Abortion barriers in Canada are back in spotlight following passage of abortion bans in U.S.

While abortion remains legal in Canada, some abortion rights advocates say women continue to face hurdles in accessing the procedure.

Funding, distance to medical facilities and a patchwork of provincial laws all mean an abortion is not as easy to obtain in Canada as some may think.

"People often conflate the two, thinking that because it's decriminalized, it's very easy to access in our country — and it's not the case," said Frédérique Chabot, director of health promotion at Action Canada for Sexual Health and Rights.

"There's been very little progress done to make sure that abortion is actually, in fact, accessible to everyone in Canada equally."

The controversial issue has gained renewed focus following the passage of abortion bans in the U.S.

Several states have in the last year passed so-called heartbeat bills, which ban abortion as soon as a heartbeat can be detected — which could be as early as six weeks into pregnancy. Just this week, Alabama made it illegal for doctors to perform abortions.

None have taken effect yet, and they're expected to be tied up in legal wrangling for a while. But they could make their way to the U.S. Supreme Court, where anti-abortion activists hope the new conservative majority might be inclined to overturn or drastically diminish the court's landmark abortion-rights precedent set in the Roe vs. Wade case in 1973.

Meanwhile in Canada, federal Liberals have accused the Conservatives of wanting to reopen the abortion debate — something party leader Andrew Scheer has insisted he will not do.

'Becomes really tricky'

Abortion has been legal in Canada since 1988 when the Supreme Court of Canada struck down laws against it. But for women living outside of big urban centres like Toronto, Montreal and Vancouver, accessing the procedure "becomes really tricky," Chabot said.

Some of those barriers include funding. Under the Canada Health Act, abortion services are insured in all provinces and territories. But some provinces have placed limits on funding for the procedure.

Ontario does not fund abortions at every clinic, while New Brunswick does not fund abortions at clinics at all, only in hospitals. In its 2016-2017 annual report, Health Canada said New Brunswick's lack of coverage "remains a concern."

The Abortion Rights Coalition of Canada (ARCC) says that's not good enough. In its interpretation of the Canada Health Act, abortion services across the country must be fully funded.

And in the case of New Brunswick, the "federal government has failed to penalize the province by withholding transfer payments."

Distance to abortion services can also be a barrier. In many remote communities, specifically northern communities, there are no abortion clinics in town and no hospitals that perform the procedure.

"So that imposes significant travel costs, you know, loss of work time, for women to get to a place where they can actually access it," said Karen Segal, staff lawyer for the the Women's Legal Education and Action Fund (LEAF).

In some regions, she said, there are only a couple of points of access. For example, in Alberta there are only two clinics: one in Edmonton and one in Calgary.

Requirements for a hospital abortion also differ across jurisdictions; provinces enforce their own health care legislation, which could include requiring a doctor's referral or gestational limits. Hospitals also often have long waiting lists.

Prince Edward Island was the last holdout, refusing to provide any abortion service on the island until, following a long legal battle, the province agreed in 2016 to open an abortion clinic. Before that, women had to travel to Halifax or Moncton, N.B., with the province paying medical costs, but not travel expenses.

P.E.I. restricts medical abortions to the first nine weeks of pregnancy and surgical abortions to 12 weeks and six days, though women still have the option of a later abortion by travelling to another province.

Long wait lists

"What we've heard anecdotally is that their wait lists are so long," Segal said. "Women face wait lists of five, six weeks — which, if you don't know you're pregnant right away, can mean that by the time you have your appointment, you're ineligible for abortion in the province."

Segal acknowledged that access to medical care in general can be a challenge for those living in rural and northern communities. But she believes the lack of access to abortion reflects, at least in part, an ideological opposition.

If a medical practitioner has a religious objection to providing abortion, they don't have to carry it out. So, for example, a doctor may be willing and capable of providing an abortion at a local hospital, but an anaesthetist may have a conscientious objection and refuse to assist.

"So, practically speaking, it's very hard to actually do it, because the staff don't agree and won't participate in providing the service," Segal said.

Other anti-abortion doctors have refused to make referrals for a doctor who will provide an abortion.

But the Ontario Court of Appeal ruled just this week that doctors in the province must give referrals for medical services that clash with their religious beliefs, including abortion.

Nova Scotia has found its own way around reluctant doctors. Instead of a referral, women can call an access-to-abortion helpline that's run by the provincial health-care system.

Sarah Baddeley, chair of the Halifax chapter of LEAF, told CBC Radio's Information Morning that there has been some improvement in the region when it comes to access, thanks to the helpline and other changes, like better access to ultrasounds and dropping the mandatory requirement to have an ultrasound.

Meanwhile, the availability of Mifegymiso — the so-called abortion pill that was first made commercially available in Canada in 2017 — has also helped with access issues, Chabot said.

The drug can be taken up to nine weeks into a pregnancy, and Health Canada recently dropped a requirement that women undergo an ultrasound before being prescribed Mifegymiso.

"That means that people might not have to leave their communities to get an abortion and it's starting to be realized," Chabot said.

But Chabot said that Saskatchewan and Manitoba remain the only two provinces that do not provide universal coverage for the pill. As well, many pharmacies across Saskatchewan do not stock the drug.

In Manitoba, women can get the abortion pill for free at three health centres, otherwise they must cover the cost — around $350 — themselves.