Reflections on Canadian abortion care in a post-Roe world

“Every mother a willing mother. Every child a wanted child.”
—Dr Henry Morgentaler

The legal framework for abortion in Canada dates back to 1892, when abortion, as well as the sale, distribution, and advertising of contraceptives, was banned under the Criminal Code.[1] It was not until 1969[2] that the government decriminalized contraception and provided allowances for abortion, when performed in hospital, for circumstances in which the health of the mother was in danger. That same year, abortion activist Dr Henry Morgentaler[1] opened an outpatient abortion clinic in Montreal. He endured years of persecution and legal battles, including serving 10 months in jail in 1975–76 and the 1992 firebombing[3] of his Toronto clinic.

It was in 1988 that Canada’s Supreme Court struck down the abortion law because it was in violation of the Canadian Charter of Rights and Freedoms, specifically a woman’s right to “life, liberty and security of person.”[1] As UBC’s Dr Dorothy Shaw wrote on the 30-year anniversary of the Morgentaler decision: “Dr Henry Morgentaler was a leader who risked his life to provide women access to safe abortions. He was integral in the Supreme Court of Canada’s decision to overturn the abortion law. . . . That was a landmark decision for reproductive rights for women.”[2]

However, the battle for access to a safe abortion did not end peacefully after the Supreme Court ruling. Abortion was thereafter controlled by the provinces and medical regulations. Threats of legislation continued, such as an attempt in 1990 to pass a bill that would imprison doctors who performed elective abortions.[1] There were also numerous attempts at provincial restrictions throughout the 1990s and 2000s, some of which were successful at targeting the abortion procedure or its funding. Reading a CBC article[1] detailing a timeline of abortion in Canada, I was surprised to see so many contemporary challenges to a procedure that, throughout my medical career, I have taken for granted as a treatment available to anybody in Canada with a uterus. The article educated me about some of the hard-fought battles brought forth by activists and doctors long before I graduated medical school. There have been many violent incidents, including in 1994 when Dr Gary (Garson) Romalis was the first Canadian abortion doctor to be shot. I had the privilege of working with Dr Romalis during my obstetrics-gynecology residency, and I would encourage anyone to read more about him in the recent BCMJ blog post by Dr George Szasz.[4]

Although abortion is not a component of my practice, I regularly prescribe Mifegymiso (mifepristone plus misoprostol) for medical management of miscarriage, and I also use assisted reproductive technologies like in vitro fertilization (IVF). I continue to ponder how I would feel if these essential tools of gynecological care were not available to my patients in a post-Roe America. It could be devastating. Take IVF,[5] for example. If state laws recognize an embryo as a person, it might prevent the discarding of genetically abnormal embryos, or limit how many eggs can be fertilized during IVF. I have read several articles[6] that point out the irony that laws aimed at “saving lives” by stopping abortion could also reduce fertility for many people. Furthermore, abortion laws that directly or indirectly restrict fertility treatments in America may also disproportionately impact people of color, who experience infertility at higher rates, and people of lower socioeconomic status, who may not be able to travel to access treatment, which can be expensive to begin with. Thankfully, most of my colleagues to the south do not appear to be facing an imminent threat to fertility care, but there are signs of an ongoing debate.[7] According to an opinion piece in the Los Angeles Times,[8] “a now-dead bill[9] introduced in the Louisiana [State] Legislature this year sought to ‘ensure the right to life and equal protection of the laws to all unborn children from the moment of fertilization by protecting them by the same laws protecting other human beings.’ The bill spoke of ‘prenatal homicide,’ assault and battery.”

Doing research for this editorial made me even more grateful to the generations of physicians and advocates who shaped the practice of modern gynecology in Canada. It is because of this groundwork that I may help patients however and whenever they choose to grow their families.
—Caitlin Dunne, MD, FRCSC

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References

1.    CBC News. Abortion rights: Significant moments in Canadian history. Last updated 27 March 2017. Accessed 6 September 2022. www.cbc.ca/news/canada/abortion-rights-significant-moments-in-canadian-history-1.787212.

2.    Shaw D. 30 years post-Morgentaler decision: The journey remembered. BC Women’s Hospital and Health Centre. 27 January 2018. Accessed 6 September 2022. www.bcwomens.ca/about/news-stories/stories/30-years-post-morgentaler-decision-the-journey-remembered.

3.    Claiborne W. Clinic bombing rekindles Canadian abortion debate. The Washington Post. 21 May 1992. Accessed 6 September 2022. www.washingtonpost.com/archive/politics/1992/05/21/clinic-bombing-rekindles-canadian-abortion-debate/f1f99d42-e58b-4fab-9721-dceb505be896.

4.    Szasz G. Access to safe abortion services: Remembering the life and work of Dr Gary (Garson) Romalis. BCMJ. 5 August 2022. Accessed 6 September 2022. https://bcmj.org/blog/access-safe-abortion-services-remembering-life-and-work-dr-gary-garson-romalis.

5.    ASRM Center for Policy and Leadership. State abortion trigger laws’ potential implications for reproductive medicine. Last updated 1 July 2022. Accessed 6 September 2022. www.asrm.org/news-and-publications/asrms-response-to-the-dobbs-v-jackson-ruling/dobbs/state-law-summaries.

6.    Jokisch Polo M. Infertility patients fear abortion bans could affect access to IVF treatment. NPR. 21 July 2022. Accessed 6 September 2022. www.npr.org/sections/health-shots/2022/07/21/1112127457/infertility-patients-fear-abortion-bans-could-affect-access-to-ivf-treatment.

7.    Gerson J. How overturning Roe v. Wade could affect IVF. PBS News Hour. Last updated 24 June 2022. Accessed 6 September 2022. www.pbs.org/newshour/health/how-overturning-roe-v-wade-could-affect-ivf.

8.    Ikemoto LC. Op-Ed: How IVF could be derailed by abortion restrictions. 7 July 2022. Accessed 6 September 2022. www.latimes.com/opinion/story/2022-07-07/ivf-roe-vs-wade-abortion.

9.    Abortion: Enacts the Abolition of Abortion in Louisiana Act of 2022. Louisiana House Bill 813. Accessed 6 September 2022. https://legis.la.gov/legis/ViewDocument.aspx?d=1259299.