Intended for healthcare professionals

Feature Commentary

Abortion care in Canada is decided between a woman and her doctor, without recourse to criminal law

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1506 (Published 24 March 2017) Cite this as: BMJ 2017;356:j1506
  1. W V Norman, associate professor1,
  2. J Downie, professor2
  1. 1Department of Family Practice, University of British Columbia, Canada
  2. 2Faculties of Law and Medicine, Dalhousie University, Halifax, Canada
  1. Correspondence to: W V Norman wendy.norman{at}ubc.ca

Regulation as a standard medical procedure has been associated with improved accessibility and fewer, safer abortions, write W V Norman and J Downie

As the UK debates decriminalisation of abortion and people wonder about the effects it might have,1 it may be useful to consider the Canadian experience of nearly 30 years without a criminal law to police access to abortion.

For many years, abortion was prohibited under the Canadian criminal code unless provided in a hospital after a “therapeutic abortion committee” confirmed that the continuation of a woman’s pregnancy “would be likely to endanger her life or health.”2

However, in 1988 the Supreme Court (in what is known as the Morgentaler case) struck down that abortion provision on the grounds that it violated the Canadian charter of rights and freedoms.3

In 1990, the federal government attempted to pass legislation to recriminalise abortion except when “the health or life of the female person would likely be threatened.” The bill passed in the House of Commons but was defeated in the Senate. Since then, various members of parliament have introduced bills with implications for abortion (for example, on the status of the fetus, conscientious objection by healthcare providers, and sex selection). None has succeeded.

All medical procedures treated equally

How can abortion practice be regulated without criminal law? In Canada, decisions about abortion are made in the same way as those about vasectomy or treatment for a ruptured appendix or an ectopic pregnancy. These decisions, even for life threatening procedures and those with potential lifelong fertility implications, take place in the context of the doctor-patient relationship. As with all medical procedures, this relationship is regulated under the standard accreditation and privileging systems of the hospital, or non-hospital facility, and by the self regulatory bodies responsible for the oversight of physicians.4 In other words, abortion is seen as, funded as, and regulated as a health service. The issue of a duty to provide or to refer for abortion remains contested.5

Have abortion rates in Canada increased over the nearly 30 years since our criminal law was struck down? No.6 After the Morgentaler decision, Canadian women saw improved access to abortion in hospitals and through the emergence of freestanding clinics,67 which now provide more abortions than hospitals.7 However, overall abortion rates have been in a steady decline since the mid-1990s, from 16 per 1000 females aged 15-44 in 1996 to 11.6/1000 in 2014, despite relative stability in birth rate.89 This is not surprising. Although worldwide we see a direct correspondence between increasing legal restrictions on abortion and increased maternal mortality and morbidity, criminalisation of abortion is not associated with fewer abortions.1011

Quicker, safer abortion

Abortion in Canada has also become safer. Ensuring access to abortion care with the fewest restrictions or delays is important because abortions are safer with each week earlier they can be performed.12 Furthermore, criminal law barriers to access are associated with the unsafe practice of illegal abortions, and can prompt women to access abortion methods without supervision and advice from regulated healthcare professionals.1013

So, what could happen if Britain followed Canada and decriminalised abortion? The absence of a criminal law regulating abortion could lead to improved access and safety without increasing abortion rates in the medium and long term. The regulation of abortion as a standard medical procedure could effectively locate the decision to have an abortion in the context of the relationship between a woman and her healthcare provider. What has worked well for nearly 30 years in Canada, could serve British women well too.

Footnotes

  • Feature, doi: 10.1136/bmj.j1485
  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare that WVN holds a chair in family planning applied public health research funded by the Public Health Agency of Canada and the Canadian Institutes of Health Research; she is a member of the board of directors of the Society of Family Planning and a member of the abortion guidelines committee for the Society of Obstetricians and Gynecologists of Canada.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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