Inequitable Access to Abortion in Rural Canada: A Persistent Issue

Introduction

In R v Morgentaler  (external link, opens in new window) (1988), the Supreme Court of Canada ruled that the Criminal Code, 1985 provisions relating to abortion were unconstitutional resulting in the decriminalization of abortion. Following the landmark decision, abortion was recognized as a  (PDF file) “medically necessary” health service across Canada (external link, opens in new window)  and became publicly funded under the Canada Health Act, 1985. (external link, opens in new window) 

Despite its legal status, barriers to accessing abortions continue to exist particularly for people living in rural areas of Canada. One significant barrier is the lack of abortion care providers located in rural communities. (external link, opens in new window)  Contributing to this issue is the shortage of provincial funding for free-standing abortion clinics across the country. Existing free-standing clinics are struggling to remain open due to financial constraints and rising operating expenses. The recent closure of Fredericton’s Clinic 554, the only free-standing abortion clinic in New Brunswick, (external link, opens in new window)  paints a dire picture of Canada’s health care system and its failure to prioritize access to safe abortion care. 

Restricting access to abortion care has disproportionately harsh impacts on people living in rural areas. Specifically, people living in rural communities must travel to larger cities to access abortion care and often face health-related risks as well as financial strain in the process. To improve access, policy reforms that make the abortion pill Mifegymiso (external link, opens in new window)  widely available should be introduced in tandem with increased funding to support the opening of more fully-funded free-standing abortion clinics across rural Canada.

I use the term “abortion services” throughout this piece to refer to both medical abortions and surgical abortions. A medical abortion (opens in new window)  stops pregnancy using medication, such as Mifegymiso, and is prescribed by a health professional for use at home. A surgical abortion (opens in new window)  is a more invasive procedure that stops pregnancy by removing tissue from the uterus and is performed by a physician at a free-standing clinic or at a hospital. 

Barriers to Access

Absence of Providers

Abortion services are offered by free-standing abortion clinics and some hospitals. There are, however, significant disparities with respect to accessing abortion services across Canada and rural areas are especially disadvantaged. In Ontario, there are a total of 45 clinics and hospitals that provide abortion services with only four located in rural areas. (external link, opens in new window)  In contrast, British Columbia has a total of 22 providers and only one is located in a rural area. (external link, opens in new window)  In some provinces, including in Manitoba, New Brunswick, and Prince Edward Island, there are no providers in rural areas. (external link, opens in new window)  Unequal access to providers leaves people living in rural areas, who are in need of an abortion, with either severely limited or no options for care.

Physicians Have the Ability to Refuse

Second, physicians in Canada can refuse to provide abortion services to patients, (external link, opens in new window)  which further restricts access to care. The College of Physicians and Surgeons of Ontario’s Human Rights in the Provision of Health Services policy (external link, opens in new window)  states that if a physician has a “conscientious or religious objection to the provision of a health service” they can decline to provide the service but must refer the patient to another provider.

Given physicians’ ability to refuse to provide abortion services and the shortage of abortion care providers in rural areas, people in need of abortion services may struggle to find willing providers in close proximity. In effect, people in need of care may be forced to travel for abortion services or stop pregnancy using unsafe methods. (external link, opens in new window) 

Impacts on People Living in Rural Settings

Financial Hardship

Without access to abortion services, people in rural areas are often left with no other option than to travel for care. In doing so, they incur significant expenses and may experience financial hardship. For example, people traveling for care might have to pay for transportation, housing, and childcare while away from home. They may also be forced to take unpaid time off work to receive abortion services. (external link, opens in new window)  On top of travel expenses, some clinics charge their patients administrative fees that are not covered by insurance. The cost of travel is a significant barrier to accessing abortion services for people living in rural areas, especially for those experiencing financial precarity.

Health Risks

As mentioned above, people living in rural areas may struggle to find abortion providers close to home and may be forced to travel as a result. Due to the time it can take to find and travel to a willing provider, pregnant people in rural communities may face delays in accessing abortion care which can lead to negative health outcomes. In R v Morgentaler  (external link, opens in new window) (1988), the Court held that the Criminal Code, 1985 provisions relating to abortion undermined security of the person, and were therefore unconstitutional, because they had the effect of delaying access to abortion care which created severe health risks for pregnant people. In particular, delayed abortions can increase complications as well as mortality rates for pregnant people (external link, opens in new window) . 

Not only does limited access to care present physical health risks, it can also affect the mental health of people in need of abortions. Given that a person’s overall health and bodily autonomy are at stake, scrambling to find abortion care in a timely manner while living in an area with few local providers can be stressful and cause emotional distress. (external link, opens in new window)  Gestational limits, which differ by province and dictate the stage of pregnancy a person can receive an abortion, may add additional pressure to people living in rural areas because they must find a provider before they reach the gestational limit set in their province or they will not be able to receive care in their home province. A person in need of an abortion in Ontario, for example, can receive an abortion up until 23 weeks and six days (external link, opens in new window)  of pregnancy whereas a person in Manitoba can only receive an abortion up until 16 weeks (external link, opens in new window)  of pregnancy.

Improving Access in Rural Settings

For a variety of reasons, including gestational age, many people in need of abortion services may require a surgical abortion over a medical abortion and vice versa. As such, discussions about addressing inequitable access to abortion care in rural areas must consider both methods.

Medical Abortion

With the introduction of Mifegymiso in Canada in 2017, medical abortion became more accessible as the medication can be prescribed by a range of health care professionals, including nurse practitioners, midwives, pharmacists, and physicians. (external link, opens in new window)  In some circumstances,  (PDF file) patients can also receive a prescription for Mifegymiso via telemedicine. (external link, opens in new window) 

That being said, Mifegymiso is relatively new to Canada and not all healthcare professionals are equipped to offer it to their patients. (external link, opens in new window)  To further improve access, healthcare professionals should receive training on the use of Mifegymiso so that they can integrate it into their practice. This way, people living in rural communities can access Mifegymiso from a wider variety of local healthcare providers and avoid traveling for care.

Surgical Abortion

Because  (PDF file) many rural areas have few or no free-standing clinics, (external link, opens in new window)  people in need of surgical abortions may have no other option than to receive care at local hospitals that offer it. For some, however, receiving care at a free-standing abortion clinic is preferred because of  (PDF file) the potential of experiencing judgment and stigma at a hospital. (external link, opens in new window)  In addition,  (PDF file) free-standing clinics sometimes offer more cost-effective services than hospitals (external link, opens in new window) . Before its closure, Clinic 554 was providing abortion services to migrants, international students, and unhoused people without insurance at a lower price than hospitals. (external link, opens in new window) 

Reliance on free-standing clinics to provide cost-effective and judgment-free abortion services, including surgical abortion, illustrates the need to introduce policy reforms which increase the number of fully funded abortion clinics in rural Canada. Not only would the opening of more clinics in rural areas make surgical and medical abortion more accessible in terms of physical proximity, it may also remove other barriers that prevent people from receiving care like stigma and cost. Ensuring that existing clinics in rural areas remain open by fully funding clinics that are currently partially funded or unfunded is also key to improving access to care in rural communities.

Conclusion

Many people in rural Canada experience additional barriers to accessing safe abortions because of their identity. This is especially true for trans and non-binary people who experience discrimination when it comes to accessing abortion services. (external link, opens in new window)  Indigenous people and people of colour have also faced, and continue to face, long-standing discrimination and racism within the healthcare system which may prevent them from accessing sexual and reproductive health services. (external link, opens in new window) 

In order to make abortion care accessible for all people living in rural Canada, it is not enough to increase the number of abortion service providers in rural areas. Issues of systemic discrimination and racism that exist within the healthcare system must also be addressed. Failure to do so undermines the bodily autonomy of marginalized people and contributes to poor sexual and reproductive health outcomes.