As health care providers continue to adapt to the demands of COVID-19, doctors in Canada say that the crisis proves we need accessible abortion services more than ever.
From routine procedures to life-saving surgeries, health authorities have deemed different services either essential or non-essential to prioritize emergency care. This need to prioritize health care based on urgency has reopened debates about the kinds of services we consider important.
In some countries, notably the US, this means political and religious authorities have the opportunity to lobby against medical care they oppose, with abortion as the main target.
States like Texas, Oklahoma, and Alabama have used the pandemic to push forward emergency anti-abortion legislation that categorizes abortions as a non-essential medical service. By claiming that abortions are non-essential, state governments can legally close clinics for the duration of the pandemic, leaving abortion providers and would-be patients in the lurch.
While the country’s northern neighbour hasn’t felt the same level of anti-abortion sentiment during the pandemic, abortion care providers are still facing new challenges.
In Canada, abortion has not been restricted federally since 1988. While the essential nature of abortion was quickly reaffirmed by policy-makers at the beginning of the pandemic, providers had to adjust the way they delivered health services so patients could continue to access abortion at the peak of regional quarantine measures.
There are two general kinds of pregnancy termination options open to patients. Medical abortion, where pills are taken orally, is generally available in early-stage, low-risk terminations, whereas surgical abortion, where instruments are used internally, is preferred for later-stage or more complicated cases.
Various Canadian abortion clinics or hospitals provide both kinds of terminations, with some exceptions, making abortion a widely-accessible, legally-permitted service for patients.
While the types of services patients need haven’t changed dramatically, the pandemic has altered the way clinics and hospitals think about accessible care. The Pigeon spoke to three Canadian abortion providers—one in B.C. and two in Ontario—about how COVID-19 has impacted access to abortion and changed the way providers administer services.
Dr. Renee Hall helps to administer abortion services in multiple settings—both private clinics and hospitals—across B.C. She told The Pigeon that the province’s care providers quickly mobilized to ensure their patients’ abortion access would not be interrupted by COVID-19.
“It was never a question of if we were going to provide [abortions], it was a question of how,” she said. “We were ready to fight with our institutions if it became an issue.”
Thankfully, Hall said the essential status of abortions were reaffirmed by both the provincial and federal governments in March, allowing abortion procedures to continue uninterrupted.
“There was not one break in our provision of services,” she said.
In order to ensure that these services could go on uninterrupted, B.C. abortion providers adapted to meet patients’ needs while also adhering to COVID-19 restrictions.
For clinics and hospitals in B.C., this meant outfitting the staff with Personal Protective Equipment (PPE), restricting the ability of patients to bring a person with them for support, and eliminating unnecessary in-person appointments.
“[Our administrators] started working 12-15 hour days to figure out how we could provide [care] with the least amount of social contact,” Hall explained.
Abortion can be an emotional experience, and the presence of a supportive loved one has a proven positive impact on patients. Hall explained that currently, patients are asked to enter the clinic alone to limit the number of people inside the space.
“For most women, it hasn’t been an issue and they’re aware of that ahead of time,” she said.
Hall added that patients with clinical appointments for other services, such as Intrauterine Device (IUD) birth control insertions, had a harder time adjusting to these rules.
“Sometimes people have wanted their partner sitting beside them and holding their hands, so that’s been a bit of a hardship.”
In Kingston, Ont., Dr. Ashley Waddington works at the department of Obstetrics and Gynecology’s Women’s Clinic within the Kingston General Hospital (KGH). Although she and her colleagues had worries about the care they could provide under COVID-19 restrictions, the hospital administration quickly reaffirmed the importance of abortion services.
Unlike many other hospitals and clinics in Canada, KGH continued to allow patients to bring a person for support during their surgical abortion appointment. Waddington said staff at the Women’s Clinic advocated for this policy.
“The hospital as a whole was still allowing people who were having surgical procedures to have one support person come in with them,” she explained. “We argued that since [this type of abortion] is also a surgical procedure, it should fall under the same set of rules.”
Because the Women’s Clinic is fully integrated into the hospital’s system, Waddington said staff had a much easier time adapting their procedures to COVID-19 than independent clinics.
“We had to make some changes, obviously, for PPE [use],” she said. “But we really never stopped providing care at any point.”
The most major change Waddington noted was the increasing use of virtual or telephone visits for follow-up appointments and patient counselling.
“We’ve always offered a follow up visit to our patients,” she said. “We changed those follow up visits specifically into virtual visits, and if there’s anything that’s identified [that] would require an in-person follow up, we would arrange that.”
Virtual visits are only one example of the new techniques Canadian abortion providers have used throughout COVID-19 to ensure patients are as comfortable as possible.
In fact, some patients have been able to terminate their pregnancies without ever stepping foot into a clinic.
The executive director of Toronto-based Choice in Health Clinic, Clare Hacksel, has overseen the administering of around 70 at-home medical abortions since the pandemic began.
“Before COVID-19, if someone wanted a medical abortion, they would come to the clinic and get an ultrasound, have some blood work, and take a history,” Hacksel explained. “What we have determined through clinical review, looking at other jurisdictions, [is that] you can absolutely and safely prescribe [abortion pills] without those [physical] diagnostics.”
After a virtual meeting to determine their eligibility, patients are prescribed Mifegymiso, a combination of two drugs that are taken in sequence to medically terminate a pregnancy up until nine weeks of gestation. The medication is delivered by courier, and post-abortion follow-up appointments are done over the phone, meaning every step of the patient’s care happens remotely.
Hacksel says this contactless model of care is removing barriers to abortion access for many of her patients, especially those who aren’t located in central Toronto, and reduces clinical exposure for patients who meet the health requirements.
“Clients who are coming from a long distance don’t have to travel to our clinic and [take] unnecessary trips on [public transit],” she said.
Additionally, women in Canada who seek abortion services are more likely to be victims of domestic violence than those who decide not to terminate their pregnancies. Hacksel said clients whose partners or families wouldn’t support their choice to have an abortion were grateful to have a more discreet care option.
“There are clients who didn’t necessarily live with people […] who are supportive of their choice to have an abortion,” she said. “It would have been very difficult for them to explain—during the middle of a pandemic and lockdown—why they needed to leave the house for three hours.”
“[Instead] they can use their phone and have this virtual appointment while sitting on their back porch or in their room privately, and then discreetly have an unmarked envelope arrive at their house.”
Making these adaptations has given Hacksel and her colleagues a lot to think about when it comes to the safety and accessibility of abortions. When COVID-19 is over, the staff at Choice in Health Clinic are considering carrying forward the social distancing measures they’ve implemented.
“I think that this project, while it was propelled forward by COVID-19, will dramatically change how medical abortion is accessed in the province,” Hacksel said. “I’m very hopeful that we can continue to expand access.”
While Hall agrees that at-home medical abortion care has helped many of her clients in B.C., she also thinks removing in-person appointments would pose a higher risk.
“You can’t just prescribe a pill,” she said. “You really do have to look at the woman’s situation [and make] sure you’re cherry picking the most healthy patients to do this virtual method.”
For patients who are unable to have a medical abortion—because they passed the nine-week deadline for Mifegymiso or because they chose a surgical abortion—B.C. providers will continue to prioritize in-person client care.
“We [work] with some women who are very stressed, very upset about their situation, and we’re ready to provide that sort of trauma-informed care,” Hacksel said. “I’m always amazed by our patients, honestly, because they’re more thankful than anything. So they’re appreciating that we’re open [and] they’ll follow whatever PPE requirements we have.”
Pro-life groups in Canada have argued abortion services should be suspended during COVID-19, as many elective medical procedures were put on hold in March.
The Campaign Life Coalition, a Canadian political lobbyist organization that mainly works to oppose medical abortions and euthanasia, even published a petition calling on the federal government to halt abortion services during the COVID-19 pandemic.
“Now is not the time for politics as usual,” the petition reads. “Now is not the time to prioritize elective abortion over essential health care.”
But, while each province or territory regulates its own medical services, abortion is federally recognized as essential. Some provinces prioritize access better than others—in New Brunswick, for example, surgical abortions are only covered when performed in hospitals, not private clinics—but a person’s ability to have an abortion is legally protected.
At the beginning of COVID-19, each provincial authority in Canada reaffirmed abortion as an essential, time-sensitive service.
“We have a time-limited situation when someone’s pregnant,” Hacksel said. “It’s essential during COVID-19 specifically, because we can’t delay [the procedures].”
Hall added that restricting abortion services only encourages those with unwanted pregnancies to explore unhealthy methods of termination. Research has shown that in countries where abortion is currently criminally restricted, illegal abortions continue at the same rate of those in countries where it is legal.
“We know that if you limit abortion legally, you do not decrease a single abortion in that country,” she said. “People find other ways.”
“It is essential, because not providing safe access to abortion harms women, period.”
Correction: This article’s original text stated that “Most” clinics or hospitals in the country offer both kinds of abortion services. This was incorrect, and the article has been updated to reflect that. The Pigeon regrets the error.