Abortion services in Canada: a patchwork quilt with many holes
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* Laura Eggertson

In Prince Edward Island, women have nowhere to go to terminate an unwanted pregnancy. In Newfoundland, a woman from an outport on the other side of the island must drive up to 12 hours to have an abortion in St. John's. In New Brunswick, she has to get approval from 2 doctors before she can get a publicly funded abortion in a hospital — unless she can afford the $400 to $700 charged for an abortion in the province's single clinic in Fredericton. In Saskatchewan, she must make her way to 1 of only 2 hospitals that will perform the procedure. And in Nova Scotia, Dr. Christina Toplack of Planned Parenthood says she often has to counsel pregnant teenagers from rural parts of the province who have no money, are afraid to go to their parents and are worried that their family doctor will not support their decision.

More than 13 years after the law criminalizing abortion in Canada was struck down and despite its status as a medically necessary service, access to abortion is becoming more and more restricted across the country. “Ironically, it seems to be getting worse rather than better since the Morgentaler decision in 1988,” says Marilyn Wilson, executive director of the Canadian Abortion Rights Action League in Ottawa. “There are a number of barriers and the [number is increasing].”

On Jan. 28, 1988, the Supreme Court struck down the Criminal Code section that made it a criminal activity to perform an abortion, a section that had been used repeatedly to charge Dr. Henry Morgentaler. Three years later, a bill passed in the House of Commons to recriminalize abortion but was defeated in the Senate. Since then, there has been no federal abortion law and no legal restrictions against the procedure.

In theory, this means that a woman can legally obtain an abortion anywhere, but the continued lobbying by churches, antiabortion groups and some political parties, as well as the actions of extremists to create a climate of fear for abortion providers, means that obtaining an abortion has become increasingly difficult. The availability of abortions in Canada now depends on a woman's location and the size of her pocketbook.

“There are huge discrepancies in the availability of reproductive services, including abortion, from province to province and, of course, within provinces,” says Martha Jackman, a constitutional law professor at the University of Ottawa. “I can't think of another medically necessary service that is so inaccessible.”

In large cities such as Toronto and Vancouver, women can go to either a clinic or one of several hospitals that perform the procedure, and both Ontario and British Columbia health insurance plans cover the entire cost. But the situation is vastly different elsewhere (see table).

View this table:
[Table1](http://www.cmaj.ca/content/164/6/847/T1)

Table 1. 

And abortion is once again a political hot potato in Ottawa because of the refusal of several provincial health insurance programs to pay for abortions unless they are performed in a hospital — even if no hospital in the province will perform them. Health Minister Allan Rock is currently embroiled in what his department politely terms “negotiations” with New Brunswick, PEI, Quebec and Manitoba, provinces that do not currently cover the full cost of abortions performed in freestanding clinics. Rock has threatened to enforce the Canada Health Act by withholding some transfer payments unless abortion is treated like any other medically insured service, regardless of where it is performed. Departmental spokesperson Steve Jeffery acknowledges that Health Canada is concerned about coverage in certain provinces. “If a medically necessary hospital service is insured when covered in a hospital, it also has to be insured in any setting, including a private clinic,” he says.

Ottawa already withholds a portion of its transfer payments to Nova Scotia because it refuses to pay facility fees charged by a private clinic in Halifax, but so far the fine is only about $50 000 a year. In 1995, then Health Minister Diane Marleau informed all the provinces that they were required to pay for a service she termed medically necessary, and she withheld transfer payments from Alberta until it agreed to pay the full cost of an abortion regardless of where it was performed. The province has recently agreed to drop the quotas it had imposed on the number of abortions it would pay for at clinics in Calgary and Edmonton.

Thus far, however, the “bilateral discussions” between Rock and the recalcitrant provinces have not resulted in any policy changes.

The lack of change translates into obstacles for women that range from concerns over confidentiality to inability to pay travel costs and the difficulty they may have in obtaining information about the service. All of these barriers are multiplied for women living in rural communities. “If you have no way of getting into the city, if confidentiality is a problem — a lot of kids [in rural areas] just end up having babies,” says Toplack, of Planned Parenthood in Halifax. “The young people may not want to disclose. Family physicians may not be supportive. Doctors you can refer to may be pretty limited. Say she's in a part of the province where she can't really find anybody or doesn't have a car, that can be a big problem.”

As well, administrators and physicians at Planned Parenthood chapters across Canada say women who want to terminate a pregnancy sometimes meet resistance from their family doctors. “A lot of women have doctors here who are not pro-choice, and often they don't find that out until they're pregnant, because it's not something you think about or talk about until you are pregnant,” says Judy Burwell, director of the Morgentaler clinic in Fredericton.

In New Brunswick, women who come to the Morgentaler clinic in Fredericton have to pay the full cost of the abortion, both doctors' fees and facility charges. An abortion costs $475 if a woman is under 12 weeks pregnant, $575 if she is at 12 to 14 weeks and $725 if she has been pregnant for 14 to 16 weeks. After 16 weeks the Fredericton clinic won't perform the procedure, meaning a woman has to go to Montreal or Toronto, where clinics will perform abortions at up to 20 weeks' gestation. But if a woman has an abortion at 1 of the 3 hospitals in the province that will perform them, medicare covers the entire cost. “The big problem for women here is access,” says Fredericton's Burwell. One doctor who performs abortions in New Brunswick — she asked that her name not be used for safety reasons — says that even doctors and hospitals that indicate they perform abortions can be difficult to access.

Many doctors refuse to provide abortions or to publicize the fact that they do for fear of reprisals — since 1994, 3 Canadian physicians who performed abortions have been shot and seriously wounded by an unknown assailant or assailants. “It takes a lot of courage, really, to say ‘I’m going to be an abortion provider' these days,” says Morgentaler, whose Toronto clinic was bombed in 1992. “Doctors who have children don't want to expose them to the dangers.”

One physician who isn't afraid to go public with what he does is Dr. Ted Busheikin, part owner of Calgary's Kensington Clinic. But he points out that by the time he left private practice to become an abortion provider, his children were grown. “Doctors are scared. If they're young and have a family, they're frightened for their own safety and their children.”

At 66, Busheikin says he doesn't care what people think about what he does. But he is worried that his retirement may leave women in Calgary with even fewer choices. “This is a problem throughout North America,” he says. “The providers are getting older and older and the younger people are not coming on board.”

One reason is the lack of training provided at medical schools. Although both Busheikin and Morgentaler offer their clinics as training centres for doctors interested in learning the procedure, Busheikin is seldom asked to teach. He attributes the lack of training at many schools to the difficult pro-choice and antiabortion politics within universities. Morgentaler has trained about 25 doctors at his Toronto clinic. Most are women, and many have gone on to work at his other clinics across the country.

Antiabortion lobby groups like Campaign Life would prefer that no abortion providers were trained. Mary Ellen Douglas, its national organizer, says Canadians have “killed almost 2.5 million babies” since abortion was decriminalized. She does not believe women have any difficulty in arranging abortions. “Certainly abortions are available — too available,” she says. Campaign Life opposes any attempt by the federal government to persuade provinces to cover the full cost of abortions. “This is a lifestyle choice, and we should not be funding lifestyle choices,” says Douglas, who equates abortions to “cosmetic surgery,” which is “not covered.” 

But for constitutional law experts like Jackman, Canada's abortion debate is not about the age-old question of when conception occurs and whether a fetus is a person — something the Supreme Court has repeatedly ruled it is not. The issue, she says, is one of equality. Section 15 of the Charter of Rights and Freedoms guarantees women equal benefit of the law in Canada, and if some provinces won't cover the cost of abortions, they are denying women that right. “There's no question that women don't enjoy full and equal access to reproductive services, including abortion services. It's sex discrimination.”

Although she believes that a strong charter case exists for any woman who has had trouble getting access to an abortion, “it's completely unimaginable that somebody like that would go all the way to the Supreme Court because her province isn't providing adequate services.” And pro-choice lobby groups have limited funds to finance such a challenge.

Still, says Jackman, the legal analysis is straightforward. “You have a service that is required by women, and because of minority opposition to reproductive choice, you have no access. And that is unconstitutional.” — 

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/164/6/847/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/164/6/847/F1)

Figure. Dr. Henry Morgentaler: “It takes a lot of courage to be an abortion provider these days.” Photo by: Canapress