By: Tatiana Furtado
Clinical associate professor at the University of British Columbia, Dr. Regina Renner breaks down terminology and procedural practises on abortion care in Canada.
After completing her residency and a family planning fellowship in Portland, Oregon, Dr. Regina Renner moved to Canada and began her practice as a fully-licensed OBGYN. Later on, Dr. Regina Renner became a clinical associate professor at the University of British Columbia, narrowing in on family planning and clinic work on Vancouver Island. Most recently, her research has led her to become the principal investigator on the 2019 Canadian Abortion Provider Survey (CAPS). Funded by the Canadian Institutes of Health Research, it surveyed physicians, nurse practitioners and administrators who partook in medical or surgical abortion care in 2019. The survey is meant to improve access to abortion care services in Canada. The data analysis is currently in its final stages of publication.
I sat down with Dr. Regina Renner to address any current accessibility issues around abortion care in Canada. Additionally, she broke down the step-by-step process of both surgical and medicated-induced abortions within different trimesters and gestational periods.
Based on your experience and research, what is the biggest accessibility issue with abortion care right now in Canada?
I think the biggest issue is still to have enough providers that are comfortable providing and that are comfortable to be public enough about their services for patients to be able to identify services in their home communities, especially when it comes to rural and remote areas. I think providers are fearful of the stigma, the harassment, how it might affect your relationships in your hospital, your office, with your coworkers and it goes so much more beyond that. We had about 12 per cent of respondents in our survey say that they experienced harassment. But those are obviously the ones who are providing and the worry about harassment will be much higher in people who chose not to provide.
Can you break down the process of first trimester surgical abortions?
In a first trimester surgical abortion, it is either done in a hospital operating room or at a surgical center. There are very strict regulations and it’s regulated by the colleges in each province. So no matter where you are, it involves stretching the cervix and emptying the uterus. Usually with vacuum suction and it takes about five to 10 minutes. It’s a very safe procedure. I always tell the patients, if you were to compare all the complications that happen to childbirth, it’s safer than childbirth. The majority are done with IV sedation and the ones that are done in the operating room are oftentimes done with deeper sedation or general anesthesia and then oftentimes we use some local anesthetic around the cervix as well.
What are some of the risks associated with first trimester surgical abortions?
There’s a small risk of bleeding to the point that you would need a blood transfusion. And if you need blood, blood is extensively tested and there’s a very low risk of transmission of an infectious disease or an allergic reaction. There’s a small risk of uterine injury, a perforation, for example, a cervical laceration or injuring any surrounding structures or leaving tissue behind any of which might then need additional surgeries. An ongoing pregnancy would be exceedingly unlikely, but theoretically could happen as well.
Can you break down the process of second trimester surgical abortions?
The second trimester is a bit different in that the products are bigger and there you need more cervical dilation. It is at that point considered safer to prepare the cervix ahead of time so oftentimes we use an osmotic dilator for that or misoprostol to soften the cervix and pre-stretch it a bit. So the way osmotic dilators work is you place them in the cervical canal and then they absorb moisture and swell up and thereby start to open the cervix, which means that there’s less mechanical dilation needed and that makes the procedure safer. And additionally, in the second trimester, we usually use forceps to help break up the fetal tissues because it would be too big to come out intact. Then we use suction as well to remove the rest of the placenta. That takes a little bit longer than the first trimester and all the risks are generally speaking the same. But with each week of gestational age, the risks go slightly up.
How much sedation does a patient typically need?
That is a really good question because it is multifactorial. It depends a bit on resources. Fortunately because people have insurance in Canada, I think that’s a big reason why our standard is IV sedation as something that is more comfortable as someone who has worked in the U.S. where people are uninsured and pay for it themselves. There is much more local sedation in the U.S. because sedation is experience and you have to pay for it. The patient factors also play into this, the gestational age, the further along someone is the more sedation usually. So the second trimester, especially past 18 weeks, oftentimes people will be intubated as it protects their airway more. If they prefer not to be and prefer to be more asleep ideally you can adjust it and have it all available but sometimes, that’s not the reality.
What is a first trimester medicated-induced abortion?
First trimester medicated abortion is the mifepristone and misoprostol that is in Canada on label. On label is up to 63 days and off label is up to maybe 77 days. It’s a phenomenal thing in Canada compared to many other countries as it’s by prescription, you can go to the pharmacy, which doesn’t mean that every pharmacy will be carrying it or, you know, supportive of getting it. But theoretically at least, it may be distributed that way. You get the medication and you take it at home. On day one mifepristone and on day two misoprostol. So, mifepristone stops the pregnancy from growing and misoprostol induces contractions and the miscarriage. There’s about a 5 per cent chance of needing a procedure in the end either because it didn’t work at all, or not the entire tissues passed or because you’re acutely hemorrhaging. So this is where it becomes important to still have access to some emergency care and it’s common to have really remote people debating this option. The risks otherwise are very similar to surgical, except for that there is no instrumentation.
What would a person experience after the pill?
I always say on the first day of the mifepristone, most people don’t have many side effects.On the second day of the misoprostol, I recommend to take it on a day where they can take off work and can be at home in their own environment. If they have children, ideally organize some childcare, because within usually four hours after taking the misoprostol, bleeding and cramping can start and that can be quite intense. The bleeding can last up from two days to two weeks.
What is the recommended gestational period for first trimester medicated-induced abortion?
The Society of Obstetricians and Gynaecologists of Canada, which is considered the professional organization guidelines, says up to 70 days. After that, at least in Canada, it isn't usually recommended. The reason why is it’s more likely not to work and the amount of bleeding and cramping increases and the risk of complications and needing to go to the emergency department. But again, I think like so many things in medicine or in life in general, the risk benefits change, depending on what resources are available. During COVID when someone might have not been able to access alternatives that might be better than the alternative to continue pregnancy.
What happens during second trimester medicated-induced abortion?
The second trimester medicated abortion happens in the hospital usually. There is sort of this interesting gestational age gap, I would say between 11 to 16 weeks where it’s not a frequently chosen approach. I think it has something to do with the risk of the placenta not coming on its own and needing a DNC, which is the section evacuation, in the end is higher. It doesn’t come up very often, where it does come up often is I would say around the 17th week onward either in the context of a spontaneous intrauterine, fetal demise or in the context of a desired pregnancy that then has some complication that makes the pregnant patient decide to terminate the pregnancy and they sometimes choose labor induction. It happens in the hospital on perinatal and you get medication similarly to if you were going to deliver a life baby. But that’s not the goal there and so that happens in the medicated second trimester abortion via labor induction.
Who has access to mifepristone and misoprostol in Canada?
In Canada we have the mature minor law, and in all provinces but Quebec there is no lower age limit for someone to be able to consent. As long as the provider has the sense that the patient understands the diagnosis and the implications of their decisions. That helps a lot because you don’t then need patient parental consent or even parental information. This doesn’t come up very often, but it's there and at least it’s something that’s not limiting.
If someone does not have coverage and is not a Canadian citizen, how much would this medication cost them?
Around $450. It depends a bit on where they go and surgical procedures would also be a few several hundred dollars.