In the wake of the Supreme Court of the United States decision in Dobbs v Jackson Women’s Health Organization in June 2022,1 the need to ensure equitable access to safe abortion services internationally is more apparent than ever. The decision overturned Roe v Wade,1 removing federal protection for abortion care in the US provided since 1973 and allowing individual states to pass criminal laws governing abortion services. Abortions were restricted in more than half of all US states,2 threatening patient safety.3 Access to abortion care outside abortion-restrictive states became imperative. Although crossing the northern border of the US into Canada to access abortion services is possible, US patients travelling to Canada may face extreme costs, including non-citizen fees for clinical services, bureaucratic barriers, and the need for a valid passport.4
Canada is 1 of the most progressive legal jurisdictions for abortions in the world, with services decriminalized in 1988.5 There are no mandatory waiting periods, partner or parental consent requirements, or gestational duration limitations in law5 that are found in jurisdictions with partial decriminalization. For example, abortions in Colombia6 are limited to pregnancies up to 24 weeks’ gestation, and abortions in Ireland7 are limited to pregnancies up to 12 weeks’ gestation, inclusive of a 3-day waiting period.
Medication and procedural abortions are free to all patients in Canada with provincial or territorial health insurance, non-insured health benefits, or coverage under the Interim Federal Health Plan.5 Despite the absence of criminal restrictions and availability of public funding for abortions, accessing services can still be challenging. Barriers to abortion access in Canada generally relate to a shortage of providers, particularly those with training in later gestational duration care who are spread across a large geographic distance. This requires patients to travel long distances for care, which is costly. For example, clinical care provided to a New Brunswick resident who travels to Ontario for second trimester abortion services is covered through reciprocal health care agreements between the provinces. However, travel costs (eg, flight, hotel) are only partially covered and require the patient to pay upfront and be reimbursed later. Lost wages, childcare fees, and other indirect costs are not covered.8
Previously, there were also differences in provincial abortion regulations and services that contributed to care gaps. Patients in New Brunswick required referrals from 2 physicians to receive publicly funded abortions until 2015,9 and until 2024, the province only funded procedures performed in a hospital.10 Prince Edward Island implemented abortion services in 2017.11 Legacies of inequities in service persist, even after they were remedied.
The decision in Dobbs v Jackson Women’s Health Organization to end the constitutional right to abortion in the US caused a worldwide reckoning about persistent inequities in abortion services. Using recent experiences of improved access to abortion care in Canada, we present global arguments for: 1) regulatory and legislative changes to remove restrictions on medication abortions, and enhance telemedicine abortion services; 2) enhancing health professional education and training, routinizing training in abortion services, developing cultural safety and confronting discrimination, extending capacity to provide care at later gestational duration, and expanding the pool of abortion service providers; 3) improving public awareness of abortion services and dispelling misinformation; and 4) providing public funding for contraception. These concrete steps are precursors to systemic work to address social injustice and its impact on reproductive freedom.
1. Regulatory and legislative changes
In 2022, the World Health Organization (WHO) updated its abortion management guidelines, defining quality abortion care as care that is “effective, efficient, accessible, acceptable/patient centred, equitable and safe.”12 This means care delivery is based on scientific evidence, optimizes resources (including human resources), is accessible (not only in timeliness and affordability, but also geography), culturally acceptable, inclusive, and safely delivered. The WHO recently released a guideline supporting self-managed health care that includes abortions.13
Removing restrictions on medication abortions. A fundamental step to improving high-quality abortion care is extending availability of the mifepristone-misoprostol medication regimen for medication abortions. In many countries, medication abortions are only available by adhering to onerous regulations.14 Health Canada eased these restrictions in 2017 so medication for abortions could be prescribed by a family doctor or nurse practitioner,15 and the abortion rate remained stable, as did the proportion of adverse events and complications.16 Research found easing restrictions on prescribing abortion medications expanded the pool of abortion providers, which rose 4-fold in the first 2 years after regulatory changes, and had a disproportionate and positive impact on rural communities.17 An Ontario study found that, between 2017 and 2022, the proportion of regions with a mifepristone-dispensing pharmacy increased to 77% from 19%.18 In Canada, medication abortions are now the most common way abortions are provided. Reducing restrictions on medication abortions is an effective way to improve access to abortion care.
Enhancing telemedicine abortion services. Conditions of the COVID-19 pandemic advanced new models of abortion care in Canada. Funding regulations, clinical protocols, and logistics allowing abortion medications to be prescribed via telemedicine emerged.19,20 The popularity of telemedicine increased physician and nurse practitioner comfort with prescribing no-touch or low-touch medication abortions for appropriate patients,21,22 where patients seeking first-trimester abortions only interacted with the health care system at the pharmacy to pick up their medications. Medication could even be delivered directly to a patient’s home address, where they and their support system could engage in care in a familiar environment. Telemedicine is particularly helpful in rural and remote settings. A 2022 review summarized other support considerations for practitioners delivering new models of care.23 Enhancing capacity for providers to deliver abortion services via telemedicine removes many travel-related barriers to patient care.
2. Enhancing health professional education and training
Routinizing abortion services training for health professionals. Without dedicated initiatives, health professionals including those already authorized to prescribe medication for abortions may be underinformed about the medications’ mechanisms of action, the medication prescribing process, community availability, safety considerations, and patient follow-up needs.24,25 In 2024, the Canadian Association of Schools of Nursing released competencies for the provision of abortion care for undergraduate and graduate nursing students.26 The WHO developed training resources for health professionals to improve the provision of comprehensive abortion services.27 Routinizing abortion services training for health professionals can help providers implement medical abortion services in their practices, further improving patient access to care.
Developing cultural safety and confronting discrimination. Despite the best intentions of abortion care providers, gendered language in clinic names, educational pamphlets, posters, intake forms, and the ways in which providers address patients seeking abortion services can exclude patients with transgender and nonbinary gender identities.28 In response, many Canadian clinics made deliberate efforts to improve gender inclusivity; work that must continue. Abortion care providers must also acknowledge and address the systemic racism of historical and contemporary obstetrics and gynecology care, and make efforts to learn about and implement cultural safety and reconciliation in their practices to best care for Indigenous patients and patients experiencing racism.29,30 Enhancing the approachability and acceptability of abortion services improves patient access to care.
Extending capacity to provide care at later gestational duration. International and domestic travel restrictions during the COVID-19 pandemic highlighted problems with limitations on gestational duration for elective procedural abortions in some geographic regions. Although not defined by law in Canada, limitations due to provider comfort and preferences, training, and facility-defined limits resulted in a concentration of later gestational duration capacity in 4 urban centres: Vancouver, BC; London and Toronto, Ont; and Montréal, Que. Conditions of the COVID-19 pandemic prompted providers across Canada to acquire new skills and levels of competence in providing care at later gestational duration, and make changes to staffing, training, equipment, and infrastructure to support these extensions.31 Building and sustaining skills in second- and third-trimester abortion services reduces stigma and decreases the risk of further delays in patient care access.
Expanding the pool of abortion service providers. In Canada, authorizing nurse practitioners to prescribe abortion medications was an important step in expanding patient access to abortion services. Midwives are also ideally suited to prescribing abortion medications to patients seeking medication abortions.32 Midwives in Quebec are authorized to prescribe mifepristone,5 and medication abortion care provision by midwives has been implemented as standard practice in some countries around the world and was shown to be effective and efficient.33-35 Expanding the authority to prescribe abortion medications beyond physicians is an important approach to improving access to abortion care.
3. Improving public awareness of abortion services
Expanded access to abortion services made possible by medication abortions is hampered by structural and informational barriers that make abortion services difficult for both patients and providers to navigate. Improving public awareness about abortion access pathways is critical to ensuring expanded access to care. Over the past several years, the Canadian government funded initiatives to develop and disseminate evidence-based tools and resources for providers and the public to enhance understanding about available abortion services.5 Improving public awareness of abortion services is critical to health service delivery, indicative of care accessibility, and an obligation of the public health sector.
Dispelling misinformation. Health institutions and governments should counter false information about abortions perpetuated by anti-abortion organizations and unregulated crisis pregnancy centres, which are often faith-based, hold charitable status, produce misleading advertisements, and include staff positions dedicated to perpetuating misinformation.36-38 Legislation was introduced in Canada in 2024 requiring such organizations be transparent about their activities or risk losing charitable status.39 The decision in Dobbs v Jackson Women’s Health Organization inflamed anti-abortion rhetoric across the US40 and echoed internationally. Considering the abundance of US media that reaches Canadian and international audiences, deliberate action by health institutions and governments is required to counter the potential harm to patients of misinformation about abortions and abortion services.
4. Providing public funding for contraception
Nearly half of all pregnancies worldwide are unintended; a “neglected crisis” according to a 2022 report of the United Nations Population Fund.41 Unintended pregnancies are disproportionately experienced by people facing poverty, racism, and intimate partner violence.41 The same people also face socioeconomic barriers to accessing abortion care, regardless of its legal status or availability of public funding.41 While abortions can resolve unintended pregnancies, access to free contraception can prevent them.41
The United Nations sustainable development goals call for universal access to family planning services, including contraception.42 Public expenditures for family planning were found to be a fiscally, ethically, and clinically prudent investment in the US and United Kingdom.43,44 A US study found a government investment of $1 in family planning programs resulted in an estimated taxpayer savings of $7.09.43 Public Health England estimated a return on investment of up to £9 for each £1 invested.44
British Columbia and Manitoba implemented universal contraception funding in 2023 and 2024, respectively, and in 2025, British Columbia, Manitoba, Prince Edward Island, and Yukon forged agreements with the federal government to provide universal access to contraception medications.45 Every Canadian province and territory should implement universal contraception funding, as it is more expensive for a health care system to pay for unintended pregnancies than it is to subsidize contraception.46 Without universal access to contraception, niche programs, such as those providing free contraception to youth,47 for certain types of contraceptives (usually less effective short-acting or barrier methods),48 or immediately following an abortion49 can create inequity and might be perceived as coercive in their restrictedness. International and domestic sexual education curricula must also be improved to ensure youth understand the benefits and concerns of how to receive timely access to contraception, emergency contraception, and abortion care.
Conclusion
The harmful consequences of the decision in Dobbs v Jackson Women’s Health Organization on US patients seeking abortion services is a call to action for countries that have fully or partially decriminalized abortion care to make additional strides in improving access to care. Canada is at the forefront of providing abortion care to patients in terms of legality and public funding, but further improvements to policy and regulatory frameworks, provider training, and public education are required. It is imperative to expand availability of medication abortions, enhance health professional education, develop clinical capacity and cultural safety, improve public understanding of abortion services, and ensure public funding for contraception.
Footnotes
Competing interests
None declared
The opinions expressed in this article are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
This article has been peer reviewed.
La traduction en français de cet article se trouve à https://www.cfp.ca dans la table des matières du numéro de novembre/décembre à la page e258.
- Copyright © 2025 the College of Family Physicians of Canada
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