WOMEN’S HEALTHFar From Home? A Pilot Study Tracking Women’s Journeys to a Canadian Abortion Clinic
Abstract
Objective
Abortion has been recognized internationally as an essential health service. The geographical distance to an abortion provider is acknowledged as a major barrier to access. This pilot study tracks women’s journeys to the Toronto Morgentaler Clinic for abortion services.
Methods
A questionnaire was developed specifically for this study and was administered over a four-month period to women using abortion services at the clinic. Questions asked for demographic information and details of the costs, distances, and women’s experiences of their journeys to the clinic.
Results
A total of 1022 of 1256 surveys were completed for an overall response rate of 81%. The majority of women in the sample (54%) were 21 to 30 years old, had a partner (55.8%), were employed full time (50.5%), and had an income of less than $30 000 per year (68.2%). Most women had travelled an hour or more to the clinic (73.5%), and the remainder had travelled for less than half an hour. Women reporting incomes of less than $30 000 were more likely than wealthier women to have travelled from 200 km to more than 1000 km (OR 1.74; 95% CI 1.16–2.71). Women who were under the age of 30 were more likely to rate their journey as difficult or very difficult (OR 1.68; 95% CI 0.98–2.88).
Conclusion
More research is needed to determine how far women must travel for abortion services in Canada and to determine the wider health, political, and legal implications of these journeys.
Résumé
Objectif
L’avortement est reconnu de par le monde comme étant un service de santé essentiel. La distance géographique séparant le fournisseur de services abortifs et la patiente constitue un obstacle important en matière d’accès. La présente étude pilote fait le suivi des déplacements qu’ont dû effectuer les patientes de la clinique Morgentaler de Toronto pour obtenir des services abortifs.
Méthodes
Un questionnaire a été conçu spécialement pour cette étude et a été administré sur une période de quatre mois aux femmes ayant recours aux services abortifs offerts par la clinique. Les questions portaient sur les renseignements démographiques et les détails quant aux coûts, aux distances parcourues et aux expériences des patientes pendant leur périple vers la clinique.
Résultats
Au total, 1 022 sondages sur 1 256 ont été remplis, ce qui représente un taux de réponse global de 81 %. L’âge de la plupart des femmes de l’échantillon (54 %) se situait entre 21 et 30 ans, elles avaient un partenaire (55,8 %), un emploi à temps plein (50,5 %) et un revenu inférieur à 30 000 $ par année (68,2 %). La plupart des femmes avaient dû voyager pendant au moins une heure pour se rendre à la clinique (73,5 %), tandis que les autres avaient dû voyager pendant moins d’une demi-heure. Les femmes signalant un revenu inférieur à 30 000 $ étaient plus susceptibles que les femmes mieux nanties d’avoir connu un déplacement se situant entre 200 km et plus de 1 000 km (RC, 1,74; IC à 95 %, 1,16–2,71). Les femmes de moins de 30 ans étaient plus susceptibles de considérer leur périple comme ayant été difficile ou très difficile (RC, 1,68; IC à 95 %, 0,98–2,88).
Conclusion
De plus amples recherches s’avèrent requises pour déterminer la distance devant être parcourue par les patientes souhaitant obtenir des services abortifs au Canada, ainsi que pour déterminer, dans une perspective plus large, les implications sanitaires, politiques et juridiques de ces déplacements.
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Cited by (43)
Understanding women's provider choice for induced abortion in Turkey
2021, Health PolicyCitation Excerpt :The literature shows that women who prefer to have abortion in shorter delays [42,54–57], concerned about their privacy [5,42,58], do not want to be judged by the provider [42] and want high quality abortion care [42,43,59] prefer private providers. However, access to private providers is more difficult for low-income women due to high costs involved and for those living in remote areas [42,43,57,59–62]. Moreover, in Turkey, not all provinces have private hospitals with obstetrics and gynaecology department, not all private hospitals contract with the SSI, and even when they are under contract with the SSI, hospitals may require additional payments and the SSI does not contract with private doctors.
In Turkey, women gained free access to induced abortion from public facilities through the legalization of abortion in 1983. However, due to unmet need and abortion stigma, women use predominantly private services. The political discourse on anti-abortion in the past decade has triggered a diminishing trend in public provision. This runs against both the 1983 Law and the healthcare reforms initiated in 2003, which aimed at universal access to health services. This study investigates the socioeconomic characteristics of women affecting the utilization of public services for induced abortion. Using “Turkey Demographic and Health Survey 2013”, the results of Probit models indicate that women who were young, unmarried, wealthier and whose abortion decisions were made by themselves or their spouses were less likely to choose the public services for induced abortion. Regional differences in the utilization of public sector were also observed. Findings indicate a need to ensure and widen women's access to abortion nationwide; both at the hospital and outpatient level. Health education programs including family planning should give special emphasis to young, single and socioeconomically disadvantaged women who are more prone to apply for unsafe abortion when access to public and/or private sector is limited. A transparent referral system should be designed to timely direct women to abortion services.
Exploring Canadian women's knowledge of and interest in mifepristone: results from a national qualitative study with abortion patients
2016, ContraceptionCitation Excerpt :Although there are no federal laws regulating abortion in Canada, disparities in abortion access persist. A body of research has demonstrated that young women, recent immigrants, First Nations women, poor women, and rural residents face significant barriers to obtaining timely abortion care [1–4]. That these women are at greater risk of unintended pregnancy reflects compounded vulnerabilities with respect to reproductive health.
Although Canada decriminalized abortion in 1988, significant disparities in access to services and an uneven geographic distribution of providers persists. Health Canada registered mifepristone, the gold standard of medication abortion, in July 2015. Our study explored Canadian women's knowledge of, interest in, and perspectives on mifepristone prior to registration.
From November 2012 through July 2015 we conducted in-depth interviews with 174 Anglophone and Francophone women from Alberta, Manitoba, New Brunswick, Ontario, and Quebec about their abortion experiences and their opinions about medication abortion. We purposively recruited participants from different age cohorts and different regions within each study province to explore a range of perspectives. We analyzed these interviews for content and themes related to mifepristone using both deductive and inductive analytic techniques.
The overwhelming majority of participants had no knowledge of mifepristone at the time of the interview. However, after providing a brief description of an evidence-based mifepristone/misoprostol regimen, more than half of the participants reported that they would have considered this method had it been available at the time of their abortion and most would have been comfortable receiving medication abortion care from a family physician or nurse practitioner. Most women supported the approval of mifepristone and felt Canadian women would benefit from having more options for early pregnancy termination.
Although knowledge of mifepristone among recent abortion patients was low, considerable interest in medication abortion exists. Expanding awareness-raising efforts and supporting the approval of evidence-based regimens and provision of mifepristone appears warranted.
The approval and introduction of mifepristone for early abortion in Canada promises to increase options and access. Creating tailored and culturally and contextually resonant messages about mifepristone is of high priority. Promoting evidence-based protocols and the inclusion of a full range of qualified professionals in service provision is also warranted.
Medical Abortion
2016, Journal of Obstetrics and Gynaecology CanadaThis guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care.
Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services.
Women with an unintended first trimester pregnancy.
Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required.
The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1).
Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability.
Introduction
- 1.
In countries where mifepristone is approved, women have improved access to medical abortion; however, abortion rates do not increase. (Level II-3)
- 2.
Women who can choose their method of abortion have higher satisfaction rates. (Level II-1)
Pre-procedure care
- 3.
In the absence of readily accessible ultrasound, gestational age can be estimated using last menstrual period (LMP), clinical history, and physical examination, in women who are certain of the date of their LMP. Ultrasound is needed when uncertainty remains. (Level II-2)
- 4.
The probability of ectopic pregnancy among women requesting abortion is consistently lower than in the general population. (Level II-3)
Medical abortion regimens
- 5.
There is limited evidence regarding teratogenicity of mifepristone, but overall the risk appears to be low. (Level III)
- 6.
Misoprostol is a known teratogen when used in the first trimester of a pregnancy. (Level II-2)
- 7.
The risk of teratogenicity is high with the use of methotrexate. (Level II-3)
- 8.
Oral mifepristone 200 mg and buccal misoprostol 800 μg is 95% to 98% effective up to 49 days after last menstrual period. The risk of ongoing pregnancy is less than 1%. (Level I)
- 9.
Oral mifepristone 200 mg and buccal, vaginal, or sublingual misoprostol 800 μg is 87% to 98% effective up to 63 days after last menstrual period. The risk of ongoing pregnancy is less than 3.5%. (Level I)
- 10.
Intramuscular/oral methotrexate and vaginal/buccal misoprostol is 84% to 97% effective up to 63 days after last menstrual period. The risk of ongoing pregnancy is 0.4% to 4.3%. (Level I)
Providing medical abortion
- 11.
There is no evidence to support or refute the routine administration of Rh immunoglobulin to Rh negative women who undergo medical abortion before 49 days last menstrual period. (Level III)
- 12.
There is no strong evidence supporting routine antibiotic prophylaxis for medical abortion. (Level II-2)
- 13.
Medical abortion is associated with bleeding, which is often heavier than a menstrual period, and with potentially severe cramping. (Level III)
- 14.
Prophylactic ibuprofen administration does not provide superior pain control compared with as-needed dosing in women undergoing medical abortion. (Level I)
Post-abortion care
- 15.
Follow-up rates are similar for both remote and in-clinic visits. (Level II-2)
- 16.
When both women and their clinician believe successful expulsion has taken place, based on history alone, complete abortion is likely. (Level II-2)
- 17.
Either ultrasound and/or serial bhCG measurements provide definitive evidence of pregnancy termination. (Level I)
- 18.
A fall of beta human chorionic gonadotropin levels of 80% or more from pre-treatment to first follow-up at 7 to 14 days is indicative of a completed medical abortion. (Level II-2)
- 19.
If ultrasound is used to assess completion of a medical abortion, endometrial thickness alone is not predictive of the need for subsequent surgical intervention. (Level II-2)
- 20.
Retained products of conception requiring aspiration are more common in medical compared with surgical abortion. (Level II-2)
- 21.
A second dose of misoprostol may lead to completion of a medical abortion when there is a retained gestational sac or an ongoing pregnancy. (Level III)
- 22.
Severe complications following medical abortion are rare. (Level II-2)
- 23.
Ovulation may occur as soon as 8 days after starting the medical abortion procedure. (Level III)
- 24.
Insertion of intrauterine device at the follow-up visit after medical abortion is associated with higher insertion rates and equivalent expulsion rates compared with delayed insertion. (Level I)
Introduction
- 1.
Women who are eligible for medical abortion should be counselled on the availability of both medical and surgical options. (Level II-2A)
Pre-procedure care
- 2.
When communicating with a woman who has an unintended pregnancy, health care providers should use appropriate nonjudgemental and nondirective language, preferably with additional written or online material, and should ensure a confidential environment. (Level III-A)
- 3.
Health care providers uncomfortable with abortion counselling or provision must promptly refer the woman to another health care provider/facility or provide information on where she may be able to access abortion care. (Level III-A)
- 4.
Women seeking an abortion should have the capacity to provide voluntary informed consent. Health care providers should counsel women on the proposed intervention and alternatives, outcomes, and risks. (Level III-A)
- 5.
Providers should use a reliable method to confirm that a pregnancy is at appropriate gestational age for effective and safe medical abortion. (Level II-2A)
- 6.
Women should be informed that medical abortion carries a small increased risk of additional intervention compared with surgical abortion. (Level II-2B)
Medical abortion regimens
- 7.
Only evidence-based regimens should be used to perform medical abortion. (Level I-A)
- 8.
Mifepristone 200 mg oral and misoprostol 800 μg buccal/vaginal/sublingual is the regimen of choice for medical abortion up to 70 days among eligible women. (Level I-A)
Providing medical abortion
- 9.
Rh immunoglobulin is recommended to Rh negative women undergoing medical abortion beyond 49 days from last menstrual period and may be offered before 49 days. (Level III-C)
- 10.
Women who have risk factors for ectopic pregnancy and/or clinical symptoms, such as abdominal pain and vaginal bleeding, should have an ultrasound and be adequately followed. (Level III-A)
- 11.
Women who have a pregnancy of unknown location and request medical abortion should receive abortion care without delay provided that they have no clinical symptoms of ectopic pregnancy (EP). If the transvaginal ultrasound demonstrates an empty uterus and the bhCG is > 2000 IU/L, the woman should be evaluated for an EP and appropriate counselling, investigations, and follow-up should be arranged. (Level III-B)
- 12.
All women with a pregnancy of unknown location, and women who have not had a pre-abortion ultrasound, must have serial bhCG levels until ectopic pregnancy has been excluded and/or the abortion is complete. (Level III-A)
Post-abortion care
- 13.
All women undergoing medical abortion should have a follow-up assessment to confirm completion of the abortion. (Level II-2A)
- 14.
A reliable method of follow-up should be used. This can be done in clinic or remotely using ultrasound and/or serial bhCG measurements combined with clinical history. (Level II-2A)
- 15.
A fall of bhCG levels of less than 80% from pre-treatment to the first follow-up at 7 to 14 days requires further investigation/management/follow-up/referral. (Level II-2A)
- 16.
Providers should inform women about symptoms and signs of complications and give them clear information on emergency care. (Level III-A)
- 17.
Women with ongoing pregnancy at first follow-up after the start of a medical abortion with mifepristone/misoprostol should be offered repeat misoprostol or surgical evacuation. (Level III-A)
- 18.
Women with ongoing pregnancy 14 to 21 days after the start of a medical abortion with mifepristone/misoprostol should be offered surgical evacuation. (Level III-A)
- 19.
Surgical abortion is recommended for women with ongoing pregnancy after methotrexate/misoprostol for attempted medical abortion. (Level III-A)
- 20.
If a woman wishes to start a hormonal method of contraception, it should be started as soon as possible after taking misoprostol. (Level III-B)
- 21.
If a woman wishes to start using an intrauterine device, it should be inserted at the follow-up visit after medical abortion, once completion of the abortion is confirmed. (Level I-B)
- 1.
Medical Students' Intentions to Seek Abortion Training and to Provide Abortion Services in Future Practice
2015, Journal of Obstetrics and Gynaecology CanadaLack of providers is a barrier to accessing abortion in Canada. The factors influencing the number of abortion providers are poorly understood. In this study, we assessed the attitudes and intentions of medical students towards abortion training and provision to gain insight into the future supply of abortion providers.
We surveyed first, second, and third year medical students at an Ontario university to determine their intentions to train in and provide abortion services during different stages of training and in future practice. We assessed students’ attitudes and intentions towards training in and providing abortions, their perceptions of social support, their perceived ability to receive training in and to provide abortion services, and their attitudes towards the legality of abortion.
Surveys were completed by 337 of 508 potential respondents (66.7%). The responses indicated that the students in the survey held relatively positive attitudes towards the legality and availability of abortion in Canada. Respondents had significantly more positive attitudes towards first trimester medical abortions (and a greater intention to provide them) than towards second trimester surgical abortions. Thirty-five percent of students planned to enter a specialty in which they could perform abortions, but fewer than 30% of these students planned to provide any type of abortion. Intentions to provide abortions were correlated with positive attitudes toward abortion in general and greater perceived social support for abortion provision.
A small proportion of students sampled intended both to enter a specialty in which abortion would be within the scope of practice and to provide abortion services. Lack of perceived social support for providing abortions and the perceived inability to obtain abortion training or to logistically provide abortions were identified as two potentially modifiable barriers to abortion provision. We propose increasing education on abortion provision and creating policies to promote medical abortion as a method of improving access to abortion across Canada.
Au Canada, l’accès à des services d’avortement est entravé par le manque de fournisseurs de soins étant en mesure d’offrir de tels services. Les facteurs qui influencent le nombre de fournisseurs de services d’avortement sont mal compris. Dans le cadre de cette étude, nous avons évalué les attitudes et les intentions des étudiants de médecine en ce qui concerne la formation en matière d’avortement et l’offre de tels services dans le cadre de leur future pratique, et ce, pour en connaître davantage au sujet de nos futurs effectifs dans ce domaine.
Nous avons sondé les étudiants de médecine de première, de deuxième et de troisième année d’une université ontarienne, à différents stades de leur formation (et en leur demandant de remplir un questionnaire traitant de la future pratique qu’ils envisageaient), en vue de déterminer leurs intentions en ce qui concerne l’obtention d’une formation en matière d’avortement et l’offre de services d’avortement. Nous avons évalué les attitudes et les intentions de ces étudiants en ce qui concerne l’obtention d’une formation en matière d’avortement et l’offre de services d’avortement, leurs perceptions en ce qui a trait au soutien social, leur capacité subjective de recevoir une formation en matière d’avortement et d’offrir des services d’avortement, et leurs attitudes envers la légalité de l’avortement.
Trois cent trente-sept des 508 répondants potentiels (66,7 %) ont répondu aux questionnaires. Les réponses indiquent que les répondants adoptaient des attitudes relativement positives envers la légalité et la disponibilité de l’avortement au Canada. Les répondants adoptaient des attitudes considérablement plus positives envers les avortements médicaux au premier trimestre (et un plus grand nombre d’entre eux avaient l’intention d’offrir de tels services) qu’envers les avortements chirurgicaux menés au deuxième trimestre. Trente-cinq pour cent des étudiants avaient l’intention de choisir une spécialité dans le cadre de laquelle la tenue d’avortements serait possible; toutefois, moins de 30 % de ces étudiants avaient l’intention d’offrir quelque type de services d’avortement que ce soit. Les intentions d’offrir des services d’avortement étaient en corrélation avec les attitudes positives envers l’avortement en général et avec la perception d’un soutien social accru envers l’offre de services d’avortement.
Une faible proportion de l’échantillon d’étudiants analysé avait l’intention de choisir une spécialité dont le champ d’activité englobe la tenue d’avortements et d’offrir des services d’avortement. L’absence subjective de soutien social envers l’offre de services d’avortement et l’incapacité subjective d’obtenir une formation en matière d’avortement ou d’offrir des services d’avortement au plan logistique ont été identifiés comme étant deux obstacles potentiellement modifiables pour ce qui est de l’offre de services d’avortement. Pour assurer l’amélioration de l’accès à l’avortement d’un bout à l’autre du Canada, nous proposons l’augmentation des efforts d’éducation au sujet de l’offre de services d’avortement et la création de politiques visant la promotion de l’avortement médical.
Perspectives among canadian physicians on factors influencing implementation of mifepristone medical abortion: A national qualitative study
2020, Annals of Family MedicineAccess to family planning health services in Canada has been historically inadequate and inequitable. A potential solution appeared when Health Canada approved mifepristone, the gold standard for medical abortion, in July 2015. We sought to investigate the factors that influence successful initiation and ongoing provision of medical abortion services among Canadian health professionals and how these factors relate to abortion policies, systems, and service access throughout Canada.
We conducted 1-on-1 semistructured interviews with a national sample of abortion-providing and nonproviding physicians and health system stakeholders in Canadian health care settings. Our data collection, thematic analysis, and interpretation were guided by Diffusion of Innovation theory.
We conducted interviews with 90 participants including rural practitioners and those with no previous abortion experience. In the course of our study, Health Canada removed mifepristone restrictions. Our results suggest that Health Canada's initial restrictions discouraged physicians from providing mifepristone and were inconsistent with provincial licensing standards, thereby limiting patient access. Once deregulated, remaining factors were primarily related to local and regional implementation processes. Participants held strong perceptions that mifepristone was the new standard of care for medical abortion in Canada and within the scope of primary care practice.
Health Canada's removal of mifepristone restrictions facilitated the implementation of abortion care in the primary care setting. Our results are unique because Canada is the first country to facilitate provision of medical abortion in primary care via evidence-based deregulation of mifepristone.
Telemedicine for First-Trimester Medical Abortion in Canada: Results of a 2019 Survey
2023, Telemedicine and e-Health
Competing Interests: None declared.