, it can cause barriers in accessing an abortion provider and receiving a timely procedure or intervention putting the woman at increased risk.

III Collaborating to Improve Abortion Services in Ontario

Echo: Improving Women’s Health in Ontario assembled a cross-provincial Abortion Expert Panel to develop a set of recommendations to improve abortion access in Ontario and to assist in developing a release strategy for key information from four Ontario-based studies. [1] The recommendations have implications for the health care, regulatory and training systems.

The background research was specific to Ontario and included a series of studies that used various methodologies and data sources including secondary data analysis, surveys and interviews.  The secondary data analysis used MOHLTC and Institute for Clinical Evaluative (ICES) data sources from fiscal years 2002 – 2009 and captured non-emergency hospital based procedures as well as non-hospital based procedures including free-standing clinics and PPOs. The studies examined provision of abortions services, an examination of short and longer-term complications associated with non-emergency abortions, an examination of policy and practices in hospitals and an examination of medical curriculum concerning abortion. [1] (A copy of these reports can be accessed on our website www.echo-ontario.ca).

After much consideration, and further consultations with key stakeholders, the Abortion Expert Panel identified the following key messages about the current state of Ontario services. A variety of players will need to be involved to act on the challenges and recommendations identified.

Key system-level recommendations to improve access to abortion:

The recommendations in this report address: 1. improving system design, 2. improving quality, 3. system monitoring and accountability, 4. improving training of health care providers, and 5. improving alignment and adherence to ethical and legal obligations of health care providers (for the full report, please go to our website www.echo-ontario.ca).

Some of these recommendations are:

  • Provide access to high quality abortion services which are readily available to support women’s reproductive health. [4 – 7] Unsafe abortions can lead to serious medical complications, including maternal death. [4, 7]
  • Approve the use of medical abortion drugs in Ontario and Canada.  The drug regimen that is currently used for medical abortion in Ontario is only effective up to seven weeks gestation. The combination of the drugs mifepristone followed by misoprostol is not available in Canada, but it has been shown that this combination can be used safely and effectively up to nine weeks gestation. [5 – 9]
  • Abortion services should be a core service available in hospitals and primary care settings to ensure access to these services for women across Ontario.  
  • Reproductive health, including abortion training, should be core content of medical, nursing and midwifery education programs. Currently only a few providers offer the majority of services, and abortion procedure training is not readily accessible for health professionals.
  • Ontario should provide a central source of information about how to access services that support women’s pregnancy choices. It is currently difficult for women to access reliable information about choices in pregnancy decision-making.
  • Ensure health care professionals are aware of and act on their duty to provide health care services in a legal and ethical way. This means protecting confidentiality, being respectful of women’s choices, and giving all options and choices in pregnancy decision-making, and providing effective referrals that meet a woman’s needs.  

Key recommendations for health promoters to support access to abortion:

The following recommendations from the Expert Panel report are particularly relevant to public health to support improving access to information on pregnancy choices and associated services:

  • Establish a centralized source of reliable information regarding accessing abortion services without putting providers that offer services at risk. Service providers that participate in offering abortion services are currently not easily identified due to concerns for their own safety and/or community sanctions. Women, particularly outside of urban areas, therefore often struggle to identify pregnancy options in a timely fashion. They often incur costs to travel to urban areas where abortion providers are more readily identifiable.  
  • Standardize pregnancy counselling to include all options, including abortion. There are many providers of pregnancy counselling; however, not all providers discuss abortion services as an option. This interferes with women’s ability to determine how to proceed in a timely fashion should they wish to have an abortion.
  • Engage with Telehealth Ontario about current protocols regarding pregnancy questions and ensure a centralized resource is the identified option. The increased visibility of this resource regarding discussion of pregnancy decision options may be a helpful mechanism to support women in accessing services in an effective manner.

IV Ongoing efforts to support accessibility

Echo is currently working with the MOHLTC and relevant stakeholders (i.e., Telehealth Ontario, AIDS and Sexual Health Information Line) to improve the accessibility of information regarding abortion service provision in the province. In the current processes, when someone calls looking for pregnancy options, they are provided with information and referred to an appropriate, local resource if possible (e.g., family physician, public health unit, or abortion service provider). The providers they have listed in their current databases only include abortion clinics in the Greater Toronto Area (GTA). They do not have a complete listing of providers across Ontario. Thus, if someone calls from Sarnia, they are still given information about providers in the GTA.

Echo will also collaborate with the Echo Chair at the University of Ottawa (Dr. A. Foster) regarding how to expand curriculum related to contraception and family planning in medical schools, expanding access to abortion procedures, sexual and reproductive health-related medical ethics as part of core content of sexual and reproductive health curricula in medical, nursing and midwifery education programs.

The Canadian Contraception Access Research Team-Groupe de recherche sur l'accessibilité à la contraception (CART-GRAC), led by Dr. W. Norman, will build a team of researchers and knowledge users across Canada with a long-term aim to improve access to high quality family planning knowledge and services for women, particularly those who are marginalized and vulnerable, to reduce unintended pregnancies (please go to http://www.cart-grac.ca , [email protected]).

V Conclusions

Public health can play a key role in facilitating access to local service providers. A continued focus on sexual health education on the full range of contraception options is necessary.  Particular attention needs to be made to improving access to contraception and family planning services for young women, marginalized women, and those living in rural and remote parts of the province.

References

1 Ferris LE, Croxford R, & Salkeld E. Induced Abortion in Ontario: Case Scenarios. Echo Report 2011.  
2 Shaw J. Reality Check: A close look at accessing abortion services in Canadian hospitals. Canadians for Choice, 2006.  
3 Dunn S, Wise MR, Johnson LM, Anderson G, Ferris LE, Yeritsyan N, Croxford R, Fu L, Degani N, Bierman AS. Reproductiveand Gynaecological Health. In: Bierman AS, editor. Project for an Ontario Women’s Health Evidence-Based Report:Volume 2: Toronto; 2011.
4 Berer, M. (2000). Making abortions safe: a matter of good public health policy and practice. Bulletin of the World Health Organization. 78(5): 580-592.
5 Erdman, J.N., Grenon, A., & Harrison-Wilson, L. (2008). Medication Abortion in Canada: A Right-to-Health Perspective. American Journal of Public Health. 98(10): 1764-1769.
6 World Health Organization, Department of Reproductive Health and Research. (2004). Reproductive health strategy to accelerate progress towards the attainment of international development goals and targets. WHO. 1-36. Accessed August 11 2010 from: http://whqlibdoc.who.int/hq/2004/WHO_RHR_04.8.pdf
7 Ipas. (2009). Ensuring Women’s Access to Safe Abortion: A Key Strategy for Achieving  Millennium Development Goals. Accessed October 29 2010 from: http://www.ipas.org/Publications/asset_upload_file557_2458.pdf
8  Gynuity Health Projects: information on medical abortion.  Accessed Jan 18 2011 from: http://gynuity.org/programs/medical-abortion/
9  Say L, Brahmi D, Kulier R, Campana A, Gulmezoglu AM. Medical versus surgical methods for first trimester termination of pregnancy (review). Cochrane Database of Systematic Reviews 2002, Issue 4. Art. No.: CD003037. DOI: 10.1002/14651858.CD003037.pub2.