"I just was really scared, because it's already such an uncertain time": Exploring women's abortion experiences during the COVID-19 pandemic in Canada.

OBJECTIVE: Travel restrictions, physical distancing and quarantine requirements, lockdowns, and stay-at-home orders due to COVID-19 have impacted abortion services across Canada. We aimed to explore the decision-making and care experiences of those who obtained abortion services during the COVID-19 pandemic and understand recent abortion patients' perspectives on demedicalized models of medication abortion service delivery. STUDY
DESIGN: We conducted 23 semi-structured, in-depth interviews with women across Canada who obtained abortion care after March 15, 2020. We audio-recorded and transcribed the telephone/Skype/Zoom interviews and managed our data with ATLAS.ti. We analyzed the English-language interviews for content and themes using inductive and deductive techniques.
RESULTS: The COVID-19 pandemic, and the associated economic and social support uncertainties, factored into many of our participants' decisions to obtain an abortion. Participants expressed relief and gratitude for being able to secure abortion care during the pandemic. Although women in our study reflected positively on their abortion care experiences, many felt that service delivery changes initiated because of the public health emergency exacerbated pre-COVID-19 barriers to care and contributed to feelings of loneliness and isolation. Our participants expressed considerable enthusiasm for demedicalized models of medication abortion care, including telemedicine services and behind-the-counter availability of mifepristone/misoprostol.
CONCLUSIONS: For our participants, abortion care constituted an essential health service. Our findings demonstrate the importance of continuing to provide access to safe, effective, and timely abortion care during public health emergencies. Exploring additional models of demedicalized medication abortion service delivery to address persistent access barriers in Canada is warranted. IMPLICATIONS: Policymakers and clinicians should consider patient experiences as well as clinical evidence when considering regulatory changes to facilitate access to abortion care during public health emergencies. Identifying a multitude of ways to offer a full range of abortion services, including demedicalized models of medication abortion care, has the potential to meet significant needs in the COVID-19 era and beyond. The COVID pandemic highlights the need for demedicalized models, not only for the sake of those seeking abortion care but also to ease the burden on medical professionals during public health emergencies.

Introduction

Since March 2020, the COVID-19 pandemic has both directly and indirectly impacted healthcare systems and service delivery. In many countries, the pandemic has resulted in decreased access to sexual and reproductive health services, in general, and abortion care, in particular [[1], [2], [3]−4]. However, the pandemic has also highlighted existing structural health inequities and accelerated efforts already underway to facilitate the provision of safe and effective medication abortion care [5].

In Canada, the Supreme Court decriminalized abortion in January 1988, and there have been no federal laws prohibiting this service for more than 3 decades [6]. Although much time had passed since decriminalization, in 2016 the United Nations indicated concern regarding disparities in access to abortion care in Canada [7], echoing Canadian researchers and advocates who had long highlighted geographic, provincial policy, and funding barriers to equitable care [[8], [9]−10]. Since then, Canada has made substantial progress in introducing, deregulating, and incorporating medication abortion into the health system [5, 11−13]. In 2017, the mifepristone/misoprostol combination pack became available under the brand name Mifegymiso® [14]. Subsequently, Health Canada updated the product monograph and associated guidance to broaden eligibility to 63 days since the first day of the last menstrual period, expand prescribing authority, permit pharmacist dispensing, and allow individual clinicians to determine the need for an ultrasound [15−16]. As a result of these regulatory changes as well as the coverage of mifepristone/misoprostol by provincial and territorial health insurance schemes, medication abortion became increasingly accessible throughout most of the country [12−13, [17], [18]−19].

At the outset of the COVID-19 pandemic, the Government of Canada reaffirmed abortion care as an essential medical service [20]. Recognizing the urgency, in April 2020 the Society of Obstetricians and Gynecologists of Canada released updated guidelines for offering medication abortion via telemedicine [21]. A number of abortion providing facilities identified ways to streamline services, reduce the number of in-person patient-clinician encounters, and minimize exposure risks [22]. However, temporary closures of clinics due to staffing shortages, local, inter-provincial, and international travel restrictions, and reluctance to travel due to exposure risk have impacted access to clinic-based abortion services, particularly at later gestational ages [6, 22]. In addition, COVID-19 has resulted in interruptions in contraceptive service delivery, economic and financial instability, increases in intimate partner violence, and disruptions in social support systems. These dynamics may also impact unintended pregnancy risk, pregnancy intentions, and abortion decision-making [6, 23].

To date, no studies have rigorously documented the experiences of Canadian abortion seekers during the COVID-19 pandemic. We undertook this qualitative study to explore the decision-making and care experiences of those who obtained abortion services during the COVID-19 pandemic and understand recent abortion patients’ perspectives on demedicalized models of medication abortion service delivery.

Methods

Between October 2020 and April 2021, we conducted semi-structured, in-depth interviews with people who obtained abortion care in Canada during the COVID-19 pandemic. In order to be eligible for the study, prospective participants had to have had at least one abortion after March 15, 2020, have resided in Canada at the time of their abortion, be sufficiently fluent in English or French to answer interview questions, and have access to a telephone, Skype, or audio-Zoom. We welcomed hearing from people who identify across the gender spectrum and recognize that not every person with the capacity for pregnancy identifies as a woman. We offered all participants a CAD40 (USD30) gift card to Amazon.ca as a token of appreciation for their time.

Recruitment

We used a multi-modal recruitment strategy that included posting on online classified sites such as Kijiji and Reddit, posting on social media outlets such as Facebook and Instagram, asking clinics and community organizations to share information about our study on their websites and listservs, and inviting early participants to refer others to the study. In order to use terms that might resonate with likely participants and be inclusive, we used parallel sets of recruitment materials with gendered and gender-inclusive language. AM and JK led the bi-lingual recruitment effort with assistance from EH and guidance from the Study Coordinator, SH, and the Principal Investigator, AMF.

Data collection

After verifying eligibility, addressing queries, and sending informed consent materials, a member of our team scheduled a mutually convenient time for the interview. AMF, an American medical anthropologist and medical doctor, and SH, a Canadian PhD candidate in Population Health, conducted the interviews. All of the interviews took place over the telephone or audio-Zoom and averaged 60 minutes in length. With participants’ permission, we audio-recorded all interviews and later transcribed them. AM, JK, and EH, all Canadian undergraduate students in the sciences or health sciences, or another member of AMF's larger research group, transcribed the interviews. Interviewers took notes throughout the interviews and memoed shortly thereafter, a process that allowed for reflection and early identification of key themes [24]. AM and JK observed a number of interviews, debriefed with AMF or SH after the interview, and independently memoed.

During the interviews, we followed a semi-structured interview guide that we adapted from prior qualitative research with Canadian abortion patients [19, [25], [26]−27]. We began with a series of open-ended questions about the participant's background and general sexual and reproductive health history, including abortion and pregnancy history. We then asked participants details about their pandemic abortion experience(s), including questions related to the specific impact of COVID-19 on abortion decision-making, method choice, and disclosure. We asked participants to provide detailed information about all of their abortions during the pandemic; for those who had obtained an abortion prior to the pandemic, we asked them to compare the different experiences. We then asked participants for their thoughts on how services could be improved, in general, and in the context of COVID-19. We concluded our interviews by asking participants about their thoughts on two different medication abortion service delivery strategies: telemedicine and behind-the-counter provision of mifepristone/misoprostol. For both models of care, we provided participants with a brief description (see Fig. 1 ), asked them to share their initial reactions, gave them an opportunity to ask questions which we responded to, and then probed deeper into what was appealing and not appealing about each service delivery strategy.

Fig. 1

Description of the telemedicine and behind-the-counter medication abortion service delivery models provided to participants.

Data analysis

We began reviewing data as we collected them and held regular team meetings throughout the project as a key part of our analytical process. During these meetings, we identified common themes as they emerged, discussed outliers, and determined when we had reached thematic saturation [28]. We believed that we had reached thematic saturation after 19 interviews and conducted four additional interviews as confirmation. Drawing on interview transcripts, notes, and memos, we conducted content and thematic analyses of the interactions using both a priori (predetermined) codes based on the research questions, interview guide, and existing literature and inductive analysis techniques to identify emerging ideas [29−30]. SH created an initial codebook and served as the principal coder for this study. We used ATLAS.ti version 9.0 to manage our data. AMF reviewed the codebook, a subset of audio recordings, and a selection of the coded transcripts. We resolved rare disagreements through discussion.

Ethical considerations

The University of Ottawa Social Sciences and Humanities Research Ethics Board approved this study. In the results section, we present our key themes and incorporate illustrative quotes and narrative vignettes to support our findings. We have removed or masked all identifying information, used pseudonyms that were either chosen by our participants or assigned by a member of the study team, and used language that conforms with the gender identity of our participants.

Results

Participant characteristics

Over the data collection window, we interviewed 23 participants all of whom were Canadian citizens or permanent residents living in 5 provinces at the time of their abortion(s) (see Fig. 2 ). Our participants ranged in age from 19 to 45 at the time of the interview, with an average age of 27.2 years. All participants identified as “women” and used she/her pronouns. A plurality of our participants identified as white (n = 10); we also had participants who identified as Asian (n = 6), Indigenous (n = 2), Black (n = 1), and bi- or multi-racial or with another racial/ethnic identity (n = 4).

Fig. 2

Map of Canada with study participants’ province of residence (N = 23).

Participants reported using medication abortion with mifepristone/misoprostol (n = 13) or instrumentation procedures (n = 11) to terminate 24 pregnancies after March 15, 2020. All abortions took place within 14 weeks gestation, with the majority in the first 10 weeks. All participants had a successful abortion, although one medication abortion user had a subsequent instrumentation procedure to complete the uterine evacuation process. Participants obtained care from freestanding abortion clinics, hospitals, and primary care clinicians. All participants had at least one in-person encounter with a health service provider as part of the abortion process.

COVID-19 influenced participants’ decision-making

As showcased in Margery's experience (Fig. 3 ) the COVID-19 pandemic influenced, both directly and indirectly, many of our participants’ decisions to have an abortion. Participants repeatedly described the uncertainties associated with the pandemic – uncertainties related to health, finances, employment, and social supports – as factoring into their decision-making. Jennifer, a 22-year-old recent graduate working two jobs who identified as a white Ontarian offered that COVID-19 was a primary concern:

Fig. 3

Margery's story.

I was just in shock, especially with COVID, I just was really scared, because it's already such an uncertain time…it's just not something to be taken lightly. So, I was really shaken up…There was no way I was going to be able to keep a baby. Just partly because, you know, I financially wasn't in a good place, and mentally I just wasn't in the best place. With the circumstances and everything that was going on in the world…I was just by no means ready to go through with [carrying a pregnancy to term].

.

Aisha, a 24-year-old bi-racial (Black-white) woman living in Quebec, explained how COVID-19 factored into her decision-making:

Yes, [COVID-19] did definitely play a role in terms of my fear. How was I going to do this and be a parent? I did entertain the idea for a couple of hours, envisioning that kind of life. For me, I kept thinking of the kind of pregnancy I would want, and the COVID situation was not anything like what I would want to be in.

However, for some, the pandemic either minimally influenced the decision to have an abortion or simply reinforced a decision that the participant felt she would have made in non-pandemic times. As Sonya, a 23-year-old white woman from Ontario who decided to have an abortion because she didn't feel she was emotionally or financially prepared to parent, explained, “I wasn't sure how expensive it would be because of the pandemic…That was pretty much the only thing I was nervous about in regards to COVID.”

Participants expressed relief at and gratitude for being able to access abortion services during the pandemic

Consistent with Arielle's experience (Fig. 4 ) participants in our study expressed a high degree of decisional certainty in that once they chose to have an abortion, they were confident in and committed to that decision. However, because of the pandemic, participants reported that they were anxious about the availability of services and feared that abortion care would be suspended. Sara, a 28-year-old Southeast Asian retail employee from New Brunswick, explained “To find out you're pregnant in a pandemic is not really knowing whether or not all the services you would need would be open at that time.” The reality that abortion services in other countries were deemed non-essential weighed heavily on the minds of several of our participants. As Olivia, a 29-year-old white student working two jobs in Ontario explained:

Fig. 4

Arielle's story.

What if the pandemic restricts that human right to access [abortion]?...Like, there have been conversations in the United States about having [abortion] restricted, and not considered essential and [I was] overjoyed that that was not the case in Canada, but certainly, like, really intensely afraid that it might be restricted.

Despite the commonality of these fears, all of our participants were able to access abortion care during the pandemic and expressed tremendous relief at and gratitude for being able to do so. Selena, a 30-year-old permanent resident and young professional residing in British Columbia said, “I didn't know what to do, I didn't know who to call…In my country [Mexico], it's about doing it silently and clandestinely. And I felt so lucky to be here. I really felt so lucky.” Olivia explained that she was “overjoyed [to be] able to access [abortion care].” Similarly, Rebecca, a white 28-year-old from New Brunswick residing in Ontario, indicated that she was expecting significant challenges but “was very grateful at how easy it was and how accessible.”

Participants reported that COVID-19 protocols exacerbated existing barriers to abortion care

Participants in our study experienced a number of barriers to accessing timely abortion services. These included cumbersome service delivery models that required multiple in-person visits to different providers (Fig. 3), confusion over the cost coverage of medication abortion care (Fig. 4), and discrimination (Fig. 5 ). Aisha, an Anglophone who resides in Quebec, explained, “[The intake nurse] did not speak English so she had to give me an assessment all in French which like, I speak French, but in a high-stress environment I couldn't understand all the medical terminology.” Participants felt that these barriers, which were not caused by COVID-19, were exacerbated by the pandemic and the associated public health measures. Lily, a 23-year-old Asian student living in British Columbia faced a stressful situation as she “was under the 14-day quarantine and I was scared that I would miss the deadline to do the [medication] abortion.”

Fig 5

Amelie's story.

Participants also reported that in-clinic COVID-19 protocols created additional barriers. Most notably, an overwhelming majority of our participants reported that not being able to have a support person join them because of COVID-19 protocols contributed to feelings of loneliness and isolation. Pardis, a 28-year-old professional who identifies as Middle Eastern and lives in Ontario, described her experience obtaining an aspiration abortion:

Basically, there were a bunch of rules I had to follow. I couldn't bring my cellphone. I couldn't…bring somebody and I had to sit in a certain place, a certain seat that was assigned to me, I guess. And there was like no one, it was just very cold. Just a cold atmosphere. Nobody was talking. The whole place was empty so I just had to sit there with my thoughts...like I couldn't use my phone or anything.

Participants repeatedly reported a preference for having a support person with them during clinical encounters, as Olivia's experience illustrates:

[Abortion is] a really intimate and sensitive procedure to have. I would have really benefited from having someone present. In COVID-19 there is no way and I think it's probably typical practices, they wouldn't let me have a support person anyway…I would have really benefited I think from having somebody there. That was very hard.

These feelings of loneliness and isolation were especially pronounced for those participants who had to have multiple in-person encounters, including separate visits for an ultrasound and bloodwork, to obtain their abortion. Participants reported that this was both logistically and emotionally challenging. Courtney, a 25-year-old Indigenous Manitoban struggling with precarious employment, expressed her frustration, “I just wanted the pill and… they put up a lot of roadblocks”.

In contrast, participants who self-administered both medication abortion drugs at home described being highly satisfied with their abortion experience because they experienced the process in a soothing environment, had better access to sources of support, and were able to exercise flexibility with respect to timing and managing other responsibilities. Olivia indicated “I was really lucky to be able to [have the abortion] at home with the support person I wanted.”

Participants expressed openness to both telemedicine and pharmacist dispensing models of medication abortion service delivery

Overall, participants expressed considerable enthusiasm for a telemedicine model of medication abortion service delivery. Participants were especially intrigued by a remote model of care that would allow eligible participants to have an initial consultation with a clinician over the telephone or video conference and then, if eligible, pick up the medication abortion drugs at a local pharmacy. As Sonya stated, “I like the accessibility of it! Talking to somebody over the phone, that would be awesome.” There were several participants, like Arielle (Fig. 4) who found the in-person clinical encounter reassuring and had a difficult time imagining being comfortable with fully remote care. However, both those who obtained medication abortions and those who obtained aspiration abortions during the pandemic felt that a streamlined service delivery model would improve access to abortion care, especially for those in rural areas, those with barriers to transportation, the immunocompromised, and those juggling multiple priorities.

Participants also expressed openness to a hypothetical behind-the-counter model of medication abortion service delivery where a pregnant person could consult directly with a pharmacist to obtain mifepristone/misoprostol. As Olivia explained:

I absolutely think there's a lot of services that don't have to be processed through a physician…it means more access because there are more people that are able to provide the service. And if more people can provide it, not only does it normalize it…secondarily [it] makes it so that you're not waiting in those same appointment lines…a pharmacist would very likely have the lens to be able to help.

Most participants were intrigued by this model and many had questions about how this type of service would be operationalized. Participants noted that for this model to work, pharmacists would need to have sufficient training to ensure that they do not judge or stigmatize abortion seekers and there would need to be a private space for the consultation. For those participants, like Arielle (Fig. 4), who had negative experiences with a pharmacist as a part of their medication abortion care there was more skepticism that this model would work. As Arielle explained,

So, personally…I don't like going to a pharmacy or asking for over-the-counter stuff, because…I feel like in pharmacies there's always a lot of people around there that are working and people walking by…I don't like to say my business out loud like that. I enjoyed or I guess kind of enjoyed, being able to talk to my doctor who kind of knew my history even though I haven't really seen her in a while but it was over the phone, it was very confidential, that I knew that nobody was listening… I liked the process that I had better, instead of just going up to a pharmacy and saying “Hey, I would like to have an abortion.”

Discussion

The COVID-19 pandemic has disrupted most aspects of day-to-day life and created tremendous uncertainty. As was the case throughout the world, people in Canada continued to need comprehensive sexual and reproductive health services, including abortion care, throughout the pandemic. Indeed, for many of our participants, the public health, economic, employment, and social support implications of COVID-19 and the associated response measures factored into their decisions to obtain an abortion. Our findings reinforce the claim that abortion is an essential health service that must continue to be provided during public health emergencies [23, 31−32].

Consistent with a number of recent studies focused on those who have obtained abortion care in Canada [19, 25−27, 33] our participants had generally positive experiences with both medication and aspiration abortion care. However, many of our participants feared that they would not be able to get a desired abortion because of the pandemic and felt tremendous relief when they learned this was not the case. Our study participants’ fears were not only due to the general uncertainties surrounding the availability of health services during the COVID-19 era and the evolving nature of public health measures but also because of extensive coverage of the onslaught of abortion restrictions that occurred in the United States in the first few months of the pandemic [4, 31]. Although the Canadian government reaffirmed in March 2020 that abortion care is considered an essential and medically necessary health service and provision would continue for the duration of the pandemic [20], for a number of our participants these messages were drowned out by stories from across the border. During future public health emergencies, it will be important for Canadian agencies to proactively message about the continuation of services.

Our participants also experienced a number of barriers to accessing timely and affordable care, including needing to have multiple in-person encounters, receiving incorrect information about cost coverage, being unable to receive care in their dominant language, and facing judgment or discrimination. Previous research [13, 19, 25−27, 33] has also identified these as barriers to abortion care in Canada, barriers that appear to have been amplified and exacerbated in the COVID-19 era. And that a number of our participants had to have multiple in-person encounters without a support person made navigating the system and obtaining abortion care even more difficult. In April 2021, the Canadian federal government released the 2021 federal budget that included CAD45 million (USD30 million) over three years to increase the accessibility of sexual and reproductive health information and services, including those related to abortion care [34]. Our findings suggest that this effort could address significant and persistent inequities.

However, the COVID-19 pandemic also provides a window of opportunity to consider new and innovative models of medication abortion service delivery. Providers in a number of countries, including the United Kingdom [35−36] and the United States [37−38], initiated or expanded telemedicine services that included fully remote protocols. The evidence is overwhelming that these services were safe, effective, and acceptable to both providers and patients. Participants in our study also looked favorably on telemedicine services and while efforts to expand this model of care are relatively nascent in Canada [39], exploring ways to ramp up this model of service delivery, including implementing appropriate provincial level reimbursement policies [6], are warranted. Further, Canada's regulatory environment, which classifies the mifepristone/misoprostol combination package as a typical prescription drug that can be dispensed by pharmacists, offers an opportunity to explore other demedicalized service delivery strategies, such as the provision of medication abortion care by pharmacists. Participants in our study were intrigued by this potential model of service delivery and many felt this could significantly increase timely, affordable, and accessible abortion care.

As per our study design, we only interviewed participants who obtained an abortion during the pandemic. Thus, we did not capture the experiences of individuals who sought abortion care but were unable to navigate accessibility barriers. Future research would benefit from exploring these people's experiences. Although fully remote telemedicine services did become available in several Canadian provinces during our data collection window, our participants did not use these services. Additional research to explore the experiences of this specific population is warranted. All of our participants obtained abortion care within 14 weeks gestation. Although this is consistent with a recent study that indicated that the overwhelming majority of abortions in 2020 took place during this same gestational period [40], we did not capture the experiences of those needing care later in pregnancy. All of our participants identified as women and all of our participants, including those residing in Quebec, were Anglophone. Future research would benefit from the inclusion of people across the gender spectrum and Francophone and other language-minority populations. Finally, although qualitative research is an excellent mechanism for exploring participants’ experiences, beliefs, and behaviors, it is not intended to yield generalizable or representative results. Our multi-modal recruitment strategy and our inclusion of participants who resided in 5 Canadian provinces at the time of their abortion gives us confidence that the themes are transferable, but we caution against using our findings to represent broader trends.

Women who obtained abortion care in Canada during the pandemic recognized the importance of having access to this essential service. Our findings demonstrate the importance of continuing to provide access to safe, effective, and timely abortion care during public health emergencies. Exploring additional models of demedicalized medication abortion service delivery to address persistent access barriers in Canada has the potential to meet a significant need of those seeking care and ease the burden on medical professionals during public health emergencies.

Acknowledgments

We are grateful to Jill Doctoroff and the National Abortion Federation Canada for their continued partnership. We also want to acknowledge the many volunteers who assisted with the transcription of interviews. We also thank the members of the Society of Family Planning's Innovations Learning Community for their support and feedback. Finally, we want to extend our thanks to our participants for sharing their stories with us.