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Provision of care to diverse populations: results from the 2019 Canadian Abortion Provider Survey
  1. Madeleine Ennis1,
  2. Regina Renner1,
  3. Bimbola Olure1,
  4. Stephanie Begun2,
  5. Wendy V Norman3,4,
  6. Sarah Munro1,5
    1. 1Department of Obstetrics & Gynaecology, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
    2. 2Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
    3. 3Department of Family Practice, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
    4. 4Public Health, Environments and Society, London School of Hygiene & Tropical Medicine Faculty of Public Health and Policy, London, UK
    5. 5Health Systems and Population Health, University of Washington, Seattle, Washington, USA
    1. Correspondence to Dr Madeleine Ennis, Department of Obstetrics & Gynaecology, The University of British Columbia Faculty of Medicine, Vancouver, Canada; madeleine.ennis{at}

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    The WHO highlighted the importance of providing culturally safe, high-quality healthcare,1 emphasising that services should be welcoming to diverse populations, including “youth and people from sexual and gender minorities, people living with disabilities, and all groups in vulnerable and marginalised situations”.

    We conducted the 2019 Canadian Abortion Provider Survey (CAPS), collecting demographics, clinical abortion practices, and stigma experiences of providers.2 3 In this research letter we present how abortion providers cared for diverse populations and the related training they had received.

    Physicians, nurse practitioners and abortion service administrators who provided abortion care in 2019 were eligible to participate. To explore dimensions of care provided to diverse populations, we asked multiple-choice and open-ended questions, including: Do you provide abortion care to diverse patient populations (eg, cultural/ethnic origins, gender/identity, etc.)? Do you adjust your abortion care to diverse patient populations? Have you ever had specific training for providing abortion care to diverse populations during your education/professional training? We present descriptive statistics analysed with R Statistical Software. We conducted a reflexive thematic analysis of the open-ended responses and organised our results in an explanatory narrative.

    Of the 500 respondents who completed the CAPS survey, 356 started the Diverse Populations section and we report on the results of this subsample. Respondents (n=356) represented every province and territory in Canada as well as urban (59.1%) and rural (40.9%) areas. The majority of respondents self-identified as women (83.5%), clinicians (92.1%) as opposed to administrators, and having less than 5 years’ experience providing abortion care (65.6%).

    While most clinicians reported they had not received specific training for providing care to diverse populations (91.2%), 91.8% indicated they provided care to diverse populations and almost half (47.0%) adjusted care to accommodate their patients' needs most or all of the time. When asked which continuing training opportunities would be relevant in supporting care of diverse populations, the majority of respondents suggested web-based training (77.3%) followed by in-person training (34.1%).

    Finally, participants who adjusted their care to diverse populations were given the option to provide an open-ended response to the question: Please explain how you adjust your abortion care (eg, to specific environment, specific personnel or specific training). Our analysis of the qualitative responses from 206 participants identified five core themes (italicised below), which we summarise with sample quotations in table 1. Participants adjusted care to the patient’s religion and/or culture, for instance by being open to managing the products of conception and/or including culturally appropriate support people. Adjusting language and communication was a core strategy participants described, through translation services, shifting the amount and speed of information shared, and offering multilingual resources with visuals.

    Table 1

    Qualitative analysis of responses to the ‘Care for Diverse Populations’ section of the 2019 Canadian Abortion Provider Survey

    Some participants specified that they provided gender-affirmative and trauma-informed care4 through use of gender-neutral language and trans-inclusive services. Other participants focused on shifting when and where services are provided including virtual health and flexible appointments. Others described relying on in-person care and closer follow-up when concerned about protocol adherence due to, for example, low literacy or English language skills. Finally, participants described offering personalised care by asking patients to share their preferences.

    We identified a gap in Canada between recommendations to provide culturally safe healthcare and abortion provider-reported training opportunities to provide care to diverse populations. Most respondents reported never receiving specific training. Less than half of respondents consistently adjusted care to diverse populations, for example, by implementing trauma-informed, culturally safe and gender-affirmative practices. We were unable to assess the quality of these care practices. In order to improve and standardise provision of culturally safe care as an indicator of equitable access to high-quality abortion care, we found there is an urgent need to develop, implement and evaluate training materials specific to providing abortion care to diverse populations.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by the University of British Columbia Research Ethics Board (H18-03313). Participants gave informed consent to participate in the study before taking part.



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    • Contributors The authors guarantee that all authors have substantially contributed to this study and letter. ME contributed to recruitment, and led the data analysis and manuscript preparation. RR is the Principal Investigator (PI) on the Canadian Institutes of Health Research (CIHR) grant funding this research. RR, WVN, SB and SM conceived and designed the diverse populations section of the survey, with elements and revisions contributed by all authors. BO contributed to data analysis and manuscript preparation. ME and RR drafted the original manuscript and all authors contributed to revisions and accepted the final manuscript.

    • Funding This work was supported by the Canadian Institutes of Health Research (PJT-162201). WVN is supported by a Canadian Institutes of Health Research (CIHR) and Public Health Agency of Canada Chair in Applied Public Health Research (2014-2024, CPP-329455-107837). SM is supported by a Michael Smith Health Research BC Scholar Award (18270).

    • Competing interests SM and WVN are both supported by grants from the Canadian Institutes of Health Research and as Scholars of the Michael Smith Foundation for Health Research. WVN is a paid consultant to the Ontario Attorney General as an expert witness for a court case relating to abortion stigma and harassment. All other authors declare they have no conflict of interest with respect to this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.