 All right I think we'll get going and allow people to come drifting in as they can. I want to say a good afternoon or good morning depending on where you're joining us from and welcome to the final fall semester Dalhousie Health Law Institute Health Law and Policy seminar. A few housekeeping details before we start. The session is recorded but the audience will not appear in the recording and you can re-watch this session or catch any of the others in this series anytime on the Shulik Law School YouTube channel. Live captioning is available. Just click on the closed caption icon at the bottom of your screen. The Q&A will take place using the Q&A function which is also at the bottom of your screen and you can type a question box at any time. I will dismiss it if it gets answered in the course of Wendy's remarks but otherwise they'll be in the box there. I'll field the questions at the end and be putting them to the speaker but we have a function that allows you to see all the questions and to vote and comment on them and I'll use the votes as a way of gauging the level of interest in the questions and I'll use that to inform my moderation. I do have to note because of unfortunate bad experiences that if this function is abused we will disable it. But with that let's turn to today's talk. It is a real pleasure for me to introduce today's speaker. Wendy Norman wears many hats. She is a family physician and an associate professor in the Department of Family Practice at the University of British Columbia and an honorary associate professor in the Faculty of Public Health and Policy at the London School of Hygiene and Tropical Medicine in the UK. Dr. Norman holds the Public Health Agency of Canada and C.I.H.R. Family Planning Public Health Research Chair and in 2016 was awarded the prestigious DARIC Award for Sexual and Reproductive Health Policy Research by the New York-based Gokmahar Institute. Wendy is an extraordinary clinician-scientist health policy researcher advocate. Her work in the area of reproductive health is a model for those who seek to engage at the intersection of health care, law, and policy. Dr. Norman founded and leads the Contraception and Abortion Research team which convenes government health system and service decision makers with national family planning organizations and researchers and health professionals representing a wide range of disciplines and C.I.H.R.T aims to conduct health policy and health services research to enable equitable access for populations across Canada to the knowledge, methods, and services they require to time and space their pregnancies and to achieve their own reproductive goals. One of the issues that this team has worked on is medical abortion and I have witnessed firsthand the rigorous empirical research and the dogged determination to get the research results in front of policymakers and the hashtag persistence in insisting that Canadian policy about medical abortion be evidence-based and equitable. What we're lucky enough to hear about today is a success story in moving from research to policy impact. It took time and patience and a lot of effort but in the end it worked. So with that I'm going to hand it over to Wendy to take us through this quite remarkable tale. Wendy take it away. Thank you very much Jocelyn. I'll just share my screen here so that you can see my slides. That was a lovely introduction. I very much appreciate the opportunity to have the chance to discuss this journey with all of you today and very much look forward to our questions afterwards so we'll make sure that we leave lots of time for that as we go forward. The disclosures are listed on the slide here as you heard from Jocelyn. I'm a university-based faculty researcher and my research is funded by not-for-profit and government organizations and I truly believe I have no conflicts of interest to declare. As well I would like to acknowledge that I am a white settler and an uninvited guest and I live and work in the UBC area on the unceded territories of the Coast Salish peoples including the traditional territories of the Musqueam, Squamish, Stolo, and Salewa tooth nations and I'm very honored to speak to you today from these lands. A few objectives of what our talk will be about today. I really hope in the end that personally you would be able to describe the relationship between restrictive laws and regulations and the incidents and safety of abortion to understand a bit about the Canadian regulatory and legal journey relating to abortion and how this might differ than other jurisdictions and as Jocelyn was alluding to in her introduction to be able to understand something of the interaction between being able to change policy and the engagement of the people who make those decisions right from the beginning in a research process which we hope will be able to illustrate for you here. As a start we already know an awful lot about the value of putting in people's hands, the ability, the knowledge, the methods, the services that they need to be able to achieve their own reproductive goals. People who are able to decide whether and when to have children and how to space them are better able to allow those children to grow up with adequate food safety and with adequate shelter. We know those children from planned pregnancies and planned birth spacing are more likely to graduate high school and less likely to envision and experience witnessing interpersonal violence in the home as they grow up. These children are less likely to carry those sorts of experiences intergenerationally and to repeat those patterns. The children themselves are more likely to have educational and economic success as are the parents who have been able to time whether and when they wanted to get pregnant. Females and those who are able to become pregnant are more likely to complete their own education and participate fully in the labor force and this of course increases household earnings and the success for not just the households but so many of the community opportunities that people who are able to manage their fertility are able to contribute for in a voluntary sense as well. Now globally when we look around the world about a third of all pregnancies and two-thirds of those that are unintended and in abortion and our own research has shown in Canada that 31 percent of people will have an abortion at some point in the reproductive life. This leads to over 70 million abortions throughout the world about a third of which are uncarried out in the least safe conditions and frankly outright dangerous conditions. A massive proportion of maternal mortality throughout the world is due to unsafe abortion such that during the course of our time together here we expect five to seven people will die somewhere in the world due to unsafe abortion with a rate of about one every 12 minutes overall. Unsafe abortions are inequitably divided. This is a charge made from the early about early 2000s but the principles are still the same. In those lower and middle income countries, LMIC settings the restrictions on the access to abortion and the legal restrictions are much more stringent than those in most high income countries with notable exceptions in our recent political climate and interestingly what we find is that the most restricted settings do not have fewer abortions. In fact what we see is that they've got higher abortion mortality and the unsafe abortions occur more regularly and maternal mortality is highest. What we know is associated with the lowest rates of abortion is access to excellent sexual healthcare, access to the knowledge, the methods of services, people need to time and space their pregnancies and particularly access to high quality contraception and ideally pre-contraception is associated with the best prevention of unintended pregnancy which is linked to improving abortion rates and abortion safety. Globally we can see in this temperature map image here across the world that where the most unsafe abortions are happening and these are also the areas where the maternal mortality is highest and globally those who are dying from abortion typically have one or two children at home under the age of five who will also die within the subsequent months once their mother has died. So abortion in lower and middle income countries particularly is often used at the end of the cycle of fertility when people cannot they feel it's a desperate move when they cannot increase. More children in the household they can't look after them they take the chance to have an abortion and then of course when the young mother dies also the fate of her children is very much up in the air. We see here the case fatality rates and it very much mirrors as you will see those areas where abortion was restricted legally in the world and these are rates of death per hundred thousand abortions and we're all becoming familiar with the rates of a COVID infection. Those are usually given per million you can see that among a hundred thousand abortions 880 or if we were saying among a million abortions nearly a thousand are dying from unsafe abortion and this compares to the rates in the areas where you have access to high and safe abortions such as the U.S. given the example here where you expect less than one person per hundred thousand less than 10 per million six people per million as your case fatality rate. Again illustrated when abortion became legal in the United States as the restrictions were gradually lifted immediately we see a plummeting in the case mortality related to abortion once legal abortion was allowed. Now the need for abortion as we discussed earlier is tied to the ability to prevent unintended pregnancy and that's very much linked to sexual health and sexual activity and we can see throughout the past decades that the amount of time when people in their lives are exposed to the potential for unintended pregnancy and unwanted pregnancy is increasing. So here is a chart showing that people born in the 1980s in the United States were not having their first birth until the age of 26. Now and yet our age at first sex and also in Canada it's about the same as around age 16 or 17 today across Canada people are not having their average age at first birth until after their 30 and so we've got to spread from a first sex at about 16 to over 30 of 15 or 16 years for people before they wish to have their first child at a time at which they're at risk for unintended pregnancy. People planning to have one or two children throughout their life and this is typical in North America although increasingly we see people not planning to have children. These people will typically have about five years being pregnant, being postpartum or trying to conceive and the remainder of their reproductive life from about age 15 to 49 over 30 years spent trying to avoid pregnancy and for those of you who are epidemiologists or good at math you can see that with pregnancy rates with the even methods like the pill the patch deep or purveyora of six to nine percent or with barrier methods much higher each year each of those 30 to 35 years that people are trying to avoid pregnancy you can see why we have a need for better access to free contraception and the knowledge people need to make their choices to a better range of contraceptive methods and just to recognize that Canada just in September 24th the subdermal implant contraceptive became available which is one of the top choices throughout the world for people wanting a range of choices range access to free contraception and to be able to time and space the pregnancies is a key way to be able to avert the need for abortion and when we don't have that access as we don't in many places in Canada then we have the need to be able to make abortion accessible. Our team undertook a door-to-door personal interview survey in a representative sample throughout all regions of the province of British Columbia in 2015 and people told us that among those who had had a recent pregnancy 40 percent of their pregnancies were unintended and among unintended pregnancy and this is mirrored throughout the world the most common outcome is that unintended pregnancies proceed to a birth. Actually when we looked across BC a third of all births are unintended at the time of conception so we've got a long way to go in Canada to be able to address the needs of people to have the knowledge methods and services they need to be able to time and space their births. We understand those births going to unintended pregnancy are more likely to result in neonatal ICU admissions stillbirth low birth weight and neonatal mortality. Similarly when we look at the group of people with an unintended pregnancy we see a concentration of the lowest and most disadvantaged social determinants of health those with low income low education those in marginalized and otherwise disadvantaged populations are concentrated in that group with unintended unwanted pregnancies and particularly among those who seek abortion care. So I hope this brief introduction has allowed you to see why the regulation of abortion and access to abortion when it is required is a very important societal issue and why those in charge of our laws and in charge of our regulatory systems need to ensure that there is good access and accessible abortion and knowledge throughout Canada. When we look at our journey in Canada as many of you will know until 1968 not only was abortion illegal in Canada but in fact it was illegal for a healthcare provider to discuss contraception with a patient up until the omnibus law introduced in 1969 that amended the criminal code and made contraception legal in Canada as well as increasing the access to abortion by making it legal under certain conditions. At that time those conditions were more strict than those recommended by a royal commission that had been performed in the years leading up to this law being introduced and they required that an abortion is undertaken only in accredited hospitals that it could only be done by physicians and that a committee a therapeutic abortion committee of at least three physicians by a majority vote had to approve that this could be done before each abortion took place. At that time only half our hospitals in Canada were accredited so this was a big problem and women's groups across the country reacted. Many people worked to be able to highlight the inefficiencies and inappropriate action as many people will know Dr. Henry Morgantala opened clinics not in hospitals and started providing high quality abortion care to people through the clinics without an abortion committee and was arrested several times in Quebec and tried but the Quebec government eventually stopped arresting him and actually in 1981 the Quebec government set up in every region of the province within their normal community service centers the CXLCs abortion service availability in every region and this was still when the federal law prohibited the provision of abortion outside of hospitals. So in 1982 the Charter of Rights and Freedoms was enacted Dr. Morgantala set up clinics in non-Quebec provinces these were charged and tried in various courts and made their way to the Supreme Court where in January of 1988 the Supreme Court ruled that Canada's abortion law violated section seven of the Charter of Rights and Freedoms and this struck the law from our criminal code. Canada became the first country in the world to entirely decriminalize abortion and one of only four countries to have no criminal law on abortion. This has been challenged at different points and people have introduced private members bills into parliament but no criminal law has been passed since 1988. So now that we have no criminal law and abortion is just managed within the health system has that made it accessible? Well not as much as we would hope. In Canada because we did not have access to the medical abortion film with a pristone until very recently and we'll talk more about that up until about 2014 96% of abortions were provided surgically with a very small number provided medically by a less effective medication at the track state and because surgical abortion needed to happen in either hospitals or purpose specific clinics these were concentrated in our largest cities for the most part our census metropolitan areas and so they weren't equally accessible abortions weren't available throughout Canada except in Quebec it's near where the distribution of populations lived and there were lots of studies Sethna and Dool did some of the wonderful work in this area showing that abortion was inaccessible and abortion access was delayed. Also the United Nations Human Rights Commission their committee on the elimination of discrimination against women highlighted this inequitable access and again through some of the advocacy of important Canadian institutions such as Action Canada for Sexual Health and Rights to be able to understand the disparity in access and to indicate to the Canadian government that they were not meeting international standards and the concern needed to be addressed. This is not a map of where abortions are available in Canada or in the UK this is a regular health services map and the blue dots represent hospitals throughout the country and the orange areas show population density and you can see that our most populated areas are the darkest orange and this roughly correlates to where surgical abortions were available in Canada outside of Quebec prior to the introduction of the medical abortion pill and you can see with the display of hospitals throughout the country that they're much more widely distributed and that normal community medicine mechanisms have primary care and services available closer to where women live and work in Europe and other countries and as you see here the UK this disparity between where a purpose specific abortion facility in a high density area would be offering services to people who are pregnant who are seeking abortion and where people live is much less concerning as you can see from the inset map in the UK. So Canada has a unique difficulty with urban rural access to abortion care when surgical abortion was our only option. However we knew that Health Canada was considering the second or third application that had been made to approve Miphapristone by 2014-15 and Miphapristone a medical abortion pill the gold standard throughout the world perhaps offered an option this is a safe effective way to cause help a person to have an abortion for an unintended unwanted pregnancy. The medicine Miphapristone stops the pregnancy growing a day or two later the second medication Miphaprostyl is taken that helps to expel the uterus the pregnancy from the uterus and thus an abortion happens like a normal miscarriage with a high success rate excellent safety this has been available around the world in more than 50 countries for more than 30 years and the profile of safety is exceptionally well known. So we had the idea that here was the potential if Miphapristone was approved to be able to offer abortion not just in these purpose specific facilities and through those abortion providers who have served Canada so well over this 30 years since decriminalization in Canada but also to be able to put the ability to offer abortion into the hands of primary care providers everywhere to a person who's pregnant with an unintended pregnancy closest primary care provider and to be able to allow them to offer a safe and effective treatment for people seeking abortion wherever people live close to home in a confidential environment that does not need you to go through protesters nobody knows why you are speaking with your in the confidential session with your primary care provider that there would be advantages for people throughout the country if this medicine could be accessible through primary care. So our team and I want to credit here also the leadership of Dr. Yvitzky Baer who has been central in Quebec throughout these decades in being able to work with the ESPQ and the public health approaches to family planning and Dr. Sheila Dunn in the Women's College Hospital Research Institute in Toronto and the University of Toronto. The three of us got together also with Dr. Judith Soon a leading pharmacist working in family planning throughout the country to engage our health professional organizations the College of Family Physicians of Canada the Society of Obstruction Gynecologists and the Canadian Pharmacists Association and after about a year also we were able to engage with Dr. Ruth Meisner a professor here at Dalhousie in the Faculty of Nursing and the Canadian Nurses Association. These organizations came together and they agreed through our discussions to recognize abortion as a core part of the primary care delivered by their members and to recognize their responsibility to set up the ability to train and accredit people to prepare their members to provide high quality service in this area. They approached Health Canada under a coalition led by SOGC and the amazing Dr. Jenny Blake to be able to discuss with them before the approval of Mipha Pristone why for Canada different than in organizations throughout the world when abortion was approved that the training education and dissemination of this health professional practice should not be done by a purpose specific abortion organization it should be centered within the normal organizations that train and accredit our primary care throughout the country as a way of destigmatizing and moving this opportunity into primary care and I think I've paused a well on this slide because I just think this was a central piece of why Health Canada and the health professional organizations were able to make the kind of globally leading change that we'll be discussing as we go through some of the evidence on what did happen later in this discussion so I wanted to just focus this piece here by engaging those central for the model that we could envision might be the solution for this urban rural disparity right at the beginning before things started and having working with them to be able to provide whatever evidence they needed this was a key factor in being able to leverage the change we envisioned so in July of 2015 Health Canada announced the approval of Mipha Pristone for availability in Canada under the brand name Miphi Gaimiso that co-packaged the Mipha Pristone and the Mipha Prostel and immediately the very same day these health professional organizations SOGC College of Family Physicians Canadian Pharmacists Association issued press releases and public announcements and announcements to their members that they saw this practice as core for those members across the country. The medication did not become available until 2017 due to manufacturing delays but the initial approval conditions included a host of restrictions that were typical for its use in other countries and these restrictions had assisted in other countries to limit the practice of abortion and we'll look at some of that evidence in a little while to purpose specific clinics which of course in Europe is not such an issue because people can access these purpose specific clinics and perhaps prefer to but in North America this would we postulated perhaps prevent their access in primary care and you can see one of our publications here we convened seven focus groups across Canada of urban and rural health professionals people who had and had never provided abortion those who were specialists and generalists to say what about these regulations what will these mean to you and we heard loud and clear in all of our groups these regulations will limit the access to abortion to purpose specific clinics we cannot implement this in primary care with this sort of restrictions so we applied to CIHR within a couple of weeks of when Mipha Pristone was approved and had funding awarded for our study starting the next spring aiming to be able to understand and assist with evidence collection the implementation of medical abortions throughout Canada and to assess whether it could move into primary care we got a host of partners all of whom have been wonderful with fabulous ideas coming forward as we've moved with this and again the idea we had postulated as central for this entire project was to engage those making legal and regulatory decisions and health system and service decisions in the provinces and the federal partners with our research team the health professional regulators the health drug regulators at Health Canada provincial government regulators of whether subsidies would be available for this method anybody who is making a decision that could affect a person's access to abortion care and to this medical abortion we wanted to engage with the right from the start to find out what evidence they would need to be able to have the best policies possible to ensure people had access to the knowledge methods and services. We designed a study of surveys of health care professionals of interviews both with health care professionals and with these knowledge translation key decision makers throughout the country and we also put together an online forum a community of practice for health care professionals to allow them to download the latest evidence guidelines little checklists that show you the what do you need to do in a 10-minute visit to make this possible in primary care resources for handouts for patients for information and a way to connect with each other and to connect with experts to get the support that they might need as they launched into a brand new practice and then to evaluate throughout the project the integrated knowledge translation. I just want to recognize here our postdoctoral fellow at the time who's now a system professor at the University of British Columbia Dr. Sarah Monroe who was absolutely fabulous in leading our integrated knowledge translation work for this. Our health professional organizations also made these opportunities available to their members in Health Canada put the link to our health professional community of practice website on their website where they were introducing the Mipha Pristone regulations and we found that more than twice as many abortion providers joined our community of practice then had been documented as being existing in Canada prior to the introduction of Mipha Pristone and people were very generous in answering the surveys and writing great volumes to us on their experiences with the barriers and whether they found facilitators to be able to introduce this practice into primary care. Among those who joined we found that we didn't have the large concentration of those in the purpose specific abortion clinics who were very familiar with abortion care but that most people were new to abortion care more than half of the people engaging with the research were new to abortion care and many had been very low volume providers before and that almost all were located in primary care settings which represented in fact about 50 more settings than documented communities that had had access to abortion prior to the introduction of Mipha Pristone with proportionately more rural providers joining into the community of practice and to recognize here some of the publications of our team looking at the implementation which was rapid across Canada outside of Quebec and some of the publications detail the difficulties in the Quebec regulations and showing how as the Health Canada learned from the surveys about the restrictions and the effect of those restrictions on primary care providers they made changes and the brilliant interview study by Sarah Monroe here looks at interviews before the changes of regulations and after to see the differences experienced by frontline primary care health care providers throughout the country so the impact this had as Health Canada saw the feedback from this community of practice and the surveys and the interviews was that they were able to take away with the evidence brought together from experiences on safety throughout the world all of the regulations that they had initially introduced in May of 2017 four months after the first approved first availability of Mipha Pristone most of those restrictions were removed and in November 11 months after Mipha Pristone availability in Canada the rest of the regulations came away accepting the need for an ultrasound in every case which was removed in April of 2019 so now none of the key regulations initially restrictive regulations initially introduced by Health Canada at the time of approval are in place and Canada is a global leader in having completely deregulated Mipha Pristone compared to every other country that has a high quality pharmaceutical regulation system in place Canada is the outstanding global leader for this and as Dr. Supriya Sharma the chief medical officer at Health Canada and a absolutely brilliant and wonderful collaborator throughout this process has given in her media interviews once the deregulation came away now Mipha Pristone is available in the way that any other pharmaceutical prescription medication in Canada is available that a person can talk to their health professional closest primary care provider receive a prescription for the drug they can fill it at any pharmacy they choose to and they can take the drug or not as they wish when and where they would like afterwards we worked also to provide evidence briefs to provincial governments on the cost effectiveness of contraception and to provide evidence briefs to health professional regulators in the provinces and the national organizations for regulating physicians pharmacists nurses across the country so we've had a wild journey since Mipha Pristone first became available in January of 2017 and understanding by 2018 with all of the regulations removed what those actions are across Canada and what the experiences are and what we really want to know now is what effect has this had on people's access to abortion and on abortion safety in Canada I want to recognize here that most of the rest of this work will be from my current postdoctoral fellow Dr. Laura Schumer is a brilliant perinatal epidemiologist who has been working with the linked health administrative data to be able to understand what the uptake of abortion has been how that's distributed and the abortion safety since Mipha Pristone's been deregulated so our first look has been in the linked administration data through the ISIS platform at the in Ontario where we looked at the five years before abortion was decriminalized deregulated for Mipha Pristone in Ontario compared to two years after the regulations had been changed so the calendar year of 2018 and the calendar year of 2019 over 300,000 abortions all together between these two periods of all at all stages and being able to look at safety and pregnancy outcomes. We found that the populations were largely the same and interestingly the number of abortions as has been found in countries all over the world when you make a medical abortion available and you make Mipha Pristone more accessible the number of abortions per thousand women did not go up and the characteristics of women were largely the same so it doesn't appear in any way that people who previously weren't able to they didn't want to have an abortion all of a sudden had an abortion just because it was easier but it appears that they were able to get their abortion closer to home similarly the the types of healthcare providers didn't change although I want to acknowledge that for the first time nurses in Canada can provide abortion they started in July of 2017 where the Ontario nurses nurse regulator their college approved for nurse practitioners to independently provide abortion medical abortion and then in November when Health Canada's regulation changed permitting nurse practitioners across the country to be able to provide medical abortion so what we saw was that the number of providers nearly doubled before Mipha Pristone was deregulated to after the deregulation and yet the proportion that were family doctors which is nearly four out of five abortion providers across Canada have always been family doctors both medical and surgical providers the proportion didn't change even though the number of providers nearly doubled and what we see is that the proportion of all abortions that happened in the first trimester that were done through medication abortion skyrocketed particularly when the when the regulations were removed so 10% in the year when we still had regulations and up to 33% two years later once the regulations were removed and for comparison we see the United States here who took us almost 18 years to reach 30% and is currently at 22 years I think 32% I think of their qualifying first trimester abortions are undertaken through Mipha Pristone largely because the restrictions are in place similar to those Health Canada had at the beginning when we look at countries around the world and their restrictions and many of these countries introduced Mipha Pristone in the late 1980s as you see we see that largely it was in many cases eight or 10 years before people reached the 30% but I want you also to see that in areas where they were able to be able to access medical abortion people became much preferring to have medical abortion over other sorts of abortion with 80 and 90% of abortions being delivered through medical abortion which we hope to see as a possibility in Canada as we move forward as well we did see that the proportion of all abortions in Ontario that were done after the first trimester so after 14 weeks of gestation decreased once Mipha Pristone was available and this is data that we're still finalizing the analysis for so this really is a first peek but interestingly the proportion of abortions at 14 weeks gestation or later reported by the Canadian Institutes of Health information has been about 10 to 12% or higher over the past several decades and what we found in Ontario was that when we were very careful in analyzing the data and looking at data cleaning throughout this episode that really a small proportion of abortions in Canada with over 94% in Ontario being provided in the first trimester very few going on to the more complicated and second trimester where people are more likely to have some complication we looked at the complications and adverse events with all first trimester abortions before Mipha Pristone deregulation and in the period of two years after the deregulation and again this is comparing largely those first trimester surgical abortions which were 96% of those abortions before the deregulation to the outcomes with Mipha Pristone abortion and you can see the outcomes are nearly the same here certainly we weren't experiencing any increase in complications due to the fact that we trusted people wishing to have an abortion to carry it out on their own whether and when they wanted it once they've been given the knowledge and the method they needed through the provision of prescription and dispensing from their nearest pharmacy similarly we wanted to know well perhaps people walked away and decided not to take the pill or they gave it to somebody else to take at that time and in fact no that didn't happen the number of subsequent deliveries among people who were ever prescribed or dispensed Mipha Pristone was very small and comparable to those seen in other countries people who needed to go on to a subsequent abortion or have a neck top of pregnancy similarly very small increase and only as expected these rates are actually the same or lower than what we see in other countries for these outcomes after Mipha Pristone when we compared not to all first trimester abortions but just comparing to the medication abortions we see that Mipha Pristone is as expected much safer than was methotrexate for medical abortion prior to the approval so then what have we seen overall in this journey in Canada we understand that when Mipha Pristone was available without restrictive regulations that the uptake of this new method was rampant both more primary care providers were willing to provide abortion to their patients and the complications and severe events were infrequent and very comparable to what we've seen in other places in the world and that ongoing pregnancies were infrequent in fact medication abortion is safe when people are supported by their public health system to access to free contraception from their closest primary health care provider and given what they need to self administer their medical abortion when and where they choose so our key points overall then abortion is common you don't make it less common by restricting it with laws or regulations but you do decrease the safety and you increase the burden on people to be able to travel and leave their communities and their families and their work to get to centers where you offer abortion if you have more restrictions abortion became legal in Canada with decriminalization in 1969 still one of the only countries in the world to have completely decriminalized abortion and our rates did not increase once decriminalization came in place but people were able to access safer care and safety for abortion improved similarly sorry it became legal in 1969 and decriminalized in 1988 more than 30 years ago now and Mipha Pristone medical abortion regulations initially were restrictive and not evidence-based when introduced in 2015 but shortly after availability in 2017 the restrictions were removed and in fact what we can see is very strong evidence that abortion is available closer to home that abortions increasingly available in primary care and that people are seeking their primary care providers and across the country primary care providers are stepping up to the plate to take on this new skill which the interviews of Dr Monroe have been illustrating people find remarkably easy to blend into their normal everyday practice with tools such as our downloadable primary care checklist for what needs to happen in in your visit with your patient asking you for a medical abortion so Canada's outcomes despite the fact that we have no regulations and we are the global leader on this mirror the international experience Mipha Pristone is safe and when you make abortion safe and accessible to people you make there you improve the health for our population so I want to recognize we have massive teams that's contributed to all of this throughout the country and many who joined after our initial team who had made the grant application here and at collaborators at universities all over and to be very happy to take your questions super thank you so much Wendy that was incredible we we have a number of questions now and I would invite you to open the Q&A box if you want to type in a question for Wendy and I'll work my way through them I will be reading them aloud because not everybody has access to read them and also we want them in the recording so that if somebody's watching this after the fact they know what Wendy is responding to so I'll start first with this it is incredible that in 2020 and some 32 years after the morgan taller case and in light of what the world health organization has said about reproductive health that reproductive health wow it's moving around okay the reproductive health and family planning related health care could be this restricted it speaks to the continuing ghettoization of women's health and women's issues although reproductive health as you have noted affects not just women but children and families are you able to say how much medical education serves as a shaper of reproductive health care availability and the regulation of same so a wonderful question I think not just medical education but I think education of everybody shapes reproductive health policy and the provision and the more that we can start talking to our children at their earliest stages of their lives on their own sexuality their sexual health on being able to take empower them to be able to live health in the full definition of their lives excuse me as well as increasing the education at the stages throughout their life so that they have the perspectives to de-stigmatize reproductive health to de-stigmatize sexual behaviors throughout our society these things will make a tremendous difference as the questioner pointed out that the provision of education within health care is also a really important factor and I want to recognize that Dalhousie leads Canada in providing the first interdisciplinary health care provider course under Martha Painter on our PhD student in the Faculty of Nursing offering health care provider educational and abortion specifically in this course so I just think that's a foundational effort that should be picked up throughout Canada the the education for health care professionals in this new skill and very similarly the education in the new skill for inserting sub-dermal implant contraception which just became available a month or so ago will happen in the normal way that health care provision happens for those already licensed and in practice that there are online courses available that there are linkages to mentors available and there's a clinical practice guidelines and as I mentioned a downloadable 10-minute here's your practice sheet that you can use to help find the steps to implement this in your everyday care but health professional training is another issue altogether and I think that medical school, nursing schools, hopefully midwifery schools and and pharmacy schools across the country now that mipipristone is available and deregulated should incorporate exposure to understanding how to use this new part of practice in their normal training mechanisms for both their pre-licensure and their undergraduate training. Thank you very much and as I move to the next question I'll flag for you that you can if you do the little thumbs up if you vote what it's going to do is generate an indication of the level of interest in the question so it'll actually bump it up in in terms of what I see so we will if you if you want to do that we can we can filter the questions that way so I'm going to move to this next question in Canada can I get a prescription for abortion pills before I become pregnant such that I may have it on hand where and when I need it what is the state of evidence in Canada on the deregulation of abortion pills as a prescription product so related to that such that they may be available over the counter or in a retail outlet without unnecessary restrictions of health professional regulation and added to that or online we had another listener at that so yeah so um a couple of things uh one of the pieces that I wanted to highlight is what a advantageous position Canada was in when the pandemic restricted our access to in-person health care it meant that immediately we were able to pivot to do telephone consultations with people accessing abortion under 10 or 12 weeks and be able to provide them with the methods that they needed to have a prescription delivered from their pharmacy or pick it up from their pharmacy after consultation with their physician by video or by telephone or their nurse practitioners so that we're in a wonderful place to be able to make telemedicine abortion available and this wasn't possible in most countries around the world where things like ultrasounds and blood tests and in-person watching you swallow the pill were massive regulatory difficulties that needed legislative change at the federal level in many cases to be able to make telemedicine abortion available so we are um tremendously lucky uh as uh presented with the deregulations and as per the um the note by uh health Canada's announcements with mipipristone the decision to make a prescription for mipipristone uh with a person seeking to have an abortion or to get the abortion pill is completely between that health care provider and that person and if those two people decide that having a prescription in advance of need is required then there are no federal regulations that would prohibit that uh that provision in events of need it would be off-label for the uh the drug and there are no guidelines uh national clinical guidelines at the moment on provision in advance of need from the Society of Obstetrician Gynecologists um but it would be up to the clinical judgment of the health care provider and their um a knowledge of and discussions with the health care person seeking uh the prescription to be able to make that decision thank you okay um if this person is saying I am a sex educator that often works with youth and we're seeing a lot of very concerning content coming from the United States on Instagram and TikTok promoting preparing naturopathic and herbal forms of abortion in the instance that abortion becomes illegal especially considering the US context of course or to be more natural um this content of course travels to Canada and influences and informs our youth do you have any advice on this so I want to just again recognize the amazing leadership of Health Canada with this before um Mipha Pristone was approved and also throughout the time in looking at these regulations with Mipha Pristone one of their primary motivations was to ensure that safe and effective abortion was available for Canadians throughout the country and because now we have the some of the most safe accessible abortion of anywhere in the world with the cost of Mipha Pristone being covered by all the provincial governments and the ability to get this from any primary care provider our hope is that people will not need to turn to those unsafe methods and to highlight for those of you who are providing counseling that those unsafe methods have been used for centuries and they are used in the low and middle income countries where abortion is illegal and where abortion is not accessible and this is largely responsible for some of the maternal morbidity and mortality experienced by those who turn to unsafe and unproven and untested methods in the context of legal restrictions or regulatory restrictions our youth do not need to turn to these unsafe methods and we should not encourage the tragedy of seeing complications with long-term fertility um perhaps being affected by undertaking an unproven or unsafe method that would have repercussions let alone those who would have serious morbidity and mortality and perhaps not survive the use of some of these uh unproven and unsafe methods for conducting abortion thank you and we've got a couple of questions here that actually relate to uh conscientious objections so i'm going to throw both of them at you and and allow you to take them as you will so what about the role of conscientious objection on the part of healthcare workers what are your thoughts on a process of effective referral to help and the second is i'm an abortion rights activist in northern manitoba only in the past year after serious advocacy we find a god miffy available in the northern health region he seems to be an abusive power by the health region in manitoba in which they're denying people access on the basis of religious freedom and they only change it when they're threatened with legal action and social backlash anyway i want to keep making miffy accessible for their up north like church will manitoba do you have any advice she knows she followed your model closely to make this happen so conscientious objection i guess on the part of providers and also on the part of institutions whether they be hospitals for instance or health authorities so great questions and certainly healthcare providers uh have a number of issues where they examine their own conscience and and make decisions about the range of care options that they will provide with primary care providers and obstetrician gynecologists and again talking to nurse practitioners they carry an obligation as part of their license from their licensing authority to be able to ensure that people have access to legal healthcare in canada and they are not permitted through physicians are not permitted through the canadian medical association guidelines and the health professional regulations to restrict on the basis of a person's diagnosis you can't discriminate in the healthcare you provide on the basis of diagnosis and if you do not feel able to provide that healthcare yourself you are obliged to find a mechanism to support your patient to be able to access that healthcare elsewhere so these throughout the country the health professional regulators and the health professional associations have struggled with issues of moral duty and health professional regulation with respect to conscientious objection and to recognize the diversity among both providers and patients but there is still a duty to allow people access to legal care in canada thank you okay um if abortion is so safe and so easy to access and such a great option for people to gain some control over their reproductive lives why should we be concerned with the number of abortions or an increase in abortion rates have a comment back to this which may set you up for your answer i don't know i think we can keep statistics data are important but we need to do it without attributing moral value to the number of abortions and without assuming that a lower number is better right um so harking back to you know the very premise at the beginning of the talk is that it isn't um i think so much about abortion this is a conversation about people's sexual health about the stigma in our society to do with reproductive health it's a conversation about whether they have access to the knowledge to the methods to the services they need to achieve their own reproductive goals and we want people to be able to be good at that if they would like to be and i think the numbers of abortion for us are just a measure of whether we've been good enough have we helped people to be able to access the ability to time and space their pregnancies and their births so that they're able to achieve their own goals and if it comes to a time where they are faced with an unintended unwanted pregnancy i think facing somebody with that realization is what we want to avoid we want to empower them so nobody has to be in that position and if once they're in that position they choose to have an abortion it should be readily available not as a stigmatized option and not as something that we consider bad but it's an indicator to us that we have an unmet need higher upstream where we have failed that person and that couple in that family in being able to support them for the optimal sexual health that they need thank you so now i have a comment which you may wish to comment upon i think that your work is formidable and crucial hopefully this will result in positive changes however i also think that we need to implement and improve education in human sexuality we don't teach sexuality even in psychiatry or medical school and last year finally the united nations recognized pleasure as a human sexual right hence the problems in abortion management i couldn't agree for i think you said it very well perfect well let the comment can stay next question amazing presentation thank you can you talk a bit more about universal cost coverage of prescription contraception topic i know is dirtier heart the group access bc has successfully advocated for it to be put into bc's budget this year are you optimistic that other provinces and territories would fall as soon hopefully without taking many years and can the federal government play a role in making this happen yeah so that's a great question and as jesslyn knows and alluded to also a issue very close to my heart and you may have heard from my haranguing earlier that i think upstream being able to provide people with free contraception is a crucial missing piece in our canadian health care system and around the world when we indicate that we provide free management for all pregnancies but we don't offer people the free way to be able to prevent those pregnancies nobody can believe that we have a health system that crazy the my contraception and abortion research team was funded by the public health agency of canada and cihr to undertake a study where we conducted a door-to-door sexual health survey i presented some of those results earlier and the main function of that was to be able to use that data to create a very nimble model for the bc government on the cost effectiveness for universal subsidy for contraception we presented that model to the government in 2018 and have provided three or four revisions at their request since that time and the chief public health officer originally peri kendall and now bonnie henry have been working with us every month to ensure that our model is representative our model was able to predict within 1.3 percent the number of pregnancies that actually occurred in bc and by inserting the changes when we make contraception free we can see a plummeting of unintended pregnancies and an improvement in many health outcomes as well as improvement costs for the province so we've been working very closely with the province of bc to be able to support them to implement this change and appreciate also the advocacy organizations that have worked in the public sector with their mp's to advocate not just in bc but i understand there's an organization in ontario as well and just to also say that one of the things we think we're seeing in the data in ontario we've got some more analysis to do is a change in the number of abortions related to ontario's decision to provide free contraception free prescriptions for all people under age 24 and we think that made an impact of course the average age of abortion is about 26 so it wasn't enough impact you've got to make contraception free for everyone and we hope that if we can see this sort of change coming up in bc that other provinces will be able to implement this improved public health approach to be able to better serve the needs of their society for healthy lives and healthy families thank you okay this is returning us to the conscientious objection piece and i think it's worth returning to it for a bit of clarification so the statement is there's really no obligation for doctors to refer appropriately in canada except for ontario i think the issue is that doctors with anti-choice beliefs will prioritize those over any obligation to refer or even treat patients respectfully we need some kind of enforcement or monitoring mechanism so i might color commentary on that a bit which is that there's there isn't a duty to refer outside ontario in the in the practice standard i would argue and got some trouble for arguing it that there's a duty to refer through tort law across the country and also a number of colleges have what's called a duty of effective transfer of care so just to nuance that question but to ask you to comment on the notion of this duty to refer the duty of effective transfer of care and perhaps something about enforcement or monitoring yes um well i think the great tragedy is that these um loopholes uh are often leveraged by health professionals and it's uh it's a minority of cases but of course these are the ones that's most concern us uh in their dealings with people with the uh most disadvantages in other aspects of their life we spoke already about how the uh within the population seeking abortion care we find a concentration of those with a range of disadvantages in their social determinants of health and when a health care provider takes advantage of a person seeking abortion to cause a delay or a blockage or a refusal to provide that care they are acting against uh those people the least resilient to be able to advocate for themselves and uh and to move on and this is why our organization such as Action Canada for Sexual Health and Rights and many others under their umbrella and uh correlating with them across the country are so important in helping to be the voice for these populations who don't have their own voice um the uh one of the areas that every province recognizes is that the health professional in question is given a license to practice uh their profession by a provincial health licensing authority and i think the more that we can empower and able and provide materials and processes that will support people to make call uh uh complaints to the licensing body the more likely it is that those who receive the license will need to adjust their care particularly for these vulnerable populations thanks very much unfortunately we have come to 120 and i am certainly could keep going for quite a while but i do have to um pull it to a close there's there's um i just i think this has been a wonderful tour through an incredible policy process um and processes really and i have to say it leaves me optimistic um with robust research careful analysis a lot of effort and patience and working collaboratively across disciplines and sectors um a positive difference really can be made in the lives of Canadians and that's extraordinary and uh so i i can ask everybody to sort of send their virtual good wishes to you and thanks for such a remarkable presentation and uh as a final word though i would note that the uh this was the last seminar for 2020 uh we will return on January 15th with a talk on the health of people who experience imprisonment in Canada and details and the full semester schedule which is truly extraordinary and Lena 10a has put together a remarkable program for us all they are available on the health law institute website and so i would say thank you dr norman thank you for a wonderful presentation and i hope to see all of you virtually in 2021 thank you dr danny it was a true honor to have the chance to present in this forum i just really enjoyed this hour thanks so much bye everyone