by Laura Schummers, Wendy Norman
BMJ Sexual & Reproductive Health, Vol 2, Issue 51, 2025 https://doi.org/10.1136/bmjsrh-2025-202912
Donald Trump’s second presidential administration has been characterised by flip-flopping policy chaos and dismantling of science, academia and health services, including reproductive health services. Trump has repeatedly referred to Canada as the ‘51st US State’, combining threats of annexation with attempts to lure Canada to join the United States (US) for military protection and unencumbered trade. In the fourth month of the Trump–Vance administration, Canadians headed to the polls for a federal election. Despite Trump doubling down on 51st state speak on Canada’s federal election day (28 April 2025), Canadians elected Prime Minister Mark Carney, who campaigned on promises to uphold Canada’s political sovereignty, economic leadership and decidedly ‘anti-Trump’, pro-Canadian platforms.
Canadians recoil at ‘51st state’ rhetoric. When it comes to reproductive health policy and access, the two countries are miles apart. As the US guts family planning service funds and dismantles public health surveillance data systems, Canadian policymakers are expanding reproductive health service coverage and access – implementing policy guided by science, not ideology…
Comparisons between reproductive health rights and access in the US and Canada may naively position Canada as merely a ‘middle of the pack’, non-US nation. In fact, Canada is a global trailblazer setting the gold standard in reproductive policy and access.
Canada remains the only country in the world to have fully decriminalised abortion. Since 1988, abortion has been provided as a standard medical procedure in Canada, free from criminal legislation. Abortion in Canada is governed as a normal health service – to ensure clinical competence and safety, just as for the clinical management of appendicitis, diabetes or hypertension. This means that, in Canada, reproductive health decisions remain firmly within the domain of healthcare, with clinical practice guided by evidence, rather than politics or ideology.
Elsewhere, abortion is legal in specific circumstances, such as within gestational week limits, for specific reasons or after specific care conditions, for example, requiring medically unnecessary tests or mandated waiting periods. In these countries, practice within these limits is governed by criminal law. As well, some countries forbid abortion under any conditions.
In contrast, decisions surrounding the management of pregnancy (no matter the outcome) in Canada take place between a patient and their healthcare provider. Providers need not consider the legal implications of providing high-quality care to pregnant individuals, whether to manage pregnancy complications or to offer the full range of choice in the context of unintended pregnancy.
Canada reinforced the position of abortion as a routine health service in 2017, with the globally unprecedented decision to regulate the medication abortion pill, mifepristone, as a routinely prescribed medication. This is unique. Elsewhere, mifepristone was mainly available from reproductive health-specific clinics, patients were required to swallow the medication under physician observation, or on the premise of specified healthcare facilities, and sign mandatory consent forms, all purportedly to preserve patient safety. However, experts had long believed these restrictions to be medically unnecessary. Canada’s regulatory approach set a global standard, positioning Canada at the forefront of progressive health policy…
In April 2025, we published new research finding that over the 5 years since mifepristone was introduced (from 2017 to 2022), access to medication abortion across Ontario increased substantially. Our related research found that despite these access gains, abortion rates have remained relatively stable. This stands in stark contrast to jurisdictions, such as Scotland, England and Wales, where limited access to sexual and reproductive health services has led to marked rises in abortion rates. This includes the US, despite their growing restrictions on abortion rights.
In fact, the US may be headed for the largest spikes globally in abortion rates. Deep cuts to safety net family planning clinics, coupled with a wave of contraception misinformation, are likely to increase rates of unintended pregnancy and the need for abortion…
As decades of evidence attest, there is scientific consensus that improved reproductive health education, information and access to the comprehensive suite of services reduces unintended pregnancy, reduces the need for abortion, and optimises health, educational and economic outcomes. Canada is demonstrating how a federal government can implement this science as policy. Canada is not the 51st state, but a shining example the US may follow when this wave of anti-science rhetoric and policy has run its course.