Left to Right: Martha Paynter and Francoise Baylis
This guest post comes to us from Martha Paynter and Françoise Baylis. Martha Paynter, RN is a registered nurse practicing in abortion and perinatal care and a PhD Candidate at Dalhousie University. Françoise Baylis, PhD is University Research Professor at Dalhousie University. The authors can be reached on Twitter @FrancoiseBaylis and @MarthPaynter.
The United Nations Populations Fund estimates a significant increase in the number of unintended pregnancies due to COVID-19 lockdowns. Some of these pregnancies will be the result of limited access to effective contraception and some will be the result of domestic violence, including sexual violence.
In Canada there are no legal restrictions on access to abortion. Nonetheless, access varies widely across the country. Longstanding challenges include important differences in provincial regulations and lack of willing providers outside of major urban centres. These challenges have been exacerbated by COVID-19 stay-at-home directives and travel restrictions.
Loss of income and health benefits, as well as supply chain disruptions limiting the availability of contraceptives have had a negative impact on family planning. As well, abuse in the home and increasing economic difficulties have made it difficult for some people to seek abortion services. In the face of these challenges, Canadian family doctors, nurse practitioners and pharmacists have been working diligently and creatively to ensure safe, continuous and timely access to contraception and abortion. Canadian health authorities have deemed abortion an essential service. And the Canadian Society of Obstetricians and Gynecologists of Canada has issued guidelines for medical abortion via telemedicine. These guidelines include instructions for responding to a request for an abortion, providing a pre-abortion consultation, prescribing Mifegymiso “the abortion pill”, instructing the patient on how to self-administer the medication at home, and ensuring proper follow-up. The cost for this service is covered by the provincial or territorial government.
Mifegymiso, available in Canada since 2017, is a combination of two medications, mifepristone and misoprostol. These medications are taken a day apart. Mifepristone works by blocking the hormone progesterone, terminating the pregnancy. Misoprostol causes the uterus to contract, expelling the pregnancy tissue. Mifegymiso requires a prescription. Anyone who provides reproductive or primary care, including family physicians and nurse practitioners, is authorized to prescribe it.
While this all seems rather straightforward, there are technical limitations, some of which are more acute in the context of the COVID_19 pandemic. First, Mifegymiso is only approved for use up to nine weeks gestation. Some have suggested it should be available up until 10 weeks or beyond. This would improve flexibility but use at later gestation may be less effective, and thus more likely to require follow-up care made difficult because of the pandemic. Second, few authorized practitioners are willing to prescribe Mifegymiso. The long-term solution for this is to increase the pool of prescribers. This will require normalizing abortion as part of routine reproductive health care and greatly augmenting the abortion curriculum in health professional training programs. The short-term solution is less clear and could become urgent if demand for medical abortion increases. Third, medical abortion requires confirmation of pregnancy through a blood test or ultrasound. As well, follow-up blood testing is required to confirm the abortion is complete. These tests require extra contact with the health care system which is challenging in the time of pandemic.
Medical abortion using Mifegymiso may not be a patient’s preferred option once they are fully informed about the process. Mifegymiso is not Plan B. Plan B is emergency contraception – it is a single medication, levonorgestrel, which prevents a pregnancy from being established. It is available over the counter without a prescription. Mifegymiso is not taking a few pills and suddenly not being pregnant.
Medical abortion involves intense cramping, labour-like contractions, and a miscarriage at home. Although everyone’s experience is different, all patients must be told to expect, and prepare for, significant pain and bleeding at the time of initial consultation. Otherwise, patients may think that the pain and blood warrant a trip to the emergency department, a usually unnecessary and anxiety-provoking visit, especially during the pandemic. For patients with concerns about pain and bleeding, a relatively quick surgical procedure may be preferable.
With a surgical abortion, instruments are used to physically remove the tissue. Although there is always waiting beforehand and a brief recovery period after, the procedure itself takes about ten minutes: first the cervix is frozen with local anesthetic, then dilators are used to open the cervix, and a small tube is inserted into the cervix to suction the content of the uterus. Surgical patients receive pain and anti-anxiety medication and do not see the pregnancy tissue or typically experience much bleeding afterwards.
A relevant consideration for those seeking abortion, especially during this pandemic, are the demands on patient time. Surgical abortion patients can have the elements of care (blood tests, ultrasound, etc.) organized into a single visit, and they can return to school/work/other activities the next day. A medical abortion is not so clearly time-bound: the process can take several days. This can be a challenge for patients with children to care for at home, or who have limited flexibility to take time away from work or other commitments. It can also be a challenge for those living in abusive relationships with limited autonomy over their movement and time.
Further, for some patients, privacy is of particular concern. Because of the pain and bleeding, medical abortion may not be easy to hide at home. Although not different from a spontaneous miscarriage, if parents, partners or children in the house are not aware of the pregnancy, the abortion may make discretion difficult. This may be particularly difficult for those who are at risk of intimate partner violence.
It follows that while access to medical abortion is an important option in the time of pandemic, to uphold the rights and safety of patients in all types of circumstances, it remains critical to ensure access to surgical services. This is now a crisis issue in New Brunswick. Clinic 554, the only provider of surgical abortion services in the capital city of Fredericton, and the only province-wide provider of surgical abortion beyond 13 weeks gestation, has been placed for sale. After five years of subsidizing abortion procedures that the province has refused to pay for, Clinic 554 cannot sustain operations. This means that New Brunswickers requiring surgical care after 13 weeks will have to travel outside of the province to access care. It is not clear how this is feasible when the province has closed its borders to prevent COVID-19 transmission.
Canadian authorities have deemed abortion an essential service. Health care providers, with support and direction from the professional association of obstetricians and gynecologists, are able to provide timely, uncomplicated access to publicly funded medical abortion. These initiatives are praiseworthy. There are, however, ways in which policy choices and the complexity of patients’ lives limit reproductive options and potentially threaten the wellbeing of those who require abortion care. This suggests that there is yet more that needs to be done to assure access to abortion care while taking into consideration the stressful circumstances in which we are all living.
