Novel Coronavirus, Access to Abortion Services, and Bridging Western and Indigenous Knowledges in a Postpandemic World

In Canada, one in three women will experience an abortion in their reproductive lifetime (Dowler, Rushton, & Kornelsen, 2020). Although Canada is currently one of four countries globally to have no national restriction in law, several studies have raised concerns about barriers women face when accessing abortion services (Ackerman & Stettner, 2019; Cano & Foster, 2016; Myran & Bardsley, 2018; Rumack, 2020; Shaw & Norman, 2020). For example, the 2016 United Nations Human Rights Commissioner's report indicated a lack of access to abortion in Canada owing to cost, knowledge, and geography (Myran & Bardsley, 2018; Shaw & Norman, 2020). These barriers are heightened for Indigenous1 women and Two-Spirit People2 owing to centuries of ongoing colonialism that have resulted in severe disparities in social determinants and outcomes (Allan & Smylie, 2015; Monchalin, Smylie, & Nowgesic, 2020b; Reading & Wien, 2009). Despite this knowledge, there is virtually no literature available surrounding Indigenous women's and Two-Spirit Peoples' experiences with abortion in Canada. This is worrisome given that existing barriers to abortion access have mounted owing to the novel coronavirus disease-2019 (COVID-19) pandemic; abortion clinics have decreased their hours or closed temporarily, and COVID-19 stay-at-home measures have resulted in a spike in violence, suggesting unplanned pregnancies and a potentially greater need for abortion service access (Abortion Rights Coalition of Canada, 2020a; Cohen, 2020; Gilmore, 2020a; Rumack, 2020).

This commentary discusses three areas. First, it explains how the response to COVID-19 has created unique circumstances and barriers for Indigenous women and Two-Spirit People in accessing abortion services in Canada. Second, it explores how ending and preventing pregnancies was (and continues to be) common knowledge within Indigenous communities, and how shame surrounding abortion arrived with settlers and persists today. This commentary concludes by arguing that access to abortion services in a postpandemic world will benefit from the bridging of Western and Indigenous knowledges and bringing Elders into the classroom.

This commentary is written from the perspective of an urban, mixed, able-bodied, cis-gendered Indigenous woman (Anishnaabe/Métis/Scottish/French) who is White-passing. About 10 years ago, in my early 20s, I had an abortion. Despite the privileges I hold while living in an urban setting and in close proximity to an abortion provider, the experience was traumatizing. In the appointments leading up to the procedure, disparaging words were shared by the health care providers, brute force was used during pre-examinations, and there was no communication of what to expect. This all happened while I was actively hiding my Indigenous identity in fear that the experience would be worse. After the abortion, no support services were offered, and I was just sent home. These experiences still haunt me 10 years later. Support from the Native Youth Sexual Health Network at the time got me through it. The aim of this commentary is to add to the conversations around Indigenous women and Two-Spirit People accessing abortion services to bring awareness to the fact that abortion being “legal” in Canada since 1988 does not necessarily make it safe or accessible.

COVID-19 and Access to Abortion Services for Indigenous Women and Two-Spirit People

There is a gap in the literature surrounding Indigenous women's and Two-Spirit Peoples' experiences with abortion services. This situation is problematic, given that Indigenous women and Two-Spirit People experience severe disparities in social determinants and outcomes compared with their non-Indigenous counterparts. Severe disparities include an increased likelihood of experiencing poverty, under-housing or homelessness, unemployment, and violence (Allan & Smylie, 2015; Reading & Wien, 2009). Sarah Hunt (Kwagu’ł) (2016) highlights how transsexual, transgender, and other Two-Spirit People face additional disparities owing to discrimination against people who do not conform to gender norms.

The literature that does exist surrounding Indigenous women's and Two-Spirit Peoples' experiences with abortion highlights the multitude of barriers that come with living in rural and remote communities (Violet Lee & Spillet, 2017). This includes cost of travel, lack of privacy, and lack of abortion service providers (Abortion Rights Coalition of Canada, 2020b). Nēhiyaw scholars Erica Violet Lee and Tasha Spillett (2017) write:

Indigenous women and girls—especially those on reserve and in rural communities—face barriers to accessing basic health care; and yes, access to abortions is a necessary part of the basic health care package that we deserve.

Although provinces and territories have deemed abortion services as “essential” during COVID-19 because it is a time-sensitive procedure, abortion clinics have decreased their hours or closed temporarily in response to physical distancing guidelines and clinic staff contracting the virus (Abortion Rights Coalition of Canada, 2020a; Gilmore, 2020a; Rumack, 2020). This situation is coupled with the alarming fact that many communities before COVID-19 did not have access to abortion providers (Loreto, 2020). For example, seven provinces and territories in Canada had (and continue to have) no access to rural abortion services. In Prince Edward Island, Yukon, and the Northwest Territories, there is only one provider in the entire jurisdiction. Abortion access is also restricted after 12 weeks in Prince Edward Island and Yukon, and after 16 weeks in Manitoba, New Brunswick, Newfoundland, and Nova Scotia (Loreto, 2020). The medical abortion pill mifepristone, which is approved to be taken only up to 10 weeks, has also undergone significant shortages owing to COVID-19 (Shaw & Norman, 2020; Gilmore, 2020b). When abortion providers and mifepristone are in short supply, health professionals fear that those who seek abortions but cannot obtain them will resort to unsafe methods in attempting to terminate their pregnancies, as those “who want an abortion will put their lives on the line to get one” (Gilmore, 2020a).

COVID-19 stay-at-home measures have also resulted in a spike in violence against Indigenous women and Two-Spirit People (Patel, 2020; Sharp, 2020). Before COVID-19, Indigenous women in Canada experienced violence (including sexual violence) at a rate three times higher than non-Indigenous women (National Inquiry into Missing and Murdered Indigenous Women and Girls, 2019). Two-Spirit women have also been found to be more likely to experience sexual and physical assault than heterosexual Indigenous women (Hunt, 2016; Lehavot, Walters, & Simoni, 2010). The Native Women's Association of Canada recently conducted an online survey surrounding the impacts of COVID-19 on Indigenous Women and Two-Spirit People in Canada. Based on 750 responses, 65% of participants indicated that they are more concerned about domestic violence during the pandemic than they are about the virus itself (Native Women's Association of Canada, 2020; Wright, 2020). A spike in violence owing to COVID-19 suggests a potentially greater need for abortion service access (Cohen, 2020).

In the event that Indigenous women and Two-Spirit People are in need of accessing abortion services during COVID-19, reproductive health services are not free from violence and harm. Literature documents experiences of Indigenous women who have sought mainstream reproductive health services and experienced forced sterilization, forced abortion, violence from physicians, and coercion to use unsafe contraceptives (Kirkup, 2018a; 2018b; Monchalin, Smylie, & Dupre, 2020a; Stote, 2016). The 2019 Final Report of the National Inquiry into Missing and Murdered Indigenous Women and Girls (2019) called for transformative legal and social changes surrounding ending violence against Indigenous women in Canada. Pamela Palmater (Mi'kmaq) (2020) states, “The federal government promised a national action plan within a year. As expected, it's one year later. Canada has no plan.” The next section illustrates how, despite Indigenous communities holding traditional knowledge surrounding preventing and ending pregnancies, stigma surrounding abortion in Canada persists, creating further access barriers during COVID-19.

Traditional Family Planning Knowledge Around Ending and Preventing Pregnancies

I hate how the people out there are clapping their hands at the non-native pro-choice movement, and totally ignoring our long standing and well documented history of self control over reproductive choices. It's disrespectful to pretend like RJ [Reproductive Justice] wasn't alive in our communities… Our RJ was made illegal on purpose, but that's never mentioned anywhere.

– Theresa Lightfoot (Mi'kmaq) in Danforth.

Before settler arrival, contraceptives and abortifacients in the form of traditional medicines were commonly used within Indigenous communities and administered by the grandmothers and aunties. This knowledge would often be passed down intergenerationally (Anderson, 2003, 2011). Swampy Cree storyteller Louis Bird has explained that “the women were the medicine people … because they had all the knowledge about the herbs and plants to cure almost any disease” (Anderson, 2011). Métis Elder Maria Campbell also shares how her grandmother used local plants that were dried and made into tea to help women prevent pregnancies (Anderson, 2011).

Although this reproductive health knowledge was often overlooked by early settlers as “unscientific,” family planning in Indigenous communities was evident based on the small family sizes within some Nations in comparison to those of settler families (Anderson, 2003). Kim Anderson (Métis) (2003) interviewed Elder Edna Manitowabi (Ojibway), who shared that before settler arrival, Indigenous families typically consisted of two or three children, whose arrivals would often be spaced out to allow families to more easily travel with animal herds for survival. Elder Joanne from the Native Youth Sexual Health Network's Sexy Health Carnival builds on this:

In our traditional way, we knew how to stop pregnancies. There were medicines. So, we knew, when women found out they were pregnant, they would know how to get un-pregnant. It is not our traditional way to pass judgment on that, the Creator always gives us choice. (in Monchalin, Lesperance, Flicker, & Native Youth Sexual Health Network, 2015)

This once commonplace reproductive health knowledge has been suppressed and systematically undermined to the point that it is now hard to find (Burnett, 2017). Religious views that came with settler arrival forced much of this knowledge “underground” (Anderson, 2003; 2011; Burnett, 2017; Redvers, 2019). Anderson (2003) states that it was “replaced by Christian morals and a Western medical paradigm that gave birth, pregnancy and female sexual and reproductive health matters over to male doctors.” State-sanctioned residential schools have further resulted in broken systems for transferring traditional family planning and reproductive health knowledge (Anderson, 2011). Although efforts are being made to reclaim traditional ceremonies around the body such as coming of age (Monchalin, Lesperance, Flicker, Logie, & Native Youth Sexual Health Network, 2016; Redvers, 2019), abortion stigma persists in communities with the belief that it is not “traditional” (Anderson, 2003). Anderson (2003) quotes Maria Campbell and writes

Maria asks the question about what we mean when we say “traditional,” suggesting that a lot of what is considered traditional is steeped in Christian thought, morality and ethics. What do we find in terms of family planning if we take a look at pre-Christian thought and practice?

The church has played a significant role in the fracture of intergenerational knowledge transfer of Indigenous reproductive health knowledge. Nicole Redvers (Dené) (2019) writes, “Traditional medicine and Indigenous spirituality were deemed by the church as being devil's work, and to this day those feelings still linger in the hearts of many who experienced those judgements.” These ongoing views of abortion have contributed to enduring stigma in both Indigenous communities and in Canadian society. This stigma, coupled with severe disparities in social determinants and outcomes, and the COVID-19 pandemic, have created an unsafe and inaccessible environment for Indigenous women and Two-Spirit People to access abortion services in Canada. The next section of this commentary provides recommendations to overcome stigma and improve access to abortion services in a postpandemic world.

A Postpandemic World and Bridging Western and Indigenous Abortion Knowledges

The report “Decolonize Abortion Care: Reproductive Justice for Indigenous Communities” by Canadian pro-choice organization Action Canada for Sexual Health & Rights lists four demands: 1) Indigenous women and Two-Spirit People must be empowered to make their own sexual and reproductive health care choices; 2) provide access to abortion drug combination Mifegymiso in on-reserve communities; 3) hire Indigenous staff in on-reserve nursing stations and off-reserve abortion clinics; and 4) abortion providers in Canada must receive ongoing Indigenous-led anti-oppression training (Abortion Rights Coalition of Canada, 2020b). Decision makers can fulfill these demands—and support the efforts of Indigenous-led organizations such as the Native Youth Sexual Health Network, Northern Manitoba Abortion Support, and Aunties on the Road Doula Collective—by bringing together Western and Indigenous knowledges in a postpandemic world.

Bridging Western and Indigenous abortion knowledges may be accomplished through bringing Indigenous Elders and Knowledge Keepers into medical schools to teach future health service providers of traditional family planning knowledge, and with that, abortion. Redvers (2019) writes, “Elders won't be here in another few decades…we have a responsibility to ensure that their teachings are respected and carried on while we have the chance.” Currently in Canada, only one-half of the 17 medical schools offer education around abortion. Schools that do offer it devote less than 1 hour on average to abortion education during the 4-year curriculum (Abortion Rights Coalition of Canada, 2018a; 2018b; Dowler et al., 2020). Furthermore, physicians in Canada can choose to provide abortion or not based on their personal beliefs (Dowler et al., 2020). By bringing Indigenous Elders and Knowledge Keepers into medical schools to teach traditional family planning knowledge, stigma surrounding abortion may be decreased, and interest in providing abortions may increase, because students will learn that this knowledge has been practiced in Indigenous communities for centuries.

Although Elders and Knowledge Keepers are commonly appointed as cultural support for students on Canadian campuses, they are often not brought in as full-time educators. However, the University of Alberta's School of Public Health is one academic institution that is beginning to rectify this shortcoming in Canada. They have appointed five Indigenous adjunct professors (nonfaculty instructors) and four Elders and Knowledge Keepers to provide advice on incorporating traditional knowledge into school planning and research; contribute to the supervision of graduate students; and lecture on a variety of topics to students, faculty, and staff (University of Alberta, 2020).

To contribute to transformative social change around abortion, medical schools across Canada should give Elders and Knowledge Keepers the opportunity to educate around Indigenous family planning. While doing so, universities have a responsibility to create culturally safe environments for Elders and Knowledge Keepers and to compensate them as they do full-time tenured professors, in recognition of the centuries of intergenerational knowledges they hold. Implementing this recommendation can help to increase the number of future abortion providers, decrease abortion stigma, and support the reproductive self-determination of Indigenous women and Two-Spirit People in a postpandemic world.

Biography

Renée Monchalin, PhD, is an Assistant Professor, School of Public Health and Social Policy, University of Victoria. Her areas of research include access to culturally safe urban health and social services for the urban Indigenous community, reproductive justice, and sexual health.