Patient-Centered Abortion Provision: A Case for More Equitable Access
By Erin Hassard
Canada is one of few places that prides itself on abortion care and for good reason, being one of the only countries in the world where abortion access exists without restriction. Though despite its legal status, abortion remains relatively taboo to talk about casually and services can vary significantly from province to province. The services that are available are dependent on clinical availability and high-touch provision as abortion care is still primarily surgical, entrenched in medical bureaucracy, and often does not reflect many diverse communities’ needs or preferences. Recently, the World Health Organization (WHO) revised their recommended mandate for abortion care, emphasizing that abortion access should be multi-provisional, co-created with those who will benefit, and reflect various local contexts. For cities that house multiple communities and enclaves that all have their own unique set of needs for abortion provision, this marks an opportunity to reflect on innovative changes to address those needs and ease local and individual barriers. In particular, I look at the case of Women on Web, a Canada-based telemedicine abortion organization, and the lessons it offers in addressing local barriers and advancing abortion provision.
Ongoing Challenges to the Equitable Access of Abortion Care
To create more patient-centered care, the involvement of abortion seekers is paramount in creating equitable access. Women on Web has been a pioneer in abortion provision for over 15 years, and in that time, we have observed first-hand accounts for why people seek outside care despite access to public services. Some of the most common barriers abortion seekers often cite are logistic and/or financial – such as travel to clinics, childcare, and time off work – or a need for privacy or secrecy, due to abusive circumstances, local stigma, or personal preference. Since abortion care often requires in-person consultation or high-touch services, additional obstacles stand in the way for immigrant and refugee communities who may not have sufficient healthcare coverage or access. For those in communities where abortion may still be incredibly taboo, seeking information on care, not to mention after-care if it is needed, may also be difficult. If cities take a more local and culturally safe approach, women and pregnant people in the community could be encouraged and empowered to self-manage their own care. Such an initiative could have many additional benefits since ultimately what many of these barriers come down to is women are still not trusted; either they’re not trusted to know their own bodies, or certain women aren’t trusted, or they’re not trusted with their own agency. These barriers are also a result of on-going medical bureaucracies that neglect cultural and personal nuance. Provincial and federal provision remain rigid in their control over self-care practices and low-touch services, despite the WHO’s guidelines and continued research demonstrating the safety of self-managed abortion.
Even if urban centers have services in place to address the above-mentioned barriers, outreach, education, and awareness need to be done to reach some abortion seekers. Subsidized care for refugees, for instance, is only effective if they know where and how to access the service, meaning they need to potentially have internet access, or get a referral in addition to a myriad of other obstacles. The same goes for secrecy and privacy; women and pregnant people need to be able to access care covertly, otherwise “safe abortion” can only refer to the procedure itself, not the situation. For those who may not be obstructed by stigma, financial means, or logistics, many may still prefer a self-managed, at-home abortion over a surgical one. The World Health Organization (WHO) has promoted the safety and effectiveness of abortion pills for nearly two decades now, and organizations such as Women on Web have contributed countless studies advocating the benefit to safe abortion provision. If self-managed, first trimester medical abortion is recognized as a safe, effective method, should it not be someone’s right to easily access this option if that’s what is best for them?
Some Possible Solutions?
Since clinical care is still the most prevalent and highly medicalized point of access, an ongoing challenge is shifting away from this model. Such a shift entails emboldening accompaniment groups to assist with self-managed abortion, encouraging the use of more discreet forms of communication such as text/chat and hotline services, telemedicine, and doing community outreach. Complementing services should be able to offer pre-and post-care information on culturally sensitive abortion options, additional birthing methods such as doulas or midwives, stigma, and additional issues that may impact certain situations such as intimate-partner violence.
When the COVID-19 pandemic broke out, Women on Web started receiving requests from Canadians to bridge access while stay-at-home measures were in place. Based on recent research conducted on the Canadian data, the dominant reasons have been preference and secrecy. Research is still needed on the demographic of Canadian requests, but both reasons could stand as over-arching themes representing the local barriers previously mentioned.
This preliminary insight into how and why people are seeking abortion despite having access to public services indicates some new initiatives are needed to address nuances the current systems don’t consider, and Women on Web’s practices and findings provide some direction. The organization was initially founded in 2005 as a response to the essential need for safe abortion access in areas where it was illegal or restricted. They now provide information on medical abortion and contraception, and their sister organization, Women on Waves, provides information on clinics and legal parameters by region. Over the years, Women on Web’s low-touch and discreet services have provided access to over 100,000 people around the world, and their advocacy work and research efforts have demonstrated not only how vital this kind of provision is but also how safe it is. For instance, Women on Web has recently started offering advance provision telemedicine, meaning people can obtain abortion pills even if they’re not yet pregnant, an initiative that could easily be applied locally. The argument that one should be able to make choices about their own body is broadened by the notion of not just “what” but “how”. Shifting focus from medical and legal gatekeepers who are sceptical of giving women more power and agency and instead providing the tools for women to seek care by any means necessary, means abortion provision starts to look a lot different on the ground: local concepts of shame and stigma can be addressed, more awareness of the impact of intimate-partner and familial violence may arise… these are all reasons why service-delivery innovations will have better outcomes than solely clinical and touch services.
Unfortunately, public services do not inherently mean everyone can access services. Granting access to those that fall outside of the immediate public service scope carries long-term benefits for diverse communities. Equitable provision means looking outside of the realm of clinical care and finding alternatives that not only consider means of access, but methods abortion seekers prefer as well. Merely legalizing and subsidizing services is not enough for the complex interpretations of what abortion means at ground level. Providing service-delivery methods that allow women to access abortion in multiple ways alleviates stress and pressure to community infrastructure in the long run. Such methods empower women and pregnant people in the community while acknowledging their needs and reservations; it cuts down on families’ childcare costs or lost wages; and it acknowledges the still grossly neglected area of gender-based violence, creating a positive ripple effect that may have intersecting benefits for reproductive health in multiple communities.
Erin Hassard is a helpdesk and communications worker for Women on Web. Her background is in linguistics and gender, she’s done research on the intersection of language and complex and developmental trauma, and has done community work on linguicism and gender-based violence.