CMYK REALITY C H E C K a close look at accessing abortion services in canadian hospitals Jessica Shaw Canadians for Choice 300-260 Dalhousie Street Ottawa, Ontario K1N 7E4 tel: 613.789.9958 fax: 613.789.9960 toll free: 1.888.642.2725 www.canadiansforchoice.ca Canadians for Choice 2 2 6 Ontario A Publication Of: Manitoba Nunavut Canadians for Choice Suite 300, 260 Dalhousie St. Ottawa, Ontario CANADA K1N 7E4 3 Yukon No part of this publication may be used for commercial or resale purposes. 2 This publication may be reproduced in whole or in part for educational or non-profit purposes without special permission from the copyright holder, provided that proper acknowledgement of the source is made. Canadians for Choice would appreciate a copy of any document that uses this publication as a source. British Columbia Copyright © 2006 Canadians for Choice Alberta Northwest Territories Saskatchewan Tel: +1 (613) 789-9958 Toll free: 1-888-642-2725 Fax: +1 (613) 789-9960 Email: info@canadiansforchoice.ca Website: www.canadiansforchoice.ca To obtain copies of this report please contact Canadians for Choice at: info@canadiansforchoice.ca New Brunswick 6 2 Nova Scotia Prince Edward Island Quebec Canadians for Choice is a pro-choice, non-profit charitable organization dedicated to ensuring reproductive choice for all Canadians. At Canadians for Choice, we envisage a world where individuals – regardless of age, ability, race, gender, sexual orientation, place of residence, or socio-economic and other status – have access to the information, resources and services required to make and exercise informed choices on all aspects of their sexual and reproductive health and rights. For this reason, we work to ensure that the general public, policy-makers and health and education practitioners are well educated and informed about all aspects of sexual and reproductive health and rights. We also aim to enhance the quality and comprehensiveness of research and information on current and emerging sexual and reproductive health issues. 2 After abortion became decriminalized in Canada, the well-known Canadian Abortion Rights Action League (CARAL) reviewed its mission statement and concluded that their goal of having abortion services be legally available to all Canadian women had been accomplished. Having recognized this, some CARAL staff, board members and sexual and reproductive health advocates in the community collectively decided that a new organization, with new goals still related to sexual and reproductive health and rights, ought to be created. Out of this vision was Canadians for Choice founded. Labrador / Newfoundland About Us Location of Canadian Hospitals with Accessible Abortion Services. CMYK REALITY C H E C K a close look at accessing abortion services in canadian hospitals Jessica Shaw Canadians for Choice REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice Acknowledgements Every publication is the result of multiple contributions by numerous individuals and this report is no exception. Personally, I would like to acknowledge the following people for their invaluable insights and observations: Barbara Legowski, Dr. Norman Barwin, Christine Dwyer, Judy Burwell, Stacey Loyer, Johanne Fillion and Kimberly Good. I am sincerely grateful for the suggestions, comments and contributions that you have provided to me and am indebted to you for the time you have spent reviewing and adding to the many sections of this report. To all of the Canadian Federation for Sexual Health affiliates who graciously completed and returned the written questionnaire, I thank you. Your co-operation has allowed us to better understand the hardships that many Canadian women face when trying to access abortion care. Also, a thankful recognition must go to the clinic and hospital staff members who were pleasant and helpful to our researcher over the phone. It is through your unbiased support that the women of Canada may continue to access all aspects of their healthcare. We applaud you for your continuous dedication to sexual and reproductive health and rights. Finally, Canadians for Choice would like to thank all of our generous and dedicated donors. Your financial contributions are what have made this report possible and your moral support is what gets us through the day. You truly are our inspiration. Jessica Shaw Canadians for Choice REALITY CHECK – a close look at accessing abortion services in canadian hospitals iii Canadians for Choice REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice TABLE OF CONTENTS Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 A Quick History of Abortion in Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 National Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Provincial and Territorial Analysis: Alberta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 British Columbia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Manitoba . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 New Brunswick . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Newfoundland and Labrador . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 Northwest Territories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 Nova Scotia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Nunavut . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Ontario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Prince Edward Island . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 Québec . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 Saskatchewan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Yukon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 Barriers to Accessibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 For Better or for Worse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 As Experienced in Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 Graph: Canadian Hospitals with Accessible Abortion Services . . . . . . . . . . . . . . . . . .62 Map: Location of Canadian Hospitals with Accessible Abortion Services . . . . . . . . . .63 REALITY CHECK – a close look at accessing abortion services in canadian hospitals v Canadians for Choice REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice EXECUTIVE SUMMARY Researched between January 2006 and August 2006, Reality Check: A Close Look at Accessing Abortion Services in Canadian Hospitals is a report that focuses on the real accessibility of hospital abortion services in Canada. Researched from the perspective of a pregnant woman in search of an abortion, Reality Check reveals shocking truths about the accessibility of services in each province and territory, and highlights some of the barriers that women face when trying to access an abortion in Canada. Key Findings Having contacted each general hospital and many sexual health clinics in Canada both over the phone and in a written survey, it was discovered that only 15.9% of Canadian hospitals provide accessible abortion services. This percentage is down since the Canadian Abortion Rights Action League (CARAL) report on abortion access of 2003, which found that 17.8% of Canadian hospitals had accessible abortion services. Having an access rate of only 15.9% means that only one in every six hospitals in Canada offers accessible abortion services. Some of the key findings that were discovered by the study include: • In the past three years, the amount of hospitals in Canada with accessible abortion services has decreased. • Hospital abortion services are poorly dispersed across Canada; the majority of providing hospitals are located in urban areas, within 150 kilometres of the American border. • The process that a woman must go through in order to obtain an abortion varies greatly across provinces, territories, and individual hospitals and often prevents women from being able to access sexual and reproductive healthcare. • Wait-times, gestational limits, and the availability of counselling varies drastically from one hospital to the next. • In some hospitals, wait times can be as long as 6 weeks. • Gestational limits range from 10 weeks to 22 weeks. • Counselling is most readily available from hospitals in Québec. • When trying to access abortion services, many women in Canada still face incredible barriers such as anti-choice healthcare professionals, unexpected costs and travel time, and bad referrals. • Personal testimonies show that in many cases, Canadian women seeking abortion services are still being gravely disrespected by healthcare professionals, organizational workers, and by the general public. Provincial and Territorial Analysis The majority of the report revolves around the provincial and territorial analysis. Through the analysis of each province and territory, it is obvious that the problems associated with abortion vary drastically across the country. For this reason, each province and territory was looked at in the context of what sexual health policies and barriers are associated specifically to it. The following graph outlines the percentage of hospitals in each province and territory that offer accessible abortion services. The 2006 percentages have been compared with the percentages that REALITY CHECK – a close look at accessing abortion services in canadian hospitals 1 Canadians for Choice were discovered by the CARAL study of 2003. It is important to note that the percentages represent the number of hospitals with accessible abortion services, rather than the number of hospitals that have abortion services available. It is important to analyze accessibility rather than availability, because only accessibility takes into consideration the real experiences and difficulties that women have when trying to access an abortion. At some hospitals, abortion services may be available, but they are not accessible. Since the scope of the study is limited to the examination of public hospitals; private hospitals, public and private clinics, and Centres locaux de services communautaires (CLSCs) were not included in the statistics. CHANGES IN ACCESS TO HOSPITAL ABORTION SERVICES IN CANADA Provinces and Territories 2003 Percentage of Accessible Hospitals 2006 Percentage of Accessible Hospitals More or less access? Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Québec Saskatchewan Yukon TOTAL= 5 22 4 7 14 67 10 0 23 0 35 3 50 17.8% 6 29 4 4 21 67 13 100 17 0 24 6 50 15.9% More More Same Less More Same More More Less Same Less More Same Less Barriers As seen through the data analysis of this and other studies, it can be concluded that barriers are a major factor in limiting a woman’s access to safe and timely abortion care. Many of the barriers exist despite the fact that abortion is generally a simple procedure and that any hospital with an obstetrics ward can be equipped to conduct the procedure. Some of the most prevalent barriers include: • Not enough abortion providers. This prevents many women from being able to exercise their right to proper sexual and reproductive healthcare. • Unexpected costs, travel time and other expenses. Especially if a woman is required to acquire an abortion outside of her area of residence, procedural costs, travel time and other expenses can amount to a large sum. In cases where the sum is too great, a woman may dangerously attempt to self-induce an abortion, or be forced to carry an unwanted pregnancy to term. • Reciprocal billing issues. Generally, medical services are covered by reciprocal billing to allow Canadians to still have full healthcare coverage when they travel between provinces. However, some provinces have yet to remove abortion from their lists of services to be excluded from 2 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice reciprocal billing. This means that if a woman is out of her province of residence and in need of an abortion, she may have to pay for the procedure up-front, with no chance of being reimbursed. • Unknowledgeable hospital staff members. Many hospital staff members are both unaware of their hospital’s policy on abortion, and are unable to refer women to a relevant and accurate source of information. For the many women who turn to a hospital as a source of help and knowledge, unknowledgeable staff members can prevent women from accessing appropriate information and care. • Judgmental healthcare professionals. There are many people within the healthcare system who act as the gatekeepers to a woman’s ability to access information about abortion services. Antichoice staff members can prevent a woman from accessing abortion services by refusing to provide her with relevant information, by treating her with disrespect, and by passing judgement on the personal decisions of the woman. • Conscience clauses. Doctors play a huge role in guaranteeing a woman’s right to choose to have an abortion when pregnant. Especially in areas where a doctor’s referral is required to gain access to an abortion, a doctor can prevent a woman from exercising her sexual and reproductive rights based on their individual beliefs about the procedure. • Bad referrals. Some women may contact many sources in their search for information about abortion services. If a woman is given a bad referral, either from a hospital, doctor, individual or organization, her ability to access accurate information about abortion may be impeded. • Voicemail. Some women do not have phones. Others live in a place where they do not want the other members of their household to know that they are pregnant or that they are considering an abortion. Still others live in abusive situations and cannot receive personal calls. Some women may question confidentiality and are just not comfortable leaving a message. All of these women are in situations where having to leave a voicemail message in order to schedule an abortion is neither an appealing, nor a possible option. • Anti-choice organizations. Many anti-choice organizations present themselves as “crisis pregnancy centres” and may purposely discourage, misinform, and coerce women into not exercising their right to an abortion. An anti-choice organization’s lack of objectivity and facts regarding abortion may leave a woman in the position of having her reproductive choices limited. Testimonial Evidence Since problems with abortion access are not only evident in statistical analysis, it is important to incorporate the stories and experiences of Canadian women into the findings. For this reason, a critical section of the report is that of personal anecdotes that describe the poor treatment that some Canadian women have received when attempting to access abortion care in Canada. The intimate descriptions of the devastating experiences that women have had reiterate the barriers that were discovered when conducting the initial empirical research, and emphasize the dire need for more information on abortion accessibility. Overall, the presented provincial and territorial statistics, the many barriers that stand in the way of women, and the experiences of Canadians who have tried to access an abortion combine to create a multifaceted representation of the real accessibility of hospital abortion services in Canada. The report seeks to generate discussion and awareness among healthcare professionals, sexual and reproductive health and rights advocates, and the general population alike. REALITY CHECK – a close look at accessing abortion services in canadian hospitals 3 Canadians for Choice INTRODUCTION While there are many areas of sexual and reproductive health and rights that need attention, one area that Canadians for Choice recognizes that there is a grave lack of information is in the availability of data regarding the accessibility of abortion services in Canada. Contrary to popular belief, abortion services are still inaccessible to many Canadian women. People often think that because abortion was legalized in 1988, it is easy for a woman to access the procedure. Such thoughts are far from the truth. In reality, as pointed out in the 2003 CARAL report, Protecting Abortion Rights in Canada, and confirmed in this current study, there are a number of barriers that continue to keep women from being able to access this medically necessary procedure. This report aims to reveal the underlying problems that women face when contacting hospitals in Canada about access to abortion services. The scope of this study focuses on hospitals for several important reasons. Even through there are a few private clinics and many public clinics in Canada that provide abortion services, CFC believes that as a medically necessary procedure, abortions should also be offered in all hospitals equipped with surgical facilities. We believe that if more hospitals offered abortion services, there would be less of a need for private clinics and all publicly funded clinics and hospital abortion providers could more openly offer and provide their services. In regions of Canada with small populations, where specialized public or private clinics are not sustainable, having abortion services provided to women at their local community hospital is essential for genuinely reasonable access. Also, as mainstream healthcare institutions, hospitals are often the first point of contact in a woman’s search for abortion services. Even if abortions are not performed in a hospital, it must nevertheless be a source of accurate information for women seeking sexual and reproductive healthcare. To date, there are no other organizations in Canada that are conducting a nation-wide study of how accessible hospital abortion services really are. Since we believe abortion to be an important aspect of sexual and reproductive health, Canadians for Choice developed a study based on the CARAL report of 2003. Our report analyzes the accessibility of hospital abortion services in Canada from the perspective of a young woman in search of information regarding the termination of her pregnancy. Conducting research from this perspective is critical because it shows not only what is said to be available, but what is really accessible to the women of Canada. For example, a young woman without a family doctor in rural Canada represents the Canadian women who are most vulnerable when trying to access abortion services. Women, particularly those in disadvantaged positions, are too often unaware of where to turn for help or for services. As there is a lack of accurate information concerning sexual and reproductive health, many Canadian women have no idea who to contact in response to an unwanted pregnancy. In many situations, they turn to their local hospital. When looking at a woman’s ability to access hospital abortion services, it is important to note that some hospitals do not have abortion programs within them but rather act as a venue for abortion providers to work out of. This means that, although some hospitals have programs set up to deal specifically with patients wishing to terminate a pregnancy, other hospitals require that a pregnant woman arrange for her abortion through the providing doctor and not through the hospital. However, Canadians for Choice believes that regardless of whether a hospital accommodates abortion services, all hospital staff members should be aware of the availability 4 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice of services at their facility and should be able to refer women to either the appropriate department or to another providing hospital. Until all Canadian women are capable of easily accessing necessary abortion services, Canadians for Choice will continue to monitor and report on the activities of hospitals and of other healthcare providers. It is important and necessary to keep reviewing and improving research on a woman’s right to choose. After all, a choice that cannot be exercised in a safe, accessible, supportive and affordable manner is no choice at all. REALITY CHECK – a close look at accessing abortion services in canadian hospitals 5 Canadians for Choice A Quick History of Abortion in Canada For many years, Canadian women and men have had to fight long and fierce battles to ensure that abortion services be legally available to all women. Abortion was officially banned in Canada in 1869. Prior to this, abortions were widely performed before the perception of foetal movement and were generally not seen as being morally or legally wrong. It was through the medicalization of reproductive healthcare and a desire to restrict the practice of medicine that doctors led the moral crusade against abortion. With the support of religious organizations and anti-choice groups, abortion and the distribution or advertisement of contraceptives became indictable offences and were enacted into the Criminal Code of Canada. Abortion became a crime that was punishable by life imprisonment and the use or sale of contraceptives was an offence punishable by a two-year term in prison. During this time however, women continued to seek abortion services. History proves that making abortion illegal does not stop women from trying to control their pregnancies and from seeking sexual and reproductive healthcare. The difference between abortions being performed under illegal circumstances compared to being practised in safe and sterile environments, is that a woman seeking to terminate a pregnancy could no longer guarantee that the person performing the abortion was either medically qualified or morally dedicated to helping her. During the time that abortion was illegal, the quality of care for women seeking an abortion was not monitored and many abortions were performed under unsanitary and dangerous conditions. Sexual assault and medical malpractice were common occurrences for the women who were unable to find a qualified performing doctor and who had to resort to back-street abortions. Women who could not find a person willing to perform an abortion often tried to induce their own miscarriage. Both assisted and self-induced abortions led to many complications including severe infection, haemorrhaging, sterilization and death. While the general consensus is that there were thousands of women who died due to illegal abortions, the exact number is not known. This is because very few of these deaths were ever brought to the attention of authorities and only a limited number of them were recorded as being the result of complications due to illegal abortion. There have been many movements to bring the importance of legalizing abortion to the attention of the Canadian government. Along with emphasizing the dangers that come with illegal abortions, individual advocates and organizations stressed the fact that when a woman is forced to carry a pregnancy to term, she may be putting the rest of her family at risk. They argued that some women seek abortion services because they already have children and cannot provide the financial, emotional and physical support that is necessary to ensure another baby a high quality of life. It was stressed that legal and accessible abortions are necessary in order to save lives, to promote good health and to allow women to plan and care for their families in the best possible way. It wasn’t until 1969 that changes were made to the restrictive laws against reproductive freedom. Under the new law an abortion could be performed if a team of three doctors, none of whom could be potential candidates to perform the abortion, all agreed that the procedure was medically necessary in order to guarantee that the woman’s health was not endangered. The team of deciding doctors formed a Therapeutic Abortion Committee and were able to interpret among themselves under what circumstances a woman’s health was considered to be endangered. However, hospitals were not required to offer abortion services or to have a 6 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice Therapeutic Abortion Committee. Because of these restrictions, legal abortions became available to only a small number of women who lived in certain parts of Canada. The few women who did have access to the service often had to wait eight weeks for an abortion; a time that often put them over the set gestational limit after which the procedure could not be performed. Despite the new laws that legalized medically necessary abortions, the majority of Canadian women were still unable to access abortion services. It was because of the continuous suffering of women that Dr. Henry Morgentaler decided to publicly denounce the restrictive abortion laws and confirm allegations that he was performing abortions without the consent of a Therapeutic Abortion Committee. By courageously challenging the controversial law, Dr. Morgentaler led a nation-wide battle to reform Canada’s abortion laws. Finally, on January 28th, 1988 after over fifteen years of legal battles, public protests and through the solidarity of thousands of Canadians, the Supreme Court declared Canada’s abortion laws as being unconstitutional. One of the main arguments used was that with the abortion laws intact, a woman’s right to liberty, as guaranteed in the Canadian Charter of Rights and Freedoms, was being infringed upon. Section 7 of the Charter of Rights and Freedoms guarantees to every individual a degree of personal autonomy over important decisions intimately affecting her or his private life. In 1988 it became recognized that a woman's capacity to reproduce is subject to her own control. The Supreme Court then announced the decision that, in order to protect the rights and liberties of Canadian women, a foetus has no inherent right to life and has no legal protection as a person until it is born alive. This decision, referred to as the Morgentaler decision, is what gave Canadians the choice to have a legal abortion. In 1995, Diane Marleau, the Canadian Health Minister at the time, deemed that because pregnancy and childbirth affects the health and lives of women, abortion is a medically necessary procedure. As such, abortion services would have to be covered by provincial and territorial health insurance plans when performed both in hospitals and in clinics. However, despite abortion being recognized as a medically necessary procedure, access to it continues to be difficult for a large number of Canadian women. Elusive medical professionals, for example, can prevent women from accessing the procedure. Reciprocal billing issues can prevent abortion care that is provided in one province or territory from being refunded by a woman’s home province or territory. Also, varying provincial laws can limit the comprehensiveness of abortion services and certain conditions, such as the requirement to see two doctors for a referral, are often in place to restrict who can access this area of reproductive health. Despite these difficulties, healthcare professionals and the general public generally recognize abortion as being medically necessary and Canada remains one of the few countries in the World without a law restricting it. Since the Morgentaler decision, abortion has been considered a private medical matter between a woman and her doctor. However, women must not take this right for granted. Since the decision of 1988, there have been numerous attempts by anti-choice groups and individuals to change the laws so that abortion becomes illegal once more. As seen through our tragic history, making abortion illegal does not stop abortions from occurring. The only thing that making abortion illegal does is force women to resort to self-induced miscarriages and unregulated abortion providers. It is therefore critical that ongoing research continues to review and improve the status of abortion services and their accessibility. Canada must not return to subjecting women to the dangerous circumstances that have surrounded abortions in the past. REALITY CHECK – a close look at accessing abortion services in canadian hospitals 7 Canadians for Choice METHODOLOGY The methodology used in this study was designed to: • Determine the number of general hospitals in each province and territory that provide abortion services or are a venue out of which physicians provide abortions • In instances where a hospital does not provide abortion services, determine whether staff provide abortion access information and analyze the nature of the referral • Whether the referral information is accurate and would facilitate a woman to access the procedure • Assess the quality of the interaction between the researcher and the hospital contact While there is data available on which hospitals in Canada offer abortion services, there is no data available on how accessible information about abortion services from hospitals really is. The methods used to evaluate hospitals do look at what services are available, but they also take into consideration how accessible abortion services really are by analyzing the actual experiences that pregnant women seeking abortion care have. The referrals that hospitals provide to the women who call asking about abortion services have also been evaluated. Referral procedures deserve critical analysis because they determine whether or not a woman will have good access to quality reproductive healthcare. A brief section on barriers that prevent women from obtaining safe abortions is analyzed based on the information collected when looking at hospital referrals. A combination of strategies were used to obtain data: Hospital Sampling Canadians for Choice obtained a list of all of the hospitals in Canada from the 2006 Canadian Almanac and Directory (159th Edition). Each hospital listed under the general and federal hospital sections was called. Hospitals listed as auxiliary hospitals, health care centres, nursing stations, special treatment centres and long-term facilities were not contacted, nor were they included in the final count of potential abortion service providers. These health care providers were not called because each has it’s own criteria for patient intake and we were looking to provide information on abortion access in hospitals that are open to the general public. Auxiliary hospitals, for example, only provide long-term services and rehabilitation. However, if an auxiliary, long-term or geriatrics hospital was mistakenly contacted under the impression that, according to the Directory it was a general hospital, it was still used in the final count of potential hospital providers. If a special treatment centre was not clearly listed in the Directory as being a facility other than a general hospital, a pregnant woman might mistakenly think that it is a general hospital and a possible provider. For this reason, hospitals that appeared to be for the general public, but when contacted proved to be for special treatment patients only, were still included in the final count of potential providers. Only facilities that are clearly not general hospitals were excluded from the list of hospitals contacted. Private hospitals were not contacted because, although they often do have surgical departments, their services are usually limited to patients who are capable and willing to pay a fee for healthcare that is not reimbursed by the government. Also, although Catholic hospitals do provide services to the general population, their general policy is to refuse to provide abortion 8 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice services on the basis of the Catholic Church’s “sanctity of life” mandate. Nevertheless, we did contact a few randomly selected Catholic hospitals. After being told by every contacted Catholic hospital that they do not provide abortions based on the mandate, we made the assumption that in general Catholic hospitals would not provide abortion services. However, since they are healthcare providers to the general population, Catholic hospitals in all provinces and territories were included in our statistics when we counted the total number of hospitals and potential providers in Canada. Canadians for Choice recognizes that some hospitals that do not have abortion programs within them still act as a venue for abortion providers. When contacted, our researcher was looking to evaluate whether information about obtaining an abortion was available from each hospital. Although some hospitals where abortions are performed do not actually have abortion programs, all hospitals were evaluated equally depending on the level of knowledge that staff members at the facility had about the provision of abortion services in their area. The questionnaires were designed to evaluate how accessible abortion services are in Canada, rather than to evaluate through what venue abortion services are being offered to pregnant women. Written Questionnaires Hospital Questionnaire (see Appendix A) A written questionnaire was mailed to all Canadian general and federal hospitals in the summer of 2006 and a fax was sent to all facilities the week of the requested deadline reminding them to please complete and return the questionnaire. The questionnaire was accompanied by a cover letter explaining the need for current information about hospital access to abortion services in Canada. The questionnaire was designed to ascertain: • Where abortion services are available • What type of policies hospitals have regarding abortions • Up to what stage in gestation abortions are performed at each hospital • What a woman needs to do in order to access abortion services • What the average wait time is for an abortion • What kind of counselling services hospitals offer • How much hospitals charge to perform an abortion on a woman who is from another province • What type of translation services are offered to patients • Where hospitals refer women to if they do not provide abortion services Out of the 791 questionnaires mailed, 183 were returned1. The responses from these questionnaires were compared to the data collected from the telephone calls made to each hospital. Organization Survey (see Appendix B) Local Planned Parenthood affiliates of the Canadian Federation for Sexual Health (CFSH) are an important resource for women seeking information on abortion services at hospitals and clinics 1 As of August, 2006 REALITY CHECK – a close look at accessing abortion services in canadian hospitals 9 Canadians for Choice because they are often the first contact that women call when facing an unintended pregnancy. Sexual health organizations are recognized as reliable sources of accurate information pertaining to sexual and reproductive health issues and are known for offering unbiased counselling services to the general population of Canada. For this reason, in the summer of 2006, a written survey was sent out to each of the twenty-one Planned Parenthood affiliates across Canada. Four written surveys were sent to sexual health organizations in Québec where there are no Planned Parenthood affiliates. The survey was designed to ascertain: • Whether the organization serves mainly a rural or urban area • How many calls the organization receives per month regarding abortions • Where women in their area are referred to for abortion services • Whether or not their organization provides abortion counselling services • What the main barriers are that women in their area face when trying to access abortion services The organizations were also asked to share with us any stories that they had heard from women in their area who had encountered problems when trying to access abortion services. Of the twenty-five surveys mailed to the sexual health organizations, eleven were returned. These surveys provided us with some qualitative data regarding abortion services in Canada. Telephone Questionnaire (see Appendix C) In order to obtain statistical information on access to abortion services in Canada, and with the exception of the hospitals listed in the hospital sampling description of the methodology section of this report, each of the 791 hospitals in Canada were called. Due to the fact that, in Québec, some of the Centres locaux de services communautaires (CLSC) act as acute hospital care providers, a sample of CLSCs were also called. While CLSC abortion providers were listed in the Canadians for Choice Hospital Abortion Access Directory, they were not included in the statistics as hospital providers in the access report. This is because they are not officially hospitals but are public health units. While there are also many public clinics in other provinces that provide abortions, the scope of the study is limited to the examination of hospital access. The researcher contacted each hospital claiming to be a young woman who was ten weeks pregnant and considering an abortion. Canadians for Choice did not use a woman who was actually pregnant and considering an abortion to conduct research for several reasons. Primarily, because of the history of poor abortion access in Canada it was acknowledged that through calling every hospital our researcher was sure to encounter at least a few negative responses. Using a woman for the purpose of research who is already in a vulnerable situation by being pregnant and in need of an abortion is unethical. The anticipated reactions from some hospitals in Canada were to be unpleasant and unsupportive of a woman’s right to choose to terminate a pregnancy. We concluded that forcing a woman to experience blatantly rude and disrespectful behaviours regarding her choice of abortion would be both traumatic and unnecessary. Also, logistically we could not have a woman who was actually pregnant and considering an abortion calling each hospital in Canada because the calling process is time consuming and a pregnant woman would have likely had her abortion before she was able to call every facility on the list of hospitals. Finally, since it was necessary to record the details given by each hospital in a 10 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice standardized manner, it was important to have the same researcher contact each hospital. Rather than risk the mental well being of a woman in a delicate situation, and due to time constraints and rigour, Canadians for Choice chose to hire a non-pregnant researcher to conduct research under the guise of being pregnant. When the researcher called the main phone number of each hospital, to the first person that answered the phones she said, “Hello, I am pregnant and am considering an abortion. Do you provide abortions at your hospital?” This exact greeting was used each time so that any variance in the response could not be attributed to what was asked of the hospital speaker. If asked for information about herself, the caller was able to divulge the following information over the phone: • 10 weeks pregnant • Just independently moved to the area for temporary residence (from another province) • No family or friends nearby • No family doctor • 20 years old • Has healthcare (but it is from a different province) • Name is Sarah Jones In addition to the information listed above, each day before beginning to contact hospitals, the caller also calculated when her last menstrual period would have been if she was ten weeks pregnant. To do this she took the date that she was calling on and counted back ten weeks. This information was sometimes requested from doctors or nurses who wanted to know how far along she was in her pregnancy. Canadians for Choice designed the characteristics of our caller so that the hospital contacted would have to take into account many of the barriers that often prevent a woman from Canada from obtaining abortion services and direct her call accordingly. These barriers will be discussed in a later section of the report. Once the researcher had asked the employee at the hospital about her ability to access abortion services, she recorded the following information: • Are abortions done at the hospital? • Did the person who answered the phone know about their hospital’s abortion services? • If abortions are provided, was information about how to access the service offered? OR Was it necessary to ask for information? • If abortions are not provided, was a referral offered about where to obtain information to access the procedure? OR Was it necessary to ask for a referral? • If contacted, was the provided referral useful? • If abortion services are available, what process must be followed in order to arrange for scheduling? • If abortion services are available, what is the average wait time for an abortion? REALITY CHECK – a close look at accessing abortion services in canadian hospitals 11 Canadians for Choice Our researcher also made notes on how she was treated by the hospital employee over the phone. She recorded whether the employee was: • Helpful, understanding • Rushed, impatient, abrupt • Rude, unpleasant • Knowledgeable • Needed to be pushed for information • Unsure but willing to check for information • Unsure and unwilling to check for information She also noted how many calls it took to reach someone who knew about the services provided and how many people she had to talk to in order to obtain information. Finally, any additional comments were written down. Data Analysis A content analysis was completed using the information provided during the telephone calls and compared to the information given by the hospitals in their responses to the written questionnaire. When the answers given in the written questionnaires did not match the information gathered through the telephone calls, the individual hospitals were contacted and the discrepancy was explained to a hospital director. All information contained in this report comes from the specific details as told to our researcher. Any discrepancy between the recorded data and the actual provision of abortion services at any given hospital in Canada may be the result of misinformation offered by uninformed staff members, or a lack of participation by the hospital in answering the written questionnaire. The scope of the report is to analyze the real access that a Canadian woman has to hospital abortion services from the perspective of a pregnant woman in search of an abortion. Therefore, the number of accessible hospitals as outlined in this report may not correspond with the number of hospitals in Canada that actually provide abortion services. This is because how accessible abortion services are is very different from how available they are supposed to be. In New Brunswick, for example, even though there are two providing hospitals we only consider one to be accessible. This is because the second hospital was contacted twelve times and each time our caller was told that abortions were not performed there. The report reflects this rejection and shows how accessible abortion services are, rather than where services are apparently available. For the purpose of this study, the term “access rate” is defined as the number of hospitals that openly offer abortion services out of the total number of hospitals in an area, expressed as a percentage value. Written Analysis The quantitative data used for the report was collected from both telephone calls and written questionnaires. When looking at quantitative measures relevant to this report, the following data was compiled: the number of hospitals that provide abortion services, the number of hospitals that provided a referral, the usefulness of the referral, whether or not the hospital staff 12 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice were knowledgeable about their hospital’s policy on abortion, the number of calls it took to obtain information on abortion services, the number of people that were spoken to in order to obtain information, the manner in which hospital staff members interacted with our researcher, how willing hospital staff members were to provide information about abortion services and how long wait-times were to access abortion services at providing hospitals. In order to create a report with more emotional and verbal impact, qualitative information was also included in the analysis of data. The qualitative information in the report came from many sources including telephone calls, written questionnaires and stories provided by various organizations and individuals. The qualitative data analyzed includes: anecdotal information describing some of the experiences that women have had when seeking abortion services, the process that a woman must go through in order to have an abortion, barriers that women face when trying to access abortion care and how various laws and policies affect Canadian women who seek access to sexual and reproductive health services. The qualitative data collected has been included in both the written analysis sections and in the As Experienced in Canada section of the report. As Experienced in Canada… The As Experienced in Canada section of the report highlights some of the experiences that women have had when trying to access abortion services in Canada. The anecdotes have been compiled from a number of sources. Some are from women who are passionate about improving abortion access in Canada and have sent their stories to Canadians for Choice hoping to prevent similar occurrences from happening to other women. A number of stories were relayed to our researcher by sexual health clinics and organizations, while others have been written by our researcher and reflect the experiences that she had when contacting Canadian hospitals as a pregnant woman in need of an abortion. All of the stories contained in this report reflect true occurrences. They have been included in the report in order to expose readers to the emotional impacts that a lack of abortion access can have on women. They have also been included to allow readers to become more aware of the reality of how some healthcare providers treat women who are trying to exercise their reproductive rights. Graphic Representation A bar graph is available for review after each written section of each province or territory. It shows the percentage of hospitals that offered each of the six types of referrals. The six types of referrals and their definitions are: • Self-referral: The hospital gave our caller a number to call or transferred her to where she would be able to make her own appointment for an abortion. • Doctor/Walk-in: The hospital gave our caller the contact information for another hospital, doctor or walk-in clinic from which she could get a referral to have an abortion. • Hospital: The hospital told our caller that she should come to the hospital in order to arrange for a referral for an abortion. • Infoline: The hospital provided our caller with a provincial or national number to call that would help her find an abortion provider in her area of residence. REALITY CHECK – a close look at accessing abortion services in canadian hospitals 13 Canadians for Choice • No Info: The hospital would not provide any information or referrals about abortion services to our caller or not enough details were given to make the referral useful. (Ex. “call a hospital in Halifax” or “look up a doctor in the Yellow Pages”) • Anti-choice: The hospital referred our caller to an anti-choice organization. The graph will look at the type of referrals offered by both hospitals that provide abortions and by those that do not provide abortions. All of the information represented on the graph comes directly from the information provided to the Canadians for Choice researcher over the phone by the contacted hospitals. In cases where a hospital provided more than one type of referral, both types are represented on the graph. This means that percentages may not always add up to 100%. Barriers Derived from the information discovered through our research, the barriers section of the report highlights some of the major barriers that women face when trying to access abortion services. As seen through the data analysis and from previous studies, barriers are a major factor in limiting a woman’s access to safe and timely abortion care. Throughout the report, barriers are mentioned both in quantitative and qualitative measures. The section will further expand on the qualitative aspects surrounding the ways in which obstacles prevent women from terminating their pregnancies. For the purpose of this study, a barrier is defined as any obstacle that a woman may face when trying to access an abortion or when trying to access information about an abortion. 14 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice NATIONAL FINDINGS Currently in Canada, only 15.9% of hospitals offer abortion services. This figure is down nearly 2% since the last report on abortion access in 2003. Having an access rate of only 15.9% means that only one in every six hospitals in Canada offers abortion services. A problem that many women in Canada face is that the majority of these hospitals are located in urban areas, within 150 kilometres of the American border, and are therefore not easily accessible to the large amount of women who live further north of the border. Over the course of the study, many of the barriers that women in Canada face when trying to access abortion services were exposed to our researcher by hospitals and by pro-choice organizations. Some of the most prevalent barriers include: anti-choice doctors, the influence of anti-choice organizations, a lack of providers in certain areas, costs and having to travel in order to access services. These barriers exist despite the fact that abortion is generally a simple procedure and that any hospital with an obstetrics ward can be equipped to conduct the procedure. Knowing that logistically abortions can be easily offered, the decline in the number of providing hospitals must be due to factors other than a hospital’s lack of having the necessary facilities to provide this medically necessary service. Some of the possible reasons why there are fewer abortion providers in Canada are outlined in the barriers section of this report. A total of 183 hospitals responded to the written survey that was sent to Canadian hospitals. Of these, 31 hospitals affirmed that they provided abortion services. A shocking reality that is further outlined in the barriers section of this report is that several hospitals who affirmed on paper that they do provide abortion services actually told our researcher over the phone that they do not. Similarly, a few hospitals returned the questionnaire saying that they do not offer abortion services while over the phone, hospital staff members assured our researcher that they did. This confusion regarding the provisioning of abortions proves that many hospital staff members do not know their hospital’s policies regarding sexual and reproductive health. This can be a major barrier to a woman who is trying to access abortion services. One part of the questionnaire inquired about the gestational limits that hospitals have regarding the point in a pregnancy at which the hospital will no longer perform an abortion. Many hospitals stated that it is up to the practising physician and that there is no written policy on the provisioning of abortions at their hospital. Other hospitals have strict policies in place limiting the point at which an abortion can be performed. Overall, there is a great range in the gestational limits after which a hospital will refuse to perform an abortion. From the hospitals that completed the section regarding gestational limits it was discovered that: 1 hospital would only perform abortions up to 10 weeks, 9 hospitals perform abortions up to 12 weeks, 3 perform them up to 13 weeks, 6 up to 14 weeks, 1 up to 15 weeks, 3 up to 16 weeks, 1 up to 18 weeks and another 2 up to 20 weeks. In other words, 50% of providing hospitals responded that they only perform abortions within the first trimester of pregnancy. Although over 90% of abortions are done within the first trimester anyway, it is crucial that more hospitals offer late-term abortion services to accommodate the women who, for various reasons including but not limited to, long-wait times, foetal anomalies and maternal health issues, need to have an abortion after the thirteenth week of pregnancy. Since deciding to have an abortion can be very emotional for some women, the hospitals were also asked about whether or not they provided counselling services to the women who accessed their abortion services. Of the providing hospitals that responded to the survey, 76% affirmed REALITY CHECK – a close look at accessing abortion services in canadian hospitals 15 Canadians for Choice that they offered counselling services to women considering abortion. Most of the hospitals that offered pre-abortion counselling services also offered post-abortion counselling services to women when necessary. When providing hospitals were asked if women who were from another province or territory could access abortion services free of charge, only 3 of the 29 respondents said yes. The amount charged to women when abortion services are not offered to residents from other provinces at no cost ranged from $140-$1200. The low number of hospitals that offer free services for out-of-province residents is most likely due to problems with provincial reciprocal billing. Reciprocal billing is discussed in detail in the barriers section of this report. Overall, the data collected from the written questionnaires offers a view of how diverse abortion services are across the country. However, while the responses to the written questionnaire are important in helping Canadians to understand the national average in the provisioning of abortion services, it is also critical that each province and territory be considered individually. Abortion regulations vary by region and each province and territory in Canada has its own advantages and disadvantages for women seeking abortion services. For this reason, each province and territory in Canada must be analyzed by taking into consideration regional policies and social norms regarding abortion care. 16 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice 6/100 Number of hospitals providing abortions… ALBERTA Highlights of Alberta Findings • At only 6%, Alberta has one of the lowest percentages of providing hospitals in Canada. • There is only one providing hospital for every 190 000 fertile women. • Most staff members at Alberta hospitals do not know what to do when a woman calls regarding abortion services. At only 6%, the percentage of hospitals that provide abortion services in Alberta is the third lowest percentage in Canada. When looking at how many women these six hospitals must provide for, there is only one hospital willing to offer abortion services for every one hundred ninety thousand fertile women. At hospitals that do provide abortion services, 75% of the staff members who answered the phone had no idea that their hospital offered the service nor had they any idea what to tell a woman who was requesting information about an abortion. A drastic example of how unknowledgeable staff members affect a woman’s access to abortion services became evident when our researcher found that of the abortion providers in Alberta, there was at least one hospital who, when contacted on the phone, insisted that they did not offer services. However, when Canadians for Choice received their completed written questionnaire, it was discovered that the hospital who over the phone was adamant about their lack of abortion services was in fact one of the leading providers in the province. As discussed in greater detail in the barriers section of this report, unknowledgeable staff members, especially those who work at providing hospitals, can be a huge obstacle for women who are trying to access information about abortions. A hospital that claims that it does not provide abortion services, when in reality it does, is as much of a barrier as if it actually does not provide any services at all. A woman will never be able to access abortion services if she is consistently being told that they are not offered. *NOTE: For a detailed explanation of how to interpret the graph shown, please refer to the methodology section of this report. REALITY CHECK – a close look at accessing abortion services in canadian hospitals Another problem that our researcher encountered when trying to access abortion services in Alberta was that nearly half of all non-providing hospitals had staff members who were unwilling to provide any 17 Canadians for Choice type of referral or information about abortion services to our researcher. When referrals were provided, almost half of them were not useful. 18% of the referrals called sent our researcher directly to a voicemail system without telling her whom she was to leave a message for. When a woman does not even know whom she is calling or when she does not have a usable call-back number, leaving a voicemail message is often not an option. One referral was to an anti-choice organization and another few were to places that were as equally unaware about regional abortion services as the hospitals. One type of referral that was useful was when a hospital suggested that our researcher call the Alberta Healthlink Line. When this line is called, the caller is put in touch with a registered nurse who will provide information on health related issues and will direct the caller to appropriate community services. Our researcher called the line several times and each time was given accurate information about the abortion services in the area from which she said she was calling from. 18 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice 26/90 Number of hospitals providing abortions… BRITISH COLUMBIA Highlights of British Columbia Findings • At 29%, British Columbia has one of the best access rates in Canada. • Our researcher’s worst experience with a hospital occurred in BC. • Nearly 60% of non-providing hospitals were unwilling to provide alternate information or a referral. Twenty-six of the ninety hospitals in British Columbia offer abortion services. This means that after the sparsely populated northern territories of Nunavut, Northwest Territories and Yukon whose combined hospital count is seven, British Columbia has the highest percentage of hospitals that provide abortion services in Canada. British Columbia is also the only province in Canada to have adopted the Access to Abortion Services Act. This act criminalizes the occurrence of any anti-abortion behaviour from happening within a certain distance of providing hospitals, clinics and the homes of doctors who perform the procedure. Whereas in other provinces some doctors have stopped performing abortions because of the insistent and frightening harassment of their clinics and homes, doctors in British Columbia may more openly perform the procedure with less fear of confronting anti-abortion crusaders. The positive effects of this act are evident when one looks at some of British Columbia’s rural hospitals. Unlike in other parts of Canada where many doctors only perform abortions in large cities where they can easily remain anonymous; our researcher discovered a providing hospital that had just twelve beds and was located in a town of only 4000 people. This discovery offers an optimistic look at what the rest of Canada might look like should it adopt an act similar to British Columbia’s Access to Abortion Services Act. *NOTE: For a detailed explanation of how to interpret the graph shown, please refer to the methodology section of this report. REALITY CHECK – a close look at accessing abortion services in canadian hospitals Although British Columbia has one of the best accessibility rates to abortion services in mainland Canada, it is also the province in which our researcher had the worst encounter with a hospital staff member. When a small-town hospital was contacted and asked about their abortion services, the staff member who answered the phone refused to give any information, laughed at our researcher and hung19 Canadians for Choice up on her. When the hospital’s alternate line was called, a different staff member answered the phone by saying, “hospital switchboard” and enquired how she could help. However, when asked by our researcher for the number to a local walk-in clinic, the staff member insisted that she was not talking to a hospital, but to the office of a lumbar company and hung-up on her. To be treated so disrespectfully by professional healthcare providers and to be denied information about a legally funded healthcare service is completely unacceptable. Unfortunately, this is just one of the many barriers that women all over Canada face when trying to access abortion services. For more information on the barriers that women encounter when seeking abortion services in Canada, please refer to the barriers section of this report. For our researcher’s personal account of above-mentioned incident, please refer to the As Experienced in Canada section. The data collected from British Columbia presents a complex image. Although British Columbia is a leader in Canadian access to hospital abortion services, it is also home to the hospital that is the leading example of how women are being treated disrespectfully when trying to access an abortion. Although not all cases of hospital staff being disrespectful are as harsh as the example discussed above, all cases are equally unacceptable. Nearly 60% of the hospitals in British Columbia that do not provide abortion services were also unwilling to provide our researcher with a useful referral. This means that nearly 60% of hospitals either did not provide any referrals, provided a bad referral that did not lead to any information, or were unwilling to even talk to our researcher. 20 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice Number of hospitals providing abortions… 2/52 MANITOBA Highlights of Manitoba Findings • 4% of hospitals in Manitoba have accessible abortion services. • As of July 2005, abortions performed both in and out of the hospital setting in Manitoba are funded by the provincial government. • Manitoba is tied with New Brunswick as having the lowest access rate of all provinces offering hospital abortion services in Canada. • More staff members were judgmental and disrespectful to our researcher in Manitoba than in any other province. Although in July of 2005, the Manitoba government amended its laws surrounding abortion service provision and mandated that abortions performed both in and out of the hospital setting would be publicly funded; Manitoba is still a province with severely restricted abortion services. Other than the 0% access rate of Prince Edward Island, Manitoba is tied with New Brunswick as the province with the lowest percentage of hospitals offering abortion services in Canada. With only two hospitals providing abortion services for more than 390 000 fertile women, access to reproductive healthcare in Manitoba is strictly limited. Wait-times can be up to three weeks and women are often required to travel great distances to access services. The providing hospitals are located at the same latitude, just one hundred kilometres north of the American border, and are only two and a half hours apart. This means that women who live in the vast majority of the province that is north of these locations must travel, or be without access to hospital abortion services. It is necessary for some women to travel over ten hours in order to access this type of reproductive health care. *NOTE: For a detailed explanation of how to interpret the graph shown, please refer to the methodology section of this report. REALITY CHECK – a close look at accessing abortion services in canadian hospitals Of the two providing hospitals, one was answered by a staff member who had no idea of her hospital’s policy on abortion and the other was not even listed in the Canadian Almanac as a general hospital. In fact, the only reason our researcher discovered the existence of the second providing hospital was because she was referred to it by several non-providing facilities. While it is encouraging that a few non-providing 21 Canadians for Choice facilities knew where to refer our researcher, it is concerning that the hospital is not easily accessible because it is not listed in the directory. When contacting hospitals in Manitoba, our researcher was surprised by the amount of staff members that either refused to give our caller a referral, or who provided a referral to an anti-choice organization. Being given bad referrals by the hospitals was more shocking to our researcher than the fact that abortions were not performed. Manitoba is an exception in its delivery of bad referrals since the rest of Canada seems to have improved the quality of referrals given to women since the CARAL report of 2003. The majority of staff members at the hospitals in Manitoba were impatient or rude with our researcher after they found out that she was calling regarding abortion care. Several staff members were adamant that our researcher required counselling and referred her to anti-choice organizations. Others cut her off mid-sentence and told her that they didn’t “have time to answer questions about that sort of thing”. Half of the hospitals that were contacted simply refused to take the time to look into where to refer our researcher or to give her any kind of information or suggestions. Overall, Manitoba has one of the lowest access rates in Canada and has the highest percentage of staff members who treated our researcher with judgement and complete disrespect. 22 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice Number of hospitals providing abortions… 1/28 NEW BRUNSWICK Highlights of New Brunswick Findings • At 4%, New Brunswick is tied with Manitoba as having the lowest access rate of all provinces offering hospital abortion services in Canada. • New Brunswick has the most restrictive policies regarding abortion care in Canada. • The government of New Brunswick refuses to pay for abortion services offered outside of the hospital setting. After Prince Edward Island, which has no hospital abortion providers, New Brunswick is the worst province in Canada for women who are in need of abortion services. With only one hospital in the entire province that will affirm that they are providing abortion services, New Brunswick has a 4% access rate and is a province with some of the most restrictive sexual health policies in the entire country. The government of New Brunswick is an anomaly in its refusal to pay for, or reimburse women for, abortion services performed outside of hospital. While women who live in New Brunswick have always had problems accessing abortion services, abortion accessibility became much worse when the sole providing hospital announced that it was discontinuing its services in June 2006. Fortunately, shortly after the announcement the provincial health minister declared that he had found two other hospitals that would begin performing the procedure. As of July 1st 2006, there are supposed to be two hospitals in New Brunswick that are facilitating abortion services. The problem with the announcement of there being two new hospital providers is that the names of the hospitals are not being released to the public. Out of fear of harassment and anti-abortion violence, only one hospital in New Brunswick will openly affirm that they offer abortion services. This is a problem since a hospital that does not affirm that it provides services is of little use to a woman in need. While physically abortion services may be available, if a woman cannot figure out how to obtain an abortion, the services remain inaccessible. *NOTE: For a detailed explanation of how to interpret the graph shown, please refer to the methodology section of this report. REALITY CHECK – a close look at accessing abortion services in canadian hospitals In order to try to find out if there actually are two hospitals that offer abortion services in New Brunswick, when calling all hospitals in the province our researcher paid special attention to the information given by the rumoured providing hospitals. One of the two 23 Canadians for Choice rumoured hospitals did affirm that they are a provider and gave our researcher detailed information about how to make an appointment. However, the other hospital gave our researcher the run-around. She was transferred to several different departments, had to make six phone calls and spoke to over twelve people. Even with a determination to discover if the hospital was providing services, she was unable to get a straight answer. If a pregnant woman in need of abortion services had called that hospital, surely she would have been deterred from seeking further information after the first few phone calls. Even if the second rumoured hospital is offering abortions, the services are certainly not accessible to the public. Therefore, because from the perspective of a pregnant woman our researcher was unable to discover if the other hospital that was rumoured to be providing abortion services actually was, there is only one hospital being analyzed as a provider in the New Brunswick section of this report. If a woman cannot access abortion services, the hospital cannot be classified as a providing facility. In addition to the fact that there is only one hospital that openly provides abortion services to the women of New Brunswick, there are many other barriers that prevent women from accessing safe and timely abortion care within the province. For one, a woman still needs the authorization of two doctors before she can receive an abortion at any hospital in the province. This requirement is an outdated practice that is remnant of the Therapeutic Abortion Committees of the past where a woman had to plea her case before a panel of doctors before obtaining permission to have her pregnancy terminated. Having to find two doctors who both agree that a woman should not have to carry her pregnancy to term can be incredibly difficult for women in small towns and for women without family doctors. The time it takes to make two separate appointments in order to have a pregnancy “assessed” can lead to unnecessary stress and to longer wait-times for the procedure. Also, if a woman cannot find two co-operative and easily accessible doctors to approve of her abortion, she may become too far along in her pregnancy to terminate it within the province. This may force her into travelling out-of-province to obtain late-term abortion care, or into being forced to bear a child. Another barrier that pregnant women in New Brunswick face is that only abortions that are performed before twelve weeks gestation, in a hospital, by a gynaecologist and that have been approved by two different medical doctors will be approved and have their fees covered by provincial healthcare. New Brunswick is the only province in Canada with such a policy. While the Morgentaler Clinic in Fredericton offers abortion services on a self-referral basis, their services are not covered by provincial healthcare. This directly violates the Canada Health Act, which has deemed abortions as being medically necessary, and which guarantees that all required medical services are accessible to all Canadians. The policy forces women who have no doctor, women who have an anti-choice doctor and women who cannot access a hospital abortion due to long-wait times and restrictive gestational limits, to go to the Fredericton clinic where they must pay between $500 and $750 for medical care. Although there have been several lawsuits against the province of New Brunswick in regards to their refusal to fund clinical abortions, the policy is still in effect. When contacted by our researcher, 86% of non-providing hospitals needed to be coaxed into talking to her once she told them that she was considering an abortion. When asked for a referral to a centre that would help her arrange for an abortion, only one hospital was immediately helpful and understanding in giving our researcher the provider’s contact information. 52% of non-providing hospitals were both unsure of where to refer our researcher, and were unwilling to look into finding any information on abortions or referrals. The remaining 43% of 24 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice non-providing hospitals only provided a referral after having been asked several times for information on who to contact in regard to abortion services. Overall, in terms of policy and restrictions, New Brunswick is the worst province in Canada in regard to abortion services and sexual and reproductive healthcare. The restrictions placed on obtaining proper and timely reproductive support are outdated and serve only as a punishment for women who find themselves facing an unplanned and unwanted pregnancy. REALITY CHECK – a close look at accessing abortion services in canadian hospitals 25 Canadians for Choice 3/14 Number of hospitals providing abortions… NEWFOUNDLAND AND LABRADOR Highlights of Newfoundland and Labrador Findings • Only three hospitals in Newfoundland provide abortion services; two of which are located in the provincial capital. • There are no abortion services in Labrador. • The majority of hospitals are unwilling to provide information to women about where an abortion, or a referral for an abortion may be obtained. While 21% of hospitals in the province of Newfoundland provide abortion services, none of them are located in Labrador. In fact, two of the three providing hospitals are located in the provincial capital of St. John’s. This means that all of the women who need access to abortion services and who live outside of the capital region must travel either to St. John’s, or to the other providing hospital on the opposite end of the island. For women living on the west coast of Newfoundland, a travel time of at least nine hours is required to reach the nearest provider. Transportation costs, lost wages and payment for child or elder care can act as major access barriers to women outside of the hospitals’ region. When contacted by our researcher, 70% of the hospital staff that answered the phone had no idea if abortion services were offered at their hospital. Of the few hospitals that had someone answer the phone who knew that the hospital did not provide abortions, rather than offer a referral, 75% of the people spoken to were not willing to even talk to our researcher after they found why she was calling. Overall, the majority of staff members at the hospitals contacted in Newfoundland and Labrador were rushed, impatient, abrupt and unwilling to help. *NOTE: For a detailed explanation of how to interpret the graph shown, please refer to the methodology section of this report. 26 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice Number of hospitals providing abortions… 2/3 NORTHWEST TERRITORIES Highlights of Northwest Territories Findings • Two of the three hospitals in the Northwest Territories provide abortion services. • A woman must go through her doctor or through a walk-in clinic in order to get a referral to a providing hospital. • Having to travel to access services is a major barrier for the women of the Northwest Territories. • In every situation, the main contact at the hospitals did not know if abortions were performed at their hospital, or know where to send a questioning woman. Two out of the three hospitals in the Northwest Territories provide abortion services. However, not a single hospital in the entire territory had a person answer the phone that knew where to direct a woman in need of services, or how to answer her questions about an abortion. This lack of knowledge constitutes a serious barrier for women seeking abortion services. Once our researcher got through to someone with knowledge of abortion services in the Northwest Territory, both providing hospitals told our researcher to contact a local clinic for a referral. One of the hospitals gave her the direct line of the doctor who performs all of the abortions in the area, while the other providing hospital encouraged our researcher to call back for help if she could not get through to a doctor who was willing to refer her from a clinic. Overall, although the hospital staff at the two hospitals that provide abortions rarely knew how to direct a call about their services, they were pleasant on the phone and were willing to find out where to transfer inquiring women. *NOTE: For a detailed explanation of how to interpret the graph shown, please refer to the methodology section of this report. REALITY CHECK – a close look at accessing abortion services in canadian hospitals The hospital that does not provide abortion services was not as helpful. In fact, when contacted, the hospital staff were both unsure of where to direct our researcher and were unwilling to look into finding out where to refer her to. She described the hospital staff as rushed, impatient and abrupt. No referrals were given and our researcher was given no advice as to what her next step in trying to access an abortion should be. 27 Canadians for Choice 4/30 Number of hospitals providing abortions… NOVA SCOTIA Highlights of Nova Scotia Findings • With an access rate of 13%, only four hospitals in the province provide abortion services. • The main providing hospital in Nova Scotia was one of the most difficult hospitals in Canada to access information from. Only four out of thirty hospitals provide abortion services to the women of Nova Scotia. Of the abortions performed in the province, nearly all of them are done at only one of the four hospitals. This presents a problem especially because, when our researcher called the main providing hospital for information, she had to make five more phone calls and explain her situation to six people. She found it very hard to get through to the right department and was constantly being transferred to different extensions. When she finally got through to the correct department, the only option was to leave a voicemail message. Having to leave a message, as discussed in the barriers section of this report, is not always a possible, nor is it a comfortable option for women seeking abortion access. Some women do not have a phone or do not have a place where they may privately talk about their unwanted pregnancy. Other women have concerns about a lack of confidentiality. These and other issues often prevent a woman from choosing or from being able to leave a voicemail message. There are no abortion clinics in the province of Nova Scotia. This means that a woman must be able to access information about abortions from hospitals. Unfortunately, of the hospitals that do not provide abortion services, almost half of them were unwilling to provide a referral or any other information about abortions. One hospital offered our researcher access to the morning-after pill. This is an unreasonable offer since by the time a woman can detect that she is pregnant, it is far too late for the morning-after pill to work. Overall, although many hospitals were uninformed about their policy on abortion, our researcher found that quite a few staff members were apologetic for not being able to help more. One hospital mentioned their need of a proper directory of abortion providers. The concern shown by staff members is an encouraging sign that many healthcare providers in the province of Nova Scotia are open to discussion about, and solutions to, the issues surrounding sexual and reproductive healthcare. *NOTE: For a detailed explanation of how to interpret the graph shown, please refer to the methodology section of this report. 28 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice Number of hospitals providing abortions… 1/1 NUNAVUT Highlights of Nunavut Findings • After several years without access, abortion services are once again being offered in Nunavut. • Women can access the services through self-referral. • Women over thirteen weeks pregnant are still required to travel out-of-territory in order to receive abortion care. An exciting improvement in abortion access since the CARAL report of 2003 is the availability of abortion services in the territory of Nunavut. The territory’s sole hospital in Iqaluit is now providing the important medical procedure. This is of dramatic significance because when abortion services were not being provided, the territorial residents were forced to travel to Ottawa and Montreal in order to access the procedure. While women who are over thirteen weeks pregnant are still required to travel to Ottawa for an abortion, women who are in their first trimester of pregnancy can make their own appointment to receive an abortion through a self-referral to the provider. Although the wait-time for the procedure can be up to three weeks, the fact that women do not have to leave the territory makes accessing abortion services much easier. When called by our researcher, the hospital was able to offer detailed information about the abortion services provided and was willing to transfer our researcher directly to the appropriate department for scheduling. *NOTE: For a detailed explanation of how to interpret the graph shown, please refer to the methodology section of this report. REALITY CHECK – a close look at accessing abortion services in canadian hospitals 29 Canadians for Choice 33/194 Number of hospitals providing abortions… ONTARIO Highlights of Ontario Findings • 17% of hospitals in Ontario have accessible abortion services. • In Ontario, there is only one providing hospital north of the Trans-Canada highway. • Ontario is home to the three hospitals with the longest wait-times to access an abortion in the entire country. • Many Ontario hospitals require women to leave their personal information on voicemail messaging systems. • The leading Canadian hospital in late-term abortion services is in Ontario. Ontario has the largest population of all provinces and territories in Canada, yet the amount of reproductive medical services offered to women is decreasing. Since 2003, there are eleven fewer hospitals in Ontario that provide abortion services. Of the hospitals that do provide abortion services, nearly all of them are located in Toronto and south-western Ontario. In fact, there are only five hospitals in the huge area north of Ottawa that offer abortion services. Only one providing hospital is located north of the Trans-Canada highway. This means that many women each year have to travel hundreds of kilometres in order to obtain proper reproductive health services. For a written account of what women from one small northern town must go through in order to access abortion services, please refer to the As Experienced in Canada section of this report. *NOTE: Unlike other provinces, Ontario has a large amount of providing hospitals that refer women directly to a voicemail messaging system to arrange for an abortion. This potential barrier is included on the referral graph for Ontario. For a detailed explanation of how to interpret the graph shown, please refer to the methodology section of this report. 30 Even in southern Ontario, where the majority of abortion services are concentrated, there are many ways in which these services are inaccessible. In Ottawa, the capital city of Canada, there is only one providing hospital. While abortion services may be done at alternate hospital campuses in the city, these other sites act mainly as ‘overflow sites’ for when there are a large number of abortions being requested at the same time. At the providing hospital in REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice Ottawa, abortion services are not offered for an entire month in the summer. This means that during the summer, all women who wish to have an abortion and who live in the city of Ottawa or in the surrounding area must access the services of a single clinic. This lack of adequate access can lead to wait-times that are, in some cases, up to six weeks long. This extremely long waittime is also how long a woman must wait to have an abortion in Sarnia and Peterborough, Ontario. The providing hospitals in Ottawa, Sarnia and Peterborough each have the longest period of time that a woman has to wait before getting an abortion in the entire country. While some non-providing hospitals gave our researcher very helpful referrals, the majority of hospitals in Ontario simply instructed her to call a doctor or go to a walk-in clinic, with no details about how to contact either. Ontario was also one of the provinces that had healthcare staff who provided our researcher with referrals to anti-choice organizations. As discussed in detail in the barriers section of this report, anti-choice organizations can be incredibly persuasive in deterring a woman from her reproductive rights by providing inaccurate information about abortion and other medical services. Another barrier that our researcher found to be prevalent specifically in Ontario was the use of voicemail messaging systems as a means of communication between pregnant women and hospital abortion clinics. Ontario is one of the only provinces in Canada that has numerous hospitals that offer information about abortion services, and book appointments for abortions, only through the use of voicemail. This method of communication has many faults. Some women do not have phones. Other women live in a place where they do not want the other members of their household to know that they are pregnant or considering an abortion. Some women live in abusive situations and cannot receive personal calls. All of these women are in situations where they simply cannot have a hospital staff member return their call. In other situations, women choose not to leave voicemail messages. There are different reasons why a woman may not be comfortable leaving a message. For one, voicemail poses the problem of a lack of confidentiality. Some women have expressed discomfort in having to leave their personal information on a machine without knowing exactly who will be listening to it. Also, having to explain an intimate situation such as an unwanted pregnancy can be difficult to do when talking to a real person, and is even more difficult when one is talking to an unsympathetic machine. If a woman cannot get through to a person at a hospital, she may try to find other places that will provide services. This can lead to calls to anti-choice organizations which, as discussed above, can cause many more problems. One area in which Ontario is a leader in reproductive rights is in the provision of abortion services to women who are further along in their pregnancies than the average woman who seeks abortion care. Although rare, women sometimes need access to abortion services later in their pregnancy than normal. There are many reasons why women need to access abortion services past the normal thirteen-week limit. Some of these reasons include foetal abnormality, maternal safety issues, or the inability to access abortion services sooner. Performing abortions up to twenty-two weeks gestation, Ontario is home to one of Canada’s leading hospital providers in late-term abortion services. While several hospital staff members were rude and many were unwilling to provide any information or referrals to our researcher, overall, the majority of hospital staff members were either indifferent to her requests for abortion service information, or were helpful and understanding of her needs. REALITY CHECK – a close look at accessing abortion services in canadian hospitals 31 Canadians for Choice 0/7 Number of hospitals providing abortions… PRINCE EDWARD ISLAND Highlights of PEI Findings • Elective abortion services are not provided in PEI. • The majority of hospitals are unwilling to provide information to women about where an abortion, or a referral for an abortion may be obtained. Prince Edward Island is the only province in Canada that still refuses to offer abortion services despite the Morgentaler decision of 1988. Women from PEI must travel out of province in order to obtain access to abortion care. As of 2005, the only relatively close hospital willing to accept PEI women as patients for abortion services is located in Halifax, Nova Scotia. Women who wish to access a funded abortion at the Halifax hospital must first be referred there by a PEI doctor who is willing to both deem her abortion as medically necessary and request that the procedure be funded by the Department of Health and Social Services. Because of these necessities, a major barrier for PEI women who are trying to access abortion services is a lack of doctors on the island who are willing to make the required referrals and requests for funding. Travel and transportation are also huge barriers for women trying to receive mainland services as a round trip from PEI to Halifax, by the cheapest means possible, costs several hundred dollars. This amount does not take into account ultrasound fees, lost wages, childcare, eldercare or an overnight stay. Women who need to access an abortion after 16 weeks gestation must travel over twelve hours to Montreal, resulting in the need for a significant amount of time and money. When our researcher called the hospitals in PEI, none of them offered her any referrals on their own accord. Even when specifically asked for another number to call for possible information, 71% of the hospitals stated that they had no idea about what to tell her and were not willing to look into finding any information for her. One of the hospitals refused to even talk to our researcher after she asked them about abortion services. In fact, there was only a single hospital that had staff members who were understanding and helpful to our researcher and who took the time to look into possible clinics that would provide referrals. *NOTE: For a detailed explanation of how to interpret the graph shown, please refer to the methodology section of this report. 32 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice Number of hospitals providing abortions… 31/129 QUÉBEC Highlights of Québec Findings • 24% of Québec hospitals, and many CLSCs, provide accessible abortion services. • Québec is a model in offering self-referral abortion services, abortion appointments within 24 hours, pre and post abortion care and counselling. • In August 2006, the provincial government set a precedent for Québec policymakers to encourage the law to change to allow for clinical abortions to be funded by the government, and for class action suits to be filed for the reimbursement of abortion fees • As a province, Québec has still not adopted a reciprocal billing agreement with other provinces in regard to abortion services. • Québec is one of two Canadian provinces that has a large amount of providers who operate only through a voicemail system. In Québec, there are two different types of public healthcare providers that are commonly used by residents: general hospitals and Centres locaux de services communautaires (CLSCs). CLSCs are publicly funded and provide, among other services, family planning, medical services and referrals. Many abortion services in Québec are offered through CLSCs. In fact, la Fédération du Québec pour le planning des naissances has calculated that there are eighteen CLSCs in Québec that offer abortion services. Since they represent a large part of the healthcare system in Québec, and because so many hospitals referred our researcher a CLSC, it was necessary for our researcher to collect information about abortion in Québec by calling both the hospitals and a sample of CLSCs. However, as *NOTE: Unlike other provinces, Québec has a large amount of providing in other provinces, hospitals that refer women directly to a voicemail messaging system to arrange for an abortion. This potential barrier is included on the referral graph for Québec. while there may be many clinics and CLSCs For a detailed explanation of how to interpret the graph shown, please refer to the in Québec that offer methodology section of this report. abortion services, the 2 Fédération du Québec pour le planning des naissances. Bottin des ressources en avortement. Montréal: Fédération du Québec pour le planning des naissances. (2006) REALITY CHECK – a close look at accessing abortion services in canadian hospitals 33 Canadians for Choice purpose of the study is to evaluate abortion services offered in public hospitals. Therefore, neither clinics nor CLSCs were included in the tally of how many hospitals in Québec offer abortion services. Overall, our researcher discovered that in Québec there are thirty-one general hospitals that provide abortion services. Of both the providing and non-providing hospitals and CLSCs in Québec, it was found that regardless of whether or not a woman needs a referral in order to get an abortion, most hospitals will transfer her to or tell her to call the Family Planning Unit. Québec is one of the only provinces in Canada that has a hospital unit whose name and purpose is similar in almost all hospitals. This consistency allows for women in need of abortion services to easily contact the appropriate department of their local healthcare provider, and for doctors to know exactly where to make abortion referrals. On August 17th, 2006, the Québec government came to a judicial decision that mandated that all women who had paid for an abortion in a clinic in Québec between 1999-2005 be reimbursed for her payment. This decision sets a precedent for future women who wish to form a class action suit, similar to the one that won the reimbursement case in August of 2006, to request to be reimbursed for their abortion fees. As it stands, a woman can still not apply for individual reimbursement. The judicial decision also sets precedence for policymakers who follow-up on amending the law that requires women to pay for abortions performed outside of hospitals and CLSCs. While having a precedent set that allows for women to lobby for the reimbursement for their abortion fees through a class action suit is encouraging, the fact that an individual woman cannot apply to have the procedure reimbursed is one example that proves there are still many barriers that prevent women from accessing proper abortion care. Another example of a barrier that is prevalent in Québec is evident when looking at the overnight requirements that some hospitals in the province have for patients who have an abortion. At one hospital in Québec, a woman who has an abortion when she is over thirteen weeks pregnant must spend one night in hospitalization. If she is over seventeen weeks pregnant when she has an abortion, she is kept hospitalized for three days. This length of hospitalization is longer than many new mothers stay in a hospital after giving birth and can be a huge problem for women who have to take time off of work or pay for childcare. Another problem that women seeking abortion care in Québec face is that Québec is still one of the few provinces in Canada that has not signed a reciprocal billing agreement with other provincial governments. Reciprocal billing agreements guarantee that a patient’s medical service costs will be covered if the patient needs to access services outside of their province of residence. Unfortunately in Québec, this agreement is not policy at the provincial level. However, at the local level, several regions of Québec have developed a policy that is similar to the idea of reciprocal billing. The city of Montréal, for example, has arranged for an inter-provincial and international agreement with other provinces and with the United States of America. This agreement allows women to access abortion services outside of their region if they are over the gestational limit that doctors in Montréal will perform the procedure. The agreement allows regional hospitals to arrange for all of a woman’s costs, including overnight stays in hotels and transportation to be paid for, if the service cannot be provided in her area of residence. While this is a great policy that benefits the women who live in Montréal, it does not benefit the other thousands of women who live outside of the area. Reciprocal billing should be a provincial-wide policy. Québec hospitals are nonetheless a model of how post-abortion services in Canada should be. All of the hospitals from Québec that returned the written questionnaire regarding access to abortion services stated that they offered pre-abortion and post-abortion care and counselling 34 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice services to women. In addition, Québec is the only province in Canada that had hospitals who stated that they had the capacity to perform abortions for women within twenty-four hours of their initial request. Also, at 64% Québec has the highest percentage of providing hospitals in Canada that offer abortion services on a self-referral basis. This means that a pregnant woman can call the hospital directly to make her own appointment for an abortion. This relieves the barrier of having to go through a doctor and can also lead to shorter wait-times since fewer appointments are needed before having the procedure. However, although offering abortions through self-referral is the ultimate way to guarantee access to the medical service, over half of the hospitals that offer self-referred abortion services in Québec do so only through the use of voicemail. Besides Ontario, Québec is the only other province in Canada that has a large amount of providing hospitals that work solely through voicemail messaging systems. As discussed in the Ontario section of this report, this method of communication has many faults. Some women do not have phones or live in a place where they do not want the other members of their household to know that they are pregnant or considering an abortion. Other women live in abusive situations and cannot receive personal calls. Some women choose not to leave voicemail messages because voicemail poses the problem of a lack of confidentiality. Women have expressed discomfort in having to leave their personal information on a machine without knowing exactly who is going to be listening to it. Also, having to explain an intimate situation such as an unwanted pregnancy can be difficult to do when talking to a real person, and can be even more difficult when one is talking to an unsympathetic machine. If a woman cannot get through to a person at a hospital, she may try to find other places that will provide services. This can lead to calls to anti-choice organizations that may try to persuade a woman against accessing her choice to have an abortion. Overall, our researcher found the staff members that she spoke with at Québec hospitals to be helpful and understanding. Due to the supportive details discussed above, Québec remains a model of how abortion services should be offered in the rest of Canada. REALITY CHECK – a close look at accessing abortion services in canadian hospitals 35 Canadians for Choice 4/68 Number of hospitals providing abortions… SASKATCHEWAN Highlights of Saskatchewan Findings • There are only four providing hospitals in the entire province. • Saskatchewan has no free-standing clinics and there are incredibly long waitlists to obtain abortion services. • Many hospital staff members are misinformed and uninformed about the provision of abortion services in Saskatchewan. Although Saskatchewan still has a very low percentage of providing hospitals, there has been an improvement in the number of providers since 2003. However, just because more hospitals are willing to provide abortion services does not mean that the services are more easily accessible. After telling our researcher that they do offer abortions, half of the providing hospitals would not give out any further information or answer any questions about their services. From the hospitals that would talk about the process that a woman must go through in order to obtain an abortion, our researcher discovered that in some hospitals, women must wait up to six weeks before having the procedure. This horrendous reality is made worse due to the fact that Saskatchewan does not have any free-standing abortion clinics. An absence of free-standing clinics, coupled with a severe shortage of doctors and facilities willing to provide abortion services, severely restricts a woman’s access to abortion. 100% of abortions performed in the province are carried out at the four providing hospitals. The information that our researcher received from the 94% of hospitals that do not offer abortion services was disheartening. While many hospitals provided detailed referrals for doctors or clinics that could possibly help a woman in search of abortion services, many more hospitals gave our researcher false information and treated her in a condescending manner. Staff members at several different hospitals insisted that our researcher would not be able to find a doctor who was willing to discuss terminating her pregnancy. One hospital insisted that our researcher call the local in-patient mental health centre in order to receive *NOTE: For a detailed explanation of how to interpret the graph shown, immediate psychiatric please refer to the methodology section of this report. treatment. Another 36 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice hospital informed our researcher that no one in Saskatchewan would terminate a pregnancy that was over eleven weeks gestation. This inaccurate statement was discredited when the first providing hospital that our researcher contacted declared that they performed abortions up to sixteen weeks. The factual limit of sixteen weeks is nearly a month and a half later than the imagined gestational limit that the misinformed healthcare provider originally recounted to our researcher. Imposed imaginary limits that are insisted upon by misinformed staff and an unwillingness to share pertinent information regarding the referral process, constitute serious barriers to women in search of abortion access. REALITY CHECK – a close look at accessing abortion services in canadian hospitals 37 Canadians for Choice 1/2 Number of hospitals providing abortions… YUKON Highlights of Yukon Findings • One of two hospitals in the Yukon provides abortion services. • Staff members at the providing hospital are not knowledgeable about the abortion services that are offered. Of the two hospitals in the Yukon, one of them offers abortion services. However, when called by our researcher, neither hospital reception was even aware of whether or not their facility had abortion providers working at it. In fact, when our researcher contacted the hospital that does provide abortion services, she had to call four different numbers and was transferred twice before she finally spoke to someone who was aware of the availability of the service at the hospital. Even when someone was reached who was able to confirm that abortion services were available at the hospital, they were unable to provide any detailed information about how a woman could schedule the procedure. The lack of information among hospital staff members regarding the services provided could lead to women being misguided about the availability of abortions, and result in denied access. A lack of information can also be a barrier for women who are travelling from out of town and need to know the details of the procedure before making the appropriate arrangements. Once transferred to the appropriate department at the hospital that does not provide abortion services, our researcher was given the number of a local doctor who performs abortions at the providing hospital. This referral proved to be useful when our researcher contacted the given number and was immediately able to arrange for an appointment with the providing doctor. Most of the staff spoken to at the non-providing hospital were both helpful and understanding and information seemed to be easily available for women in need of reproductive services. *NOTE: For a detailed explanation of how to interpret the graph shown, please refer to the methodology section of this report. 38 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice Barriers to Abortion Accessibility This section highlights some of the major barriers that women encounter when seeking abortion services in Canada. The barriers listed in this section were identified based on the responses to phone calls and surveys sent to general Canadian hospitals and organizations. For the purpose of this study, a barrier is defined as any obstacle that a woman may face when trying to access an abortion, or when trying to access information about an abortion. Most of the barriers identified can easily be addressed and resolved. However, as seen through the results of this report, many Canadian governments, hospitals and doctors choose to interpret laws and policies in ways that fulfill their own personal beliefs and commitments rather than in ways that best serve to provide health services for pregnant women. For this reason, Canadians for Choice will continue to report on what women experience through the actions of policy makers and healthcare providers. We will strive to ensure that there is public knowledge of abortion services and promote the support of reproductive rights for all Canadians. Barrier: Not enough Abortion Providers A major finding of this report is that hospital access to abortion services in Canada is declining. Fewer than 16% of hospitals are providing abortion services and fewer doctors are being trained in the abortion procedure3. Also, as older abortion providers retire, there are often no younger providers to take their place. This poses a serious problem for women seeking services from a hospital that either does not have an abortion program, or that does not have a program under which the hospital replaces providers as they retire. When a doctor is just using a hospital as the venue for abortion provision and there is no established abortion program within the facility, there is also no requirement for the hospital to hire another provider when the current one leaves. According to previous research, there are several explanations as to why the number of abortion providers in Canada is diminishing. For one, the loss of abortion providers can be attributed to a doctor’s increased fear of violence and harassment by anti-choice crusaders. For years abortion service providers have been the targets of attack. Canadian clinics have been bombed, doctors have been shot and patients have been harassed. To counter this harassment, British Columbia became a leader in protecting abortion providers and their clients when they established the Access to Abortion Services Act that criminalized the occurrence of any anti-abortion behaviour from happening within a certain distance of providing hospitals, clinics and the homes of doctors who perform the procedure. If the rest of Canadian provinces and territories were to adopt a similar act, a doctor’s fear of violence due to his or her chosen career as an abortion provider would surely be reduced. Another way to decrease acts of violence and harassment against abortion providers would be to designate anti-abortion acts as Hate Crimes under the Criminal Code of Canada. This would allow the Canadian government to prosecute, to the full extent of the law, any persons found guilty of engaging in hate crimes or acts of violence against doctors, patients, and all healthcare workers involved in the provision of abortion services. Another reason explaining the decrease in the number of abortion providers in Canada since 2003, is the steady decline in the amount of time that medical schools spend teaching their students the technical aspects of the abortion procedure. In fact, a study done by medical 3 Koyama & Williams. Abortion in Medical School Curricula. McGill Journal of Medicine. Vol. 8 No. 2. 157-160. Montréal: McGill Journal of Medicine. (2005) REALITY CHECK – a close look at accessing abortion services in canadian hospitals 39 Canadians for Choice students at McGill University found that nearly 40% of medical schools do not teach any aspect of the abortion procedure in the pre-clinical years4. Furthermore, it was discovered that more class time is dedicated to the study of Viagra than to abortion law, policy, procedures and pregnancy options counselling combined. One way to better guarantee access to abortion services would be to encourage medical schools to reinstate abortion as a medical procedure in the curriculum of obstetrics and gynaecology, and to ensure that it is taught according to models of best practice. A reinstatement of the procedure into the medical school curricula is important -both because more doctors need to be encouraged to perform abortions and because doctors are so well respected in Canadian society. In general, anything that is seen as being taboo to a doctor is also seen as being unnatural to the rest of society. In order to make abortion a more openly accepted practice, it needs to become normalized both within the medical community as well as within the general population of Canada. Several organizations contacted during the study identified hospital mergers as a third factor limiting the availability of abortion providers in Canada. In the recent period of hospital restructuring, several hospital mergers have resulted in a secular hospital being absorbed within the mandate of a Catholic one. The new hospital is usually required to adopt the Catholic Health Ethics Guide, which restricts accessibility to many aspects of reproductive and sexual health including, but not limited to, a woman’s right to contraception and abortion services. Unfortunately, until it becomes illegal for publicly funded facilities to adopt anti-choice policies, this trend of severe restriction is likely to continue in Canada. One way that provincial and territorial governments could prevent this trend from continuing would be to mandate that abortion services be offered within any certified general hospital that is equipped with surgical facilities. A mandate such as this could be made applicable to all hospitals regardless of whether or not the hospital currently has a providing doctor on staff. If all general hospitals were required to endorse the provision of abortions and be equipped to perform them, non-secular but still publicly funded hospitals would have to comply with provincial or territorial rulings. Barrier: Cost and Travel Through discussions with various Canadian Federation for Sexual Health affiliates, it was noted that although abortion services are generally covered by provincial healthcare, there are many costs that a woman may still incur when seeking access to the procedure. Especially if a woman is required to acquire an abortion outside of her area of residence, procedural costs, travel time and unexpected expenses can amount to a large sum. In cases where the sum is too great, a woman may attempt to self-induce an abortion or be forced to carry an unwanted pregnancy to term. Selfinducing is very dangerous and can lead to severe medical complications such as infection, infertility and death. It is therefore critical that the barrier of cost and travel be addressed. Some provincial governments, such as New Brunswick, still refuse to pay for abortions that are performed outside of hospitals. This means that the women of New Brunswick who cannot access an abortion at a hospital must use their own money to pay for an abortion at a clinic. Even outside of New Brunswick, some clinics in Canada require the women who use its services to pay a fee that goes towards paying for facility costs and physician services. Despite the fact that in the majority of cases provincial governments reimburse the fees paid, for many women, having to produce enough money to make the initial payment can be too financially straining. 4 Koyama & Williams. Abortion in Medical School Curricula. McGill Journal of Medicine. Vol. 8 No. 2. 157-160. Montréal: McGill Journal of Medicine. (2005) 40 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice There are different reasons why a woman may choose to have an abortion at a clinic rather than at a hospital. Some women simply feel more comfortable in a setting that has been designed to deal specifically with pregnancy termination. Other women fear a lack of confidentiality in the hospital setting. Particularly if the pregnant woman lives in a small town, she may have qualms about having the procedure done in a public institution where she is likely to run into someone whom she knows. Another reason may be that, by the time a woman realises that she is pregnant, she is already past the gestational limit set by her local hospital provider. In other situations, long hospital wait-times may require a woman to look for abortion services in places outside of her local area where the procedure can be done at an earlier date. In many situations, abortion services are simply not offered in a woman’s area of residence. As discovered by our researcher, having to travel in order to access services is an obstacle for many women in need of an abortion. For one, some provinces do not offer funding for women who must travel to access abortion services. This means that many women across Canada have to use their own money to pay for the travel that is necessary in order to get to a facility that offers abortion services. This can be a problem since having to travel is expensive not only because of transportation and accommodation costs, but also because of other indirect costs. These indirect costs include, but are not limited to: having to take time off work, arranging for elder or childcare, and arranging for someone else to accompany the woman who is terminating her pregnancy. Arrangements to travel with another person are necessary because it is the general policy of hospitals and clinics that a woman may not drive herself home or travel alone immediately following an abortion. Aside from the financial distress of lost wages and indirect costs, it can be extremely difficult for some women to find a person whom they are willing to ask to accompany them before and after the abortion procedure. Also, since most women are required to have a preliminary consultation before obtaining an abortion, they are often required to make more than one trip to the provider’s office or hospital. Especially for women who live in rural areas where the necessary follow-up services are not available, two or more trips may be needed in order to ensure that the abortion procedure is properly completed. To read what women from one small, northern town must go through in order to access abortion services, please refer to the As Experienced in Canada section of this report. Another way in which travel makes for an expensive situation is when a woman is travelling out of her area of residence when she discovers that she is pregnant. Even if she tries to access abortion services at a providing hospital that is publicly funded by the government, a woman that is temporarily outside of her province or territory of residence may be required to pay for her abortion. This unexpected and unavoidable cost is due to the possibility of the procedure not being covered, or only being partially covered, through reciprocal billing. Barrier: Reciprocal Billing Reciprocal billing is an agreement between provincial and territorial healthcare providers that allows Canadians to access healthcare services free of charge when they are outside of their province or territory of residence. Our researcher was able to assess the impact that this barrier has on women by contacting hospitals that were outside of her province of residence. The idea behind reciprocal billing is that if a patient needs to access medical services when they are outside of their province or territory, they may do so easily and without cost. Reciprocal billing can occur in two ways. Sometimes, a person will be able to access medical services for free, as if they were in their own province. If this happens, the medical facility that treated the patient will REALITY CHECK – a close look at accessing abortion services in canadian hospitals 41 Canadians for Choice transfer the amount of the medical bill directly to their home provincial healthcare system for payment. Alternately, sometimes a patient has to pay a fee up front to the hospital or clinic where they received their healthcare and then get reimbursed for the amount of the bill when they return to their home province. Either way, through reciprocal billing, necessary medical services are guaranteed to be offered to Canadian residents free of charge, and regardless of where they are located in the country. Unfortunately, since individual provinces can decide what to include and what to exclude on their lists of acceptable medical services eligible for reciprocal billing, many provincial billing lists exclude abortion as a portable medical service. Portability is seen as one of the strengths of the Canadian health care system since it allows people who are travelling or moving to another province to maintain full medical coverage. Since abortion is excluded by some reciprocal billing lists, a woman who is in a province temporarily or has recently moved to a new province but not yet received her new provincial health insurance plan, will often have to pay cash to access abortion services and may not get reimbursed for her payment. The values of anti-choice legislators and their impact on the healthcare system become blatantly obvious when we look at how a pregnant woman is treated under Canadian Medicare. While a woman who wishes to complete her pregnancy in a province other than her own can do so, a pregnant woman who wishes to terminate her pregnancy in another province cannot. This differential treatment of pregnant women, based on their feelings about their pregnancy, contradicts Health Canada’s mandate to support of all aspects of reproductive health. Due to a lack of universal governmental participation in resolving reciprocal billing issues and because women often have to access abortion services in clinics outside of hospitals or in other provinces, the individual costs indebted to women who are in need of an abortion can be overbearing. Until there is a consensus among all provinces and territories to include abortion on the lists of medically necessary procedures eligible for reciprocal billing, and until either all hospitals provide abortion services or services can be freely accessed in other provinces without cost, women will continue to be forced to pay for some of their medically necessary procedures. All provinces and territories should be dedicated to providing free and proper reproductive healthcare for all women. Barrier: Unknowledgeable Hospital Staff Members In many hospitals across Canada, the staff members who were contacted by our researcher were unaware of their hospital’s policy on the provision of abortion services. In fact, Canadians for Choice found that 41% of hospitals that provide abortion services had staff members answer the phone who did not know if abortions were offered or where to transfer our researcher. Incredibly, some hospitals even had executive directors who were unable to answer the question of whether or not the hospital provided abortion services, either through an abortion program or through individual providers. Other staff members admitted that they were both unaware of information about abortions and unwilling to look into finding out any relevant information. This presents a huge problem for women seeking access to reproductive healthcare. Unfortunately, unknowledgeable staff members are not just uninformed about the services offered at their own hospital. If a staff member is unaware of the policies and services at their own hospital, it is quite likely that they are also unaware of the abortion policies and services at neighbouring hospitals. This means that if a woman is turned away from a providing hospital because the staff member that they spoke with was unable to provide correct information about 42 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice abortions, the pregnant woman is also likely to not be offered a proper referral. Not knowing a hospital’s policy on abortions and not knowing where to refer a pregnant woman in need of abortion services are two major barriers that affect a woman’s access to the medically necessary procedure and are both due to unknowledgeable staff members. The barrier of unknowledgeable staff members could be overcome if hospital boards mandate that all staff members at their hospitals be aware of their facility’s policies regarding the provision of abortions. It would also be beneficial if a directory of proper referrals be easily available for use at each hospital so that staff members who deal with women in search of abortion services may know where to send them if the service is not provided at their hospital. Barrier: Judgmental Gatekeepers There are many people within the healthcare system who act as the gatekeepers to a woman’s access to information about abortion services. Our research has identified two general types of gatekeepers within the Canadian healthcare system. Staff members who answer the phone at hospitals or staff members to whom a call about abortion is transferred to compose the first group of healthcare providers and include, but are not limited to: receptionists, switchboard operators, nurses, on-call physicians, counsellors and interns. The other type of gatekeeper within the Canadian healthcare system is the doctor. Since doctors are some of the most persuasive and trusted individuals within the healthcare system, an entire subcategory within the barriers section of this report will be devoted to their discussion. When our researcher called a hospital looking for abortion services she often had no idea who to ask to be transferred to, whether or not the hospital actually offered abortion services, or how she would be treated when she told the hospital about her plans to terminate her pregnancy. Women seeking abortion care are in a vulnerable and delicate situation and need to be treated with compassion and respect. The first person that a pregnant woman speaks with regarding abortion care is therefore critical in moulding how the pregnant woman will feel about the entire termination process. If the staff member who receives her call is judgmental or impatient, the woman may feel that her decision to have an abortion is shameful. Several times throughout the course of this study, our researcher was hung-up on, laughed at, told that no one would want to talk to her about getting an abortion and was told many myths and inaccuracies about what would happen to her if she terminated her pregnancy. Some pregnant women find themselves in vulnerable situations where they are extremely impressionable and would become very distraught by such behaviour. For this reason, it is very important that a woman always speak with a staff member who is supportive and understanding of her situation. Aside from having tremendous influence on a pregnant woman’s feelings about terminating her pregnancy, staff members also have complete control over what kind of information a woman receives regarding abortion care. As our researcher found, if the staff member receiving the inquiry about abortion services is anti-choice, they may try to talk the pregnant woman out of having an abortion or refer her to an anti-choice organization. Some staff members may also limit a woman’s ability to access abortion services by withholding important and relevant information about the procedure. Several times during this study, our researcher spoke with judgmental hospital staff members who insisted that no one in the area knew anything about abortion services. In one case, a nurse insisted that there were no doctors at the hospital who REALITY CHECK – a close look at accessing abortion services in canadian hospitals 43 Canadians for Choice would be willing to talk to a pregnant woman about how to get a referral for an abortion. However, as discovered when our written questionnaire was returned, the hospital from the experience mentioned above was actually one of the main providers in the province. This is just one example of how anti-choice staff members act as gatekeepers of important information. All Canadians should have unrestricted access to accurate information about abortion services. It would also be beneficial if employers ensured that all clinic, hospital and medical office employees clearly understand and accept that they have no right to deliberately deny women information or services that are covered by the Canada Health Act. In order to ensure that employees comply entirely with the above-mentioned idea, healthcare facilities could enforce a zero tolerance policy that requires employees to follow the mandate as a condition of employment. Barrier: Conscience Clauses Abortion is one of the very few medical procedures that has a conscience clause attached to it that allows healthcare professionals to opt out of offering abortion services due to their personal belief system. As confirmed by several affiliates of the Canadian Federation for Sexual Health, anti-choice doctors are one of the biggest barriers that women face when trying to access abortion services. Countless women and countless organizations have told their stories of how they were unable to access timely abortion care due to the anti-choice beliefs of their doctors. In many parts of Canada, a woman is required to obtain a referral from a doctor before having an abortion. In New Brunswick, women must get the approval of two doctors before being able to access the procedure. If a doctor is anti-choice, a woman’s path to accessing safe and timely abortion care is often blocked. While some parts of the country have hospitals and clinics where a woman may self-refer herself in order to access an abortion, there are some areas of Canada where there are no public or private clinics and no hospitals that will offer an abortion on a selfreferral basis. In these parts of Canada, there are no alternatives for women who cannot obtain a doctor’s referral for a hospital procedure. Since doctors play such a huge role in guaranteeing a woman’s right to choose to have an abortion when pregnant, it is critical that some form of regulation prevent anti-choice doctors from denying healthcare to patients. One way that the Canadian Medical Association could help women to overcome the barrier of anti-choice doctors is to, in co-operation with the Society of Obstetricians and Gynaecologists of Canada (SOGC) and Colleges of Physicians and Surgeons, regulate their members with respect to the unbiased treatment of women requesting medical care related to abortion services. Also, if professional organizations stopped defending doctors who practice in clear violation of the medical code of ethics, anti-choice healthcare practitioners would be required to admit that they are providing biased healthcare to pregnant women. Finally, in order to abolish the barrier that anti-choice doctors present, all women need to be allowed to refer themselves for an abortion. Barrier: Bad Referrals Whether due to a lack of knowledge or to deliberate deception, our study found many instances of bad referrals acting as a major barrier for women who are trying to access information about abortion services in Canada. There are many types of bad referrals. Some bad referrals are made by healthcare professionals who are unaware of where to refer women who need to access abortion services. In this case, 44 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice healthcare providers may give a pregnant woman the name and number of either a facility that in actuality does not provide references or abortion services, give her the contact information for an anti-choice organization whom they really believe to be supportive of women’s rights, or give her the contact information for a facility or person who has nothing to do with reproductive healthcare at all. While these useless referrals are often not given as a deliberate attempt to prevent a woman from accessing abortion services, this is nevertheless the outcome. When a woman does not know how to access abortion services on her own, she may call her local hospital. If the hospital offers her the contact information for a facility that does not deal with pregnancy terminations, the pregnant woman is faced with an impasse. In many women’s eyes, if a hospital is unable to help her with a medical need, there is nowhere else for her to turn to. For this reason, it is imperative that all healthcare providers know where to access information about abortion services in Canada. Another type of bad referral, often with much worse consequences than those given due to inaccurate information, are those given as deliberate attempts to block a woman’s access to abortion services. Whether from an anti-choice doctor or a judgmental gatekeeper, deliberately bad referrals can lead women to anti-choice organizations, facilities that are not healthcare providers and to contacts who do not even exist. Barrier: Voicemail Although in mainstream society voicemail is a welcome alternative to hearing the busy signal during a phone call, when it comes to women who are seeking abortion services, a mechanical voicemail messaging system is often the last thing they want to hear. While rare in most provinces, our research has found that hospitals having voicemail systems set up to take the calls of women regarding abortion services is a common practice in Ontario and in some parts of Québec. Hospital voicemail systems that take the calls of women who are seeking abortion services work by asking the woman who calls them to leave her name and phone number as a recording. The idea is that someone at the hospital will call the woman back with all of the information that she may need. However, this method of referral has many flaws. A woman may not be able to leave her name and number on a voicemail system for many reasons. Some women do not have phones. Other women live in a place where they do not want the other members of their household to know that they are pregnant or that they are considering an abortion. Some women live in abusive situations and cannot receive personal calls. All of these women are in situations where leaving a voicemail message is neither an appealing, nor a possible option. In other situations, a woman may not be comfortable leaving a message. For one, voicemail poses the problem of a lack of confidentiality. Some women have expressed discomfort in having to leave their personal information on a machine without knowing exactly who will be listening to it. Also, having to explain an intimate situation such as an unwanted pregnancy can be difficult to do when talking to a real person, and is rendered even more difficult when one is talking to an unsympathetic machine. Having to leave a voicemail message can be so daunting to some women that they choose to try to access services somewhere else, rather than leave a detailed message with the hope of a returned call from an understanding person. If a woman feels this way and decides to call somewhere else, there is a greater possibility of her accidentally REALITY CHECK – a close look at accessing abortion services in canadian hospitals 45 Canadians for Choice calling an anti-choice organization that rather than helping her, will try to dissuade her from following through with her decision to have an abortion. Women should be able to access abortion services without going through a voicemail messaging system. This means that staff members at all hospitals should be aware of the possible sensitivities of women inquiring about abortion services and be able to provide accurate and relevant information. Whether by providing a referral to another centre or by helping a woman schedule an appointment for her abortion, healthcare providers that answer the phone in place of a voicemail messaging system can have a huge effect on improving women’s access to medically necessary reproductive services. Barrier: Anti-choice Organizations One of the most dangerous and persuasive barriers that a woman may encounter when trying to access abortion services are certain anti-choice organizations. Many anti-choice organizations refer to themselves as “crisis pregnancy centres” and often purposely discourage, misinform and coerce women into not exercising their right to an abortion. From the few bad referrals by hospitals that led our researcher to anti-choice organizations, it was discovered that some groups are still telling women myths about the abortion process and about the after effects of having an abortion that have been proven to be completely false. Inventions such as there being a link between breast cancer and abortion, the medically unrecognized “post-abortion stress syndrome” and the false idea that a woman who has an abortion will be unable to bear children in the future are myths that are told as truths by some anti-choice groups. To a naïve woman who is unaware of the anti-choice organization’s lack of objectivity and facts regarding abortion, these myths may be believable and may leave a woman in the position of having her reproductive choices limited and her health negatively affected. A woman facing an unwanted pregnancy and considering an abortion should be able to access unbiased and medically accurate information. For this reason, all clinics, hospitals and doctors offices should be informed about the potential negative affects that some anti-choice organizations may have on women. Also, all healthcare professionals should be able to access accurate information about which organizations are accepting and supportive of sexual and reproductive health and rights. 46 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice FOR BETTER OR FOR WORSE? Three Years Later Since the CARAL report of 2003, there have been many changes in the accessibility of abortion services in Canadian hospitals. Overall, the access rate of abortion services in Canadian hospitals has declined from 17.8% to only 15.9% in just three years. This means that only one in every six Canadian hospitals offers accessible abortion services. An unfortunate and unchanging trend that many women still face is the fight that they must put up in order to access accurate information about reproductive medical services. Many Canadian doctors and healthcare providers refuse to provide women with information pertaining to their sexual and reproductive health and rights. Also, as seen throughout the report, there are still many barriers that keep women from being able to access abortion services from the small pool of providing hospitals. While some barriers, such as cost and travel issues have always been a problem for women seeking abortion services, there are also new barriers, such as having to leave a voicemail message in order to get information, that have only recently emerged. However, as serious as the fight for reproductive freedom in Canada still is and as daunting as these changes sound, Canada has certainly made some definite improvements in its provision of abortion services. Fewer healthcare professionals gave our researcher bad referrals and in some areas of Canada, accurate information pertaining to the availability of abortion services seems to be more accessible to questioning women. Anti-choice organizations are more often being recognized as being potentially detrimental to the health of women and fewer of them are being promoted by healthcare professionals. Several provinces have addressed the issue of reciprocal billing and Nunavut went from having no abortion services, to having a dedicated provider in the field of sexual and reproductive health. As of July 2005, all abortions performed both in and out of the hospital setting in Manitoba are funded by the provincial government. Also, in August 2006, the Québec government set a precedent that will both encourage policymakers to change the Québec law to allow for the provincial funding of abortions performed in clinics, and will encourage more women to form class action suits to lobby for reimbursement of the fees that they pay for abortions. These positive changes in the trends of reproductive healthcare are the direct result of the continuous work and dedication of abortion providers, pro-choice organizations and the general population of Canada. It is through the advocacy of sexual and reproductive health issues that abortion services remain protected and legal. It is through the dedication of abortion providers that the abortion procedure remains safe and available. As a result of the courageous battles that have been led against anti-choice propaganda, more Canadian women and men are being educated with the truth about abortion and about their sexual health in general. Canadians for Choice therefore thanks and applauds all healthcare professionals, advocacy groups, financial donors and individuals who, through their continuous support, are ensuring that the sexual and reproductive rights of Canadians remain legal, safe and accessible. REALITY CHECK – a close look at accessing abortion services in canadian hospitals 47 Canadians for Choice As Experienced in Canada… The following anecdotes highlight some of the negative experiences that Canadian women have had while trying to access abortion services in Canada within the past few years. The experiences have been collected from a number of sources. Some have been relayed to Canadians for Choice from social workers and public sexual health organizations. Some are from women who have sent their stories to us, hoping to prevent similar occurrences from happening to other women. Others have been written by our researcher and reflect the experiences that she had when contacting Canadian hospitals as a pregnant woman in need of an abortion. The experiences described in this section represent only a small fraction of the many negative responses that Canadian women in search of abortion services encounter every year. All of the described experiences reflect true occurrences. A young woman of thirteen went to her doctor and told him that she thought she was pregnant. The doctor did a pregnancy test and confirmed that she was. When she asked him how far along she was her doctor lied to her and told her she was many more weeks pregnant than she actually was. Not knowing how to calculate how long she had been pregnant and dismayed at not having any options since she was so far along, she went home. A few weeks later, she went to the hospital to have an ultrasound done and found out that she was not nearly as far along in her pregnancy as her doctor had told her she was. She tried to arrange for an abortion but was told that although she would have been able to have one when she originally asked about her pregnancy options, she was now too far along to have one done in her area of residence. As a result of her doctor’s lie, she had to travel to another province to have an abortion. Had her family doctor truthfully informed her of how far along in her pregnancy she was she would have been able to access an abortion free-of-charge in her hometown. Instead, she was forced to find enough money to pay for her travel and accommodations while she accessed an abortion in a neighbouring province. A woman went to her family doctor knowing that she was pregnant and looking to get a referral for an abortion. After she told her doctor of her decision to terminate the unplanned pregnancy, her doctor had her lay on the examining table and placed a stethoscope to her belly. He then pretended to listen to the heartbeat of her “unborn child” and in rhythm with the beat he said, “I love you mommy… I love you mommy…” I had called a hospital in my area to arrange for an abortion. The woman who answered the phone told me that they did not provide abortion services anywhere in the area but that I should try calling an organization in another town to get some medical advice. When I called the number that she gave me and explained my situation, the woman on the other end of the line told me that I didn’t need to arrange for an abortion right away. She told me that almost all young women who get pregnant end up having a miscarriage anyway and that I had lots of time to wait a few weeks and see if my body would reject the pregnancy naturally. She told me to call her back if I was still pregnant in a few weeks. I called back in a few weeks, just like she had asked me to. When I explained to her that I had not had a miscarriage and that I still wanted to terminate the pregnancy, she told me that it was too late. No one would 48 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice perform an abortion on me now, I was too far along in my pregnancy. Later, after looking into the likelihood of women having miscarriages I realised that not very many women did have miscarriages after 10 weeks gestation. I had been tricked into carrying my pregnancy to term. A woman went to her doctor to obtain a referral for an abortion. The doctor refused to give her a referral and refused to provide her with any information about how to obtain one. She left her doctor’s office with heavy feelings of guilt and uncertainty. Why was her doctor refusing to make a referral for her to access a simple medical procedure? Feeling ashamed and confused, she had to call several other doctors before finding one that would help her arrange for an abortion. Even after finding a helpful and caring doctor, she could not get out of her mind the way in which her primary doctor had treated her. She continued to feel disrespected and confused about why her initial request for help had been denied. I called a local hospital for information regarding abortion services in the area. When an attendant answered the phone I told her that I had just found out that I was pregnant and was considering an abortion. I asked her if they offered abortion services at the hospital. Instead of replying, the woman who I was talking to laughed at me and hung-up the phone. I was shocked, but gave the hospital the benefit of the doubt and tried calling again. This time when the attendant answered I said, "I'm sorry, we must have been disconnected. I just called asking about abortion services?” This time, the hospital staff member sighed, clicked her tongue in disapproval and told me that she would put me on hold. I waited on hold for ten minutes before getting disconnected. By this point I was very frustrated and upset. I was hurt that I had been treated so disrespectfully but still needed to know if abortion services were offered in the area. Since the hospital that I was calling is located in a fairly isolated town, it can be difficult to access services outside of the municipality. I decided to try calling the hospital once more, but this time I called their alternate number. The person who answered the phone was not the same person who had answered the first time, but I knew that I had reached the hospital because she answered the phone, "Hospital switchboard, how may I direct your call?" I recognized the voice of the first woman that I had talked to in the background. In fear of receiving the same reaction that I had encountered on my previous calls, I did not repeat my story. Instead, I simply asked if the attendant had the number for a walk-in clinic from which I might be able to get a doctor's referral. I didn't even mention the word "abortion", I simply asked for the contact info for a local walk-in clinic. It sounded like someone put their hand over the phone. The woman paused and although I couldn't make out what she was saying, I could tell that she was talking to someone in the background. After a brief moment she came back to the phone, said, "I'm sorry, we're a lumbar company.” and hung up. I couldn't believe it. Did she think that I hadn't heard her answer the phone advertising herself as being the hospital switchboard? Instead of transferring me to another department or giving me another number to call or even telling me that she didn’t know where to refer me, she lied to me. I had called the hospital hoping to find out information about a healthcare service and had been both denied information and disrespected. Being isolated in a small town without a referral or another hospital to turn to, what was I to do? REALITY CHECK – a close look at accessing abortion services in canadian hospitals 49 Canadians for Choice A social worker wrote to Canadians for Choice describing some of her experiences working with women in crisis situations. She described one situation she encountered as follows: I worked with one woman who left an abusive relationship and was living in a transition house with her two children from a previous marriage. While she was staying in the transition house she found out that she was pregnant with her abuser’s child. She had already suffered several miscarriages at his hand and was unwilling to put herself in danger again should he discover that she was pregnant. (A likely scenario in a small community like ours.) She had just gathered up the courage to leave him and did not want him to be involved in her life anymore. She went to her family doctor (a woman) who was aware of her history. She asked for a referral for an abortion and was refused. Her doctor’s recommendation was that she either go back to her first husband for shelter and support or that she pick up her two children, leave her family and the community where she had lived her whole life and move to another town. The woman was made to feel like she would be a horrible, unfit mother were she to abort her third child. She is now living in poverty and fear with her three children. A counsellor at a Canadian Federation for Sexual Health affiliate centre spoke to Canadians for Choice about the many women with whom she had worked with who had an awful time trying to access abortion services in their area. One of the experiences that she recounted involved a woman who worked in a factory from Monday to Friday from 8am to 4pm. During these hours, she had no access to a private telephone. When she found out that she was pregnant and tried to call the hospital (that provides abortion services for women who are up to fourteen weeks pregnant) to arrange for an abortion, she discovered that the abortion clinic in the hospital was only open Monday to Friday, 8am to 4pm. These were the same hours that she worked at the factory and even on her lunch break, she was unable to get to a private phone to make an appointment at the hospital. Since the hospital would not accommodate her schedule and insisted that she come in during working hours, the woman was required to go out of town to obtain an abortion; even though she was only eight weeks pregnant. A new resident to Canada, a young woman discovered that she was pregnant and began looking for abortion services. When she called the providing hospital in her area, she could not make her appointment because the person at the booking department could not understand what she was saying. English was her second language and the hospital where she went has a translation policy that allows speakers of other languages to have access to professional translators. However, rather than transfer her to someone who might understand her better or arrange for her to have a translator, the woman was forced to find her own interpreter to accompany her to the hospital in order to obtain access to abortion services. When she brought in her interpreter to arrange for her appointment, the hospital refused to book her for an abortion because her interpreter was not from the hospital staff. At the hospital in her area that provides abortion services, a woman attempted to arrange to have an abortion. As is the policy of many hospitals, she was told that she would first have to have an ultrasound done before booking an appointment so that the hospital staff would know exactly how far along in her pregnancy she was. She had an ultrasound and waited for 50 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice the results. Instead of analyzing the ultrasound immediately, the hospital delayed telling the woman how far along in her pregnancy she was for a lengthy period of time. By the time the results of her ultrasound were ready and she was able to make an appointment, she discovered that her pregnancy was past the hospitals set gestational limit. As a result, she was required to take time off work and travel out of town to obtain her abortion. Had she received the results in a timely manner, there would have been plenty of time for her to arrange for an abortion in her area of residence. One northern Ontario doctor described to our researcher what she would have to do in order to obtain an abortion. The doctor explained that women from the small, northern town must travel out of the area at least twice before having the procedure done, and again after the procedure is completed for necessary follow-up. For the second trip out of town, she must travel over 1400 km to get to the city where northern doctors make their referrals for abortions. This would be a trip that involves over 14 hours of travelling, without taking into account stopovers and schedule conflicts. A woman living in this small town must first fly into another small community and then either fly or take the train further south until there are roads. From there she could drive, bus, fly or take the train; but all of these options are expensive. The really scary part about this example of what a woman must go through in order to access a simple medical service, is that the small town from where the doctor is from is not even close to being one of the most northerly towns in Ontario. A young woman who was a recent immigrant found out she was pregnant not long after having moved to Canada. She did not have any identification and was not yet eligible for healthcare services. She needed a registered photo identification card to get healthcare insurance and she needed old photo ID in order to get a new, Canadian registered card. Since she had no ID at all, she was denied access to free abortion services even though she was a resident of the province. Without healthcare insurance, she was required to find a clinic that would perform an abortion for her for cash. She finally found a place that would do the procedure for $700. After much deliberation, she decided that she was able to afford the cost of the procedure. However, when she went to have the procedure done she was asked to show the photo ID that she did not have. She was stuck. Finally, after seeking help from several organizations, she was referred to an agency that deals specifically with immigrant women. The organization was able to advocate on her behalf and to help the woman to overcome the barriers of not having proper identification and of having to pay for a medical service that, as a provincial resident, is supposed to be free. By the time she was able to have an abortion, she was much further along in her pregnancy and the procedure was much more complicated than it would have been had she been able to access a timely abortion when she first requested the service. REALITY CHECK – a close look at accessing abortion services in canadian hospitals 51 Canadians for Choice 52 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice REFERENCES Abortion Rights Coalition of Canada. Backgrounder: Abortion Access Issues. Vancouver: Abortion Rights Coalition of Canada (2006) http://www.arcc-cdac.ca/backgrounders/access.htm> Accessed: July 24, 2006 Access to Abortion Services Act, R.S.B.C. 1996. Victoria: Queen’s Printer (2005) http://www.qp.gov.bc.ca/statreg/stat/A/96001_01.htm Accessed: July 23, 2006 Canada Revenue Agency. Guidelines for Registering a Charity. Reference CPS-024. Version updated March 10th, 2006. Ottawa: Canada Revenue Agency. (2006) http://www.cra-arc.gc.ca/tax/charities/policy/cps/cps-024-e.html Accessed: August 24, 2006 Canadian Abortion Rights Action League. Protecting Abortion Rights in Canada. Ottawa: Canadian Abortion Rights Action League (2003) Childbirth by Choice Trust. Abortion in Canada Today: The Situation Province-by-Province. Toronto: Childbirth by Choice Trust (2006) Collège des Médecins du Québec. Ordonnance Collective: Procédure d’évaluation pour une demande d’interruption volontaire de grossesse (IVG). Révisé le Janvier 2006. Montréal: Collège des Médecins du Québec (2004). Cour Supérieure. Association pour l’Accés à l’Avortement c. Procurer Général de Québec. N0: 500-06-00158-028. Montréal: Trudel & Johnston. (2006) http://www.trudeljohnston.com/en/avortement/jugement_170806.pdf Accessed: August 21st, 2006 Edminston-Lange, Rebecca. Perspectives: Unitarian Universalist. Washington: Religious Coalition for Reproductive Choice. http://www.rcrc.org/perspectives/unitarian.cfm Accessed: August 10th, 2006. Fédération du Québec pour le planning des naissances. Bottin des ressources en avortement. Montréal: Fédération du Québec pour le planning des naissances. (2006) Health and Wellness. Government of Alberta (2005) http://www.health.gov.ab.ca/public/in_primary.html Accessed: July 25, 2006 Health Canada. The Canada Health Act: An Overview. Version updated November 28th, 2002. http://www.hc-sc.gc.ca/ahc-asc/media/nr-cp/2002/2002_care-soinsbk4_e.html Accessed: August 15th, 2006 Health Canada. The Canada Health Act: Administration and Compliance. Version updated April 27, 2006. http://www.hc-sc.gc.ca/hcs-sss/medi-assur/administration/index_e.html Accessed: August 15th, 2006 REALITY CHECK – a close look at accessing abortion services in canadian hospitals 53 Canadians for Choice Koyama & Williams. Abortion in Medical School Curricula. McGill Journal of Medicine. Vol. 8 No. 2. 157-160. Montréal: McGill Journal of Medicine. (2005) MapQuest, Inc. MapQuest. http://www.mapquest.com (2006) Reissman, Catherine. “Women and Medicalization: A New Perspective”. In Rose Weitz, ed. The Politics of Women's Bodies: Sexuality, Appearance and Behavior. New York: Oxford University Press (1998) Statistics Canada. Population by sex and age group, by province and territory 2005. Version updated May 29, 2006. Ottawa: Statistics Canada. (2006) http://www40.statcan.ca/l01/cst01/demo31a.htm Accessed: July 24, 2006 Yeh, Shie-Mee (Ed.) 2006 Canadian Almanac and Directory. (159th ed.) Toronto: ProQuest Information and Learning Company (2005) 54 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice APPENDIX A *NOTE: All French hospitals/organizations were corresponded with in French. CFC Hospital Access Project Questionnaire Hospital: Phone Number: Contact Name/Title: Notes/Comments: Does your hospital provide elective abortions? q YES q NO Does the hospital have a written policy on the provision of abortion services? q YES q NO If yes, please attach a copy of your policy and state how the policy was determined. (i.e. hospital board or other body.) If your hospital does not provide abortion services, does it provide referrals to other centres? q YES q NO If yes, which one(s)? If your hospital does provide abortion services, please describe these services by answering the following questions. After what stage of gestation (in number of weeks) will the hospital refuse to provide an abortion? Does a woman need to be referred by a physician in order to obtain an abortion? q YES q NO OR can she call and make her own appointment? REALITY CHECK – a close look at accessing abortion services in canadian hospitals 55 Canadians for Choice q YES q NO Can the hospital provide an abortion within 24 hours of intake? q YES q NO If not, what is the average waiting period for the procedure? Does your hospital provide abortion-counselling services? q YES q NO Are clients from outside of the province allowed to obtain abortion services free of charge? q YES q NO If not, what are the charges for the procedure? Does that hospital offer translation services? q YES q NO If yes, what languages are offered? If no, where does it refer people for service in other languages? 56 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice APPENDIX B *NOTE: All French hospitals/organizations were corresponded with in French. CFC Hospital Access Project Questionnaire Planned Parenthood: Address: Phone Number: Executive Director: Notes/Comments: Does your Planned Parenthood service primarily a rural or urban area? (If you service both a rural and urban area, please check both.) q Rural q Urban Does your office record the number of calls that you receive about abortion? q YES q NO If yes, on average, how many calls does your office receive about abortion services per month? What percentage of your total calls are about abortion services? How many doctors provide abortions in your area? Where do you refer women for abortion services in your area? (For each please include to what gestation period they will perform the abortion procedure.) Name Gestation Period REALITY CHECK – a close look at accessing abortion services in canadian hospitals 57 Canadians for Choice Are there any abortion providers in your area where you prefer not to refer women? q YES q NO If yes, which providers are these and why do you prefer not to refer them? If any hospitals in your area provide abortion services, what is your agency’s relationship with those hospitals? In your area, can a woman call and make her own appointment for an abortion? q YES q NO OR. Does she need to be referred by a physician? q YES q NO What are some of the barriers that women in your area face around obtaining abortions? Does your Planned Parenthood provide abortion-counselling services? q YES q NO In order to be able to write a report that has an emotional impact on its readers, we encourage women who have had abortions to come forward and share their stories. Please share any stories that you have heard from women in your area who have encountered problems accessing abortion services. (Please use more paper if necessary.) 58 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice APPENDIX C *NOTE: All French hospitals/organizations were corresponded with in French. Canadians for Choice Abortion Access Questionnaire for Canadian Hospitals Hospital: Phone Number: Address: Website: http://www. You are calling to inquire about abortion services. You are about 10 weeks pregnant. If they ask you about the date of your last menstrual period (LMP) take the date you are calling on and count backwards 10 weeks. (Ex. If today is June 15th, your LMP would be April 7th.) Information that you may divulge over the phone includes: • 10 weeks pregnant • just independently moved to the area for temporary residence (from outside province) • no family or friends nearby • no family doctor • 20 years old • have healthcare (but its from a different province) • name (when asked) is Sarah Jones Today’s Date: LMP: Script Call the main hospital number. Talk to the first person that answers the phone. Say, “Hello, I am pregnant and am considering an abortion. Do you provide abortions at your hospital?” q YES q NO Comments: (reaction when asked about services) q Reception didn’t know REALITY CHECK – a close look at accessing abortion services in canadian hospitals 59 Canadians for Choice If YES, record the process that you must follow in order to get referred to a physician for scheduling. (Circle if: you needed to ask for the info OR if info is offered to you.) Ask what the average wait time is for an abortion. If NO, did they offer referrals without being asked? (If they do not, ask for referrals.) q YES q NO List of referrals offered: (Name, number and details?) When contacted, was this referral useful? q YES q NO Comments: END OF PHONE CALL Overall, the person on the phone from the hospital was: q Helpful, understanding q Rushed, impatient, abrupt q Rude, unpleasant q Indifferent q Knowledgeable q Needed to be pushed for information q Unsure, willing to check q Unsure, unwilling to check Number of calls needed to get info: Number of people spoken to: 60 REALITY CHECK – a close look at accessing abortion services in canadian hospitals Canadians for Choice Notes Additional comments: REALITY CHECK – a close look at accessing abortion services in canadian hospitals 61 CANADIAN HOSPITALS WITH ACCESSIBLE ABORTION SERVICES Canadians for Choice 62 REALITY CHECK – a close look at accessing abortion services in canadian hospitals 2 2 6 Ontario A Publication Of: Manitoba Nunavut Canadians for Choice Suite 300, 260 Dalhousie St. Ottawa, Ontario CANADA K1N 7E4 3 Yukon No part of this publication may be used for commercial or resale purposes. 2 This publication may be reproduced in whole or in part for educational or non-profit purposes without special permission from the copyright holder, provided that proper acknowledgement of the source is made. Canadians for Choice would appreciate a copy of any document that uses this publication as a source. British Columbia Copyright © 2006 Canadians for Choice Alberta Northwest Territories Saskatchewan Tel: +1 (613) 789-9958 Toll free: 1-888-642-2725 Fax: +1 (613) 789-9960 Email: info@canadiansforchoice.ca Website: www.canadiansforchoice.ca To obtain copies of this report please contact Canadians for Choice at: info@canadiansforchoice.ca New Brunswick 6 2 Nova Scotia Prince Edward Island Quebec Canadians for Choice is a pro-choice, non-profit charitable organization dedicated to ensuring reproductive choice for all Canadians. At Canadians for Choice, we envisage a world where individuals – regardless of age, ability, race, gender, sexual orientation, place of residence, or socio-economic and other status – have access to the information, resources and services required to make and exercise informed choices on all aspects of their sexual and reproductive health and rights. For this reason, we work to ensure that the general public, policy-makers and health and education practitioners are well educated and informed about all aspects of sexual and reproductive health and rights. We also aim to enhance the quality and comprehensiveness of research and information on current and emerging sexual and reproductive health issues. 2 After abortion became decriminalized in Canada, the well-known Canadian Abortion Rights Action League (CARAL) reviewed its mission statement and concluded that their goal of having abortion services be legally available to all Canadian women had been accomplished. Having recognized this, some CARAL staff, board members and sexual and reproductive health advocates in the community collectively decided that a new organization, with new goals still related to sexual and reproductive health and rights, ought to be created. Out of this vision was Canadians for Choice founded. Labrador / Newfoundland About Us Location of Canadian Hospitals with Accessible Abortion Services. CMYK CMYK REALITY C H E C K a close look at accessing abortion services in canadian hospitals Jessica Shaw Canadians for Choice 300-260 Dalhousie Street Ottawa, Ontario K1N 7E4 tel: 613.789.9958 fax: 613.789.9960 toll free: 1.888.642.2725 www.canadiansforchoice.ca Canadians for Choice