Some barriers to abortion in Nova Scotia have come down in recent weeks, but for many rural women there are still hurdles to overcome.
Earlier in September the Nova Scotia government announced the end of the need to get a doctor or nurse practitioner's referral for a surgical abortion at the Termination of Pregnancy Unit (TPU) at the QE II Hospital in Halifax.
It was also announced that funding would be given to women whose insurance does not cover the $300 to $400 cost of the drug, Mifegymiso, for a medical abortion. Mifegymiso must be prescribed by a doctor.
"This is definitely a step in the right direction," said Julie Veinot, executive director of the Lunenburg Sexual Health Centre.
But the self referral rules only extend to the TPU and not to other medical practitioners like Obstetrician Gynecologists (OBGYNs). Around 85 per cent of the abortions in the province are performed at the TPU, but they can be done by OBGYNs at South Shore Regional Hospital in Bridgewater.
For women trying to access abortion in their own community or nearby there are multiple steps as well as problems they can face, which often leads them to seek help from people like Veinot.
"Most of the people who contact us, typically don't have family doctors," said Veinot. "The ones who are contacting us who don't have family doctors are typically contacting us as a last resort hoping we have doctors here."
That typically happens around once a month and the centre doesn't provide care, only education and direction.
Besides needing a referral for a surgical abortion from an OBGYN, women also have to get blood work and an ultrasound done in order to see how far along they are, which also require doctor referrals. The only ultrasound machine in Lunenburg/Queens counties is in Bridgewater.
Even if women get those two appointments done, there is no guarantee their physician will give them a referral for an abortion or prescribe Mifegymiso as they have the option to decline.
If they don't have a primary health care provider, women can go to outpatients or a walk-in clinic, but there they may face the chance their doctor will not be pro-choice. There is also only one Nova Scotia Health Authority walk-in clinic on the South Shore, which is located at the South Shore Regional Hospital in Bridgewater.
"It's more of a challenge in rural Nova Scotia because of course if they're in Halifax I can refer them to the Halifax Sexual Health Centre. They actually have doctors on staff," said Veinot, adding that all of the doctors there are pro-choice.
A spokesperson for the Nova Scotia Health Authority told LighthouseNOW in an email that if a woman is unable to get a primary referral the authority's office staff would be able to assist.
Veinot says there is little education on the subject of abortion and that details on where to go and what to do on the South Shore are murky.
She isn't sure which OBGYNs in the area perform a surgical abortion, which doctors are pro-choice, and which doctors are certified to prescribe Mifegymiso.
Doctors have to take training around the drug before becoming accredited to prescribe it and Veinot believes there are only about 15 doctors in the province who have that accreditation.
"With 15 doctors across the province, odds aren't good that every community is going to have access," said Veinot.
"The question is, are more doctors going to do that and of course are they going to be open so that we know we can refer people to those doctors as well?"
She believes because of the stigma attached to performing or seeking abortions, it's harder for doctors to come out and talk about it as well.
Barriers in rural areas
Traveling for the various appointments can be a difficult task for vulnerable women such as those with low incomes or no vehicle access, women who may already have children but no access to childcare, or those dealing with domestic violence. These issues can also extend to teenagers who may not have family support, money, or vehicle access either.
Shannon Hardy started Maritime Abortion Support Services (MASS) five years ago after hearing about women on Prince Edward Island who were unable to access the service on the island.
Her group of volunteers provides services like driving to the TPU, sometimes picking up people from as far away as Cape Breton or helping find accommodations for women who need to spend the night in Halifax due to an early morning appointment. They also answer calls and emails from people wondering how to access the services.
Hardy says the barriers, including financial ones, in rural areas have been on her radar for a long time.
"Not everyone who lives rurally lives in poverty, but it's much more common in rural areas," said Hardy, adding that there are also infrastructure issues as well like a lack of public transportation.
Rural women also often face fears of privacy violations, particularly if they have to have multiple appointments where they run a greater chance of meeting staffers or members of the public who they know. Hardy notes that breaches of confidentiality in their own communities are a big fear for women who choose to go to Halifax.
"Rural women may not want to seek these services in their community because there is still stigma," said Hardy, noting that she believes things are starting to improve on that front in recent years.
Hardy also noted that it's not just getting the abortion itself that can be difficult either, it's also seeking aftercare too.
"Do you have someone to talk to? Do you have a doctor to go to? All of this, just doesn't have to be a barrier; we can do this," she said.
Mifegymiso may help rural women who want to have a medical abortion in their own community. The drug can be taken up to 49 days in a pregnancy. An ultrasound is still required before taking the drug.
The Nova Scotia Health Authority says 25 per cent of women who had an abortion in 2016 had one before the seven week mark, which is an improvement over previous years when TPU used to follow a guideline that required women to be at the eight week mark. In an email to LighthouseNOW it was also noted that the earlier the abortion can be performed, the safer it is for the patient, thus the change.
The province estimates the cost for covering Mifegymiso to be between $175,000 and $200,000 per year.
And although these announcements have removed some barriers, Veinot says it comes down to primary health care, meaning women need access to physicians and nurse practitioners to be able to get reproductive care like birth control prescriptions and tests for STIs. That will ultimately eliminate some of the need for abortions at all.
"It really comes down to that," said Veinot. "In a perfect world, we would have a stand-alone sexual health centre like in Halifax where pro-choice options can be delivered to everyone."
"Ideally they would have access to family care so that they can access contraceptives and the sort of things they need to prevent pregnancy in the first place."