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Report of proceedings, May 5, 2014 Contraception & Abortion in BC: Experience Guiding Research, Guiding Care conference (3rd : 2014) May 5, 2014

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Contraception  and Abortion in BCReport of Proceedings, May 5, 2014AcknowledgementsThe Contraception & Abortion in BC: Experience Guiding Research, Guiding Care Conference was made possible by the efforts of numerous individuals and organizations. The Contraception Access Research Team-Groupe de recherche sur l’accessibilité à la contraception (CART-GRAC) would like to thank the following organizations for their sponsorship and support:•	 BC	Women’s	Hospital	and	Health	Centre	(BC	Women’s)•	 Canadian	Institutes	of	Health	Research	(CIHR)•	 Options	for	Sexual	Health	BC	(Opt	BC)•	 Rural	Coordination	Centre	of	BC	(RCCbc)•	 Ryan	Residency	Training	Program	in	Family	Planning	•	 The	National	Abortion	Federation	(NAF)•	 University	of	British	Columbia’s	Department	of	Obstetrics	&	Gynecology	•	 Michael	Smith	Foundation	for	Health	Research	(MSFHR)•	 Women’s	Health	Research	Institute	(WHRI)The conference would not have been possible without the diligent efforts of the Organizing	Committee,	including	CART-GRAC	leads	Dr	Wendy	Norman	and	Dr	Perry	Kendall,	Provincial	Health	Officer,	as	well	as	Joan	Geber,	Executive	Director,	Healthy	Populations	and	Well-Being	Branch,	Ministry	of	Health,	Cheryl	Davies	Vice	President,	Ambulatory,	BC	Women’s	Hospital	and	Health	Centre,	and	CART	Team	members.We	are	very	grateful	for	the	support	of	our	Opt	partners:	Jennifer	Breakspear,	Executive	Director	and	her	organizing	team	for	their	work.Thank	you	to	graphic	illustrator,	Lisa	Edwards.In	addition	we	are	greatly	indebted	to	our	tireless	conference	staff	and	our	exceptional	student volunteers.  Above all, CART wishes to thank the 84 policy makers, health care providers, front-line staff, hospital administrators, health authority leaders, students, patients, community organization representatives, and researchers who attended the conference and provided critical input into the future direction of abortion health system improvement in British Columbia. 1Executive SummaryPurpose of the Conference To address an urgent need for abortion services in rural British Columbia (BC), the Contraception Access Research Team-Groupe de recherche sur l’accessibilité à la contraception (CART-GRAC) convened policy makers, health care providers, patients, administrators, researchers and community organizations from family planning,	abortion	and	sexual	health	care	sectors	for	the third Contraception & Abortion in BC: Experience Guiding Research Guiding Care Conference. The previous conference (April 2011) identified a rapid attrition of rural BC abortion services and launched research to understand the etiology, gaps and barriers. The aim of this 2014 conference was to disseminate, evaluate and incorporate research evidence into potential strategies for health service improvement in BC. The over-arching goal is improved health for women and families through equitable access to high quality abortion care.Morning Plenary Delegates	were	welcomed	to	the	morning	plenary	by	Joan	Geber,	on	behalf	of	Dr.	Perry	Kendal,	Provincial	Health	Officer,	Government	of	BC.	Local,	national	and	international speakers presented the latest evidence and best practices for abortion service delivery. Afternoon	Facilitated	Working	GroupsThe afternoon workshop facilitated interprofessional, inter-sectoral group discussions where participants shared	expertise	and	perspectives	to	develop	and	prioritize solutions to the identified abortion health services	challenges.	Specific	action	plans	resulted,	and	five	committed	“Regional	Implementation	Teams”	were	formed.Results This conference is part of an ongoing engagement with stakeholders within the family planning community in BC. Participant input has informed innovative approaches to health system improvements and suggested areas for additional research. The ultimate aim is to equitably support British Columbians to time and space their pregnancies to meet their own reproductive and family health goals.AppendicesThe over-arching goal is improved health for women and families through equitable access to high quality abortion care.2MAjor BArriers MAjor FAcilitAtors•	Distance•	Logistics•	Increase	training	and	provision	of	medical	abortions•		Transition	surgical	abortion	provision	into	ambulatory	settings•	Lack	of	effective	data	collection	and	surveillance •		Data	sharing	and	monitoring	agreements	engaging	relevant	provincial partners•		Stigmatization	and	public/provider	attitudes	 toward abortion•		Increase	awareness	and	dialogue	on	abortion	and	 reproductive health•		Lack	of	rural	health	professionals	providing	 abortion services•		Increased	training	and	support	for	physician	providers	•		Expand	scope	of	practice	for	abortion	service	provision:	training	for	NP,	midwivesKey WorKing group theMes  |   Key chAnge topics1.  Knowledge Translation and Education:	Increase	health	professional	 education on the unmet need for abortion and contraception services  and associated costs.2.  Access:	Improve	access	to	information	and	services	through	region	 specific initiatives to support facilities and providers.3.  Training: Address health professional abortion and contraception training in multiple disciplines (midwives, nurse practitioners, pharmacists	and	MDs).4.  Funding: Examine	potential	cost-savings	of	30%	per	procedure	through	delivery of surgical abortions of surgical abortions in ambulatory vs operating room settings.5.  Support:	Improve	support	for	rural	providers	(mentoring,	centralized	counselling services, locum program, Community of Practice).6.  Monitoring and Surveillance:	Standardize	data	collection	and	surveillance through data sharing and monitoring agreements between organizations currently collecting abortion data.criticAl coMponents•	Collaboration	and	networking•	Reduce	stigma	and	dispel	myths•		Public	campaigns	and	political	advocacy	•	Policy	reform	•	Cost-benefit	analysisKey plenAry & discussion pAnel theMesRapid attrition of rural abortion providersUneven distribution of access to services Rural/urban disconnect (barriers, knowledge, training)Unmet need for abortion services locally, nationally  and globallyGaps in data and community stigma hindering progress2 3Contentsexecutive suMMAry 1pArt i: plenAry  5	 Welcome		 5	 Current	Knowledge,	BC	Evidence	and	Best	Practices	 5	 Ryan	Foundation	Keynote	Address	 6	 Abortion	in	Outpatient	Settings:		 6	 Access,	Safety,	Acceptability	 6	 Abortion	in	the	Global	Context	 7 Abortion in Canada: You are not Alone 8	 Medical	Abortion:	How	to	and	What’s	New		 9	 Abortion	service	in	BC:	Findings	from	the	British	Columbia	Abortion	Providers’	Survey	 10	 Lightning	Presentations	on	BC	Services,	Organizations,	and	Opportunities		 10 Panel Questions  14pArt ii: developMent oF proposed solutions 17	 Presentation	of	Innovative	Solutions	in	BC	Communities		 17	 Summary	of	Feedback	 19	 Open	Space	Dialogue	Session:	Generating	Solutions	and	Recommendations	 20	 Action	Planning:	Sharing	and	Setting	Priorities		 24	 Next	Steps	 26Appendices 28 Appendix	A:	Agenda	 28	 Appendix	B:	Speaker	Bios	 30	 Appendix	C:	Participant	Sectors	 32	 Appendix	D:	Abstracts	 334On	May	5,	2014,	the	Contraception	Access	Research	Team-Groupe de recherche sur l’accessibilité à la contraception (CART-GRAC)	and	Options	for	Sexual	Health	(Opt)	brought	together health care providers, patient representatives, front-line workers, administrators, policy makers, researchers and others from British Columbia’s (BC) family planning,	abortion	and	sexual	health	care	sector	for	the	third Contraception & Abortion in BC: Experience Guiding Research, Guiding Care Conference (CART Conference). The rapid attrition of rural abortion services throughout BC, and a paucity of information on factors influencing rural abortion services were identified in the last conference (April	2011).	This	resulted	in	a	mixed	methods	study,	The	BC	Abortion	Providers	Survey	(BCAPS).	This	study	identified	specific addressable challenges, gaps, and barriers, as well as highlighting local innovations and practical solutions that have been successful in BC rural communities (Appendix	D).	The goals of the 2014 CART Conference were to facilitate the dissemination, evaluation and incorporation of the latest research evidence on abortion and family planning services into potential strategies for health service delivery in BC. The over-arching goal for this meeting was improved health for women and families through access to high quality	family	planning.	Delegates,	many	of	whom	were	participants in the 2011 meeting, brought together a wide range of perspectives from the private, public and not-for-profit sectors.To achieve these goals, the day’s work focused on four objectives:1.  To engage interdisciplinary health professionals, policy-makers and patient-representatives in discussions on the most current national and international evidence for high quality abortion health service delivery.2.  Provide a forum for health professionals to network, learn of new opportunities, and build collaborations.3.  To disseminate the findings of the BC Abortion Providers Survey, and abortion provision in different contexts, that could inform decision making, clinical care, share best-practices and influence health system design.4.  Facilitate small-group discussions on the implications and opportunities within the research findings of the BC Abortion Providers Survey, and sharing of best-practices, supporting development of strategies for health system/health services improvements that will increase equitable access to, and quality of, family planning for BC women.Local, national and international speakers presenting the latest evidence on delivery of high quality abortion health services,	including	the	results	of	the	BCAPS	research.	The	afternoon workshop centered on interprofessional, inter-sectoral group discussions where participants shared their knowledge and discussed potential solutions for priority challenges and gaps in contraception and abortion health services in BC. Experience Guiding Research, Guiding Care4 5Part I: Plenary Welcome The	conference	began	with	a	traditional	First	Nations	welcome	to	the	Musqueam	Traditional	Territory	by	Elder	Mary	Charles,	a	Queen’s	Jubilee	Medal	recipient.	Elder	Charles led the participants in a prayer, asking for the creator to unite all participants physically, mentally and spiritually to lead the way for future generations and make this world a better place.Joan	Geber,	Executive	Director,	Population	Health	&	Well-being	(including	the	Women’s	Health	Directorate);	Population	and	Public	Health,	BC	Ministry	of	Health,	offered	greetings	on	behalf	of	Dr	Perry	Kendall,	Provincial	Health	Officer,	BC	Ministry	of	Health.	She	referred	to	the	Provincial	Health	Officer’s	Report,	The Health and Well-being of Women in British Columbia released in 2011 which is a comprehensive appraisal of women’s health in BC. This report outlines where further efforts are required and outlines 43 recommended actions, ten of which are related to reproductive care, including recommendations specific to abortion: “to ensure equitable and timely access to	abortion	services.”	She	indicated	that	she	was	pleased	the morning conference and the afternoon working groups were convened to help the Ministry address this recommendation.Dr	Jan	Christilaw,	President	of	BC	Women’s	Hospital	&	Health	Centre,	gave	a	welcome	on	behalf	of	the	hospital.	She	recognized	that	because	of	the	work	done	in	this	room	and by CART-GRAC, this conference represents a leading national initiative in research and planning around abortion and	contraception	access.		She	noted	that	BC	Women’s	has	a strong hub of leaders who are passionate about these issues and a network of dedicated individuals around BC who contribute to effective health improvements through delivery	of	high	quality	care.	She	emphasized	that	one	of her hopes for the day was a renewal of some of those relationships so that we can work together to ensure better access to abortion and contraception services for all women in BC. Dr	Wendy	Norman,	Conference	Chair,	set	the	stage	for	the	day’s	events.	She	said	the	goal	of	the	conference	was	to improve contraception and abortion services in BC, especially rural areas, by looking at the results of the BC Abortion	Providers	Survey	(BCAPS)	and	current	research.	She	also	introduced	our	graphic	illustrator,	Lisa	Edwards,	who captured a visual representation of presentations and	discussion.	Her	illustrations	from	the	day	can	be	seen	throughout this document. Current Knowledge, BC Evidence and Best PracticesSeveral	speakers	set	the	context	for	current	evidence	on	provision of high quality abortion health services locally, nationally and internationally. 6RyAn FoundAtIon KEynotE AddRESSAbortion in outpatient Settings: Access, Safety, AcceptabilityDr Eve Espey, Professor, Department of OB-GYN and Chief, Family Planning Division, University of New Mexico in Albuquerque, NM, gave the keynote address in which she discussed the barriers to abortion provision in a national	and	international	context,	and	described	her	experience	with,	and	the	documented advantages of, providing abortion in outpatient settings. Dr	Espey	noted	similar	rates	of decline in rural abortion providers	for	Canada	and	the	United	States,	as	well	as similar access barriers for women including the long distances many must travel to access care. Dr	Espey	highlighted	a	2011	New	Mexico	study1 of family practice	physicians	and	OB-GYNs	comparing	the	number	of	abortion	providers	in	2001	(N=210)	and	2008	(N=165).	Similar	rates	among	all	clinicians	for	any	providing	abortion	service	in	2001	(11%)	and	2008	(15%)	were	found.	However,	there	was	a	significant	decline	in	rural	clinicians	providing	these	services,	dropping	from	7%	to	2%	in	the	same	interval.	Despite	the	availability	of	mifepristone,	the	pill	used	for	medical	abortions,	in	the	US	since	2000,	this	study showed little increase in abortion access overall, and a significant decrease in rural abortion access.The	study	also	explored	barriers	to	providing	abortion	services	for	OB-GYNs	and	family	practice	physicians,	and	Dr	Espey	noted	the	differences	between	the	two	disciplines.	For	OB-GYN’s	the	main	barriers	reported	were:	personal	moral	or	religious	beliefs	(50%);	practice	restrictions	against	abortion	(36%);	and	office	staff	attitudes	against	abortion	(35%).	For	family	practice	physicians,	the	most	common	barriers	were:	lack	of	training	in	abortion	(70%);	lack	of	training	in	ultrasound	(60%);	lack	of	ultrasound	in	office	(55%);	and	practice	restrictions	against	abortion	(44%).	1					Espey,	E.,	Eyman,	C.,	Leeman,	L.,	Ogburn,	T.,	&	North,	M.	(2010).	Has	mifepristone	medical	abortion	expanded	abortion	access	in	New	Mexico?	A	survey	of	Ob/Gyn	and family medicine physicians. Contraception, 82(2), 206.Improving	training	for	family	practice	physicians on abortion provision is one potential strategy to improve abortion access for women. Abortion training for advanced practice clinicians, such as nurse practitioner, nurse midwives and physician assistants is another strategy to	increase	access.	Dr	Espy	noted	that	some similar issues were reflected in the British Columbia Abortion Providers Survey2 including professional isolation (i.e.	stigma);	logistics,	such	as	lack	of	operating	room	(OR)	time;	and	lack	of	replacement	providers (see page 10 for more information). Dr	Espey	then	discussed	the	advantages	of	providing	abortions in outpatient settings, by reflecting on the University	of	New	Mexico	Hospital	(UNM)	journey	taken	to	introduce abortion services to the hospital, which included a series of educational, political, logistical and economic challenges.	Today,	the	UNM	Center	for	Reproductive	Health	(UNMCRH)	is	a	9000	square	foot	outpatient	clinic	that offers both medical and surgical abortion services, as well as other family planning services. The clinic also has	a	RYAN	program	and	a	Family	Planning	Fellowship.In	the	US,	like	Canada,	the	majority	of	abortions	are	performed	in	outpatient	clinics,	90%	and	86%,	respectively.	Some	of	the	advantages	to	offering	abortion	in	such	settings	include:	cost	effectiveness	(i.e.	not	requiring	OR	time	or	staff);	reduction	in	complications	(i.e.	safety	of	analgesia	over	general	anesthesia);	flexibility	(i.e.	greater	ease	with	patient	scheduling);	and	the	ability	to	offer	better	patient-centered	care	(i.e.	increased	privacy).	Over	a	two-year	period,	Dr	Espy	noted	that	her	clinic	moved	from	performing	90%	of	miscarriage	management	and	abortion	procedures	in	the	OR	to	90%	in	the	outpatient	setting.	Patient	reported	advantages	include	efficiency	and	privacy.	2						Norman,	W.	V.,	Soon,	J.	A.,	Maughn,	N.,	Dressler,	J.,	&	Vitzthum,	V.	J.	(2013).	Barriers	to	Rural	Induced	Abortion	Services	in	Canada:	Findings	of	the	British	Columbia	Abortion	Providers	Survey	(BCAPS).	PLoS ONE, 8(6), e67023.No woman can call herself free who does not own and control her body. No woman can call herself free until she can choose consciously whether she will or will not  be a mother.– Margaret Sanger6 7Research supports providing abortion care in outpatient settings. A retrospective study reviewed 170,000 outpatient 1st trimester abortion procedures confirming the safety of such settings, showing no deaths, no major surgery and very low rates of hospitalizations.3	Dr	Espy	noted	that studies show that the majority of patients choose outpatient settings to receive abortion care, if given a choice.	Notably,	the	duration	of	procedures	are	almost	80%	longer	in	the	OR	settings	and	the	estimated	costs	are	twice	as high. Additional justification for delivering abortion care in outpatient settings includes the simple set up and cost-effectiveness	of	the	equipment	(i.e.	Manual	Vacuum	Aspiration instrument). Dr	Espy	concluded	her	speech	by	reflecting	on	the	reasons	that keep her fighting for improved access to abortion services.	Despite	harassment	and	stigma,	her	team	are	passionate to proving abortion services and training. Providing safe and legal abortion services in critical to reducing the number of maternal mortalities associated with unsafe abortions. Abortion in the Global ContextDr Dorothy Shaw, Clinical Professor, UBC and Vice President, Medical Affairs, BC Women’s Hospital & Health Centre, gave an overview of global abortion access and provision.	She	noted	that	unsafe	abortion	is	a	public	health	problem	primarily	affecting	poor	women.	While	these	global statistics are likely under reported, it is estimated that there are between 180-210 million pregnancies every	year	and	273,500	maternal	deaths.	Eighty	percent	of maternal deaths are due to obstetrical complications during	child	birth.	However,	the	World	Health	Organization	(WHO)	estimates	unsafe	abortions	account	for	13%	of	all	maternal mortality worldwide. That is, 47,000 of these maternal deaths are a result of unsafe abortion procedures and about 5 million women are hospitalized every year with complications of abortion. Additionally, 220 million women have unmet contraception needs. The	1994	International	Conference	on	Population	and	Development’s	(ICPD),	Programme	of	Action	(PoA)	established a goal for all governments to “meet the family planning needs of their populations as soon as possible and	should,	in	all	cases	by	the	year	2015.”	However,	Dr	Shaw	3						Hakim-Elahi	E,	Tovell	HM,	Burnhill	Ms	Complications	of	first-trimester	abortion:	 a	report	of	170,000	cases.	Obstet	Gynecol.	1990;76(1):129–135stated that one of the major barriers to achieving this goal is the statement included in the PoA which indicates that “in no case should abortion be promoted as a method of family planning.”Each	year,	nearly	20	million	of	the	42	million	induced	abortions	are	carried	out	using	unsafe	procedures.	Dr	Shaw	noted	that	safe	abortion	access	and	contraception	availability is correlated with maternal mortality rates. Twenty-six	percent	of	women	live	in	countries	where	abortion is generally prohibitive and these tend to have the highest rates of maternal mortality and lower rates of contraception prevalence. Dr	Shaw	went	on	to	debunk	several	myths	that	prevail	around	abortion	and	contraception.	She	noted	that	the	idea	that	“abortion	is	rare”	contributes	to	the	stigma	associated	with	this	issue.	However,	statistics	show	31%	of	Canadian	women	and	30%	of	Brazilian	women	ended	at	least	one	pregnancy in their life time. Religious countries do not have lower abortions rates. A study from Brazil, a highly Catholic country, showed a large portion of gynecologists would help a woman to access an abortion, or would access an abortion themselves. Dr	Shaw	discussed	numerous	concerns	related	to	unsafe	abortion. Timely access to care for complications due to unsafe	abortions	is	a	serious	concern.	In	Gabon,	a	study	reviewing maternal deaths showed that women had to wait significantly longer to access care due to unsafe abortion complications, compared to women accessing care for other reasons. Persecution and imprisonment of women is also	a	concern.	In	El	Salvador,	abortion	is	not	permissible	under any circumstance, even to save the life of a woman. Women	are	jailed	if	they	are	found,	or	believed	to	have	undertaken	an	induced	abortion.	Incomplete	spontaneous	abortion may be indistinguishable from induced abortion. The	costs	of	unsafe	abortions	are	also	significant.	In	low	and	middle	income	countries	(LMIC),	up	to	50%	of	hospital	budgets allocated to obstetrics and gynecology are used to treat	complications	of	unsafe	abortions.	Infant	mortality	is	also	related	to	pregnancy	spacing	and	maternal	mortality/morbidity.	Finally,	there	is	growing	evidence	that,	especially	in adolescent girls, unintended pregnancy and unsafe abortion	is	associated	with	violence	and	sexual	coercion.	The lowest abortion rates are found in countries with access	to	comprehensive	sexuality	education,	contraceptive	services and legal safe abortion. Legal reforms have occurred	in	several	countries,	including	Nepal	in	2002,	8which	has	seen	a	50%	reduction	in	maternal	mortality.	Other	countries	that	have	made	legal	reforms	include:	Columbia,	Ethiopia,	Sierra	Leone,	Kenya,	Malawi,	Mexico	City,	Mozambique,	Nigeria	and	Uruguay.Dr	Shaw	pointed	to	examples	of	progress,	including	the 2006 International Federation of Gynecology and Obstetrics’s Prevention of Unsafe Abortion Initiative. Forty-six	countries	participated	in	this	initiative	which	involved a situational analysis of induced and unsafe abortions and the implementation of a country-based plan	of	action.	Finally,	in	March	2014,	a	meeting	of	political, health, and human rights leaders from over 30 countries resulted in the Airlie Declaration for Safe Legal Abortion which calls on governments to: “make safe legal abortion universally available and accessible to all women	regardless	of	age,	income,	or	where	they	live.”	Unmet	contraception	needs	are	significant	and	directly	impacts the rates and need for abortions. At least one in four women seeking to avoid pregnancy is not using an effective	method	of	contraception.	Women	with	unmet	contraceptive	needs	account	for	82%	of	all	unintended	pregnancies. Addressing the unmet need for contraceptive information	and	services	would	result	in	approximately	22	million fewer unplanned births, 25 million fewer induced abortions and 150,000 fewer maternal deaths each year. Dr	Shaw	concluded	her	presentation	with	some	thoughts	on	next	steps	including	reducing	stigma	by	being	mindful of language (i.e. pro-choice vs. pro-abortion) and	debunking	the	myth	that	abortion	is	rare.	Seeking	consensus, rather than continuing the polarizing rhetoric, and	willingness	to	engage	in	difficult	conversations	are	all strategies required to improve access to safe and legal abortion for all women.Abortion in Canada:  you are not AloneMs Dawn Fowler, Director, National Abortion Federation, Canada,	gave	an	overview	of	how	NAF,	the	professional	association	of	abortion	providers	in	Canada,	the	United	States	and	Mexico,	can	assist	rural	providers	and	address	some	of	the	issues	around	stigma.	Since	1977,	NAF	has	ensured the safety and high quality of abortion practice with standards of care, protocols, quality improvement programs, and accredited continuing medical education for	both	surgical	and	medical	abortions.	NAF	also	aims	to	provide a scientific evidence base for good quality, safe abortion	care.	Several	years	ago	the	Canadian	program	was created to address specific issues and challenges of providing	abortion	care	in	this	country.	There	are	28	NAF	member	facilities	in	Canada	which	provide	approximately	80%	of	all	abortions.NAF’s	medical	education	activities	include	publishing	the	only	clinical	textbook	on	surgical	and	medical	abortions;	webinars;	conferences	and	onsite	trainings	(CME	credits).	NAF	also	sets	standards	through	their	evidence-based Clinical Policy Guidelines which are reviewed and updated annually. Member facilities are visited on a regular basis by NAF’s	clinical	services	staff	to	verify	that	they	comply	with	the	guidelines.	NAF	collects	statistics	(i.e.	complication	statistics) to monitor performance and also develops public education campaigns to help reduce stigma and raise awareness around the issues of abortion.NAF’s	24-Hour Clinic Support Services are available to members who may be the target of anti-choice violence or	disruption.	NAF	can	provide	member	agencies	security	assessments	(on-site	and	in-home)	and	trainings.	NAF	also tracks violence and disruptive activities, and can help liaise with local, provincial and federal administrators and	law	agencies	to	reduce	security	concerns.	NAF’s	Public Policy activities help to dispel myths and counter misinformation around the safety of abortion (e.g. press conferences	and	research	briefs).	NAF	also	meets	with	parliamentarians, members of provincial legislatures and colleges around legislation concerns and to continue to lobby	for	abortion	rights	and	increased	access.	Finally,	NAF	can directly assist women through information pamphlets, their	toll-free	hotline	(1-800-772-9100),	multilingual	website (www.prochoice.org), and the Canadian Patient Assistance	Fund	which	can	provide	financial	assistance	for travel, birth control, and other related costs. “…the idea that “abortion is rare” contributes to stigma associated with this issue. However, statistics show 31% of Canadian women and 30% of Brazilian women have at least one abortion in their life time.” – Dr Dorothy Shaw8 9Medical Abortion:  How to and What’s new Dr Ellen Wiebe, Clinical Professor, UBC, and director of the Willow Women’s Clinic, provided an overview of innovative methods for the provision of medical abortions. Medical abortions, as provided in BC, are shown	to	be	98%	effective	when	gestational	age	is	less	than	seven	weeks;	and	85%	for	eight	weeks	or	more.	There are several benefits to providing medical abortions, including timeliness and privacy of the procedure. Medical abortion, a non-invasive procedure, may allow abortion care to be more accessible, especially in rural and remote areas,	and	allow	partner	involvement	if	desired.	Some	of	the	drawbacks	Dr	Weibe	outlined	for	providing	medical abortions include the uncertain time line for completion, several visits required throughout the	procedure,	and	the	cost	of	medication.	Women	experience	numerous	side	effects	with	medical	abortions,	including	nausea	(44%),	chills	(44%),	diarrhea	(26%),	fever	(21%),	vomiting	(17%)	and	pain.	Additionally,	surgical	completion	is	required	in	5-10%	of	cases	–	2%	require	surgery	due	to	continued	pregnancy	or	excessive	bleeding,	while	the	rest	account	for	women	choosing	surgery	due	to	delayed	completion.	Women	should	be	counselled	on	what	to	expect	and	be	given	anti-emetics	and/or	analgesics	to	manage	side	effects.	Despite	the	uncertain	timeline	and	side	effects,	85%	of	women	indicate	that	they	would	choose	the	same procedure again. The approval of mifepristone in Canada, is much anticipated, given the drug’s quicker response, greater safety and fewer reported side effects than the only agent currently available in Canada, methotrexate	(used	in	combination	with	misoprostol).Dr	Wiebe	discussed	basic	requirements	to	provide	medical abortions in a rural community. These include the ability to determine gestational age and confirm completion	of	the	procedure	(e.g.	ultrasound;	HCG).	Physicians must also ensure patients are provided with counselling,	including	explanations	of	medications	and	side effects and the importance of follow up to assure completion. Physicians will also need access to Rh testing and	suction	aspiration	procedures.	Finally	a	24/7	on-call	service and patient follow up protocol is necessary. Dr	Weibe	concluded	by	discussing	the	protocol	for	providing medical abortions which requires assessing for eligibility (under	seven	weeks	and	no	medical	contraindications);	obtaining	informed	consent	(discuss	efficacy,	risks,	side	effects and patient agrees to surgical abortion if regimen fails).	All	patients	are	given	methotrexate	and	misoprostol	(various	protocols	were	discussed).	Follow	up	to	ensure	the	pregnancy	is	terminated	is	extremely	important	for	all patients due to the teratogenicity of both drugs.10Abortion service in BC:  Findings from the British Columbia Abortion Providers’ SurveyDr Wendy Norman and Dr Jennifer Dressler provided an overview of the findings from the BC Abortion Providers Survey	(BCAPS)	study,	as	launched	at	the	2011	CART	Conference.	While	BC	abortion	rates	have	remained	largely	unchanged	from	1996	to	2005,	there	has	been	a	65%	drop	in provision of abortions in rural locations, and of rural abortion providers, during this time.The	BCAPS	study	aimed	to	quantify	determinants	for	BC	abortion providers, and facilitators and barriers to provision of	care.	Self-administered	questionnaires,	were	distributed	to	all	known	BC	abortion	providers	in	2011.	Optional	semi-structured interviews were conducted, transcribed and analyzed. The	BCAPS	study	found	50%	of	abortion	providers	were	family physicians, and half overall were female. The three largest	urban	areas	reported	91%	of	all	abortion	provision	and	98%	of	second	trimester	services.	Only	57%	of	reproductive age women reside in the associated regions. All rural providers performed surgical abortions within a hospital operating room, although three indicated the use	of	a	hospital	outpatient	facility	as	well.	In	contrast,	all	of the urban facilities offered surgical abortions within an outpatient setting. Rural abortion services have more limited	accessibility	and	lower	gestational	limits.	While	there	were	no	personal	experiences	of	harassment	reported	by rural providers, a small number of urban providers reported receiving threats to themselves or family, property vandalism, and trespassers at their home.  Overall,	urban	providers	reported	a	supportive	environment	and	few	barriers	to	service	provision.	In	contrast, rural providers reported significant barriers, many	to	do	with	logistics	included:	insufficient	operating	room	time;	high	demand	for	services	with	no	relief	providers;	professional	isolation,	and	abortion	cases	being	given	low	priority	in	the	OR.	Rural	physicians	also	noted	scheduling	difficulties	due	to	time	spent	on	counseling	and	preparation, activities that are usually undertaken by allied professionals	in	urban	clinics.	Finally,	rural	physicians	noted	a concern about burn-out due to having no replacement providers available. Concluding	their	presentation,	Drs	Dressler	and	Norman	discussed	potential	next	steps.	They	indicated	that	the	largest common barrier reported for rural services are difficulties	related	to	providing	services	within	an	OR.	Performing abortion services in ambulatory settings could reduce many of these logistical barriers and result in cost savings. They also discussed the importance of improving professional support for rural abortion providers (e.g. practice support, consultation links, continuing professional education) and increasing training among family physicians and obstetrician gynecologists, particularly those planning to	practice	in	rural	areas.	Finally,	they	pointed	to	the	need	to work with rural health system stakeholders to identify facilitators that will improve access and reduce costs for abortion services.Lightning Presentations  on BC Services, organizations, and opportunities Short	overviews	on	key	initiatives,	services	and	organizations supporting access to abortion services in BC were given by the following presenters:BC	Ministry	of	Health	Joan Geber, Executive Director, Population Health & Well-being (including the Women’s Health Directorate); Population and Public Health, BC Ministry of Health, noted	that	the	Ministry	of	Health	released	its	directional	document Setting Priorities for the Health Care System in February	2014.	This	document	outlines	eight	priorities	to support the health and well-being of BC citizens. The second priority in the document, “implement targeted and effective primary prevention and health promotion through a coordinated delivery system,” especially guides the	work	of	the	Healthy	Development	and	Women’s	Health	Directorate.	As	such,	they	work	closely	with	BC	Women’s	Hospital,	the	BC	Centre	of	Excellence	for	Women’s	Health,	the	health	authorities,	including	the	First	Nations	Health	Authority,	non-profits,	as	well	as	with	women’s	health researchers to improve the health for women and families	in	BC.	One	of	their	main	priorities	is	to	respond	10 11to	the	Provincial	Health	Officer’s	Report,	The	Health	and	Well-being	of	Women	in	British	Columbia	released	in 2011 which made 43 recommendations to support the health and well-being of women in BC. Ten of the recommendations are related to reproductive health. Ms Geber pointed to two recommendations that were of particular relevance to the CART audience: “improve access to contraception, especially long –acting reversible contraception”;	and	“ensure equitable and timely access to abortion services.”	Ms	Geber	noted	that	she	was	pleased	to	be	linking	with	Dr	Norman	and	CART	in	the	planning	and	implementation of initiatives, such as the provincial door-to-door	Sexual	Health	Survey.	This	survey	will,	for	the	first	time,	collect	comprehensive	sexual	health,	contraception	practices and social determinants of health information on a representative sample of British Columbians. 12BC	Women’s	Hospital	&	Health	Centre	Cheryl Davies	stated	that	BC	Women’s	provides	primary to tertiary care along the continuum of reproductive care services, including abortion care services.	BC	Women’s	CARE	(Comprehensive	Abortion	and	Reproductive	Education)	Program	provides	early	surgical abortions as well as advanced terminations for fetal anomalies or critical maternal indications. BC	Women’s	employs	a	range	of	providers	(e.g.	general	practitioners;	OBGYNs,	Maternal	Fetal	Medicine	specialists)	within an interdisciplinary approach to care which also includes	nurses,	counsellors,	and	support	staff.	BC	Women’s	also hosts students across those disciplines with the aim of knowledge sharing and ensuring successors for future services.	BC	Women’s	offers	the	majority	of	abortion	services in an ambulatory setting within the hospital, removed	from	acute	care	services.	Ms	Davies	indicated	that	BC	Women’s	was	pleased	to	be	part	of	a	network	of	collaboration, professional support and knowledge sharing in BC (hospitals, community clinics, physicians and allied health professionals). This network of support is unique amongst abortion care services and is key to sustainability, good practices, and nurturing inspiration in this area of	women’s	health.	She	noted	that	this	work	cannot	be	done in isolation, whether in rural or urban settings. Ms	Davies	concluded	by	encouraging	those	providers	who are seeking to start offering abortion services or feeling isolated, to make connections with other abortion care	services,	including	BC	Women’s.	BC	Women’s	can	help with advocacy efforts, policy development, and clinical case consultation. They can also assist with hospital based operations and logistics for providing abortion services, including identifying opportunities for offering services in an ambulatory setting (rather than operating room setting) within hospitals. Options	for	Sexual	Health	Jennifer Breakspear, Executive Director, stated that Options for Sexual Health (Opt), is Canada’s largest	non-profit	provider	of	sexual	health	services	through clinics, education programs, and their 1-800 Sex	Sense	hotline.	There	are	60	Opt	clinics	around	BC, many of those operating in rural communities. The three pillars of the organization are: clinical services, education and their toll-free information and referral line which serves the public, physicians, and allied health professionals. Ms Breakspear noted how proud	she	was	of	the	expertise	within	the	organization	and	the	alliances	between	Opt	and	the	network	of	abortion	care	providers	throughout	province.	Opt	also	partners with researchers to investigate critical issues around abortion care. Ms Breakspear concluded by encouraging	rural	providers	to	connect	with	Opt	to	receive support for themselves, staff and patients.Ryan	Program:	Training	at	BC	Women’s	Brian Fitzsimmons, MD, FRCSC, FACOG, Clinical Associate Professor, and Director of the Ryan Residency in Family Planning, Department of Obstetrics and Gynaecology at UBC, and the Medical Director; CARE Program, BC Women’s Hospital & Health Centre discussed the Ryan Program.	Six	years	ago	The	Ryan	Program	of	Family	Planning	Training	for	Obstetrics	and	Gynecology	Residents	was	started	at	BC	Women’s	with	its	first	cohort	of	residents	graduating	this	year	as	OBGYNs.	Dr	Fitzsimmons	noted	that these graduates will hopefully meet some of the needs in abortion care provision around the province. The Ryan Program also hopes to train more family practice physicians who are interested in providing abortion services.	Dr	Fitzsimmons	encouraged	anyone	who	is	interested in getting training or updating to contact them. He	noted	the	importance	of	training,	research,	education	in the area of abortion provision. The Ryan Program works closely	with	CART,	NAF,	UBC	and	partner	abortion	clinics	(Willow	Women’s	Clinic,	Elizabeth	Bagshaw	Women’s	Clinic,	Everywoman’s	Health	Centre,	and	Vancouver	Island	Women’s	Clinic)	to	help	enhance	training.	Dr	Fitzimmons	pointed	to	the	success	of	influencing	the	UBC	Undergraduate	training	program	to	have	more	emphasis	on	family	planning	and	contraception	as	one	example	of	their	contribution. Acknowledging tight resources everywhere, 12 13Dr	Fitzimmons	emphasized	the	need	to	work	together	to	increase training opportunities, and therefore improve access to abortion services for women in the province.Rural Coordination Centre of BCLeslie Carty, Executive Manager, presented on the Rural Coordination Centre of BC (RCCbc), which is funded by the	Joint	Standing	Committee	on	Rural	Issues	(BC	Ministry	of	Health	and	Doctors	of	BC),	and	works	closely	with	the	Department	of	Family	Practice	(UBC).	The	RCCbc	seeks	to	improve rural health education and advocates for rural health	in	British	Columbia.	The	RCCbc	focuses	on	six	pillars	of interest which includes identifying the needs of specific populations (e.g. aboriginal, mental health, emergency services,	and	geriatric	services);	and	communication (promoting ongoing discussion and networking of rural health care professionals on education and practice). The RCCbc also engages in rural health services research,	evaluation	and	quality	improvement;	recruitment	and	retention;	and	education	and	training.	The	RCCbc	supports	the	Rural	Education	Action	Plan	(REAP)	Program	through	UBC	which	provides	funding	for	physicians	to	receive	extra	training	and	upgrade	their skills. The RCCbc aims to support and foster networking amongst rural health care practitioners. Women’s	Health	Research	Institute	Dr Kathryn Dewar, Research Director, gave an overview of	the	Women’s	Health	Research	Institute	(WHRI)	which	supports and promotes women’s health research across BC and networking between stakeholders. She	indicated	that	WHRI	is	proud	to	be	one	of	the	supporters of the CART Team and of this Conference. The	WHRI	hosts	monthly	research	rounds	which	showcase various topics on women’s health research. The	monthly	rounds	are	CME	accredited	and	can	be	broadcast to other health care sites across the province. The	WHRI	also	facilitates	several	research	grant	awards	throughout	the	year,	for	example	the	Nelly	Auersperg	Award which supports preliminary studies in women’s health	research.	Dr	Dewar	encouraged	anyone	who	is interested in receiving updates to check out their website or sign up for their email distribution list. There	is	no	cost	to	join	the	WHRI.	As	a	member,	the	WHRI	can	offer	research	facilitation	services-	support	through all stages of the research process (data collection, grant applications and statistical analysis). The	WHRI	can	also	help	to	promote	news	and	events	to the women’s health research community. UBC	Women’s	Health	Family	Physician	Fellowship	Dr Wendy Norman	explained	that	the UBC	Enhanced	Skills	training	through	the	Department	of	Family	Practice	offers funding for a tailored package in women’s health issues (three months). This program can help with covering the costs of travel and training for family physicians interested in abortion care, family planning as well as other women’s health areas (e.g. obstetrics, breast diagnostics, and	HIV).	She	noted	that	supporting	providers’	education	around the province is a top priority for the program.Conference Partners, Audience MembersDr	Norman	opened	the	floor	to	audience	members	for	any	updates	on	current	initiatives	and	services.	Dr	Judith	Soon,	Assistant	Professor,	UBC	Faculty	of	Pharmaceutical	Sciences	discussed	a	current	research	project,	Emergency Contraception IUDs: Pharmacist Provision Pilot Project. Dr	Soon	noted	recent	increased	interest	in	Copper-T	intrauterine	devices	(Copper	IUD)	as	an	effective,	form	of	emergency	contraception.	She	noted	that	women	coming	into	pharmacies,	sexual	assault	programs,	emergency	departments,	and	Opt	clinics	could	be	provided	with	information	about	copper	IUDs,	if	relevant.	This study involves a free accredited training program for	pharmacists	in	Vancouver	and	Victoria	to	provide	eligible	women	with	information	about	copper	IUDs.	Women	who	are	interested	are	provided	rapid	access	(within	seven	days,	usually	next	day)	for	the	copper	IUD	insertion	at	two	clinics:	Willow	Women’s	Clinic	(Vancouver)	or	the	Vancouver	Island	Women’s	Clinic	(Victoria).	Some	of	the	costs	are	covered	by	insurance	companies	and	MSP	will	cover	the	cost	of	insertion.	14Panel Questions Concluding, all presenters from the morning gathered for a panel discussion. The following highlight just a few of the numerous questions posed by participants. Are there any articles countering the myths associating abortions with breast cancer and/or mental health concerns?Dawn	Fowler	noted	that	there	is	a	vast	amount	of	literature	on	this,	and	that	NAF	has	a	package	available for providers on how to counter such myths,	as	well	as	information	on	the	NAF	website.What is your opinion on the progress towards global abortion rights and access? Dr	Dorothy	Shaw	said	there	is	uneven	progress	globally.	While	there	has	been	definite	progress	in	some	countries,	the	opposition	is	very	well	organized.	She	gave	the	example	of	Kenya	who	changed	their	constitution	to	include legal access to abortion for specific indications, but then halted the process due to pressure from anti-choice	organizations.	However,	she	pointed	to	examples	of	great	progress,	such	as	Uruguay’s	harm	reduction model which has been implemented in several other	countries.	She	emphasized	the	importance	of	continuing to advocate for access to reliable, effective contraception, and safe abortions when it fails. Why isn’t contraception free?Dr	Norman	acknowledged	that	health	care	resources	are	not	always	distributed	in	a	way	that	seems	equitable.	In	order to equitably plan and space pregnancies, women need access to high quality contraception services and to	have	contraception	provided	free.	In	order	to	present	a business case to government that free contraception would be cost effective and improve equity, she noted a comprehensive	sexual	health	survey	using	representative	data from the province to determine the current burden to	manage	unintended	pregnancies	is	needed.	She	indicated	that	CART,	BC	Women’s	and	the	Ministry	of	Health	were	working	together	collect	this	data.It is estimated that 30% of women will have had an abortion by the end of their reproductive years, yet so many do not make this public. There may be an opportunity for mobilizing a huge number of change agents to advocate for better expenditures of health care dollars to support women in their reproductive years and to align services to where they are needed. How do you see facilitating a public discussion to support political will to make these kinds of change?Dr	Espey	noted	that	the	evidence	is	indeed	there	to	support	providing	low	or	no	cost	contraception.	It	is	a	fact	that	spending	money	on	contraception	saves	money.	Dr	Espy	also	noted	that	unfortunately,	the	facts	don’t	matter	for	many	conservative	decision	makers.	It	is	important	to get abortion out of the shadows and for women to start	to	speak	up	about	their	abortions.	She	noted	the	need to make it less taboo for women to speak about their	abortions.	Ms	Fowler	also	pointed	to	the	need	to	educate the public on abortion and normalize it as a part of reproductive health.In BC where abortion is legal, there is stigma about providing this service. Many physicians who are willing to provide abortion care are reluctant because of the fear of stigma. How can we change this?Dr	Espey	noted	that	the	need	to	create	a	supportive	environment where physicians and staff are empowered to	speak	up	and	say	“yes	I	would	be	willing	to	do	this	and	I	believe	in	the	importance	to	provide	safe	abortion	care.”	Values	clarification	is	also	important.	Bringing	together	people who support abortion provision to discuss the issues and build networks of support, will reduce feelings of isolation.	Dr	Espey	also	noted	the	importance	of	champions	in this area, as well as continued efforts to increase 14 15training, research and education. Government support is also key to reducing the stigma associated with abortion. Given the lack of abortion providers in rural and remote locations, are midwives being trained in abortion care? Dr	Shaw	indicated	that	at	the	latest	International	Confederation of Midwives general assembly a policy statement was passed that stated “midwives could,  should	and	would	be	trained	to	provide	abortion	care.”	 Dr	Shaw	noted	that	midwives	are	in	the	position	to	see	the	consequences of unsafe abortion but generally are not in the position to assist. Although many countries are adopting this, there are still some barriers including current abortion providers being hesitant to facilitate this transition and hand over this responsibility to midwives in rural and remote locations.	She	stated	that	“we	are	making	progress	and	I’m	optimistic	that	we	can	utilize	midwives	to	help	deliver	these	services	over	time.”	She	also	noted	that	research	has	shown	the	efficacy	and	safety	of	midwifery	and	nurse	practitioner management of abortion, especially medical abortions. Legislation and political will are the main barriers.Does NAF provide a mentoring program for physicians that are now trained, but are uncertain on how to manage the dialogue and security concerns related to providing these services in their communities?Ms	Fowler	confirmed	that	NAF	does	have	such	a	program.	She	noted	that	they	try	to	provide	mentoring	support	in	two	ways.	First	they	link	new	physicians	up	with	seasoned	abortion care providers who are fairly local. They also have	people	in	the	NAF	office	who	can	support	them	in	navigating questions- how to dialogue and when to walk away	from	certain	questions.	NAF	is	also	willing	to	send	people into a facility to spend time with new physicians to help problem solve and provide mentorship. What would you say to physicians who are reluctant to provide medical abortions in their community because  of concerns about complications?Dr	Wiebe	simply	responded	that	if	physicians	can manage a miscarriage in their community, they can manage a medical abortion.While I agree that ambulatory settings would be ideal for abortion provision, in most rural hospitals, the operating room is about the only facility suitable, because there are no ambulatory care facilities. We know that we do not need to put women to sleep in order to use that space and perform the procedure. How can we get education to the operating room staff about not requiring general anesthesia for all patients? Dr	Norman	noted	that	some	of	the	larger	rural	centres	where abortion care is being provided in operating rooms, are running some ambulatory clinics within the hospital (e.g. colposcopy or colonoscopy clinics). These clinics have the space, training and staff to potentially also offer abortion services.	Dawn	Fowler,	also	noted	it	is	very	important	to have staff working in abortion care by choice when providing these services in hospital. A more women-centred and supportive environment can be offered when staff is working there by choice, rather than scheduled to be there.Given that one of the main barriers noted by the rural providers was the time allocated to counselling, and how burn out is an issue, is there any consideration for providing that counselling centrally, perhaps by Skype or phone? Dr	Norman	referred	to	the	Provincial	Pregnancy	Options	Service	line,	which	was	developed	by	BC	Women’s	Hospital	and	the	Ministry	of	Health,	and	staffed	with counsellors who can provide counselling and information	about	regional	services	Dr	Norman	stated	that she believed there is an opportunity the potential of investing in a central service which could better support many of the rural providers, giving information about the procedure and providing remote counselling to	patients.	She	noted	that	Options	for	Sexual	Health	has also been a partner in providing counseling locally and centrally through their hotline and clinics.1616 17Part II: development of Proposed SolutionsThe conference shifted in the afternoon to a planning workshop for designated interprofessional and inter-sectoral stakeholders. The aim was to use the information presented	in	the	morning	and	participants’	expertise	to	explore	of	ways	of	collectively	planning	and	strategizing	to improve support for rural abortion services and the provision of services closer to home for women in BC. Presentation of Innovative Solutions in BC Communities Dr	Norman	began	the	afternoon	by	reading	two	write-in	testimonies that were sent in by physicians working in northern BC communities, and discussing the challenges they	have	experienced	in	offering	abortion	services	in	their	rural setting. The physicians noted being overwhelmed with the workload and struggling to continue providing abortion services with such tight resources. The lack of relief for rural providers and patient travel issues were noted as major barriers. Both physicians noted the need to	explore	new	models	of	care	to	ensure	the	abortion	and family planning needs of rural women are met. The audience then heard, via video conference, about two services in BC that had moved their abortion provision out	of	the	OR	and	into	ambulatory	settings	within	their	hospital. Presenters discussed the impact this shift had on their hospital, staff and feedback from patients.Women’s	Services	Clinic	–	Kelowna	Bev Sieker, Health Services Director, Kelowna General Hospital,	noted	that	the	Women’s	Services	Clinic,	was	established at the hospital in 2000. The clinic was originally funded to provide 650 procedures a year and provide services up to 12 weeks gestation. The weekly clinic is located within the acute care facility, but in an area that	is	separated	from	patient	wards.	Staffing	includes	a	unit	clerk	(three-day/week)	to	book	appointments	and support the running of clinic. The clinic is also staffed with four registered nurses who rotate through counseling, pre-post procedure care, and providing support during the procedure, with one licenced practical	nurse	and	one	Sterile	Processing	Technician.	While	the	funding	and	staffing	model	has	stayed	the	same,	efficiency	continues	to	increase,	with	750	abortion	procedures	performed	in	2013-2014.	Ms	Sieker	noted	that	the long wait list, an average of four weeks, is a major barrier	to	meeting	the	needs	of	women	in	the	Okanagan	and beyond. They continue to advocate for additional resources	to	run	more	clinics	per	week.	In	terms	of	safety	and security, the clinic has the recommended control features and access restrictions, but does not require security presence at the clinic. There have been no security incidents in 14 years. They have seen a savings of between $300-$350 per case by moving the procedures out of the operating	room	(avg	$830/case),	and	into	this	ambulatory	care	setting	(average	$520/case).	Since	Fall	2009,	the	hospital has also been able to use the clinic space one day a week to perform gynecological procedures, moving them out of the operating room. This has seen similar savings per case. The patient and physician response to providing abortion procedures in the clinic space has been overwhelmingly positive, with a concomitant decrease in stigma for the abortion service, as all women’s services are	now	offered	in	the	same	“Women’s	Services	Clinic”.Kootenay	Boundary	Regional	Hospital,	TrailCindy Ferguson, Manger of Surgical Services and Ambulatory Care, Kootenay Boundary Regional (KBR) Hospital and a local physician in the region discussed their ambulatory abortion clinic. The program originated in	1990s	at	Castlegar	Hospital	and	was	moved	to	the	KBR	Hospital	in	2002.	Abortion	services	were	moved	out	of	the	OR	and	into	an	ambulatory	setting	two	years	ago.	Her	clinic	noted almost identical savings per procedure as noted by the	Kelowna	service.	Ambulatory	staff	(one	RN,	one	LPN,	and one clerk) are used to run the bi-weekly clinic which utilizes	the	surgical	day	care	centre.	While	most	staff	have	no	concerns	working	in	the	clinic,	Ms	Ferguson	noted	that	she allows staff to opt out of working there if they choose. On	average,	between	six	to	ten	patients	are	seen	per	clinic. The clinic sees patients from across the Kootenays. 18Ultrasounds	are	performed	in	the	clinic	on	the	day	of	the	procedure	when	needed.	The	move	from	the	OR	to	the	ambulatory setting was a positive move for the patients, allowing	for	a	much	more	relaxed	atmosphere.	Ms	Ferguson	noted that the KBR clinic also has no onsite security during the day, and has never encountered a security issue. The physician noted that one of the challenges to running this clinic is that there are not funding for abortion provision,	therefore	only	staffing	and	infrastructure	funding	comes from the hospital budget and the only physician payment	is	fee-for-service.	Unlike	other	centres,	there	are no counsellors to provide support and counselling to patients. This responsibility falls on the physician who sees patients outside clinic the day before (pre-operative intake,	counseling,	consent	etc).	Follow	up	is	done	with	the	patient’s	GP,	at	an	Opt	Clinic,	or	a	walk-in	clinic.	However,	the physician noted that some GPs refuse to provide care to abortion patients. The clinic does not provide medical abortions, because the sole physician is not readily available for the volume of follow up and on-call services as required for	methotrexate	medical	abortions.	The	physician	reported	that it would be ideal if more GPs in the area provided medical abortions and thus the KB hospital service would surgical abortions as a backup. Being the only provider of abortion services, the physician noted potential issues of burn out due to her need to be on-call at all times, although she is rarely called off hours, and to a sense that it is hard to be away from the community as there is no one to undertake the service in her absence. 18 19MAjor BArriers MAjor FAcilitAtorsProvider relief and succession Training and EducationCost and logistics Innovations in practice and careLack of data Better data collection and reportingStigmatization Advocacy and dispelling mythsDistance Rural provider support and counselingSummary of FeedbackThe rest of the afternoon was spent in a facilitated workshop to discuss and generate ideas on how to improve family planning health service access throughout rural BC. Facilitator,	Jen	Reed-Lewis	recognized	that	participants	connected	around	the	content presented in the morning through different disciplines, geographies and perspectives. The afternoon session was intended to create coordinated action to mitigate the gaps and service needs discussed in the morning sessions. Ms Reed-Lewis, invited participants to reflect on the content and issues they want to coordinate around and to drive that to action. Key theMesBC has a significant unmet need for abortion servicesUneven distribution of access to services and providersRural providers facing major logistical barriers and stigmaMedical abortions are underutilized Gaps in knowledge and data hindering progress20open Space dialogue Session:  Generating Solutions and RecommendationsMs Reed-Lewis	lead	participants	through	an	Open	Space	dialogue	process	which	aimed	to	generate	list	of	key change topics and move participants through three conversation rounds to focus the discussion on solutions and recommendations. First	participants	were	asked	to	respond	to	a	focused	question	to	generate	change	topics:	“If	we	are	going	to provide safe, high quality abortion support in rural communities,	we	really	need	to	focus	our	efforts	on...”	Participants were asked to shout out response and then write it down on a piece of paper and post it on a whiteboard for everyone to see. After generating a robust list of change topics, participants were lead through three rounds of discussion in small working groups to	further	explore	the	change	topics.	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. Groups structured their conversation by answering the following questions:1. What are we doing well?2. What are the barriers? What can we improve on?3. What’s one recommendation?20 21change topic What are we doing well? What are the barriers?  What can we improve on? What’s one recommendation?1.  Increase medical student interest –		Medical	School	curriculum	and Problem Based learning covers abortion–		More	hands	on	learning–		Include	a	mandatory	½	day	rotation–		Increase	awareness	of	GPs	as	abortion	providers–		Increase	focus	on	abortion	during	family residency training in rural areas2.  Increase training opportunities for rural GPs–		REAP	funding –		Give	priority	to	physicians	with	a	practice	location			•	Flexibility	in	schedule	and	duration			•	Peer	mentoring			•	Distance	education			•	Geographic	support	communities–		Provide	more	flexible	abortion	training with priority given to practicing physicians3.  Systematic monitoring and surveillance –		Individual	clinics	get	their own data to use for planning and monitoring–		Consistent	standardized	collection	and	consolidation of data used for planning and monitoring–		Data	sharing	agreements–		Relax	the	interpretation	of	Freedom	of	Information	Act	(FOI)	with	respect	to	abortion data between institutions–		Pull	together	a	broad	based	working group to develop a system of data collection, monitoring and surveillance	(clinicians,	policy,	FOI,	researchers, etc)4.  Make health authorities responsible for providing abortion services–		Most	HAs	are	offering	some	ambulatory care–		Collaboration	between	CART	and	Ministry	of	Health	–		Better	compliance	with	SOGC	standards–		Improved	funding	levels	for	Opt	Clinics–		HAs	making	access	to	abortion	a	priority	–		Inter-collaborative	conversation	needed			•		Where	is	the	best	place	to	provide	services?			•	Look	at	Quebec	model			•	Discuss	pay	per	performance–		Give	incentive	to	hospitals	and	administrators5. Provider retention –		There	are	some	dedicated	and inspired providers–		Fee	codes–		Recruitment	in	rural	communities	for	abortion training–		Funding	and	support	should	be	more reflective of the work done by abortion	providers	(Surgical	TAs)–		A	rural	abortion	provider	locum	pool is needed–		A	community	of	practice	for	providers could be supportive and helpful6.  Explicit mentoring support –		Assume	mentoring	integrated with skills training–		Ryan	Fellowship	working	for	GYN	residents–		NAF	monitoring	support–		More	access	to	training	for	family	physicians–		Formalized	training	system	–		Use	connections	from	the	training	process	to	maintain support network–		Training	to	include	more	than	skill	development as well as follow up supportRound A22Round Bchange topic What are we doing well? What are the barriers? What can we improve on? What’s one recommendation?1.  Improve grassroots local advocacy and support–		There	are	Opt	Clinics,	women’s organizations and NAF	involvement	in	some	communities–		Make	grassroots	support	more	effective–		Identify	champions	–		Use	less	obvious	networks	to	make	abortion	issue	more	explicit–		Sustaining	existing	surgical	services–		Develop	a	way	to	leverage	existing	supportive community groups to facilitate grassroots support and advocacy2.  Examine the scope of practice for interdisciplinary teams (e.g. nurse practitioners, midwives)–		NPs	have	a	fairly	large	scope	now –		Midwifery	more	interested	in	contraception issues –		Pharmacists	have	great	expertise	about	contraception	and abortion–		Good	resources	for	resource-limited communities–		More	choice	in	providers	for	women	–		More	scope	in	practice	for	other	providers;	including	counselling	–		Prototype	for	doula	care–		Diversify	the	level	of	support	for,	and	team members to support, abortion care providers–		Expand	beyond	physicians	(but	first	focus on contraception) 			•	NP	pilot	project			•	Pharmacists3.  Patient counseling support for rural providers–		Sharing	information	between	clinics–		Standardizing	documents	between	all	clinics/	providers–		Access	to	resources	in	other	languages–		Central	bank	of	guidelines	and	patient	information			•	Easy	access				•	Clear	owner	for	updates				•		Access	to	remote	counselling	(Opt	hotline, etc). –		Would	BC	Women’s	consider	a	central	counselling	services?4.  Eradicate stigma and isolation –		NAF	ads/	anti–stigma	campaigns –		Talking	about	it;	normalizing	the	experience–		Being	explicit	about	being	pro-choice–		Public	education	and	patient	education –	Get	education	system	on	board–		Hold	teachers	and	schools	accountable to deliver on mandated learning outcomes–		Broad	reaching	public	education	campaign (using social media) to get people to understand that abortion is safe, legal and normal5.  College eliminate 14 week TA restriction for General Practitioners–		Recognizing	that	all	other	provinces have no such limitations–		CollegePSBC	has	recognized	that there are gaps, and no formalities required, so they may be amendable to change–		Changing	attitudes	in	the	hospitals	for second trimester abortions –		Training	should	be	recognized	by skills and competency, not professional designation –		Training	currently	is	signed	by	but	there	is	no	formal	“form”	or	training	list of competencies–		While	training	criteria	should	be	set,	the	designation	GP/OB/GYN	should	now be removed. Timing may be optimal now6.  Provider Engagement and Competency–		RCC/	REAP	funding	–		NAF	Conference	and	CART	Conference–		A	system	of	connecting	new	providers	with	experienced,	local		mentors –		Connecting	providers	with	NAF	and	other organizations to support them–		Organizational	system	of	notifying	providers	about	updated	training/	CMEs	etc	–		Establish	a	discussion	network–		Proactive	system	for	contacting	and connecting abortion providers regarding training opportunities and support7.  Peer Support and Counselling–		Counselling	services	offered	by providers and allied health team –		Pregnancy	Options	and	Opt	phone lines–		Better	engagement	of	women	with	abortion history to provide support to current patients–		Normalization	and	de-stigmatization of abortion–		Educational	resources	to	support	counsellors–		A	pilot	project	“The	Book	Club”	e.g.	Choices	Study.	Providers	as	coordinator/liaisons	to	start	conversation about supporting the next	generation	of	women.	Help	connect and support women with similar	experiences22 23change topic What are we doing well? What are the barriers? What can we improve on? What’s one recommendation?1.  Strategies to move procedures out of the OR and into ambulatory setting–		Cost	argument–		Kelowna	data	may	work	for	some	settings	to	keep	on	OR	slate–		Educate	Anesthesiologist	that	standby	or	IV	sedation	=	same	fee	code as general anesthesia–		General	anesthetic	not	best	practice	-	local anesthesia is safer–		Early	Pregnancy	Loss	Clinics	could	be		incorporated–		Location	-	ER	or	ambulatory	procedure room–		Advocate	for	standards	to	include	alternatives to general anesthesia–		Undertake	and	publish	research	in	BC on various funding models, costs and outcomes2.  Mobilize the public to recognize abortion as a public health issue–		Mobilize	the	public	to	recognize abortion as a public health issue–	We	are	funding	the	procedure–	Need	to	talk	about	abortion	more–		More	‘story-telling’–		Look	at	the	social	costs	of	unwanted	children–		Need	politicians	to	embrace	the	issue–		Public	media	campaign	with	charismatic spokesperson		•	Gain	widespread	support		•	De-stigmatize		•		Acknowledge	abortion	as	a	common	practice of women3.  Streamline and standardize accreditation and regulation for abortion car–		Keeping	patients	safe–		Clinics	are	working	together	and coming from evidence based approach to problem solving–		Collaboration	with	other	institutions–		Encouraging	evidence	based	consistent standards–		Encourage	setting	appropriate	standards that are applied consistently through an integrated single accreditation4.  Prevention of unintended pregnancy, through better sexual health and contraception education–		Sexual	health	education	is	embedded into mandated curriculum–		We	have	60	Opt	clinics	(but	need more)–		Standardize	delivery	of	sexual	health	education and make sure that it is delivered–		Community	physicians	delivery	of	sexual	health	info	(e.g.	Oregon’s	1	Key	Question Program)–		Standardize	sexual	health	and	family	planning education for all5.  Develop regional centres for abortion care–		Kelowna	is	a	‘go	to’	facility	for	the	Interior	region–		Develop	related	and	similar	services	(e.g	fertility,	D&C)	to	use	the	same	type of facility–		Use	population	data	and	geography	to determine most effective location–		Use	the	model	of	Kelowna	clinic	to	develop in four areas of province –		make	these	services	more	integrated	and “program-based6.  Free contraception for all–		Opt	clinics	-	in	public	health	offices	offer	inexpensive	contraception –		Only	four	clinics	able	to	insert	IUDs–		NIHB	program–		Insurance	companies	should	be	required to cover contraception–		Government	funded	contraception–		CADTH	current	recommendations	are	efficacy	not	effectiveness	based	and	a change here could go a long way to supporting government and private insurance subsidy to contraception–		Compile	and	present	evidence	to	support providing contraception to all women –		Present	a	business	case	to	CADTH	to consider changing their current perspective and recommendations with regard to contraceptives.7.  Vacation relief for rural providers and staff–		Providers	empathetic	-	would	be willing to help if they could–		Increase	the	number	of	abortion	clinic	days/week			•	Both	items	require	funding!–		Rural	providers	locum	resource	with	funding for travel, accommodation, premiumsIn	addition	to	the	above	change	topics	generated	and	explored	in	working	group	discussions,	the	following	issues	were also brought up in the initial brainstorming session: 1.		Policy	Reform	–	allow	portability	of	medical	insurance	coverage for abortion between provinces2.		Improvements	in	MSP	funding	for	rural	providers	who	don’t have counsellors or access to counselling services3.		Support	and	infrastructure	for	abortion	services	from	hospitalsRound C24What is your ‘aim’?	 •		Focus	on	training	for	medical	abortions	 •		Involve	providers	from	multiple	disciplines	 (i.e.	NP	in	Port	Hardy)	 •		Increase	exposure	during	family	residenceBenefits to rural women	 •		Reduced	travel	for	proceduresHigh level plans	 •		Include	training	in	family	practice	residency	 –		exposure	more	important	than	gaining	competency	 •		Collect	data	to	support	feasibility	of	this	planWho’s involved?	 •		UBC	Family	Residency	program	 •		Island	Health	ProvidersHow will you know the plans are addressing  the aim?	 •		Collect	data	on	medical	abortions	provided	 •		Collect	data	on	complications	(i.e.	lost	to	 follow-up)   What is your ‘aim’?	 •		Initiate	an	abortion	clinic	in	Cranbrook	supported by established clinics	 •	Benefits	to	rural	women	 •	Increase	access	to	service	 •	Decrease	travel		 •	High	level	plans	 •		Establish	meeting	with	stakeholders	to	discuss needs and logistics	 –		Logistics.	Staff,	Equipment,	MDR	 –		Space	 –		Who	are	our	clients?	Who	does	the	prep	and	 follow	up?	Education	 –		What	next?Who’s involved?	 •		Trail	–	administrator	and	physician	 •		Cranbrook	–	two	administrators	and	two	physicians 	 •		Support:	three	other	IHA	group	membersHow will you know the plans are addressing  the aim?	 •		Regular	clinic?	–	every	two	weeks	 •		Clients	from	East	Kootenays	and	Kootenay	Boundary having quality abortion services  in Cranbrook.group 2: island healthgroup 1: interior healthAction Planning:  Sharing and Setting Priorities The afternoon concluded with participants breaking into their respective geographic, health authority groups	(“Regional	Implementation	Teams”	to	engage	in action planning. Participants reviewed the change topics and recommendations generated throughout the afternoon, and in like groups, chose one theme for which to develop an initial action plan. The participants then gathered as a large group, with a representative from each working group summarizing the key issues, priorities and benefits of their action plans. 24 25 What is your ‘aim’?	 •		We	will	approach	Northern	Medical	Program	and	Prince	George	Family	Practice	Residency	Program to provide the following:	 			–		Skills	on	counselling	for	options	in	pregnancy	 			–		Skills	on	medical	and	surgical	abortions	 			–		Explore	women’s	health	clinic	in	Prince	George	Opt	clinic	in	PG	currently	only	serves	women up to 26 years of age) Benefits to rural women	 •		Accessibility	and	sustainabilityHigh level plans	 	•		We	already	see	and	train	medical	students	and 	residents	–	just	need	to	incorporate	this	into	 the trainingWho’s involved?	 •		Physician	providers	from:	Prince	George,	Smithers,	Dawson	CreekHow will you know the plans are addressing  the aim?	 •		Decreased	referrals	for	TA	locally	and	to	C.A.R.E.     What is your ‘aim’? 	 •		Change	public	opinion	with	respect	to	the	value	(financial and otherwise) of free contraceptionBenefits to rural women	 •		Cost	is	a	big	barrier	to	accessing	contraception.	 •		Contraception	is	highly	useful	for	rural	women	who have more complications in accessing abortions.High level plans	 	•	Evidence	to	support	free	contraception	 			–		Opt	has	compiled	reports	in	the	past	 			–		More	research	about	rural	access	to	contraception	 			–		More	research	about	Canadian	context	 	•		Evidence	won’t	necessarily	be	adequate	–	often	the	evidence	already	exists,	but	for	ideological	reasons, there are still barriers.	 •		Bring	the	issue	of	abortion	and	contraception	to	people’s	‘radars’.	 			–		More	forums,	networking	between	organizations	(Opt,	NAF)	and	the	hospitals	and health authorities	 			–		Increased	webcasting	and	webinarsWho’s involved?	 •		Epidemiologists	 •		Government	 •		Researchers	 •		Advocates	 •		Canadian	expertsHow will you know the plans are addressing  the aim?	 •		When	contraception	is	free!	 •		Hopefully	abortion	rates	will	go	down	and	 rural women will have less hardships in  accessing abortion.group 3: northern health group 4: vancouver coastal & Fraser health26  What is your ‘aim’?	 •		Build	business	case	for	sharing,	surveillance	and	monitoring of abortion data.Benefits to rural women	 •	Increased	access	to	abortions	locally.	 •		Decreased	travel	and	associated	costs.High level plans	 •		Determine	current	resources	and	who	is	providing services.	 •		Pull	together	data	from	health	authorities,	 Opt,	BC	Women’s,	Perinatal	Services	BC	(PSBC)	and	NAF.	 •		Use	the	Hospital	Services	Review	as	a	hook	to	justify the service plan.Who’s involved?	 •		Pull	together	a	taskforce	that	includes:		 			–		Data	people	 			–		FOI	people	 			–		Opt	 			–		PHSA	 			–		RCCBC	 			–		CART	 			–		Pharmacy	(Judith)	 			–		NAF	(Dawn)How will you know the plans are addressing  the aim?	 •		The	data	is	collected	and	then	the	plan	 is developed. 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 and their individual advocacy	efforts.	Dr	Wendy	Norman	described	the	work of the day as just the beginning of a continuous engagement with stakeholders within the abortion and family planning community in BC. Ms Reed-Lewis	expressed	her	hope	that	participants	can	continue to advocate and share information about what was presented and discussed today. 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 working towards the CART aim of 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.grac@ubc.ca  or visit our web site: www.cart-grac@ubc.ca group 5: provincial services & government26 2728Appendix A: AgendaMorning current KnoWledge, Bc evidence & Best prActices Participants:   Open invitation for all family planning clinicians, service providers and regional    administrators, researchers, patient group representatives, and trainees8:00–8:10	 First Nations Welcome Ceremony   First Nations Elders8:10–8:25	  Welcome and Overview   Dr Perry Kendall, Provincial Health Officer, BC Ministry of Health;  Dr Jan Christilaw, President, BC Women’s Hospital and Health Centre;   Dr Wendy V. Norman, Conference Chair8:25–8:30	 	Introduction of the Ryan Program International Speaker   Dr Brian Fitzsimmons, Assistant Professor, and Director,  Ryan Program in Family Planning, Dept of Obstetrics & Gynecology, UBC;  Medical Director, CARE Program, BC Women’s Hospital8:30–9:10	 Keynote Address: Abortion in outpatient settings: Access, safety, Acceptability   Dr Eve Espey, Professor, Department of OB-GYN Chief, Family Planning Division, University of New Mexico, Albuquerque, NM09:10–09:30	 Abortion in the Global Context   Dr Dorothy Shaw, Clinical Professor, UBC, Vice President, Medical Affairs,  BC Women’s Hospital, Vancouver, BC09:30–09:50	 Abortion in Canada: You Are Not Alone  Ms Dawn Fowler, Director, National Abortion Federation, Canada09:50–10:10	 NUTRITION AND NETWORKING BREAK – POSTER VIEWING SESSION 10:10–10:30	 	Medical Abortion – How To and What’s New  Dr Ellen Wiebe, Clinical Professor, UBC10:30–10:50	  Abortion Service in BC: Findings from the British Columbia Abortion Providers’ Survey  Dr Wendy Norman, Assistant Professor, UBC  Dr Jennifer Dressler10:50–11:10	 2-minute Lightning Presentations on BC Services, Organizations, Opportunities 	 	 BC	Ministry	of	Health	–	Joan Geber;    BC	Women’s	Hospital	&	Health	Centre	–	Cheryl Davies; 	 	 	Options	for	Sexual	Health	–	Jennifer Breakspear;  Ryan	Program:	Training	at	BC	Women’s	–	Dr Brian Fitzsimmons;  Rural	Coordination	Centre	of	BC	–	Dr Kirstie Overhill;  Women’s	Health	Research	Institute	–	Dr Kathryn Dewar;  UBC	Women’s	Health	Family	Physician	Fellowship	–	Dr Wendy Norman, Conference Partners, Audience Members28 2911:10–11:50	 Interactive Audience-Panel Discussion: –	Audience	Submissions	of	Comments,	Reaction,	Questions	 –	Ideas	to	Address	Identified	Challenges/Opportunities  All Speakers, Moderator and Audience Members11:50–12:00	 Conference Summary and Morning Session Closing Remarks   Dr Dorothy Shaw    Dr Wendy NormanAFternoon By invitAtion onlyAFternoon developMent oF proposed solutions Participants  Invited Knowledge User leaders, Health System Decision-Makers,  Patients, Rural physicians, Researchers and Trainees12:00–12:30 INTER-SECTORAL, INTERDISCIPLINARY LUNCH 12:30–13:00	 Presentation of Innovative Solutions in BC Communities   Providers from several BC communities13:00–14:30	 Creating Change Conversation Rounds	 –	Change	Topics	generated	by	participants,	choose	3	topics	for	3	conversation	rounds	 –	Open	Space	Technique	  Facilitator14:30–14:45	 NUTRITION AND NETWORKING BREAK	 –	Gallery	walk	on	Themes	14:45–15:30	 Issue to Action	 –		In	like	groups,	choose	a	theme	to	act	on	and	within	sphere	of	control	identify	improvement areas to take on   Facilitator15:30–16:15	 Report Outs   Facilitator16:15–16:45	 Meeting Summary, Next Steps –	Conference Chair16:45–17:00	 Closing Ceremony(DURING	LUNCH)30Appendix B: Speaker BiosDr Jan ChristilawDr	Jan	Christilaw	is	President	of	BC	Women’s	Hospital	&	Health	Centre	(BC	Women’s)	and	a	leader	in	Canada	and internationally in ensuring women have access to high	quality	reproductive	health	care.	She	is	a	Clinical	Professor	in	the	Department	of	Obstetrics-Gynecology,	holds	a	Masters	of	Health	Science;	is	a	Past-President	of	the	Society	of	Obstetrician-Gynecologists	of	Canada;	a	Co-Chair	of	the	Women’s	Health	Task	Force,	a	member	of	the	JOGC	Editorial	Board,	and	past	chair	of	the	SOGC	Ethics	Committee.	Jan’s	recent	Awards	include:	the	Federation	of	Medical	Women	of	Canada	Reproductive	Health	Award,	and	the	Queen	Elizabeth	II	Diamond	Jubilee	Medal.	Cheryl DaviesCheryl	is	currently	the	Vice‐President,	Patient	Care	Services	at	BC	Women’s.	She	has	over	20	years	experience	in	women’s	health	as	a	nurse,	educator	and	executive	leader, in both community and hospital settings, and	is	a	former	Executive	Director	of	the	Elizabeth	Bagshaw	Women’s	Clinic.	A	lifelong	volunteer,	she	is	currently	a	Board	Director	with	Health	for	Humanity.	Dr Kathryn Dewar Dr	Kathryn	Dewar	is	the	Research	Program	Manager	at	Women’s	Health	Research	Institute,	BC	Women’s	Hospital	&	Health	Centre.	She	collaborate	with	clinicians,	residents	and	hospital staff to develop and implement research projects within	the	clinical	programs	of	BC	Women’s	Hospital.Dr Jennifer DresslerDr	Jennifer	Dressler	is	a	rural	family	physician	living	in	Grand	Forks	and	working	in	and	around	the	West	Kootenay/Boundary	region.	She	graduated	from	the	Okanagan	Rural	Family	Medicine	Program,	during	which	she	was	a	co-investigator	in	the	BCAPS	study.	She	is	returning	to	UBC	to	complete	additional	training in obstetrics and women’s health. Dr Eve EspeyDr	Eve	Espey,	MD	MPH	is	Professor	and	Chair	of	the	Department	of	Obstetrics	and	Gynecology,	and	Family	Planning	fellowship	director	at	the	University	of	New	Mexico.	She	is	President-elect	of	the	Society	of	Family	Planning, the Medical Advisory Committee Chair for the	National	Campaign	to	Prevent	Teen	and	Unplanned	Pregnancy	and	Chair	of	the	American	College	of	OB-GYN’s	Committee	on	Underserved	Women.	She	has	numerous	publications in the area of family planning and medical education and has presented locally, regionally and nationally on these topics.Dr Brian FitzsimmonsBrian	Fitzsimmons,	MD,	FRCSC,	FACOG	is	a	Clinical	Associate	Professor,	and	Director	of	the	Ryan	Residency	in	Family	Planning,	in	the	Department	of	Obstetrics	and	Gynaecology	at	UBC,	and	the	Medical	Director	of	the	CARE	(Comprehensive	Abortion	and	Reproductive	Education)	Program	at	BC	Women’s	Hospital	and	Health	Centre.	Dawn FowlerDawn	Fowler	is	the	Canadian	Director	for	the	National	Abortion	Federation.	Previously,	she	worked	at	Health	Canada	as	Chief	of	Reproductive	and	Child	Health	and	coordinated the development of Canada’s Perinatal Surveillance	System	which	she	insisted	include	abortion.	She	has	also	been	a	consultant	with	WHO	–	EURO	Office	and worked on reproductive health and quality assurance issues	in	the	newly	independent	states	of	the	former	Soviet	Union.	Dawn	organized	the	opening	of	Vancouver	Island	women’s Clinic in British Columbia and managed the facility for	four	years	before	taking	her	current	position	at	NAF.30 31Joan GeberJoan	Geber	has	worked	in	government	since	2004.	She	is	currently	the	Executive	Director	of	the	Population	Health	and	Well-being	Branch	at	the	Ministry	of	Health.	Within	that	Branch	she	provides	leadership	for	two	Directorates:	the	Healthy	Development	and	Women’s	Health	Directorate,	and	most	recently,	the	Seniors’	Health	Promotion	Directorate.	Her	responsibilities	include	development	of	policy	and	initiatives related to health promotion and prevention in the areas of women’s, maternal and children’s health, and seniors’ health and well-being. Additionally, she supports the federal-provincial-territorial status of women table. She	holds	a	Masters	of	Public	Administration,	a	Bachelor	of	Nursing,	and	a	Psychiatric	Nursing	diploma.	Dr Perry KendallDr	Perry	Kendall	has	been	British	Columbia’s	Provincial	Health	Officer	since	1999.	As	senior	medical	health	officer	for the province, he is responsible for advising the minister and senior members of the ministry on health issues in BC	and	on	the	need	for	legislation,	policies	and	practices;	monitoring	the	health	of	the	people	of	B.C.;	providing	information	and	analyses	on	health	issues;	and,	reporting	to	the public on health issues or on the need for legislation or a	change	of	policy	or	practice	respecting	health.	In	2011,	Dr	Kendall	published	the	report	on	the	Health	and	Wellbeing	of	Women	in	British	Columbia.	Dr Wendy Norman (Conference Chair)Dr	Wendy	V.	Norman	has	been	a	family	physician	since	1985,	and	has	been	an	abortion	provider	since	1991.	She	is	an	Assistant	Professor,	and	Director,	Clinician	Scholars	Program	and	Family	Practice	Research	Training	in	the	Department	of	Family	Practice	at	UBC,	and	a	Scholar	of	the	Michael	Smith	Foundation	for	Health	Research.	Norman’s	research	program	seeks	to	improve	family	planning	access,	quality	of	care,	and	health	policy.	She	founded and co-leads the national collaboration: Canadian Contraception	Access	Research	Team/Groupe	de	recherche	sur l’accessibilité à la contraception. www.cart-grac.ca Dr Dorothy ShawDorothy	Shaw,	(MBChB,	FRCSC,	FRCOG,	CEC,	CCPE)	is	the	Vice	President,	Medical	Affairs	for	British	Columbia’s	Women’s	Hospital	&	Health	Centre,	responsible	for	quality	and safety in patient care using patient-centred, cost-effective	approaches.	She	is	a	Clinical	Professor	in	the	Departments	of	Obstetrics	and	Gynaecology	and	Medical	Genetics	in	the	Faculty	of	Medicine	at	the	University	of	British	Columbia	(UBC).	Dr	Shaw	is	Past	President	of	the	Society	of	Obstetricians	and	Gynaecologists	of	Canada	(1991-1992)	and	was	the	first	woman	President	of	FIGO	from	2006-2009.	She	currently	chairs	the	Canadian	Network	for	Maternal,	Newborn	and	Child	Health.She	is	recognized	for	her	contributions	to	the	health	and	rights of women in Canada and globally and has received several highly prestigious awards in Canada and around the world.Dr Ellen WiebeDr	Ellen	Wiebe	is	a	Clinical	Professor	in	the	Department	of	Family	Practice	at	the	University	of	British	Columbia.	After	30 years of full-service family practice, she now restricts her	practice	to	women’s	health.	She	is	the	Medical	Director	of	Willow	Women’s	Clinic	in	Vancouver	providing	medical	abortions	and	contraception.	Her	research	interests	include	abortion and contraception.Facilitator: Jen Reed-LewisMs	Jen	Reed-Lewis	has	a	MA	in	leadership	training	and	is a seasoned leadership and organization development consultant,	with	20	years	experience	as	a	catalyst	and	facilitator.32Appendix C: 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 half 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 community-based non-profit organizations•	 Academic faculty and researchers.32 33Appendix d: AbstractsAbstracts of the articles of research on which this conference is basedNorman WV.  Abortion In British Columbia: Trends Over 10 Years Compared To Canada Contraception 2011, 84 (3), 316 University	of	British	Columbia,	Vancouver,	British	Columbia,	Canadaobjectives: To determine trends and distribution in Canadian and British Columbia (BC)	abortion	services	from	1995	to	2005.Methods:	We	performed	a	secondary	analysis	of	published data and data available through the BC Pregnancy	Options	Services	database.	We	measured	age-specific population trends and trends for abortion rates and service location in Canada and BC, and trends for the number of BC physicians performing abortions.results: While	Canadian	abortion	rates	declined	12%	from	1995	to	2005,BC	rates	have	remained	largely	unchanged	(0.6%	decline	overall,	9%	in	highest	risk	group).	Age-specific	population	shifts	do	not	explain	the	trends	nor	the	difference	between	Canada	and	BC.	In	both	jurisdictions,	a trend towards abortion provision in purpose-specific clinics	prevails.	In	BC,	81%	of	abortions	are	now	provided	within clinics located in large urban centers, almost exclusively	in	Vancouver	and	Victoria.	Since	1995,	BC	has	experienced	an	estimated	decline	in	the	number	of	abortion providers offering services at hospitals outside the	clinic	system	of	upwards	of	60%,	and	a	65%	decline	in the number of abortions provided in such hospitals.conclusions: BC abortion rates are not following Canadian declining trends and are increasingly available only in clinics located in large population centers. Accessibility for women in rural and remote locations	has	declined	65%	from	1995	to	2005.WV Norman, JA Soon, N Maughn, J Dressler.  Barriers to Rural Induced Abortion Services in Canada: Findings of the British Columbia Abortion Providers Survey (BCAPS). PloS one 8 (6), e67023Background: Rural induced abortion service has declined	in	Canada.	Factors	influencing	abortion	provision by rural physicians are unknown. This study	assessed	distribution,	practice	and	experiences	among rural compared to urban abortion providers in the Canadian province of British Columbia (BC).Methods:	We	used	mixed	methods	to	assess	physicians	on	the	BC	registry	of	abortion	providers.	In	2011	we	distributed a previously-published questionnaire, and conducted semi-structured interviews. results: Surveys	were	returned	by	39/46	(85%)	of	BC	abortion	providers.	Half	were	family	physicians,	within	both	rural	and	urban	cohorts.	One-quarter	(17/67)	of	rural hospitals offer abortion service. Medical abortions comprised	14.7%	of	total	reported	abortions.	The	three	largest	urban	areas	reported	90%	of	all	abortions,	although	only	57%	of	reproductive	age	women	reside	in	the	associated	health	authority	regions.	Each	rural	physician	provided	on	average	76	(SD	52)	abortions	annually,	including	35	(SD	30)	medical	abortions.	Rural	physicians provided surgical abortions in operating rooms, often using general anaesthesia, while urban physicians provided the same services primarily in ambulatory settings using local anaesthesia. Rural providers reported health system barriers, particularly relating to operating room logistics.	Urban	providers	reported	occasional	anonymous	harassment and violence. interpretation:	Medical	abortions	represented	15%	of all BC abortions, a larger proportion than previously reported	(under	4%)	for	Canada.	Rural	physicians	describe addressable barriers to service provision that	may	explain	the	declining	accessibility	of	rural	abortion services. Moving rural surgical abortions out of operating rooms and into local ambulatory care settings has the potential to improve care and costs, while reducing logistical challenges facing rural physicians.34J Dressler, N Maughn, JA Soon, WV Norman.  The Perspective of Rural Physicians Providing Abortion in Canada: Qualitative Findings of the BC Abortion Providers Survey (BCAPS). PloS one 8 (6), e67070Background: An increasing proportion of Canadian induced abortions are performed in large urban areas.	For	unknown	reasons	the	number	of	rural	abortion providers in Canadian provinces, such as British Columbia (BC), has declined substantially. This	study	explored	the	experiences	of	BC	rural	and	urban physicians providing abortion services. Methods:	The	mixed	methods	BC	Abortion	Providers	Survey	employed	self-administered	questionnaires,	distributed to all known current and some past BC abortion providers in 2011. The optional semi-structured interviews	are	the	focus	of	this	analysis.	Interview	questions	probed	the	experiences,	facilitators	and	challenges faced by abortion providers, and their future	intentions.	Interviews	were	transcribed	and	analyzed using cross-case and thematic analysis.results: Twenty interviews were completed and transcribed,	representing	13/27	(48.1%)	rural	abortion	providers,	and	7/19	(36.8%)	of	urban	providers	in	BC.	Emerging	themes	differed	between	urban	and	rural providers. Most urban providers worked within clinics and reported a supportive environment. Rural physicians, all providing surgical abortions within hospitals, reported challenging barriers to provision including operating room scheduling, anesthetist and nursing logistical issues, high demand for services, professional isolation, and scarcity of replacement abortion providers. Many rural providers identified a need	to	‘fly	under	the	radar’	in	their	small	community.	interpretation:	This	first	study	of	experiences	among rural and urban abortion providers in Canada identifies addressable challenges faced by rural physicians.	Rural	providers	expressed	a	need	for	increased support from hospital administration and policy.	Further	challenges	identified	include	a	desire	for continuing professional education opportunities, and for available replacement providers.34


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