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The perspective of Canadian health care professionals on abortion service during the COVID-19 pandemic

The perspective of Canadian health care professionals on abortion service during the COVID-19... Background: The COVID-19 pandemic and pandemic response created novel challenges for abortion services. Canada was uniquely positioned to transition to telemedicine because internationally common restrictions on abortion medication were removed before the pandemic. Objective: We sought to characterize the experiences of abortion health care professionals in Canada during the COVID-19 pandemic and the impact of the pandemic response on abortion services. Methods: We conducted a sequential mixed methods study between July 2020 and January 2021. We invited physicians, nurse practitioners and administrators to participate in a cross-sectional survey containing an open-ended question about the impact of the pandemic response on abortion care. We employed an inductive codebook thematic analysis, which informed the development of a second, primarily quantitative survey. Results: Our initial survey had 307 respondents and our second had 78. Fifty-three percent were family physicians. Our first survey found respondents considered abortion access essential. We identified three key topicss: access to abortion care was often maintained despite pandemic-related challenges (e.g. difficulty obtaining tests, additional costs); change of practice to low-touch medication abortion care and provider perceptions of patient experience, including shifting demand, telemedicine acceptability and increased rural access. The second survey indicated uptake of telemedicine medication abortion among 89% of participants except in Quebec, where regulations meant procedures were nearly exclusively surgical. Restrictions did not delay care according to 76% of participants. Conclusions: Canadian health care professionals report their facilities deemed abortion an essential service. Provinces and territories, except Quebec, described a robust pandemic transition to telemedicine to ensure access to services. Podcast: An accompanying podcast is available in the Supplementary Data, in which the authors Dr Madeleine Ennis and Kate Wahl discuss their research on how family planning care and access to abortion services have changed during the COVID-19 pandemic. © The Author(s) 2021. Published by Oxford University Press. i30 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/fampra/article/38/Supplement_1/i30/6358430 by DeepDyve user on 14 July 2022 Impact of COVID-19 on Canadian abortion access i31 Key Messages • Access to abortion care could potentially be jeopardized by the COVID-19 response. • Unique regulations enabled Canada to deliver virtual abortion through primary care. • Evidence-based virtual abortion services may increase access to care. • Regulatory factors influence jurisdictions’ abilities to deliver care. Lay Summary Access to abortion care was challenged by the response to COVID-19. Canada had fewer restrictions on medical abortion than many other countries when the pandemic began. The goal of this study was to describe the experiences of health care practitioners providing abortion in Canada and the impact of the pandemic and the pandemic response measures on abortion services. We conducted two surveys of physicians, nurse practitioners and administrators between July 2020 and January 2021. Most of the health care practitioners who participated reported that medical and surgical abortion care were essential and that, except in the province of Quebec, there was a rapid transition to virtual telemedicine care for first trimester abortions. Several practitioners said that virtual care made abortion more accessible. Other practitioners reported that it was challenging to order certain tests, access operating room facilities or make referrals for late second trimester cases. Practitioners felt that patients had strong fears about COVID-19 exposure and reported that limited contraception access was increasingly a reason for seeking abortion care. The results of the study suggested that abortion was considered essential and that the pandemic instigated a transition to virtual care in all provinces and territories except Quebec. Key words: Access to health care, Canada, COVID-19, induced abortion, surveys and questionnaires, transition care surgical services (14,15). Barriers to providing MA care in Quebec Background include restrictive provincial medical licensing body policies, re- Access to essential, safe and comprehensive abortion care was jeop- strictive facility approaches with perceived vested interests in ardized by the global response to the COVID-19 pandemic in early preserving surgical provision, lack of inter-professional support and 2020. Restrictive measures designed to limit the spread of the virus, general professional uncertainty about the regulations (14). including those on nonessential travel and medical care, affected ac- A growing body of evidence points to the safety and acceptability cess to reproductive and sexual health care (1). Legal and regulatory of low- or no-touch telemedicine abortion. An analysis of more than responses to this challenge were often regressive in international jur- 52 000 MA in the UK showed that the telemedicine‐hybrid model isdictions where abortion access was already limited (2–5). In other for care adopted in response to the pandemic was as effective, safe, jurisdictions, progressive responses focussed on preserving access acceptable and more accessible than conventional care provided in through telemedicine for early medical abortion (MA) care, since the first 3 months of 2020 (16). These findings align with other re- this minimized clinical points of contact and decreased the risk of search showing that home-based and telemedicine first trimester MA COVID-19 exposure. For example, the UK, France, Australia and are safe with high rates of efficacy and acceptability (17,18). Existing New Zealand temporarily allowed telemedicine for early MA, re- research in several high-income nations also suggests providers may moved requirements for routine screening ultrasounds and labora- be interested in maintaining the liberalized practice changes imple- tory testing and increased gestational age limits for early MA to mented since the beginning of the COVID-19 pandemic (19,20). 10–13 weeks of gestation (6–8). However, more research is required to assess the sustainability of Canada was uniquely positioned to transform MA care in- these regulatory changes. Turning to Canada, the impact of the sofar as several of these requirements regarding MA (mandatory COVID-19 pandemic and pandemic conditions on abortion care is screening ultrasound, physician dispensing of mifepristone) were re- unknown. moved prior to the pandemic (9–11). The Society of Obstetricians Therefore, our objective was to characterize the experiences of and Gynaecologists of Canada (SOGC) also clearly stated at the be- health care practitioners on the impact of COVID-19 and pandemic ginning of the pandemic that abortion care is an essential service, response measures on abortion care in Canada, with a focus on ac- and access needed to be maintained (12,13). Abortion care is gov- cess, telemedicine and early MA provision. erned in Canada in the same way as any other reproductive health service, and is not regulated by criminal law. The decision to have an abortion is solely between a pregnant person and their health care Methods provider and is not restricted by indication (e.g. foetal anomaly) or gestational age (9). By 2020, many primary care providers in Canada We conducted an exploratory sequential mixed methods study that had incorporated first trimester MA into their clinical practices. An involved the collection and analysis of qualitative data from our exception exists in the province of Quebec, which uniquely main- 2019 Canadian Abortion Provider Survey (21) which, in turn, in- tained restrictions that effectively limited MA care, and promoted formed the development of a second primarily quantitative survey. Downloaded from https://academic.oup.com/fampra/article/38/Supplement_1/i30/6358430 by DeepDyve user on 14 July 2022 i32 Family Practice, 2021, Vol. 38, No. S1 We adapted the Standards for Reporting Qualitative Research Results Checklist for a mixed-methods approach (22). We conducted this Survey 1 results second survey to further understand and quantify factors identified A total of 307 participants responded to the pandemic-related open- in the first survey through a refined set of questions and in response ended question. Their demographics are provided in Table 1. All to a request from federal regulatory stakeholders. participants confirmed they completed the survey only once, were no longer in training, and independently provided abortion care in Survey 1: The Canadian Abortion Provider Survey Canada. Twelve participants indicated they were both clinicians and Data collection administrators. Between July and December 2020, we conducted a self-administered, We identified three common topics related to the impact of the anonymized, cross-sectional survey of Canadian physicians, nurse COVID-19 pandemic on abortion care in Canada: access to care, practitioners and administrators who provided first, second or third change in practice and perceptions of the patient experience. trimester medical or surgical abortion provision in 2019 (21). The University of British Columbia Children’s and Women’s Hospital Access to abortion care Research Ethics Board approved the survey (UBC-CW REB, H18- Many abortion providers indicated that the pandemic did not affect 03303). It was available in English and French on the Research their ability to provide access because they or their province con- Electronic Data Capture (REDCap) platform, and included a con- sidered abortion care essential. One family physician from Alberta sent form, as well as sections on demographics, clinical character- (ID 110) said, ‘In our community, we have considered abortion and istics of abortion care and stigma experienced by providers. We contraceptive care to be an essential service and have made sure ac- distributed the survey through health care professional networks, cess continued throughout COVID restrictions’. Several participants using a modified Dillman technique to maximize participation (23). We included a non-mandatory, open-ended question: ‘What impacts Table 1. Demographics of respondents to the COVID-19 open- has Covid-19 had on your individual abortion practice and/or access ended question in the Canadian Abortion Provider Survey con- to abortion in your province?’ ducted in 2020 (n = 307) Province , n Data analysis British Columbia 66 ME, KW and KK conducted a codebook thematic analysis (24) of Alberta 13 open-ended responses following an inductive approach. We each Saskatchewan 7 read the same 50 responses to familiarize ourselves with the data and Manitoba 8 then independently coded these responses. Next, we compared our Ontario 93 analyses, and agreed on an initial set of codes and descriptions for Quebec 73 the codebook. We then divided the full set of responses and coded Prince Edward Island and 7 these independently. Subsequently, we refined existing codes and de- Newfoundland and Labrador New Brunswick 11 scriptions and agreed on new codes that were identified in the inde- Nova Scotia 18 pendent analysis. We used the revised codebook in a final analysis Territories 11 of the data, after which we organized the codes into topics related Role, n to the research question (see Supplementary Data). In the context Clinicians 280 of this low-inference approach, contemporaneous team discussions Administrator 39 helped identify how personal attributes, qualifications and assump- Profession , n tions interacted with the data and analysis. Physician 262 Nurse practitioner 18 Specialty , n Survey 2: Community of Practice Survey Family physician 163 We used the identified topics in the Survey 1 analysis to develop a General OB/GYN 69 second survey to assess the impact of the pandemic on the provi- OB/GYN with MFM subspecialization 25 sion of Canadian abortion services. From December 2020 to January Other 5 2021, we conducted the survey (UBC-CW REB, H16-01006), Provision, n which included a consent form and questions assessing brief demo- First trimester MA 212 graphics, monthly MA volume from January to September 2020, First trimester surgical abortion 114 previous experience providing MA via telemedicine, and the impact Second trimester surgical abortion 55 Second trimester MA 55 of the COVID-19 pandemic on the provision of abortion services Third trimester MA 35 (see Supplementary Data). We excluded respondents practicing in Age (median, range) 41 (26–76) Quebec from analysis of MA-related questions, as restrictive med- Gender, n ical policies sustained providers’ preference for surgical abortion and Women 234 provincial/administrative inertia limit access to MA (15,25). This Men 46 survey was available in English and French and we invited mem- Other 0 bers of the Canadian Abortion Providers Support—Communauté de pratique canadienne sur l’avortement network (a national commu- MFM, maternal–foetal medicine; OB/GYN, obstetrician–gynaecologists. nity of practice to support mifepristone abortion practice) via regis- Some provinces and territories were combined for confidentiality pur - tered email (10,26). As Survey 1 also recruited through this platform, poses. there may have been overlap in participants. We generated summary Profession of clinicians; does not include administrators. statistics on R, version 3.6.1 and applied the Survey 1 codebook to Speciality of physicians; does not include administrators or nurse practi- open-ended responses. tioners. Downloaded from https://academic.oup.com/fampra/article/38/Supplement_1/i30/6358430 by DeepDyve user on 14 July 2022 Impact of COVID-19 on Canadian abortion access i33 described an increase in access to care during the pandemic, ‘We hotel hubs for 14 days before re-entering the territory’. Participants have found that many patients throughout the province have util- shared anecdotes about patients who presented for care at a later ized our service due to an increase in accessibility that accompanies gestational age or continued with pregnancy because of fears about telemedicine, and we are hopeful to continue to offer this care. contracting COVID-19 or, in one case, because a patient tested posi- However, we are also aware that for patients who do not have access tive for the virus and was unable to travel for care. Participants gen- to a phone/internet, telemedicine is not accessible’ (administrator, erally reported that patients were more likely to request MA care Ontario, ID 27). Some participants providing in-person care noted over surgical, felt that patients were anxious, and noted that at most that reduced clinic hours had affected access. Barriers to timely care clinics, support people were not permitted to attend appointments. included challenges accessing tests, for example ‘Difficulty getting ultrasounds, labs done (less staff for both for booking/performing) Survey 2 results [and] difficulty communicating with other offices as people are gen- The survey was completed by 78 respondents. Their demographics erally more busy and understaffed’ (administrator, British Columbia, are provided in Table 2. The number of MAs provided monthly by ID 272). Some abortion providers reported fewer requests for abor- respondents increased slightly in April 2020, with the mean volume tion (both from patients and through referrals) and a number of ranging from 4.9 to 5.8 prior to April 2020, and ranging from 6.1 surgical providers indicated that access to operating theatres was to 7.3 after April 2020. Since March 2020, 91% of respondents had limited. Finally, several participants perceived that their patients had provided medical or surgical abortion services. We did not iden- experienced limited access to contraception care. tify any new codes in the qualitative analysis of the open-ended questions. Change of practice The majority of respondents reported a change from in clinic to Volume low- or no-touch care with virtual components. The degree of this Among respondents who reported providing MA during the pan- change varied from ‘I have shifted the first or subsequent visits to demic (n = 61), 52.5% reported that the number of MAs increased, telephone visits but usually require in person assessment at least 41% reported that the number of MAs did not change and 6.5% once’ (family physician, British Columbia, ID 6) to ‘I have offered reported a decrease in the number of MA. entirely telehealth abortion care for early first trimester pregnan- cies. Minimized investigations—bloodwork initially and clinically Timely access history of heavy bleed and resumption of menses as confirmation’ Among respondents who have provided medical and/or surgical (family physician, British Columbia, ID 196). Some first trimester abortion during the pandemic (n = 63), 76% reported that their pa- MA providers prescribed a second dose of misoprostol routinely. tients did not experience delays in care due to restrictive measures. Others indicated increasing gestational age limits for second tri- mester in hospital abortions/labour inductions when patients Telemedicine could not be referred elsewhere. An obstetrician–gynaecologist Among respondents who have provided first trimester MA virtually (British Columbia, ID 164) described, ‘We are providing medical (n = 55), 83.6% had no experience providing MA virtually before abortion care to women ≥25 weeks gestation with fetal anomalies/ the pandemic. However, 88.9% responded that they had provided genetic anomalies that we would have normally referred to a US MA virtually since the pandemic. The majority of respondents pro- centre’. viding first trimester MA virtually offered pre-abortion consultation/ Many participants described positive experiences, for example counselling, prescription and follow-up virtually (90.9%, 85.5% ‘We have moved quite seamlessly to no-touch medical abortion and 90.9%, respectively). Forty-nine percent responded that they services and this has been quite successful and rewarding’ (nurse provided virtual emergency care. practitioner, Ontario, ID 498). Participants who did experience difficulties with the transition to low- or no-touch care identified resource issues, including increased costs to adhere to infection pre- Table 2. Demographics of the Community of Practice Survey re- vention and control measures as well as staffing shortages resulting spondents (2020–21; n = 78) from secondment to other roles, new childcare demands or limited Province , n ability to travel between clinics. Depending on jurisdiction, billing Western Provinces 32 contributed to or mitigated costs. In Alberta, a family physician (ID Ontario 29 29) described ‘the telephone visit code really doesn’t compensate for Quebec 10 the length of time spent counselling pre and post abortion’ whereas Maritime Provinces and Territories 7 in Nova Scotia, a family physician (ID 284) highlighted ‘Provincial Role, n fee to provide medical care via telephone has been helpful’. Physicians 65 Nurse Practitioners 6 Pharmacists and Administrators 7 Perceptions of the patient experience Geography, n Many respondents commented on patient behaviour and experi- Urban 51 ences. A common observation was that demand for care decreased Rural 25 in the early months of the pandemic, and providers hypothesized that this was due to decreased frequency of intercourse as well as Some provinces and territories were combined for confidentiality purposes. fears about contracting COVID-19, as a family physician from the b Included participants from British Columbia, Alberta, Saskatchewan and Territories (ID 691) described, ‘Patients are more reluctant to travel Manitoba. out of territory to access abortion care beyond the first trimester be- Included participants from New Brunswick, Newfoundland and Labrador, cause they are terrified of the virus, and do not want to self-isolate at Nova Scotia, Northwest Territories and Yukon. Downloaded from https://academic.oup.com/fampra/article/38/Supplement_1/i30/6358430 by DeepDyve user on 14 July 2022 i34 Family Practice, 2021, Vol. 38, No. S1 Table 3. Requirements for clinical tests by Canadian medical abortion providers during the COVID-19 pandemic (2020–21; n = 48) Always, n (%) As indicated, n (%) Never, n (%) Not applicable, n (%) Ultrasound 9 (18.8) 39 (81.2) 0 (0) 0 (0) Rh testing 17 (35.4) 20 (41.7) 10 (20.8) <5 Serum bHCG 28 (59.6) 18 (38.3) <5 0 (0) Haemoglobin 25 (55.6) 16 (35.6) <5 0 (0) STI testing 18 (37.5) 25 (52.1) 5 (10.4) 0 (0) STI, sexually transmitted infections. <5 is used to ensure confidentiality of participants. Does not include participants from Quebec; only includes participants who provided first trimester medical abortion care during the COVID-19 pandemic. Table 4. Difficulties for patients to access services during the COVID-19 pandemic (2020–21) as reported by Canadian abortion providers (n = 63) Number of providers who responded that their patients mentioned experiencing difficulty, n (%) Difficulty obtaining information on abortion services 16 (25.4) Delay in getting a referral for abortion care 16 (25.4) Social distancing 8 (12.7) Lockdowns or decrease transportation between regions 12 (19.0) Interruption of local transportation 11 (17.5) Increase of restrictive legal measures against abortion 0 (0) Re-organization of medical services 11 (17.5) Medical leaves of health professionals <5 Change in opening/closing hours of shops, clinics or community organizations 13 (20.6) Fear of getting COVID in public locations 28 (44.4) Being diagnosed with a positive test for COVID-19 9 (14.3) Lack of privacy for medical abortion at home <5 Intimate partner violence 10 (15.9) Loss of income 14 (22.2) Difficulty related to technology 15 (23.8) <5 is used to ensure confidentiality of participants. Furthermore, respondents who provided first trimester MA virtu- and regulatory restrictions on abortion care have been a barrier ally during the pandemic (n = 48) were asked about situations where to following evidence-based guidelines for pandemic abortion care they required testing, summarized in Table 3. (2,27). In contrast, the Canadian transition to pandemic abor- Finally, respondents who have provided medical and/or surgical tion care, similar to that reported by Gibelin in France (19) and abortion during the pandemic (n = 63) were asked about difficulties Aiken in the UK (16), was quickly implemented and deemed es- mentioned by patients in accessing abortion services, summarized sential. Rapid transition to telemedicine first trimester MA was in Table 4. The most common mentioned difficulty was fear of ex- likely facilitated by the removal of restrictions by the federal drug posure to COVID-19 in public locations. regulator Health Canada in 2019, and hindered by the ongoing restrictive regulations in Quebec (14,15,30). The supportive regu- latory framework—which did not prescribe testing—enabled pro- Discussion viders to adopt evidence-based guidelines for abortion care during This study, which assesses changes in access to Canadian abortion pandemics and periods of social disruption beginning in April services since the COVID-19 pandemic, is novel, timely, and has the 2020 (12,13), including reductions in the indications to order pre- potential for rapid impact on policy. Most abortion providers in procedural ultrasound, bHCG and Rh factor tests. most Canadian provinces and territories reported a seamless switch The results of this study may have important implications in jur- to providing a higher proportion of MA compared with surgical isdictions seeking to advance reproductive health during and after abortion, and an increase in telemedicine. Though several difficulties the COVID-19 pandemic response. Our findings suggest that low- were reported most strikingly in Quebec, this transition was enabled or no-touch MA provided in primary care may increase geographic by the support and pandemic guidelines of SOGC (12). equity in access to safe care. This approach has the potential to ad- Our findings indicate that the availability of abortion care dress barriers to in-clinic care, such as the burden among patients was maintained and a rapid transition to telemedicine MA was who care for others. Our results indicate that consideration of pa- experienced, in provinces and territories except for Quebec. This tient economic status (results of Survey 2) and access to communi- contrasts to the experiences reported in some jurisdictions inter- cation technology (results of Surveys 1 and 2)  may be important nationally (1,4,5,19,27–29). For example, a rapid response for optimizing equitable access to abortion. Finally, a comprehen- survey of independent abortion clinics in the USA showed that, sive approach to reproductive health care is vital, since considering 51% of clinics, clinicians or staff had been unable to work be- contraception care as nonessential or implementing policy restricting cause of the pandemic or public health response (27). Across many dispensation (31), may have negative consequences even where ac- European nations, the USA and in other jurisdictions (3,5), legal cess to abortion care is preserved. Downloaded from https://academic.oup.com/fampra/article/38/Supplement_1/i30/6358430 by DeepDyve user on 14 July 2022 Impact of COVID-19 on Canadian abortion access i35 2. Upadhyay  UD, Schroeder  R, Roberts  SCM. Adoption of no-test and The experiences of health professionals providing abortion care telehealth medication abortion care among independent abortion pro- in Canada during the COVID-19 pandemic illustrates opportun- viders in response to COVID-19. Contracept X 2020; 2: 100049. ities for evidence-based provision of low- and no-touch first tri- 3. Aiken ARA, Starling JE, Gomperts R, Scott JG, Aiken CE. Demand for self- mester MA in primary care and providing advanced gestational age managed online telemedicine abortion in eight European countries during the abortions closer to the patient’s home rather than referring them COVID-19 pandemic: a regression discontinuity analysis. BMJ Sex Reprod elsewhere including to the USA. Strengths of the study include the Health 2021: bmjsrh-2020-200880. doi:10.1136/bmjsrh-2020-200880 large national sample and the integration of qualitative and quanti- 4. Donley G, Chen BA, Borrero S. The legal and medical necessity of abortion tative data, which provided a rich contextual understanding of the care amid the COVID-19 pandemic. J Law Biosci 2020; 7(1): lsaa013. Canadian transition to pandemic abortion care from a front-line 5. Moreau  C, Shankar  M, Glasier  A, Cameron  S, Gemzell-Danielsson  K. perspective. Interpretation of the results may be limited by the po- Abortion regulation in Europe in the era of COVID-19: a spectrum of policy responses. BMJ Sex Reprod Health 2020: bmjsrh-2020-200724. tential for overlap in participants between the surveys. A  further doi:10.1136/bmjsrh-2020-200724 limitation is that the patient experience of pandemic abortion care 6. R COG. Coronavirus (COVID-19) Infection and Abortion Care: Informa- is described from the perspective of health care professionals. The tion for Healthcare Professionals (Version 3.1). London, UK: Royal Col- second survey had a smaller sample size than the first. We sought lege of Obstetricians & Gynaecologists, 2020. understanding to assist interpretation of our qualitative findings and 7. CNGOF . Prise en charge des IVG médicamenteuses hors établissements thus fielded the quantitative questions using a limited recruitment hospitaliers durant l’état d’urgence de l’épidémie de COVID et Règles method through one network, that was open to respondents for de facturarion. Paris, France: Collège National des Gynécologues et 2 months. While beyond the scope of this study, future research led Obstétriciens Français, 2020. by our team will investigate patient experiences, including percep- 8. RANZCOG. COVID-19: Access to Reproductive Health Services. 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Could implementation of mife- www.pharmacists.ca/news-events/news/covid-19-and-the-responsible- pristone address Canada’s urban-rural abortion access disparity: a allocation-of-medications-to-patients/ (accessed on 29 April 2020). http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

The perspective of Canadian health care professionals on abortion service during the COVID-19 pandemic

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Oxford University Press
Copyright
Copyright © 2022 Oxford University Press
ISSN
0263-2136
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1460-2229
DOI
10.1093/fampra/cmab083
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Abstract

Background: The COVID-19 pandemic and pandemic response created novel challenges for abortion services. Canada was uniquely positioned to transition to telemedicine because internationally common restrictions on abortion medication were removed before the pandemic. Objective: We sought to characterize the experiences of abortion health care professionals in Canada during the COVID-19 pandemic and the impact of the pandemic response on abortion services. Methods: We conducted a sequential mixed methods study between July 2020 and January 2021. We invited physicians, nurse practitioners and administrators to participate in a cross-sectional survey containing an open-ended question about the impact of the pandemic response on abortion care. We employed an inductive codebook thematic analysis, which informed the development of a second, primarily quantitative survey. Results: Our initial survey had 307 respondents and our second had 78. Fifty-three percent were family physicians. Our first survey found respondents considered abortion access essential. We identified three key topicss: access to abortion care was often maintained despite pandemic-related challenges (e.g. difficulty obtaining tests, additional costs); change of practice to low-touch medication abortion care and provider perceptions of patient experience, including shifting demand, telemedicine acceptability and increased rural access. The second survey indicated uptake of telemedicine medication abortion among 89% of participants except in Quebec, where regulations meant procedures were nearly exclusively surgical. Restrictions did not delay care according to 76% of participants. Conclusions: Canadian health care professionals report their facilities deemed abortion an essential service. Provinces and territories, except Quebec, described a robust pandemic transition to telemedicine to ensure access to services. Podcast: An accompanying podcast is available in the Supplementary Data, in which the authors Dr Madeleine Ennis and Kate Wahl discuss their research on how family planning care and access to abortion services have changed during the COVID-19 pandemic. © The Author(s) 2021. Published by Oxford University Press. i30 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/fampra/article/38/Supplement_1/i30/6358430 by DeepDyve user on 14 July 2022 Impact of COVID-19 on Canadian abortion access i31 Key Messages • Access to abortion care could potentially be jeopardized by the COVID-19 response. • Unique regulations enabled Canada to deliver virtual abortion through primary care. • Evidence-based virtual abortion services may increase access to care. • Regulatory factors influence jurisdictions’ abilities to deliver care. Lay Summary Access to abortion care was challenged by the response to COVID-19. Canada had fewer restrictions on medical abortion than many other countries when the pandemic began. The goal of this study was to describe the experiences of health care practitioners providing abortion in Canada and the impact of the pandemic and the pandemic response measures on abortion services. We conducted two surveys of physicians, nurse practitioners and administrators between July 2020 and January 2021. Most of the health care practitioners who participated reported that medical and surgical abortion care were essential and that, except in the province of Quebec, there was a rapid transition to virtual telemedicine care for first trimester abortions. Several practitioners said that virtual care made abortion more accessible. Other practitioners reported that it was challenging to order certain tests, access operating room facilities or make referrals for late second trimester cases. Practitioners felt that patients had strong fears about COVID-19 exposure and reported that limited contraception access was increasingly a reason for seeking abortion care. The results of the study suggested that abortion was considered essential and that the pandemic instigated a transition to virtual care in all provinces and territories except Quebec. Key words: Access to health care, Canada, COVID-19, induced abortion, surveys and questionnaires, transition care surgical services (14,15). Barriers to providing MA care in Quebec Background include restrictive provincial medical licensing body policies, re- Access to essential, safe and comprehensive abortion care was jeop- strictive facility approaches with perceived vested interests in ardized by the global response to the COVID-19 pandemic in early preserving surgical provision, lack of inter-professional support and 2020. Restrictive measures designed to limit the spread of the virus, general professional uncertainty about the regulations (14). including those on nonessential travel and medical care, affected ac- A growing body of evidence points to the safety and acceptability cess to reproductive and sexual health care (1). Legal and regulatory of low- or no-touch telemedicine abortion. An analysis of more than responses to this challenge were often regressive in international jur- 52 000 MA in the UK showed that the telemedicine‐hybrid model isdictions where abortion access was already limited (2–5). In other for care adopted in response to the pandemic was as effective, safe, jurisdictions, progressive responses focussed on preserving access acceptable and more accessible than conventional care provided in through telemedicine for early medical abortion (MA) care, since the first 3 months of 2020 (16). These findings align with other re- this minimized clinical points of contact and decreased the risk of search showing that home-based and telemedicine first trimester MA COVID-19 exposure. For example, the UK, France, Australia and are safe with high rates of efficacy and acceptability (17,18). Existing New Zealand temporarily allowed telemedicine for early MA, re- research in several high-income nations also suggests providers may moved requirements for routine screening ultrasounds and labora- be interested in maintaining the liberalized practice changes imple- tory testing and increased gestational age limits for early MA to mented since the beginning of the COVID-19 pandemic (19,20). 10–13 weeks of gestation (6–8). However, more research is required to assess the sustainability of Canada was uniquely positioned to transform MA care in- these regulatory changes. Turning to Canada, the impact of the sofar as several of these requirements regarding MA (mandatory COVID-19 pandemic and pandemic conditions on abortion care is screening ultrasound, physician dispensing of mifepristone) were re- unknown. moved prior to the pandemic (9–11). The Society of Obstetricians Therefore, our objective was to characterize the experiences of and Gynaecologists of Canada (SOGC) also clearly stated at the be- health care practitioners on the impact of COVID-19 and pandemic ginning of the pandemic that abortion care is an essential service, response measures on abortion care in Canada, with a focus on ac- and access needed to be maintained (12,13). Abortion care is gov- cess, telemedicine and early MA provision. erned in Canada in the same way as any other reproductive health service, and is not regulated by criminal law. The decision to have an abortion is solely between a pregnant person and their health care Methods provider and is not restricted by indication (e.g. foetal anomaly) or gestational age (9). By 2020, many primary care providers in Canada We conducted an exploratory sequential mixed methods study that had incorporated first trimester MA into their clinical practices. An involved the collection and analysis of qualitative data from our exception exists in the province of Quebec, which uniquely main- 2019 Canadian Abortion Provider Survey (21) which, in turn, in- tained restrictions that effectively limited MA care, and promoted formed the development of a second primarily quantitative survey. Downloaded from https://academic.oup.com/fampra/article/38/Supplement_1/i30/6358430 by DeepDyve user on 14 July 2022 i32 Family Practice, 2021, Vol. 38, No. S1 We adapted the Standards for Reporting Qualitative Research Results Checklist for a mixed-methods approach (22). We conducted this Survey 1 results second survey to further understand and quantify factors identified A total of 307 participants responded to the pandemic-related open- in the first survey through a refined set of questions and in response ended question. Their demographics are provided in Table 1. All to a request from federal regulatory stakeholders. participants confirmed they completed the survey only once, were no longer in training, and independently provided abortion care in Survey 1: The Canadian Abortion Provider Survey Canada. Twelve participants indicated they were both clinicians and Data collection administrators. Between July and December 2020, we conducted a self-administered, We identified three common topics related to the impact of the anonymized, cross-sectional survey of Canadian physicians, nurse COVID-19 pandemic on abortion care in Canada: access to care, practitioners and administrators who provided first, second or third change in practice and perceptions of the patient experience. trimester medical or surgical abortion provision in 2019 (21). The University of British Columbia Children’s and Women’s Hospital Access to abortion care Research Ethics Board approved the survey (UBC-CW REB, H18- Many abortion providers indicated that the pandemic did not affect 03303). It was available in English and French on the Research their ability to provide access because they or their province con- Electronic Data Capture (REDCap) platform, and included a con- sidered abortion care essential. One family physician from Alberta sent form, as well as sections on demographics, clinical character- (ID 110) said, ‘In our community, we have considered abortion and istics of abortion care and stigma experienced by providers. We contraceptive care to be an essential service and have made sure ac- distributed the survey through health care professional networks, cess continued throughout COVID restrictions’. Several participants using a modified Dillman technique to maximize participation (23). We included a non-mandatory, open-ended question: ‘What impacts Table 1. Demographics of respondents to the COVID-19 open- has Covid-19 had on your individual abortion practice and/or access ended question in the Canadian Abortion Provider Survey con- to abortion in your province?’ ducted in 2020 (n = 307) Province , n Data analysis British Columbia 66 ME, KW and KK conducted a codebook thematic analysis (24) of Alberta 13 open-ended responses following an inductive approach. We each Saskatchewan 7 read the same 50 responses to familiarize ourselves with the data and Manitoba 8 then independently coded these responses. Next, we compared our Ontario 93 analyses, and agreed on an initial set of codes and descriptions for Quebec 73 the codebook. We then divided the full set of responses and coded Prince Edward Island and 7 these independently. Subsequently, we refined existing codes and de- Newfoundland and Labrador New Brunswick 11 scriptions and agreed on new codes that were identified in the inde- Nova Scotia 18 pendent analysis. We used the revised codebook in a final analysis Territories 11 of the data, after which we organized the codes into topics related Role, n to the research question (see Supplementary Data). In the context Clinicians 280 of this low-inference approach, contemporaneous team discussions Administrator 39 helped identify how personal attributes, qualifications and assump- Profession , n tions interacted with the data and analysis. Physician 262 Nurse practitioner 18 Specialty , n Survey 2: Community of Practice Survey Family physician 163 We used the identified topics in the Survey 1 analysis to develop a General OB/GYN 69 second survey to assess the impact of the pandemic on the provi- OB/GYN with MFM subspecialization 25 sion of Canadian abortion services. From December 2020 to January Other 5 2021, we conducted the survey (UBC-CW REB, H16-01006), Provision, n which included a consent form and questions assessing brief demo- First trimester MA 212 graphics, monthly MA volume from January to September 2020, First trimester surgical abortion 114 previous experience providing MA via telemedicine, and the impact Second trimester surgical abortion 55 Second trimester MA 55 of the COVID-19 pandemic on the provision of abortion services Third trimester MA 35 (see Supplementary Data). We excluded respondents practicing in Age (median, range) 41 (26–76) Quebec from analysis of MA-related questions, as restrictive med- Gender, n ical policies sustained providers’ preference for surgical abortion and Women 234 provincial/administrative inertia limit access to MA (15,25). This Men 46 survey was available in English and French and we invited mem- Other 0 bers of the Canadian Abortion Providers Support—Communauté de pratique canadienne sur l’avortement network (a national commu- MFM, maternal–foetal medicine; OB/GYN, obstetrician–gynaecologists. nity of practice to support mifepristone abortion practice) via regis- Some provinces and territories were combined for confidentiality pur - tered email (10,26). As Survey 1 also recruited through this platform, poses. there may have been overlap in participants. We generated summary Profession of clinicians; does not include administrators. statistics on R, version 3.6.1 and applied the Survey 1 codebook to Speciality of physicians; does not include administrators or nurse practi- open-ended responses. tioners. Downloaded from https://academic.oup.com/fampra/article/38/Supplement_1/i30/6358430 by DeepDyve user on 14 July 2022 Impact of COVID-19 on Canadian abortion access i33 described an increase in access to care during the pandemic, ‘We hotel hubs for 14 days before re-entering the territory’. Participants have found that many patients throughout the province have util- shared anecdotes about patients who presented for care at a later ized our service due to an increase in accessibility that accompanies gestational age or continued with pregnancy because of fears about telemedicine, and we are hopeful to continue to offer this care. contracting COVID-19 or, in one case, because a patient tested posi- However, we are also aware that for patients who do not have access tive for the virus and was unable to travel for care. Participants gen- to a phone/internet, telemedicine is not accessible’ (administrator, erally reported that patients were more likely to request MA care Ontario, ID 27). Some participants providing in-person care noted over surgical, felt that patients were anxious, and noted that at most that reduced clinic hours had affected access. Barriers to timely care clinics, support people were not permitted to attend appointments. included challenges accessing tests, for example ‘Difficulty getting ultrasounds, labs done (less staff for both for booking/performing) Survey 2 results [and] difficulty communicating with other offices as people are gen- The survey was completed by 78 respondents. Their demographics erally more busy and understaffed’ (administrator, British Columbia, are provided in Table 2. The number of MAs provided monthly by ID 272). Some abortion providers reported fewer requests for abor- respondents increased slightly in April 2020, with the mean volume tion (both from patients and through referrals) and a number of ranging from 4.9 to 5.8 prior to April 2020, and ranging from 6.1 surgical providers indicated that access to operating theatres was to 7.3 after April 2020. Since March 2020, 91% of respondents had limited. Finally, several participants perceived that their patients had provided medical or surgical abortion services. We did not iden- experienced limited access to contraception care. tify any new codes in the qualitative analysis of the open-ended questions. Change of practice The majority of respondents reported a change from in clinic to Volume low- or no-touch care with virtual components. The degree of this Among respondents who reported providing MA during the pan- change varied from ‘I have shifted the first or subsequent visits to demic (n = 61), 52.5% reported that the number of MAs increased, telephone visits but usually require in person assessment at least 41% reported that the number of MAs did not change and 6.5% once’ (family physician, British Columbia, ID 6) to ‘I have offered reported a decrease in the number of MA. entirely telehealth abortion care for early first trimester pregnan- cies. Minimized investigations—bloodwork initially and clinically Timely access history of heavy bleed and resumption of menses as confirmation’ Among respondents who have provided medical and/or surgical (family physician, British Columbia, ID 196). Some first trimester abortion during the pandemic (n = 63), 76% reported that their pa- MA providers prescribed a second dose of misoprostol routinely. tients did not experience delays in care due to restrictive measures. Others indicated increasing gestational age limits for second tri- mester in hospital abortions/labour inductions when patients Telemedicine could not be referred elsewhere. An obstetrician–gynaecologist Among respondents who have provided first trimester MA virtually (British Columbia, ID 164) described, ‘We are providing medical (n = 55), 83.6% had no experience providing MA virtually before abortion care to women ≥25 weeks gestation with fetal anomalies/ the pandemic. However, 88.9% responded that they had provided genetic anomalies that we would have normally referred to a US MA virtually since the pandemic. The majority of respondents pro- centre’. viding first trimester MA virtually offered pre-abortion consultation/ Many participants described positive experiences, for example counselling, prescription and follow-up virtually (90.9%, 85.5% ‘We have moved quite seamlessly to no-touch medical abortion and 90.9%, respectively). Forty-nine percent responded that they services and this has been quite successful and rewarding’ (nurse provided virtual emergency care. practitioner, Ontario, ID 498). Participants who did experience difficulties with the transition to low- or no-touch care identified resource issues, including increased costs to adhere to infection pre- Table 2. Demographics of the Community of Practice Survey re- vention and control measures as well as staffing shortages resulting spondents (2020–21; n = 78) from secondment to other roles, new childcare demands or limited Province , n ability to travel between clinics. Depending on jurisdiction, billing Western Provinces 32 contributed to or mitigated costs. In Alberta, a family physician (ID Ontario 29 29) described ‘the telephone visit code really doesn’t compensate for Quebec 10 the length of time spent counselling pre and post abortion’ whereas Maritime Provinces and Territories 7 in Nova Scotia, a family physician (ID 284) highlighted ‘Provincial Role, n fee to provide medical care via telephone has been helpful’. Physicians 65 Nurse Practitioners 6 Pharmacists and Administrators 7 Perceptions of the patient experience Geography, n Many respondents commented on patient behaviour and experi- Urban 51 ences. A common observation was that demand for care decreased Rural 25 in the early months of the pandemic, and providers hypothesized that this was due to decreased frequency of intercourse as well as Some provinces and territories were combined for confidentiality purposes. fears about contracting COVID-19, as a family physician from the b Included participants from British Columbia, Alberta, Saskatchewan and Territories (ID 691) described, ‘Patients are more reluctant to travel Manitoba. out of territory to access abortion care beyond the first trimester be- Included participants from New Brunswick, Newfoundland and Labrador, cause they are terrified of the virus, and do not want to self-isolate at Nova Scotia, Northwest Territories and Yukon. Downloaded from https://academic.oup.com/fampra/article/38/Supplement_1/i30/6358430 by DeepDyve user on 14 July 2022 i34 Family Practice, 2021, Vol. 38, No. S1 Table 3. Requirements for clinical tests by Canadian medical abortion providers during the COVID-19 pandemic (2020–21; n = 48) Always, n (%) As indicated, n (%) Never, n (%) Not applicable, n (%) Ultrasound 9 (18.8) 39 (81.2) 0 (0) 0 (0) Rh testing 17 (35.4) 20 (41.7) 10 (20.8) <5 Serum bHCG 28 (59.6) 18 (38.3) <5 0 (0) Haemoglobin 25 (55.6) 16 (35.6) <5 0 (0) STI testing 18 (37.5) 25 (52.1) 5 (10.4) 0 (0) STI, sexually transmitted infections. <5 is used to ensure confidentiality of participants. Does not include participants from Quebec; only includes participants who provided first trimester medical abortion care during the COVID-19 pandemic. Table 4. Difficulties for patients to access services during the COVID-19 pandemic (2020–21) as reported by Canadian abortion providers (n = 63) Number of providers who responded that their patients mentioned experiencing difficulty, n (%) Difficulty obtaining information on abortion services 16 (25.4) Delay in getting a referral for abortion care 16 (25.4) Social distancing 8 (12.7) Lockdowns or decrease transportation between regions 12 (19.0) Interruption of local transportation 11 (17.5) Increase of restrictive legal measures against abortion 0 (0) Re-organization of medical services 11 (17.5) Medical leaves of health professionals <5 Change in opening/closing hours of shops, clinics or community organizations 13 (20.6) Fear of getting COVID in public locations 28 (44.4) Being diagnosed with a positive test for COVID-19 9 (14.3) Lack of privacy for medical abortion at home <5 Intimate partner violence 10 (15.9) Loss of income 14 (22.2) Difficulty related to technology 15 (23.8) <5 is used to ensure confidentiality of participants. Furthermore, respondents who provided first trimester MA virtu- and regulatory restrictions on abortion care have been a barrier ally during the pandemic (n = 48) were asked about situations where to following evidence-based guidelines for pandemic abortion care they required testing, summarized in Table 3. (2,27). In contrast, the Canadian transition to pandemic abor- Finally, respondents who have provided medical and/or surgical tion care, similar to that reported by Gibelin in France (19) and abortion during the pandemic (n = 63) were asked about difficulties Aiken in the UK (16), was quickly implemented and deemed es- mentioned by patients in accessing abortion services, summarized sential. Rapid transition to telemedicine first trimester MA was in Table 4. The most common mentioned difficulty was fear of ex- likely facilitated by the removal of restrictions by the federal drug posure to COVID-19 in public locations. regulator Health Canada in 2019, and hindered by the ongoing restrictive regulations in Quebec (14,15,30). The supportive regu- latory framework—which did not prescribe testing—enabled pro- Discussion viders to adopt evidence-based guidelines for abortion care during This study, which assesses changes in access to Canadian abortion pandemics and periods of social disruption beginning in April services since the COVID-19 pandemic, is novel, timely, and has the 2020 (12,13), including reductions in the indications to order pre- potential for rapid impact on policy. Most abortion providers in procedural ultrasound, bHCG and Rh factor tests. most Canadian provinces and territories reported a seamless switch The results of this study may have important implications in jur- to providing a higher proportion of MA compared with surgical isdictions seeking to advance reproductive health during and after abortion, and an increase in telemedicine. Though several difficulties the COVID-19 pandemic response. Our findings suggest that low- were reported most strikingly in Quebec, this transition was enabled or no-touch MA provided in primary care may increase geographic by the support and pandemic guidelines of SOGC (12). equity in access to safe care. This approach has the potential to ad- Our findings indicate that the availability of abortion care dress barriers to in-clinic care, such as the burden among patients was maintained and a rapid transition to telemedicine MA was who care for others. Our results indicate that consideration of pa- experienced, in provinces and territories except for Quebec. This tient economic status (results of Survey 2) and access to communi- contrasts to the experiences reported in some jurisdictions inter- cation technology (results of Surveys 1 and 2)  may be important nationally (1,4,5,19,27–29). For example, a rapid response for optimizing equitable access to abortion. Finally, a comprehen- survey of independent abortion clinics in the USA showed that, sive approach to reproductive health care is vital, since considering 51% of clinics, clinicians or staff had been unable to work be- contraception care as nonessential or implementing policy restricting cause of the pandemic or public health response (27). Across many dispensation (31), may have negative consequences even where ac- European nations, the USA and in other jurisdictions (3,5), legal cess to abortion care is preserved. Downloaded from https://academic.oup.com/fampra/article/38/Supplement_1/i30/6358430 by DeepDyve user on 14 July 2022 Impact of COVID-19 on Canadian abortion access i35 2. Upadhyay  UD, Schroeder  R, Roberts  SCM. Adoption of no-test and The experiences of health professionals providing abortion care telehealth medication abortion care among independent abortion pro- in Canada during the COVID-19 pandemic illustrates opportun- viders in response to COVID-19. Contracept X 2020; 2: 100049. ities for evidence-based provision of low- and no-touch first tri- 3. Aiken ARA, Starling JE, Gomperts R, Scott JG, Aiken CE. Demand for self- mester MA in primary care and providing advanced gestational age managed online telemedicine abortion in eight European countries during the abortions closer to the patient’s home rather than referring them COVID-19 pandemic: a regression discontinuity analysis. BMJ Sex Reprod elsewhere including to the USA. Strengths of the study include the Health 2021: bmjsrh-2020-200880. doi:10.1136/bmjsrh-2020-200880 large national sample and the integration of qualitative and quanti- 4. Donley G, Chen BA, Borrero S. The legal and medical necessity of abortion tative data, which provided a rich contextual understanding of the care amid the COVID-19 pandemic. J Law Biosci 2020; 7(1): lsaa013. Canadian transition to pandemic abortion care from a front-line 5. Moreau  C, Shankar  M, Glasier  A, Cameron  S, Gemzell-Danielsson  K. perspective. Interpretation of the results may be limited by the po- Abortion regulation in Europe in the era of COVID-19: a spectrum of policy responses. BMJ Sex Reprod Health 2020: bmjsrh-2020-200724. tential for overlap in participants between the surveys. A  further doi:10.1136/bmjsrh-2020-200724 limitation is that the patient experience of pandemic abortion care 6. R COG. Coronavirus (COVID-19) Infection and Abortion Care: Informa- is described from the perspective of health care professionals. The tion for Healthcare Professionals (Version 3.1). London, UK: Royal Col- second survey had a smaller sample size than the first. We sought lege of Obstetricians & Gynaecologists, 2020. understanding to assist interpretation of our qualitative findings and 7. CNGOF . Prise en charge des IVG médicamenteuses hors établissements thus fielded the quantitative questions using a limited recruitment hospitaliers durant l’état d’urgence de l’épidémie de COVID et Règles method through one network, that was open to respondents for de facturarion. Paris, France: Collège National des Gynécologues et 2 months. While beyond the scope of this study, future research led Obstétriciens Français, 2020. by our team will investigate patient experiences, including percep- 8. RANZCOG. COVID-19: Access to Reproductive Health Services. Mel- tions of telemedicine abortion care and safety of low- and no-touch bourne, Australia: The Royal Australian and New Zealand College of Ob- stetricians and Gynaecologists, 2020. abortion care in Canada. Further investigation into provincial/ter- 9. Shaw D, Norman WV. When there are no abortion laws: a case study of ritorial differences in care and access, including factors explaining Canada. Best Pract Res Clin Obstet Gynaecol 2020; 62: 49–62. the persistence in restrictive policies on first trimester MA care in 10. Munro S, Guilbert E, Wagner MS et  al. Perspectives among Canadian Quebec, would allow for more targeted knowledge translation and physicians on factors influencing implementation of mifepristone medical policy development plans. abortion: a national qualitative study. Ann Fam Med 2020; 18(5): 413–21. In the 10  months following the outbreak of the COVID-19 11. Health Canada. Health Canada Approves Updates to Mifegymiso Pre- pandemic, Canadian abortion providers from all provinces except scribing Information: Ultrasound No Longer Mandatory. 2019. https:// Quebec, reported quickly and easily transitioning to the provision healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2019/69620a-eng. of virtual MA. This transition was influenced by previous federal php (accessed on 29 January 2021). removal of regulatory restrictions, and by the rapidly developed 12. Costescu D, Guilbert E, Wagner M-S et  al. Induced Abortion: Up- dated Guidance during Pandemics and Periods of Social Disrup- and disseminated national guidelines on virtual abortion care. Our tion. SOGC COVID-19 Resources: Society of Obstetricians and results highlight opportunities to optimize equitable abortion care Gynaecologists of Canada, 2020. https://sogc.org/en/content/ both in Canada and internationally. COVID-19/COVID-19.aspx?WebsiteKey=4d1aa07b-5fc4-4673-9721- b91ff3c0be30&COVIDResources=2 (accessed on 29 January 2021). Supplementary material 13. Guilbert E, Costescu D, Wagner M-S et  al. Canadian Protocol for the Provision of Medical Abortion via Telemedicine SOGC COVID-19 Re- Supplementary material is available at Family Practice online. sources. Society of Obstetricians and Gynaecologists of Canada, 2020. https://www.sogc.org/common/Uploaded%20files/CANADIAN%20 Declaration PROTOCOL%20FOR%20THE%20PROVISION%20OF%20MA%20 VIA%20TELEMEDICINE.pdf (accessed on 29 January 2021). Funding: both surveys were approved by UBC Children’s and Women’s Re- 14. Guilbert E, Wagner M-S, Munro S et al. Explaining slow implementation search Ethics Board (H18-03303 and H16-01006). Survey 1 (The Canadian of mifepristone in Quebec with the transtheoretical model of change. J Abortion Provider Survey) was funded by The Canadian Institutes of Health Obstet Gynaecol Can 2020; 42(5): 677. 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Journal

Family PracticeOxford University Press

Published: Aug 27, 2021

Keywords: abortion, induced; canada; pandemics; coronavirus pandemic; telemedicine; abortion access; quebec; covid-19; health personnel; nurse practitioner

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