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Report of proceedings April 28, 2011 Contraception & Abortion in BC: Experience Guiding Research, Guiding Care conference (2nd : 2011) Apr 28, 2011

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Report of ProceedingsApril 28, 2011Contraception and Abortion in BC:Experience Guiding Research Guiding Careii	 Cart	ConferenCe	ProCeedings,	aPril	2011AcknowledgementsThe Contraception & Abortion in B.C.: Experience Guiding Research, Guiding Care conference was made possible by the efforts of numerous individuals and organizations. CART would like to thank the following organizations for their sponsorship and support:•  Options for Sexual Health BC (OPT BC)•  Government of BC, Ministry of Health (MOH)•  BC Women’s Hospital and Health Centre (BC Women’s) •  Canadian Institutes of Health Research (CIHR)•  Women’s Health Research Institute (WHRI)•  BC Centre for Disease Control (BCCDC)•  National Abortion Federation (NAF)•  Ryan Foundation Family Planning Residency Program•  BC Centre of Excellence in Women’s Health (BCCEWH)•  University of British Columbia (UBC)•  Kwantlen Polytechnic University (KPU)The conference would not have been possible without the diligent efforts of the Organizing Committee, including CART leads Dr. Wendy Norman, Dr. Jean Shoveller,  and Dr. Janusz Kaczorowski; and CART team members and discussion group leaders:•  Joan Geber (Executive Director, Women’s Healthy Living Secretariat, MOH)•  Dr. Jan Christilaw (President, BC Women’s)•  Dr. Perry Kendall, BC’s Provincial Medical Officer of Health•  Dr. Dorothy Shaw (Professor, Obstetrics & Gynecology, UBC; past president FIGO) •  Sharon Cook (Director of Care, Kelowna General Hospital)•  Dr. Paul Hassellback (Medical Officer of Health, Okanagan, Interior Health) •  Cheryl Davies (VP, BC Women’s)•  Dr. Judith Soon (Assist Professor, Pharmaceutical Sciences, (UBC),  and  •  Ann Pederson (Director, BCCEWH)We are very grateful for the support of our OPT partners: Greg Smith, Executive Director and his organizing team led by Danielle Chard. In addition we are greatly indebted to our tireless conference staff: Dr. Eleanor Alzona-Malabanan,  Barbara Grantham, Penelope Hutchison, Mihaela Albu, Sophia Miller-Vedam, Arezou Azampanah,  and our exceptional volunteer corps: Natasha Berntsen, Maya Hari, Erika Yamada, Laura Riley and  Ali MajdzadehAbove all, CART wishes to thank the 122 health care providers, front-line workers, administrators,  researchers and others who attended the conference and provided critical input into the future  direction of contraception and abortion health system improvement in British Columbia. Cart	ConferenCe	ProCeedings	,	aPril	2011		 1Table of ContentsExEcutivE Summary 2Welcome	 5Part 1: PlEnary 5International	&	National	Perspectives	 5Ryan	Foundation	Keynote	Address:	Best	Practices	in	Contraception	&	Abortion	 8Access	to	Family	Planning	in	BC	 9Audience	Speak-Out:	Barriers	&	Solutions	to	Accessing	Contraception	and	Abortion	Services	 10BC	Abortion	Providers	Survey		 11CART	Pre-Conference	Survey	 12Summary	of	Feedback	 13Part ii: HEaltH SErvicES DESign & rESEarcH Planning WorkSHoP 13Partnership	in	Health	Systems	Improvement	Grant:	Vision	 14CHAP	Experience	 14Working	Group	I	&	II:	Possibilities	for	Program	Design	&	Priority	Setting	 15Plenary:	Sharing	&	Setting	Priorities		 16Common	Themes	&	Messages	 19Next	Steps	 19aPPEnDicES 20Appendix	A:	Agenda	 21Appendix	B:	Participant	Sectors	 23Appendix	C:	Posters	 24Appendix	D:	Pre-Conference	Survey	 252	 Cart	ConferenCe	ProCeedings,	aPril	2011On April 28, 2011, the Contraception & Abortion Research Team (CART) and Options for Sexual Health (OPT), in collaboration with sponsoring organizations, brought together 122 health care providers, administrators, front-line staff and researchers to explore the barriers and facilitators for reducing unintended pregnancies by improving access to high quality contraception and abortion services in British Columbia. The aim of the Contraception & Abortion in B.C.: Experience Guiding Research, Guiding Care conference was to solicit expert opinion and collaborative interprofessional input on priority issues to support the development of community-based health service demonstration projects, and the appropriate associated research, for health system improvement. Executive Summarymajor BarriErS major FacilitatorSlack of knowledge (public, provider, decision-makers) Education (patient, professional and decision-makers)cost of contraception Free contraceptionDistance & rural/urban service inequitiesincreased fundingHealth professional educationlack of effective data Better data collection and reportingStigmatization & public/provider/decision-maker attitudes towards sexuality, contraception and abortionPolicy framework for sexual healthlack of health professionals providing contraception  and abortion servicestraining for health professionals facilitating service provision: rn, nP, midwives, pharmacists, mDs>  Bc has a significant unmet need  for contraception>  uneven distribution of access to services >  rural/urban disconnect (access,  knowledge, training)>  challenges facing sub-populations  (immigrants, aboriginal women)>  gaps in knowledge and gaps in  data are hindering progresskEy tHEmESCart	ConferenCe	ProCeedings	,	aPril	2011		 3The morning plenary session speakers provided the international-to-local perspectives on the state of and issues surrounding contraception and abortion care.  An audience ‘speak-out’ gave participants the opportunity to share their experiences and opinions regarding the  key barriers and facilitators to good family planning care in the province. During the afternoon workshops, participants gathered in small working groups to prioritize the issues and explore potential ideas for health systems improvement and potential associated research initiatives. CART proposes to apply for a CIHR “Partnerships in Health Systems Improvement” (PHSI) grant. This grant will support a demonstration project in 1-4 BC communities, and will include a rigorous evaluation component. CART leaders asked conference participants to determine key components and themes for a demonstration health system improvement project aiming to reduce unintended pregnancies and improve access to high quality contraception and abortion services.The CART conference marked the beginning of an ongoing engagement with stakeholders within the family planning community in BC. Participant input will assist in informing effective approaches to the development of health system improvement demonstration projects and associated evaluation research with the ultimate aim to reduce unintended pregnancies and improve access to high quality contraception and abortion services for all British Columbians. Possibilities & Priorities:1.  knowledge translation & Education: increase public and health professional education on the unmet need for contraception, highly effective contraceptive methods including the advantages of long acting reversible contraception (larc); and abortion.2.  access: improve access to information, resources, services and contraceptives.3.  training: address lack of access in rural communities through contraception and abortion health professional training in multiple disciplines (midwives, nurse practitioners, pharmacists and physicians  (both family physicians& obstetricians/gynecologists)4.  Funding: remove financial barriers to contraception accesscritical components>  collaboration & Partnerships>  community Engagement>  target 20-29 age group; underserved population groups>  tailor projects to needs of individual communitiesPotential Stakeholder roles:>  advocate>  researcher>  Health system-health administration advisor>  Service deliverer>  Health Professional Educator/resourcekEy Working grouP tHEmES4	 Cart	ConferenCe	ProCeedings,	aPril	2011Experience  Guiding Research,  Guiding CareOn April 28, 2011, the Contraception & Abortion Research Team (CART) and Options for Sexual Health (OPT) brought together 122 health care providers, front-line workers, administrators, researchers and others from British Columbia’s (BC) family planning, abortion and sexual health care sector. (See Appendices A and B for the day’s agenda and participant affiliations.)The goals of the Contraception & Abortion in BC: Experience Guiding Research, Guiding Care conference were to identify the important health services systems and barriers that need to be addressed; identify and describe what an appropriate system of services would look like; and describe and delineate the research required to get us there.To achieve these goals, the day’s work focused on four objectives:•  Develop knowledge on recent best practices in contraception and abortion care.•  Identify gaps in knowledge and health system delivery of effective contraception and abortion service provision;•  Establish open multi-lateral working relationships between health system decision makers, front line clinicians, senior academic researchers, and researchers in training from private, public and non-profit sectors;•  Plan a Contraception and Abortion research agenda to address identified needs; The morning plenary set the current context for abortion and contraception care, with a variety of speakers moving from an international to a local perspective. The afternoon workshop centered on interprofessional, inter-sectoral group discussions where participants shared their knowledge and explored possibilities for health systems improvement and associated evaluation research in this field.  Cart	ConferenCe	ProCeedings	,	aPril	2011		 5WelcomeThe conference began with a traditional First Nations welcome to this Territory by Gloria Nahanee of the Spritist Squamish Nation. Honouring the spirits of the eagle, killer whale, wolf and rabbit, participants enacted a brief dance of each animal, energizing the room and setting a positive tone for the day.Dr. Jan Christilaw, President of BC Women’s Hospital & Health Centre, then gave the official welcome and said her hope for the day was for all participants to leave with a better sense of how we can work together to improve abortion and contraception services in BC.Dr. Wendy Norman, a CART leader, set the stage for the day’s events. She said the goal of the conference was to improve contraception and abortion services in BC by looking at the current barriers and gaps in accessing services to inform the planning for health system improvement demonstration projects and evaluative research to make positive changes. Her desire for the day was to hear the stories of people working on the front lines and about the needs of women, and to use that information as key identifiers to make the services we bring to women and their families even better. International & National PerspectivesThree speakers set the international and national context for current state of unmet need for contraception. Meeting the Needs of Family Planning GloballyDr. Dorothy Shaw, immediate past president of the International Federation of Gynecology and Obstetrics (FIGO), and Canadian spokesperson for the Partnership for Maternal, Newborn and Child Health, talked about family planning globally and the lessons to be learned from the international experience.Dr. Shaw noted that women having two children will spend about 5 years trying to get pregnant or being pregnant, and more than thirty years trying to avoid pregnancy. With typical contraceptive failure rates of 5% of users per year, more than 33 million among the 700 million women using contraception, experience an accidental or unintended pregnancy annually, with many of these ending in abortion. In terms of abortion, globally the lifetime average is about one abortion per woman.She highlighted that among 180-210 million pregnancies worldwide every year, 80 million are unwanted, resulting in 50 million abortions and among the 22 million unsafe abortions: 47,000 subsequent deaths. Maternal conditions globally are the second leading cause of death among women, noting that unsafe sex and unmet need for contraception are the leading modifiable risk factors for death of reproductive age women in the world.Women  having two children  will spend about 5 years trying to get pregnant or being pregnant, and more than thirty years trying to avoid pregnancy.Dr. Dorothy ShawPart 1: Plenary6	 Cart	ConferenCe	ProCeedings,	aPril	2011Multiple factors affect women’s access to health services which Dr. Shaw stated are as applicable in BC as they are worldwide, such as political will, legislation, geography, and culture. She noted there are inequities in terms of maternal health, maternal morbidity and access here in Canada as well, especially among First Nations and immigrant populations. There is a global recommitment to family planning especially through the Global Strategy for Women’s and Children’s Health. The ultimate goal is to ensure access to universal reproductive health by 2015 [Millennium Development Goal 5B]. Canadian Legal, Political & Medical Barriers to Access to AbortionVicki Saporta, President and CEO of the National Abortion Federation (NAF), discussed the legal and political barriers to timely abortion care access in Canada. She began by noting how this CART conference marked the first meeting of its kind to discuss setting a research agenda for abortion and contraception. Canada is one of only a few countries without a federal law restricting abortion however, there is inequitable access to abortion care in this country. In recent years the number of hospitals providing abortion care has decreased to 1 in 6 in Canada, with the majority of services provided by clinics and concentrated in urban areas. She noted that the potential introduction of mifepristone in Canada in the future could help support better access to abortion care for women in rural areas. There are few opportunities for physicians and front-line workers to stay current on the latest trends and research on abortion care. NAF supports its members by publishing clinical policy guidelines, a clinical textbook, and hosts an annual meeting – some of the only places physicians can obtain continuing education in abortion care. Vicki stated the need to continue to work to ensure all women have access to the highest quality of abortion care, to fight legal inequities and to ensure providers can include abortion care in their practice and ensure women can obtain care. With typical contraceptive  failure rates of 5% of users per year,more than 33 millionamong the 700 million women using contraception, experience an accidental  or unintended pregnancy annually,  with many of these ending  in abortion.  Dr. Dorothy ShawThere is inequitable access to abortion care in Canada…with  the majority of services provided  by clinics and concentrated  in urban areas.Vicki SaportaCart	ConferenCe	ProCeedings	,	aPril	2011		 7Challenges to Understanding Abortion:  the Data collection and access issue  in Canada and BCDawn Fowler, NAF’s Canadian Director, gave an overview of the challenges around data collection and access to abortion in Canada. Statistics Canada first began collecting and reporting data on abortions in Canada in 1970. Budget cuts and changes in data collection since 1988 have resulted in uneven collection of data on abortion with missing information on well over 10% of provincial and national abortions. Today, data collection and reporting resides with the Canadian Institute for Health Information (CIHI). Most abortions in Canada now occur in clinics. While hospitals must report, there is incomplete reporting from clinics meaning that the true number of abortions occurring in Canada remains a mystery. The result is that we are unable to produce a basic statistical profile of abortion in Canada. The implications of this situation are that it is difficult to know if abortion is increasing or decreasing; it makes creating good public policy a challenge; and means benchmarking and supporting resource planning is difficult.Panel Questions The following highlight just a few of the numerous questions participants had for the speakers. 1.  How do we get government to make funding available for all abortion and contraceptive services – what would make sense financially and for women’s health?  Dr. Jan Christilaw noted that free contraception is one part of an effective solution and would result in significant costs savings however the problem is the initial outlay of funding. Dr. Dorothy Shaw said ministries of finance need to be accurately informed about the cost-effectiveness of family planning initiatives for them to be successfully adopted. She noted this is an area in which politicians often have little information or exposure to facts, and that we may have a role to provide this education.2.  What would be most effective strategy to reduce unintended pregnancies in the developing world?  Dr. Dorothy Shaw said a multi-pronged strategy is needed that includes education for women and girls along with access to free or reasonably priced contraception that reflects the surrounding economic conditions. 3.  What changes are happening around medication for abortion services and what are the challenges of making those changes?  Vicki Saporta said NAF has considered advocating for mifepristone in Canada as a high priority among their activities. Mifepristone is the gold standard of medical abortion care and its availability in Canada is long overdue.  Incomplete reporting  from aborion clinics means  the true number of abortions occuring in Canada remains a mystery.Dawn Fowler8	 Cart	ConferenCe	ProCeedings,	aPril	2011Ryan Foundation Keynote Address:  Best Practices in Contraception & AbortionDr. Mark Nichols, MD, Professor and Division Head, General Gynecology and Obstetrics, Director of the Family Planning Fellowship at Oregon Health Sciences University (OHSU), and current President of the Society of Family Planning, gave the keynote address on the evidence regarding ‘what works’ for better family planning services. There are four sources of information on best practices:•  Cochrane reviews•  Society of Family Planning clinical guidelines•  NAF clinical guidelines •  High quality individual studiesIn the US medical abortions are increasing (nearly half of all abortions under 9 weeks gestational age) while surgical abortions are on the decline. In terms of clinical complications, some amount of retained products was  the most common complication for both medical and surgical abortion but the overall complication rate is under 0.5% of patients, demonstrating the overall safety of either abortion method. Dr. Nichols reviewed research on the use of paracervical block, which for many years has been the standard of care for surgical abortion. The literature indicates the best paracervical block technique includes injecting and waiting 3 minutes prior to dilation; that deeper injection is better than shallow; and that a paracervical block reduces pain for both dilation and aspiration among patients undergoing surgical abortion. He highlighted the underutilization of those contraceptives in the top tier of effectiveness: long acting reversible contraception (LARC) such as intrauterine devices (IUDs) and contraceptive implants. With typical intrauterine system failure rates of 0.3%, (compared to 5-8% for oral contraceptives for example) many more unintended pregnancies could be prevented using LARC methods. In reviewing studies on the cost-effectiveness of contraception methods, LARC methods such as intrauterine contraception are the most cost effective contraceptive options.In the US a study showed that long acting reversible contraceptives, such as IUDs and implants, are cost effective, with $7 saved for every dollar spent. Another study found that the cost of providing IUD immediately after delivery in a US hospital would result in the hospital losing 70 cents per dollar but would result in the State saving $2.94 for every dollar spent. Dr. Nichols said the complex funding system for health care in the US prevents changes from being made but demonstrates the savings of immediate postpartum contraceptive provision.Panel Questions1.  Do you have data comparing rates of complications from medical to surgical abortion?  No, we don’t have data that compares the two but the message I would give is abortion is safe, and rates of infection or other complications are low for both. The experience in the US shows how abortion is a very  safe procedure.Long acting   reversible contraceptives,  such as IUDs and implants, are the  most cost effective contraceptive  methods…with studies supporting  a health system savings of $7 for every  dollar spent.Dr. Mark NicholsCart	ConferenCe	ProCeedings	,	aPril	2011		 92.  There are challenges in providing medical abortions in rural areas as it is difficult to get women to follow up, can you comment?  Women know when they’ve completed their medication abortions after using mifepristone. They’ve bled, their nausea is gone; they don’t feel pregnant anymore. In the US we want them to come back for follow up but in the developing world there is a move away from routine follow up visit because it’s not often feasible. Dr. Norman also commented that in Canada we have only methotrexate available for medication abortion. Due to the teratogenicity of the agent we have a much higher responsibility to ensure follow up with every pregnant woman who has received this medication. There was general agreement that availability of mifepristone could greatly increase access and ease of medical abortion for Canada.Access to Family Planning  in BCThe second panel of the morning focused on the topic of access to family planning in British Columbia. Aboriginal Women’s PerspectiveLerinda Swain, Nurse and Program Coordinator for BC Women’s Aboriginal Health Program, said it is important for providers to get to know the protocols when working in First Nations communities and with First Nations peoples. She said there are more than 203 bands in BC representing a diversity of populations. Approximately 74 % of those who identify as Aboriginal people (including non-status, Métis, First Nation, and Inuit) live off reserve, and 40% of the Aboriginal population in BC is under 25 years of age compared to 16% in the general population. Teen pregnancies remain four times higher among Aboriginal girls. Aboriginal women view sexuality as a gift but community attitudes are highly influenced by individual Nations and beliefs. Abortion is a touchy subject, many communities don’t recognize abortion however women traditionally had medicine plants for those who didn’t want to have a pregnancy. The lack of communication within the community means that when Aboriginal women and girls want to travel to access an abortion, they are afraid to ask their ‘aunties’ for help. Often young girls know they aren’t ready but are pressured into having children by parents, partners, and the community. There are also restrictions to accessing contraception and it is important to look at how accessible the community is to services.Due to the significant judgment placed on Aboriginal women, a big role for BC Women’s Aboriginal Health Program is in teaching cultural competency and awareness. Reaching Youth  through TechnologyDr. Mark Gilbert, MD, leads the HIV and Sexually Transmitted Infections (STI) surveillance program at the BC Centre for Disease Control (BCCDC). He spoke about BCCDC’s experiences reaching out to youth through social media avenues. Given that 66% of youth use social networking, it is imperative to deliver services online as a way to reduce barriers to sexual health care and reduce the overall burden of STI’s in BC. In focus groups, youth say they are looking for websites that offer clear concise reliable information from an official agency that looks and feels relevant. At inspot.org youth can send an anonymous e-card to a partner telling them they may have been exposed to an STI. Dr. Gilbert also said models are being developed to deliver online STI testing. A client can go to a testing site, do the online assessment, print off a lab requisition and go to lab, then get the results online or over the phone where they would access a referral for treatment. Another example to reduce access barriers is the provision of online contraception (currently offered from one California based site) where an in individual can request a contraceptive online and have it delivered to them. As most youth use cell phones to access the internet, one organization, bedsider.org, will send individuals reminders to take their birth control or other contraceptive method through a phone application. Dr. Gilbert noted how these are great pilot programs but we don’t fully understand their impact, benefits and/or challenges. He said this changing technology is not a revolution but a revelation and the health sector needs to catch up. 10	 Cart	ConferenCe	ProCeedings,	aPril	2011Trends in Abortion Access  in BCDr. Wendy Norman, MD, Clinical Professor in the Department of Family Practice at the University of British Columbia, and a CART leader, provided an overview of the key trends in abortion access in BC. She stated abortion is a marker for an unmet need for contraception. In Canada there are approximately 100,000 abortions performed annually with rate in BC of 16 per 1,000 women of reproductive age (15-44) compared to a Canadian rate of  14 (2005). While there has been a concerted effort to reduce teen pregnancy, resulting in rates dropping in this age bracket, the highest users of abortion services are in the 20-29 age groups. Many public health youth services are limited to women under 25 and some to those under 19, and therefore missing a large group of women who have a proven unmet need for contraception. Dr. Norman said abortion is a commonly accessed reproductive service. 31% of Canadian women reaching age 45 in 2005 had at least one lifetime abortion, demonstrating the unmet need for contraception. She talked about how accessibility to abortion outside major urban areas is low, and noted how only 19% of abortions in BC are offered outside Vancouver, Victoria or Kelowna. In addition, there has been a 60% decline in the number of abortion providers between 1998 and 2010, and a further 10% drop in the number of abortion providers outside urban BC in 2010-11 alone, highlighting this as a call to start improving access to abortion in our community hospital system and to support training of rural health professionals would could provide abortion services closer to women’s home communities.Audience Speak-Out:  Barriers & Solutions to Accessing Contraception  and Abortion ServicesFollowing the panel discussion, participants were asked to reflect on what they heard, share their experiences and talk about the barriers to access and potential solutions. All panel speakers gathered at the front table to answer questions and facilitate discussion.Policy ChangeThe discussion began with a question about what the one most important policy change that we should be focusing on, given all the options. Dr. Norman said we can learn from other jurisdictions in that taking one measure does not do justice to providing the best care. Free contraception is good but you need public health education on risks and benefits for women and updated education for health providers on highly effective contraceptive methods. BarriersDr. Ellen Wiebe highlighted information from studies she’d conducted on what women who are having abortions in BC say they want. The number one issue was getting an abortion as soon as possible, with the number two priority being getting an appointment for an abortion – getting through to a human being on the telephone. Another study comparing the amount of time loss from work (disability) between women choosing a medical or a surgical abortion, found surgical abortions disabled women to a greater extent in terms of taking time off work/school or childcare duties due to length of the wait time before their actual abortion appointment. A final study asking about barriers to contraception access found that 25% of immigrant women had difficulty (and in general this difficulty was in access to knowledge about contraception and abortion services) compared to 15% of non immigrant women in Vancouver, among whom cost was found to be the main barrier. Other providers discussed the challenges they faced trying to provide abortion care in small communities. One physician noted that unlike urban clinics where a variety 31% of Canadian women currently starting menopause  have had an abortionWendy NormanCart	ConferenCe	ProCeedings	,	aPril	2011		 11of staff provide comprehensive care, ‘I do everything’. She described facing barriers such as funding, limitations on OR scheduling, and OR closures. Another provider said she wanted to provide abortion care in an outpatient setting but was denied by the hospital, despite the fact that it is more cost-effective to provide the service in an ambulatory setting (for example with a nurse providing intravenous sedation support rather than an anesthesiologist), citing problems such as availability of trained nurses, and support staff. MessagingOne physician suggested taking a more personal approach to getting the message across to government such as providing vignettes of individual patients impacted by poor access to abortion and contraception. Vicki Saporta noted a key part of NAF’s work is to collect patient stories and support patients to speak about their experiences. “I have not seen anything more effective in changing minds than patient stories”. Dr. Dorothy Shaw said it is also important to never make the assumption that government officials are well informed about family planning issues because that has not been her experience. Later, during the conference, other delegates noted that few politicians and health administrators hear the stories of women having difficulty accessing abortion and contraception care in BC. Front  line care providers in BC should encourage women and families to bring their stories of difficulty accessing contraception and abortion care to the attention of government and our politicians. Stigma & SexualityParticipants made a number of comments about the stigma related to sexuality and our inability as a society to openly discuss issues of contraception and abortion. One administrator stated that politicians and administrators are not willing to engage in these conversations openly and the need to find other ways to move the agenda forward. Dr. Shaw noted how this is due to the fact that we don’t talk about sex or sexuality in public. Another participant, specializing in Adolescent Medicine, noted condom use should be an important component of all education messaging and not limited to discussion of sexually transmitted infection prevention, but should also be highlighted in contraception education. Conference delegates supported this suggestion enthusiastically.The development of a sexual health action framework for BC was highlighted as a progressive step being made by the Ministry of Health in collaboration with regional health authorities and BC Women’s Hospital & Health Centre. The framework will include recommendations to improve sexual health and reduce disparities for all citizens.Data Collection & ReportingWhen asked what we can do to improve data collection and reporting in BC, Dawn Fowler suggested that all facilities need to report on their statistics using the same definitions of elements. There also needs to be a central collector and repository of information, with health authorities defining the data set and mechanisms for reporting. BC Abortion Providers Survey Preliminary results of a new survey, the BC Abortion Providers Survey (BCAPS), to better understand the challenges, service parameters and career intentions of physicians providing abortion service in BC, were highlighted by Drs. Jennifer Dressler and Nanamma Mauhgn, Family Practice Residents in the Rural Residency Program, Kelowna Site, UBC Department of Family Practice. The preliminary results from 17 urban and rural physician respondents, collected just two hours prior, were highlighted. The survey will continue over the coming months and attempt to include every physician providing abortion services in BC.Interestingly the early results showed a majority of the current physicians providing abortions had practiced for more than 25 years, supporting the observation that attrition in rural abortion providers may be due at least in part to retirement (without replacement).12	 Cart	ConferenCe	ProCeedings,	aPril	2011CART Pre-Conference SurveyResults of the CART pre-conference survey were highlighted at the start of the afternoon health systems improvement planning session by facilitator Barbara Grantham. The following results are inclusive of answers from all 52 respondents who took the survey. Many comments and elaborations for each question were submitted, and can be found in full in the appendix. (See Appendix C for the complete survey results).conference Survey Participant Demographics:•  58% of participants work in a large urban setting,  23% in a community under 10,000 population. •  54% are front line health professionals;  27% health service administrators;  23% physicians providing abortion services,  and 15% university based researchers. top 3 Barriers to Delivering Effective contraception:1.  Cost was chosen as one of the three factors for 29.4% of the responses (ie: by nearly every responder); 2.  Public knowledge about effective methods 21.8%;3.  Public attitudes towards certain contraceptive methods 15.4% top 3 Barriers to Providing abortion Services:1.  Lack of physician abortion providers 21.2% (again chosen by the majority of responders as one  of their three choices)2.  Harassment/stigma from members of our community 15.7%3. Access to operating room time 13.2% Facilitators to reducing unintended  & unwanted Pregnancies:(The following facilitators were each rated.  The percentage indicates the proportion of respondents rating this factor “Very important”)1.  Public Education about highly effective contraceptive methods 84.6%2.  Provision of free contraception for all women 71.2%3.  Health professional education program in family planning 63.5%Facilitators to improving  Provision of abortion Services:(The following facilitators were each rated.  The percentage indicates the proportion of respondents rating this factor “Very important”)1.  Health administrator/health authority support  to create or expand an abortion clinic 61.5%2.  Training programs to teach GPs to become abortion providers 55.8%3.  Training for Obstetricians/Gynecologists to become abortion providers 26.9%Cart	ConferenCe	ProCeedings	,	aPril	2011		 13The conference shifted in the afternoon into a planning workshop for 65 designated interprofessional and inter-sectoral participants. The aim was to develop partnerships and explore ideas for health systems improvements (and rigorous evaluation) that could lead to a reduction in unintended pregnancies and improved access to highly effective contraception and abortion services. Summary of FeedbackConference facilitator Barbara Grantham summarized the morning’s key themes to contextualize the afternoon’s discussions. In addition, the full responses to the pre-conference survey, including all comments and suggestions, were provided to each discussion group.Part II: Health Services Design  & Research Planning WorkshopkEy tHEmES>  Bc has a significant unmet need  for contraception>  uneven distribution of access to services  and providers>  rural/urban disconnect (access,  knowledge, training)>  challenges facing sub-populations  (immigrant, aboriginal women)>  gaps in knowledge and data are  hindering progressmajor BarriErS major FacilitatorSknowledge Education (public, professional and decision-makers)cost Free contraceptionDistance innovations in practice and careData Better data collection and reportingStigmatization Policy framework for sexual health14	 Cart	ConferenCe	ProCeedings,	aPril	2011Partnership in Health Systems Improvement Grant: VisionThe CART leaders, Dr. Wendy Norman, Dr. Jean A. Shoveller, and Dr. Janusz Kaczorowski, reviewed the CIHR Partnerships in Health Systems Improvement (PHSI) grant guidelines and their project vision.A PHSI grant provided funding to host this conference with the aim to bring together groups of front-line health workers, health service administrators and academic researchers to tackle complex problems at a systems level. The purpose of the grant is to support the development and implementation of demonstration projects at the community level. The grant is an opportunity to test a scale model for a redesign of the health system in terms of how contraception and abortion services are delivered in BC. The $400,000 available in grant funding from CIHR, along with support and in-kind donations from partner organizations, will support the team to design and implement a health system improvement demonstration project in possibly up to four BC communities. CART team members asked conference participants to help them determine the key components and themes for a demonstration project that would be scalable, cost effective, work in urban and rural areas and ultimately could make a difference to reduce unintended pregnancy and improve access to highly effective abortion and contraception services in BC. CHAP ExperienceDr. Janusz Kaczorowski summarized the results of a community-based randomized cluster trial project in Ontario to improve cardiovascular health. The purpose was to draw important parallels regarding how to design, implement and evaluate community level intervention which can improve outcomes at the population level.CHAP – Cardiovascular Health Awareness Program – started out as a series of pilots and community level demonstration projects, then progressed to a large randomized cluster design of all 39 Ontario communities with populations between ten and sixty thousand people. The project is a community-based program bringing together local family physicians, pharmacists, other health professionals, public health representatives, volunteers, and health and social service organizations to promote and actively participate in the prevention and management of heart disease and stroke. The project included:•  Opportunities for multiple accurate blood pressure readings and the promotion of healthy eating, physical activity and smoking cessation.•  Invitations to older adults to measure their blood pressure in pharmacies and other familiar community settings, using an automated blood pressure measuring device with help from a trained volunteer.•  Ability of participants to take home a copy of their results and give their permission to have this health information shared with their family physician and pharmacist. This allows physicians and pharmacists to follow-up with their patients if required.•  Measurement of outcomes and effectiveness from population health administrative databases, facilitating community and professional engagement in the intervention.CHAP acted as funding agency and solicited proposals from volunteer and community based organizations within the intervention communities on how they would collaborate and what activities they would undertake to improve cardiovascular (CV) health. Agencies in each of the 20 intervention communities selected received $5,000 to lead mobilization activities around CVD awareness and health promotion utilizing volunteer peer health supporters, family physicians and pharmacists. With a coordinated community intervention lasting only 10 weeks, the CHAP researchers were able to show a 9% reduction in hospital admissions for cardiovascular related events over the following year. In extrapolating CHAP’s results population-wide, it was found that the program would result in 5,000 fewer annual CV hospital admissions in Ontario. Factors contributing to CHAP’s success were:•  Working with and mobilizing local community organizations •  Guidance and support from CHAP team•  Focus on collaboration and multi-pronged approach Further information on the CHAP project can be found at: www.chapprogram.ca Cart	ConferenCe	ProCeedings	,	aPril	2011		 15Working Group I & II:  Possibilities for Program Design & Priority SettingParticipants spent the majority of the afternoon in working groups discussing the possibilities for health service demonstration project design and research to improve contraception and abortion services. Working groups were an interdisciplinary, inter-sectoral mix of health system administrators, front-line providers, researchers, representatives of community based organizations and others from each health authority region to support meaningful conversation. The first working group session asked participants to answer the following questions:1.  What are the most important issues that need to be addressed:2.  What components of a health service will we need to address the gaps in service we identified this morning? What are the possibilities in designing this health service approach? What’s our wish list?3.  From my perspective, five years from now, this demonstration heath service project will have been a success if….After an hour of robust discussion and a brief break, the working groups reconvened to prioritize the issues arising in their discussions. Groups structured their conversation by answering the following questions:1. What are the priorities?2. Why are they priorities?3.  How would you rank them? Are there important linkages between them? 4. One thing that will work is…5. One thing that won’t work is…16	 Cart	ConferenCe	ProCeedings,	aPril	2011Plenary: Sharing & Setting Priorities The conference returned to a plenary forum, with a representative from each working group summarizing their key issues and project possibilities, their priorities and the role they individually or as a group wanted to play as CART moves forward with its work. grouP 1Possibilities & Priorities:•  Interventions aimed at populations in the 20-29 age group•  Target small and medium-sized communities around knowledge translation projects.•  Educational initiatives around contraception aimed at entire communities (patients, providers, general public) using innovative media (print, web, social network tools) that are professionally sourced, culturally appropriate and language accessible•  Training for nurse practitioners in contraception and abortion care•  Remove financial barriers to contraception access.•  Take a 4-pronged community-based research approach:  1. One community is status quo 2.  One community receives the educational component for services providers and in schools 3.  One community has barriers to contraception access removed 4.  One community has barriers to both education and contraception removed.What Won’t Work•  Maintaining the status quorole: •  Advocate•  Researcher•  Advisory member•  Service deliverergrouP 2Possibilities & Priorities:1.  Lack of public education on contraception and abortion, need to target education to underserved population groups.2.  Need for timely access to a range of services with evaluation pre and post-project.3.  Lack of abortion providers; urban/rural disconnect and lack of access to contraception and abortion services. •  Public knowledge and access connected, focus on disseminating accurate information about different methods of contraception and abortion services through various youth-engaging media (online, social networking sites, cell phone); don’t be dependent on school education •  Expand OPT clinics around BC, utilize online drug ordering and pick up.  •  Success markers: wait times for abortion are less than 1 week.What Will Work•  Knowledge component – critical to have community engagement as a starting point.What Won’t Work•  Having health system as the gatekeeper controlling servicesrole:•  Advocate•  Researcher•  Advisory member•  Service delivererCart	ConferenCe	ProCeedings	,	aPril	2011		 17grouP 3Possibilities:•  Examined issue from an access lens: Access to education, care, timely service, geographic perspective, sub-population (youth and need for confidentiality)•  Issue of access to contraception and abortion key factors that could be improved upon.Priorities:1.  Broad-based provider education for physicians, nurse practitioners, pharmacists and other allied care providers on contraception and abortion.2. Public education•  Key linkage for provider education is free contraception as a way to enhance quality of care and skills of providers.•  Take a universal approach to free contraception implementation. Be mindful of unique needs of special populations so we don’t enhance divisions between groups.•  Initiatives need a supportive funding structure and take a comprehensive approach (fulsome analysis of any strategy)•  Broad stakeholder engagement within each participating community•  Utilize a community development approach with different community engagement processes•  Demonstration project strategies must be universal and transferable, but ensure there is flexibility and sensibility to local context.What Will Work•  Projects focused on the ‘low hanging fruit’ or easy wins – contraception and abortion access and provider education.•  Projects that are achievable, measurable, utilize existing data to support it, and have a comparison group.•  Focus on the success of a strategy to keep momentum going towards ultimate vision of good sexual health  for all.grouP 4Possibilities & Priorities:•  Ultimate goal: Change public and health official attitudes.1.  Education and transfer of knowledge that is scientifically based, supports transfer from professionals to patients and between professionals.2. Funding needs to be in place3.  Access – need access to information, resources, services and birth control.•  To ensure effective implementation, need a strategic plan or map across the province to ensure collaboration and standards of practice in place.•  Reduce redundancies and costs by examining overlaps in services (i.e. between what youth clinics and emergency rooms offer in small communities) to use resources more effectively and efficiently.What Won’t Work•  Lack of collaborationSuccess in 5 years looks like…•  Not having money does not prevent a patient from having access to timely care. •  Correct information is available to make informed decisions•  Providers don’t have to hide, be afraid, abortion talked about as a normal medical service.Pilot Project•  Education in schools (K-12) involving parents and well-trained professionals coming in. •  Community and health professional education (physicians, NP’s, pharmacists) in targeted communities. Measure results at end (number  of pregnancies and abortions, use of emergency contraception before and after study) to see  if there’s a difference between study and  non-study communities.18	 Cart	ConferenCe	ProCeedings,	aPril	2011grouP 5Success in 5 years looks like…•  Every male and female who wants sexual health information can access it when they want; information is reliable•  People feel free to openly and safely discuss sexual health and abortion in their community.•  Every pregnancy is wanted.Possibilities & Priorities1. Sexual health education and knowledge translation for women and men around contraception across the lifespan.•  Need to combat stigma and shame around contraception and abortion•  Recognize rural/urban disparities. Projects should be tailored to needs of individual communities (not one size fits all), look at professional mixes and ensure health and social service providers have the same information (include addition and other professionals in education).•  Focus on privacy and confidentiality issues at an institutional level•  Strengthen data collection and reportinggrouP 6Possibilities & Priorities:•  Focus on health service perspective: Need for information-sharing, surveillance, and knowledge transfer to health professionals.•  Issue of lack of providers and access linked. •  Project 1: Develop an itinerant abortion team that would go out to different communities and provide services, provide training to health professionals to build community capacity.•  Project 2: Develop divisions within Family practice, stratify and incorporate contraception/abortion training/knowledge transfer.•  Project 3: New scope of practice for RN’s in development provides opportunity to incorporate contraception/abortion training/knowledge transfer.•  Project 4: Changing scope of practice for pharmacists to support enhanced over-the-counter dispensing of contraception.•  Project 5: Create a randomized controlled trial around free contraception in a few communities.What Will Work•  Clear questions with a defined scopeWhat Won’t Work•  Trying to accomplish too muchgrouP 7Possibilities & Priorities:1.  Access, specifically the rural/urban divide and how rural access to contraception and abortion more difficult than in urban settings.  •  Project: Examine rural equity of access with equal focus on providers and women.  •  Provider side: Examine barriers in rural settings, isolation, lack of support, security concerns. Priority is creation of a network to champion recruitment, continuing education, development of a community of practice with a research arm, collaborative work. Ensure professional education and training available, provide training to NP’s, midwives, nurse and relate that to expanding scopes of practice. Tie into current Rural GP Incentive Program. •  Patient side: Our dream is to create a comprehensive women’s all inclusive health service including public education and expanded suite of services. Focus on 20-29 age group and marginalized women (culture, language, poverty). •  Use a community engagement model with partnerships between communities and providers and women. •  Priority should be on network development and service provision.Cart	ConferenCe	ProCeedings	,	aPril	2011		 19Common Themes & MessagesDr. Jean Shoveller summarized the themes and messages elicited through the working group discussions. She described participants as not only service providers, administrators, social workers, statisticians and front-line providers but as individuals who are clients and users of the system. “We’ve all been there and maybe we don’t want to be there again but be in a better place.”inequities in access & knowledgeOne of the key overarching themes from the day was about the need to address inequities – across age groups, geography, cultural and gender divides and knowledge. The need to tackle issues of access and knowledge translation through education of providers, patients and the public were reiterated over and over again throughout the day.Feasibility & learningsDr. Shoveller expressed her appreciation for the generation of a highly feasible set of researchable questions and projects. She described them as ‘early wins’ which will help guide care, practice and result in some early learnings. She said we can learn about what it would take to change our system, to address cost as a barrier, and how that links up with use. We can also learn about what it takes to change the culture of our system, studying that process and linking access and cost and distribution, and linking it with a health budget and health issue, not a moral dilemma no one wants to talk about. PartnershipsEvery group talked about the importance of partnerships as model, across communities and with the communities we work in. Dr. Shoveller described the conference as a significant next step towards expanding and solidifying such partnerships. normalizing needsOther participants highlighted their take-away messages from the day’s discussions. One stakeholder noted “It’s about normalizing needs. We haven’t normalized the need for contraception, and for abortion where contraception fails, and we haven’t normalized sex education.” Facilitator Barbara Grantham closed the day by summarizing the four themes she came away with from the day’s discussions: •  Overcoming Distances •  Getting better at Data •  Tackling system Disincentives •  Engaging Decision-makers Next StepsAs the conference came to a close, there was confidence and commitment on the part of participants to remain engaged in the CART process. Dr. Wendy Norman described the work of the day as just the beginning of a continuous engagement with stakeholders within the family planning community in BC. She said everyone’s input was and will continue to be critical to the success of the Contraception and Abortion Research Team’s work and hoped participants would continue to be an ongoing voice in how projects move forward.The next steps for the CART process are to review the conference proceedings and the input and actions prioritized by participants. This will enable the team to determine the most effective approach to developing demonstration health system improvement projects, with appropriate evaluation research, that will address the CART aim to reduce unintended pregnancies and improve access to highly effective contraception and abortion services in BC. Further comments ideas and suggestions can be directed to the CART team at: CART @cw.bc.ca20	 Cart	ConferenCe	ProCeedings,	aPril	2011Cart	ConferenCe	ProCeedings	,	aPril	2011		 21Appendices22	 Cart	ConferenCe	ProCeedings,	aPril	2011Appendix A: AgendaMorning	session:	Plenary7:30–8:00 am  registration8:00–8:25 am 	Welcome	Plenary:	Welcome	to	the	territory	of	the	spritist	squamish	nationGloria Nahanee  Welcome:	Dr. Jan Christilaw, President BC Women’s Hospital and Health Centre 	experience	guiding	research	guiding	Care:	reducing	Barriers	to	Contraception	&	abortion	services	in	BC	Dr. Wendy V. Norman8:20–9:15 am Panel	session	1: the	international	and	national	Perspective	 Moderator: Dr. Wendy V. Norman  Meeting	the	need	for	family	Planning	globallyDr. Dorothy Shaw 	Canadian	legal,	Political	and	Medical	Barriers	to	access	timely	High	Quality	abortion	Care	Vicki Saporta  Challenges	to	Understanding	abortion	in	Canada	&	BC:	the	data	Collection	and	access	issueDawn Fowler Questions	for	panel9:15-10:00 am ryan	foundation	Keynote	address:		 Best	Practices	in	Contraception	&	abortion	Care	 dr.	Mark	nichols:	evidence	on	“What	Works”	for	Better	family	Planning	services 10:00 -10:20 am BreaK:	Poster viewing session and networking 10:20–11:00 am Panel	session	2:	focus	on	access	to	family	Planning	in	BC	 Moderator: Jean A Shoveller 	aboriginal	Women’s	PerspectiveLerinda Swain 	reaching	youth	through	technologyDr. Mark Gilbert 	 	trends	in	abortion	access	in	BCDr. Wendy V. Norman  	Questions for panel11:00–11:50 am  the	audience	speaks: Barriers	and	solutions	to	accessing	Contraception	&	abortion	services Moderated panel with all speakers: Share your experience; submitted and live audience cases    Moderator: Barbara Grantham11:50 am–12:10 pm survey	Preview: BC	abortion	Provider’s	survey,	Preview	of	early	results	 Drs. Jennifer Dressler and Nanamma Maughn Plenary	summary	and	Plenary	Closing	remarks	 Dr. Wendy V. NormanCart	ConferenCe	ProCeedings	,	aPril	2011		 23afternoon	session:	WorKsHoPsHealth	services	design	and	research	Planning	Workshop	(for designated participants) 12:10–1:00 pm  LUNCH AND NETWORKING  1:00–1:20 pm   Workshop	Welcome:	summary	of	feedback	from	the	Pre-Conference	survey	and	the	Morning	Barbara Grantham 1:20–1:30 pm  Partnership	in	Health	systems	improvements	grant:		Cart	team	leaders’	Vision	for	the	ProjectDr. Wendy V. Norman, Dr. Jean A. Shoveller, Dr. Janusz Kaczorowski1:30–1:50 pm  CHaP	experience:	a	Community-based	approach	 Dr. Janusz Kaczorowski1:50–2:20 pm Working	group	a:		Possibilities	for	Program	design	&	research	approach		 	  2:40–3:00 pm  nUtrition	BreaK: featuring scientific posters and networking2:40 – 3:10 pm Working	group	B:		Priority	setting	for	action 3:10 – 4:10 pm  Workshop	Plenary:		sharing	and	setting	Priorities	for	Programming	with	integrated	research4:10 – 4:20 pm Workshop	Closing	remarks CART team leaders24	 Cart	ConferenCe	ProCeedings,	aPril	2011Appendix B: Participant SectorsConference participants included representatives from all CART partner organizations, and from the Northern , Interior, Vancouver Island, Vancouver Coastal and Provincial Health Services health authority regions of British Columbia. Participants	represented	•  Health professionals and staff from all BC abortion clinics •  More than a third of BC’s rural physician abortion providers•  Front line health professional and administrative staff from public health and Options for Sexual Health contraception and sexual health clinics throughout BC•  BC Women’s Hospital leadership and staff•  BC Ministry of Health and Provincial and health authority regional medical officers of health •  Regional hospital administrators•  Members of at least 6 community-based non-profit organizations•  Academic faculty and researchers from UBC, Kwantlen, and 3 research institutes.The following sectors were represented (with many participants representing more than one sector):Front-line health workers 48% (Including physicians providing abortions 17%)Non-Profit Community organizations 41%Academic Researchers 21%Health Administrators,Students, CART staff,    and Health professionals in Training  15% Cart	ConferenCe	ProCeedings	,	aPril	2011		 25Appendix C: PostersThe following posters were displayed throughout the conference:1.  Ames CM, Norman WV.  Preventing	repeat	abortion:	is	the	immediate	insertion	of	intrauterine	devices	Post-abortion	a	Cost-effective	option	associated	With	fewer	repeat	abortions?	2.  Bergunder J, Eccles L, Norman WV.  Women	seeking	abortion	underreport	gestational	age	by	an	average	of	one	week	based	on	last	menstrual	period	compared	to	ultrasound	dating.	3.  Collins M, Holehouse R, Kaczorowski J.  Chlamydia	screening	in	an	international	resort	Community:	a	Pilot	outreach	Program	to	expand	access.	4.  Dueck R, Hestrin B, Norman WV.  Provincial	Pregnancy	options	telephone	referral	service:	ten	year	retrospective	review.	5.  Egan G, Soon JA, Levine M.  impact	of	Physician	dispensing	on	access	to	emergency	Contraception. Alan C. Hayman Summer Student Research Poster Competition. Faculty of Pharmaceutical Sciences. Vancouver, BC. September 5, 2008. 6.  Leung F, Jelescu A, Soon JA, Norman WV, Bacon A, Porter A, Li J, Cortina S, Nakamichi A, Kwok E,  Foster S.  development	of	Virtual	Patients:	a	new	learning	strategy	to	enhance	the	Pharmacy	family	Planning	Curriculum.		Alan Hayman Memorial Summer Student Research Poster Competition. Vancouver, BC. September 7, 2010. 7.  Leung VWY, Soon JA, Marra CA, Lynd LD, Levine M. History	of	regular	hormonal	contraceptive	use	among	emergency	contraceptive	users	in	British	Columbia. J Popul Ther Clin Pharmacol 2011;18:e200-1.8.  MacDonald K, Norman WV.  Better	Contraceptive	Choices:	immediate	vs	interval	insertion	of	intrauterine	contraception	after	second	trimester	abortion. 9.  Norman WV, Dicus L, Lam M, Gurm B.  a	multi-cultural	contraception	satisfaction	questionnaire	for	use	in	studies	of	women	following	abortion.	10.  Soon JA, Levine M, Schmidt T.  Use	of	emergency	Contraception	in	Women	Presenting	for	abortion	in	British	Columbia:	differences	and	similarities	across	Major	language	groups. Proceedings of the 2003 National Abortion Federation Annual Meeting. Seattle, WA. April 7, 2003.11.  Soon JA, Leung VWY, Levine M, Reade JA, Shoveller JA.  Utilization	of	regular	Contraception	among		rural	northern	youth	in	British	Columiba:		an	ethnographic	study. J Popul Ther Clin Pharmacol 2011; 18(2):e212. [abstract]. Canadian Association for Population Therapeutics Annual Conference. Ottawa, April 17-19, 2011.12.  Teng F, Kwok E, Goldstein K, Cessford T, Ng C, Leslie J; Norman WV, Soon J, Malhotra U, Fitzsimmons B, Vedam S, Garrett B.  Cares:	Computer-assisted	reproductive	health	education	for	students.	13.  Wiebe E, Kozoriz K, Lam J.  Cell	Phones	in	abortion	Clinics:	exploring	the	Use,	Benefits	and	Problems	of	Mobile	Cellular	Phones	in	abortion	Clinics.14.  Wiebe E, Byczko B, Johnson M.  environmental	Benefits	of	Manual	Vacuum	aspiration.26	 Cart	ConferenCe	ProCeedings,	aPril	2011Appendix D: Pre-Conference SurveyThis report contains a detailed statistical analysis of the results to the survey titled CART pre-conference survey. The results analysis includes answers from all respondents who took the survey in the 7 day period from Wednesday, April 20, 2011 to Wednesday, April 27, 2011. 52 completed responses were received to the survey during this time. 57.7%23.1%13.5%5.8% Large Urban setting Large community (50,000 to 250,000)Medium sized community (under 50,000)Small community (under 10,000)0 20 401.9%3.8%9.6%15.4%21.2%23.1%26.9%53.8%Health professional in trainingResearcher in trainingOther (specify in comments)University-based researcherUniversity-based health professional educatorPhysician performing medical and/or surgical abortionsHealth service administratorFront line health professional0 20 40 60 80 100 120 140 160 180 20029.4%21.8%15.4%14.5%8%7.3%3.6%Other Misinformation among the community about Emergency Contraception  Health professionals knowledge about effective contraception use/products Lack of facilities/trained personnel (for example for intrauterine contraception provision)Public attitudes towards certainPublic knowledge about effective contraception use/productsCost for contraception number of responsesnumber of responses0 20 40 60 80 100 120 140 160 180 200Other (specify in comments) Misinformation among the community about Emergency Contraception  Health professionals knowledge about effective contraception use/products Lack of facilities/trained personnel Public attitudes towards certain contraceptive methodsPublic knowledge about effective contraception use/productsCost for contraception 8%3.6%7.3%14.5%15.4%21.8%29.4%number of responses57.7%23.1%13.5%5.8% Large Urban setting Large community (50,000 to 250,000)Medium sized community (under 50,000)Small community (under 10,000)0 20 401.9%3.8%9.6%15.4%21.2%23.1%26.9%53.8%Health professional in trainingResearcher in trainingOther (specify in comments)University-based researcherUniversity-based health professional educatorPhysician performing medical and/or surgical abortionsHealth service administratorFront line health professional0 20 40 60 80 100 120 140 160 180 20029.4%21.8%15.4%14.5%8%7.3%3.6%Other Misinformation among the community about Emergency Contraception  Health professionals knowledge about effective contraception use/products Lack of facilities/trained personnel (for example for intrauterine contraception provision)Public attitudes towards certainPublic knowledge about effective contraception use/productsCost for contraception number of responsesnumber of responses0 20 40 60 80 100 120 140 160 180 200Other (specify in comments) Misinformation among the community about Emergency Contraception  Health professionals knowledge about effective contraception use/products Lack of facilities/trained personnel Public attitudes towards certain contraceptive methodsPublic knowledge about effective contraception use/productsCost for contraception 8%3.6%7.3%14.5%15.4%21.8%29.4%number of responses57.7%23.1%13.5%5.8% Large Urban setting Large community (50,000 to 250,000)Medium sized community (under 50,000)Small community (under 10,000)0 20 401.9%3.8%9.6%15.4%21.2%23.1%26.9%53.8%Health professional in trainingResearcher in trainingOther (specify in comments)University-based researcherUniversity-based h alth professional educatorPhysician performing medical and/or surgical abortionsHealth service administratorFront line health professional0 20 40 60 80 100 120 140 160 180 20029.4%21.8%15.4%14.5%8%7.3%3.6%Other Misinformation among the community about Emergency Contraception  Health professionals knowledge about effective contraception use/products Lack of facilities/trained personnel (for example for intrauterine contraception provision)Public attitudes towards certainPublic knowledge about effective contraception use/productsCost for contraception number of responsesnumber of responses0 20 40 60 80 100 120 140 160 180 200Other (specify in comments) Misinformation among the community about Emergency Contraception  Health professionals knowledge about effective contraception use/products Lack of facilities/trained personnel Public attitudes towards certain contraceptive methodsPublic knowledge about effective contraception use/productsCost for contraception 8%3.6%7.3%14.5%15.4%21.8%29.4%number of responses2)		 My	role(s)	include(s):	(choose	all	that	apply)1)		 i	work	in	a	setting	described	as	a:	Other Resp nse :• Interpretation• Researcher at health authority (BCCDC)• Medical Health Officer • Advocate for women’s health• Community base researcherCart	ConferenCe	ProCeedings	,	aPril	2011		 273)		 	What	are	the	top	3	barriers	to	delivering	effective	contraception	in	your	facility/community?	4)		 	Please	tell	us	about	any	other	important	barriers	in	your	community	to	provision	of	effective	contraception:>  Lack of knowledge among the public and fellow health professionals about long acting reversible contraception and IUDs> I do not have enough experience>  Myths such as IUDs inappropriate for using among those under 20 years>  A reluctance in certain population groups to embrace contraception>  Travel to Vancouver for procedures above 12 weeks ( 9 hour car journey), only 1 physician available in our town to perform TAs >  Very low socioeconmic population equates to inability to pay for birth control, non-status individuals are limited to pay for birth control while their status First Nations friends pay nothing. Young girls are pressured very early to begin sexual relationships and have limited knowledge of effective birth control and STI prevention. Girls as young as 11 and 12 are afraid of 57.7%23.1%13.5%5.8% Large Urban setting Large community (50,000 to 250,000)Medium sized community (under 50,000)Small community (under 10,000)0 20 401.9%3.8%9.6%15.4%21.2%23.1%26.9%53.8%Health professional in trainingResearcher in trainingOther (specify in comments)University-based researcherUniversity-based health professional educatorPhysician performing medical and/or surgical abortionsHealth service administratorFront line health professional0 20 40 60 80 100 120 140 160 180 20029.4%21.8%15.4%14.5%8%7.3%3.6%Other Misinformation among the community about Emergency Contraception  Health professionals knowledge about effective contraception use/products Lack of facilities/trained personnel (for example for intrauterine contraception provision)Public attitudes towards certainPublic knowledge about effective contraception use/productsCost for contraception number of responsesnumber of responses0 20 40 60 80 100 120 140 160 180 200Other (specify in comments) Misinformation among the community about Emergency Contraception  Health professionals knowledge about effective contraception use/products Lack of facilities/trained personnel Public attitudes towards certain contraceptive methodsPublic knowledge about effective contraception use/productsCost for contraception 8%3.6%7.3%14.5%15.4%21.8%29.4%number of responsesinfection or have someone know they are taking the pill thus risk pregnancy and STI’s due to the stigma of being labeled promiscuous. The educators within the primary and secondary schools are reluctant to provide sexual education to the younger youths in fear that “we are promoting early sexual activities”. Condoms are not provided in the primary schools though some grade 6 & 7 girls’ frequent public health for weekly pregnancy tests, plan B, and condoms. >  No health centre at the university>  It is a very small community. There is no such thing as confidentiality at the Dr’s office, hospital settings. People are reluctant to access service due to perceived privacy issues and real privacy issues. Next town is 400 km away in one direction. Dr’s are not up to date on current practices and reluctant to incorporate new information into their practice- despite numerous attempts.>  We are in a children’s setting>  Community facility that makes it hard for young people to access service discreetly>  N/A (I do not work in contraception service provision or research.)28	 Cart	ConferenCe	ProCeedings,	aPril	2011>  Health authority attitude of risk avoidance, and the belief that contraception and abortion are controversial issues - therefore easiest solution is to avoid them. >  OPT in PG provides services to youth under 25 years, and others have to go to the walk in clinic if they have no doctor. >  Transportation issues for getting to clinics. Lack of physicians, many people in our community do not have a family physician and have to access walk in clinic to get their contraception.>  Lack of good and sound sexual education program in the school system. Sexuality being a hidden topic not openly addressed at home, school, etc.>  Many options are not suitable for clients. New contraceptive methods that do not involve hormones.>  Availability of staff to administer >  Religious beliefs>  Health professionals need to build trusting relationships with young people who are leading high risk lifestyles-especially using alcohol and drugs to self medicate emotional pain. This requires time and dedication-more money needed for PHNs to help with and build relationships with students in schools around the issues of healthy sexuality>  Time-- for providers and clients to get to real issues in sexuality - complexity of issues regarding sexuality - abortion misinformation and link to STI prevention >  Inconvenience of accessing health care centres, and limited availability of family doctors.>  Though in a large urban setting with a diversity of service providers available to most, we can still encounter outdated information among health care professionals, as well as the public, about contraceptive methods/use. As well, though contraception for youth can be fairly accessible, there is inequity in such access among sub-populations and, increasingly, cost is a barrier to adult women.>  No youth clinic services. Limited hours of operation and cost for attendance at sexual health clinic.>  Remote rural communities - travel to services>  Cultural versus religion blending of the two also creates shaming and stigmas>  Health care providers attitudes and occasional sabotage>  Media involvement5)		 	Please	rank	in	order,	from	#1	as	most	important,	the	following	challenges	or	barriers	to	providing	abortion	services	in	your	community?	  0 10 20 30 40 50Q5Q4Q3Q2Q1Not helpful            Helpful              Very important0 20 40 60 80 100 120 140 160 180 200 220 240Other (specify in comments) Lack of equipment (u/s, etc.)Harassment/stigma from colleagues/health professionals Training – lack of time/ability for continuing professional education Lack of nurses, other allied staff to work in abortion cases Access to operating room timeHarassment/stigma from members of our communityLack of physician abortion providersOther (specify in comments)Health professional opportunities to learn advanced family planning where our doctors/nurses/midwives could go to acquire specific skillsHealth professional education programs in family planning provided in our communityProvision of free contraception for all womenPublic education about highly effective contraceptive methods7.6%9.1%10.2%10.3%12.8%13.2%16.7%21.1%number of responsesnumber of responses0% 1.9% 7.7%3.8% 36.5% 55.8%5.8% 26.9% 63.5%5.8% 19.2% 71.2%0% 7.7% 84.6%Cart	ConferenCe	ProCeedings	,	aPril	2011		 296)   Please tell us about any other important barriers faced by women in your community, or you in your professional role, preventing timely access to abortion services.>  Lack of effective sex education within school district powerful and vocal position within the local churches against abortion, requiring women to have to leave the community for service provision. >  There are few barriers, except that I am the sole provider of the service, and if I am out of town, there is no one who can/will step in. Some physicians are unwilling to refer patients for religious reasons...>  Lack of resources>  Politics around funding and health authorities. Funding for extra services in abortion clinics i.e. HIV testing, staff education Difficulty getting trained counsellors. >  Language barrier and lack of knowledge of Canadian health care system (do not know where and how to access abortion service)>  Lack of sufficient government funding>  No routine u/s service within this community. Physicians do no have the training for u/s dating (frequent locums)Women must drive 120 km to the next community where the option of a medical abortion is provided if the women is less than 7 weeks pregnant. All other pregnancies must be sent off island to Prince Rupert, Terrace or Vancouver which is costly and inconvenient. >  People have to travel 400 km one way to the nearest abortion provider. If you are a teenager this means parents must be involved as it would be an overnight trip. Plus confidentiality issues in a small town and poor school age reproductive health teaching in schools.>  Not in our setting at BCCH, but maybe an issue in BC Women’s Hospital>  Nearest provider is 2 hours away and due to high poverty, transportation is an issue>  N/A (Not familiar with abortion services or research.)>  Health authority perceptions. >  If clients are unable to get services in PG due to no OR time or GP available, they must travel out of community to Quesnel & pay if overnight stay.>  We have one physician in our community that provides abortion services. If that physician is not available then clients have to travel to another community and finances can be a barrier. Women on social assistance have huge loopholes to go through to get funding in place to travel. This is incredibly stressful for them.>  Lots of referrals from other communities were the referral process takes a bit of time and also for woman to come and travel to caregiver providing the service not located in their community. US availability for dating,woman not always aware of LMP.>  Physical environment/weather>  Inadequate funding, no reciprocal billings with most other provinces>  Access to abortion due to distance and cost to them incurred by travel.>  Difficult access due to large distances to travel to obtain services >  Need access to confidential services to assist with transportation and costs for people- especially if relatives work in the departments where they need to access service and funds>  I now live an urban environment with access but as a past provider with a high rural clientele- lack of confidential financial support for traveling and access to credible information in the early stages of an unintended pregnancy were huge barriers.>  Patients feel that they cannot talk with their family physicians about this or ask for a referral due to the physicians personal opinion on abortion>  Language and cultural barriers, and lack of knowledge of rights and services available in Canada. >  In my particular community, stigma and negative attitudes prevail to limit access to needed termination services for later pregnancies. In the reality of having to deal with these limitations, women’s choices are not honoured, additional barriers/harms are created and, at times, the ethical decision-making framework that we say we promote for patients in health care is not upheld.>  Distance for travel to city where abortion services are available. Huge wait times if a woman is told by abortion clinic that she needs an abortion to confirm dates prior 30	 Cart	ConferenCe	ProCeedings,	aPril	2011to attendance at abortion clinic. There are no providers locally.>  Parts of health authority have to travel distances to larger centre to access abortion services>  Lack or cost of travel to access services>  Lack of services in Fraser Health Authority Health care provider attitudes >  Cost for travel out of their home communities.>  Lack of access to contraception and abortion services/info in rural areas>  Doctors that won’t support women’s choice>  Patient Access to Abortion Services (i.e. Transportation)0 10 20 30 40 50Q5Q4Q3Q2Q1Not helpful            Helpful              Very important0 20 40 60 80 100 120 140 160 180 200 220 240Other (specify in comments) Lack of equipment (u/s, etc.)Harassment/stigma from colleagues/health professionals Training – lack of time/ability for continuing professional education Lack of nurses, other allied staff to work in abortion cases Access to operating room timeHarassment/stigma from members of our communityLack of physician abortion providersOther (specify in comments)Health professional opportunities to learn advanced family planning where our doctors/nurses/midwives could go to acquire specific skillsHealth professional education programs in family planning provided in our communityProvision of free contraception for all womenPublic education about highly effective contraceptive methods7.6%9.1%10.2%10.3%12.8%13.2%16.7%21.1%number of responsesnumber of responses0% 1.9% 7.7%3.8% 36.5% 55.8%5.8% 26.9% 63.5%5.8% 19.2% 71.2%0% 7.7% 84.6%7)		 	Please	tell	us	about	the	probable	importance	of	the	following	facilitators	that	could	enable	you/your	facility/your	community	to	reduce	unintended	and	unwanted	pregnancies?	Comment	responses:>  Simply put, Mirena should be free for all women under 25, not just first nations.>  Information provided in multiple languages>  Enforcing stricter regulations for individuals who are breaching the age of con ent for sexual activity such that older men who are engaging in sex with pre-adolescent girls are punished appropriately. Thereby supporting and sending a cle r es age.>  Most of our clients are FN and so receive contraception free if status through DIA>  Increased demonstration of public support for women’s health issues>  Include emergency contraception in the above. Also public education about sexuality >  I think that we must recognize the complexity of sexual health issues, including contraceptive use, in the real lives of people e.g. the many factors that contribute to “risk-taking” (pregnancy, STI/HIV) like alcohol use, violence, poverty/self-efficacy.>  Screening and brief interventions for problem alcohol use for youth and young adults, wherever they are, e.g. at sexual health clinic, at youth centres. Clinical impression is that most unprotected sex occurs due alcohol/substance use.>  Research to identify communities in which reproductive health services and education are deficient. Also, research to evaluate services and educational programs.Cart	ConferenCe	ProCeedings	,	aPril	2011		 318)		 	Please	indicate	which	of	the	following	facilitators	would	enable	you/your	facility/your	community	to	improve	your	delivery	of	abortion	services?	0 20 40Other Other (specify in comments section)Training for Obstetricians/Gynecologists to become abortion providersTraining programs to teach GPs to become abortion providersHealth administration/health authority support to create or expand an abortion clinic3.8%9.6%26.9%55.8%61.5%number of responsesother	responses:>  Let people especially immigrants or international students know abortion in Canada is legal, safe and accessible, although not a big number, there are people have to fly to their home country to do an abortion due to the lack of knowledge.>  Better funding for existing clinics>  Support to create a health clinic>  Dr’s here reluctant to do training as are hospital nurses. The hospital here has not done ANY surgery other than c-section in years.>  Use of misoprostol in clinics not restricted to physicians, with back up>  Use of nurses and midwives as TA providers why are we only relying on MDs>  Anesthetists who would be willing to provide services>  I think that there is good momentum with training; health administration must step up to support abortion services & interested providers now, particularly in areas where gaps exist.>  Exposure to abortion care services for health care providers who do not intend to provide but would refer for services9)		 	Please	tell	us	anything	else	about	barriers	to	effective,	accessible	contraception	and	abortion	services	in	your	community.>  Women frequently discontinue contraception shortly after prescribed, due to side effects and compliance issues. Additional patient-specific counselling by a trained health professional during the first 3 months to teach medication management skills to the patient may reduce unintended pregnancies related to poor compliance.>  Most young non native girls can not afford Mirena, the only effective way to provide contraception to teenagers. Our rate of unplanned pregnancies amongst our native population has dropped dramatically since Mirena arrived. We do also need better and more relevant sex-education at our local schools - this is done in a haphazard way. The abortion service functions well overall, with little harassment (except that my kids were kicked out of the local Roman Catholic private school because their father provided abortions!)>  Able to meet the needs of marginalized populations (addictions, isolation of new immigrants, working mothers)>  When I think of barriers to care. I think outside the lower mainland, there is not good knowledge of where services available. I understand this to be a matter of security for providers, but health authorities should advertise 32	 Cart	ConferenCe	ProCeedings,	aPril	2011where their abortion services can be obtained without identifying who the abortion providers are. We need to be more out there as far as advertising services.>  Our university has no health clinic. Students/employees need to go to services in the health authority. Some do not want to access through their GP>  Again we have an OPT clinic but it is under utilized do to lack of client knowledge of what is available, teaching is schools is almost non-existent, Dr’s reluctant to provide services, and perceived and real confidentiality issues.>  Transportation as noted previously>  Inconsistent policies. Insufficient HA resources to support contraceptive services (and abortion services). >  Age of OPT in PG, appointments available for OPT (only 21 as a one afternoon clinic) >  Patient travel to care is another barrier. It is astounding to me that patients from Kamloops must travel 2.5 hours to Kelowna for care. There should be a requirement that all tertiary care hospitals within a health authority should have dedicated abortion care as part of complete reproductive care services.>  Middle and high school outreach program to promote access to OPT and established Youth Clinics or to furnish contraception directly. Do schools still have nurses? If not, an RNP on site could be a valuable source of information and provider of contraception and information and referral for medical care.>  Restrictions put on by the health authority of how many abortions can be done each year.>  Just figuring out a new system to manage the new CRNBC guidelines on medication distribution >  We have a very supportive GP – when she is away or ill we have no local service – too much depends on her- we are very thankful for her>  Poverty, impact of hyper sexualization of girls and impact of parenting earlier than 30 plus years of age on young women and their children. >  Fragmented services with hospitals and community based providers>  I would like to see abortion care seen as a normalized part of women’s care services with advertising in the same manner as other clinics. I just wish we did not have this security shadow hanging over us. I truly believe that younger generations do not attach the same stigma to this part of medicine that we ourselves do.>  Cultural influences, inequities that women face. >  Safety>  There is currently a barrier to accessing data for research in the areas of contraception and abortion services.>  I also wanted to express strongly my belief that contraception should be provided free of charge to anyone desiring it. I believe Holland and (one of the Scandinavian countries) have the lowest unplanned pregnancy rates in the world; they also provide free contraception to their citizens.Contraception & Abortion Research TeamWomen's Health Research InstituteB3 - 4500 Oak StreetVancouver, BC  V6H 1N3CART@cw.bc.ca

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