Patient experiences with requests for medical assistance in dying: Perspectives of those with complex chronic conditions.

OBJECTIVE: To explore experiences of patients who have complex chronic conditions (CCCs), such as fibromyalgia and chronic fatigue syndrome, when they request medical assistance in dying (MAID) in Canada. DESIGN: Qualitative study using semistructured interviews. SETTING: Canada. PARTICIPANTS: Individuals with CCCs who had contacted any 1 of 4 advocacy organizations between January 21, 2021, and December 20, 2022, about requesting MAID for suffering related to CCCs or who had applied and been assessed for MAID. METHODS: Interviews were conducted virtually (by video or audio) and recordings were transcribed. Thematic analysis was conducted in an iterative manner with abductive analysis. As interviews were completed, transcripts were reviewed and emerging themes were discussed at regular intervals. MAIN FINDINGS: Sixteen individuals were interviewed. All spoke of long-lasting suffering that was unresponsive to an array of medical treatments. Although some participants had hoped to receive MAID immediately following the 90-day assessment period, many mentioned that approval would provide or had provided validation of their illness and a sense of control, especially should their illness become unbearable. Participants sharply distinguished between MAID and suicide, saying they preferred MAID because it offered greater certainty and caused less emotional pain to others. Many said that participating in this research was beneficial because they believed the interviewers truly listened to them. CONCLUSION: Participants described experiences with CCCs and requests for MAID. This information may provide family doctors with new insight to inform interactions with patients with CCCs.

Are unmet needs driving requests for Medical Assistance in Dying (MAiD)? A qualitative study of Canadian MAiD providers.

In this study, 20 medical assistance in dying (MAiD) providers were interviewed about their experience when assessing patients with unmet needs, including medical, financial or social needs. Collectively they had experience with over 3700 MAiD assessments and found that unmet needs were rare. In the cases where patients had unmet needs, these were usually related to loneliness and poverty. This led to the ethical dilemma of providers deciding to honor their wishes for MAiD, knowing that some of their suffering was due to society's failure to provide for them.

Medical assistance in dying when natural death is not reasonably foreseeable: Survey of providers' experiences with patients making track 2 requests.

OBJECTIVE: To describe clinicians' experiences with assessing patients making track 2 requests for medical assistance in dying (MAID) and providing MAID to such patients in the first 6 months after Canada amended relevant legislation in March 2021 to expand access to MAID. DESIGN: Online survey with closed and open-ended questions about clinicians' experiences with individual patients making track 2 MAID requests. SETTING: Canada. PARTICIPANTS: Doctors and nurse practitioners who were members of the Canadian Association of MAID Assessors and Providers. MAIN OUTCOME MEASURES: The most common reasons patients gave for making track 2 MAID requests and the challenges providers identified in doing these assessments. RESULTS: Twenty-three MAID providers submitted information about 54 patients who had made track 2 requests between March 17, 2021 and September 17, 2021. The most common diagnoses were chronic pain syndromes, affecting 28 patients (51.9%), and complex chronic conditions such as myalgic encephalomyelitis or chronic fatigue syndrome, affecting 8 patients (14.8%). The most common challenges providers reported were related to patients having concurrent mental illness, noted in 37 assessments (68.5%). In 8 cases (14.8%), providers faced challenges in finding experts to help with assessments. In 19 cases (35.2%), providers felt patients had not been offered all appropriate and available treatments, and in 9 cases (16.7%) providers encountered difficulties in finding such treatments for patients. CONCLUSION: Providers of MAID described many challenges in their experiences with patients making track 2 requests, including assessing individuals with concurrent mental illnesses, being uncertain that patients had been offered appropriate treatments prior to seeking MAID, and being unsure whether patients had seriously considered available treatments. Many providers experienced moral distress in attempting to balance patients' rights with what might be in patients' best interests. This is different from experiences providers have had with patients making track 1 requests, as most of these patients have end-stage malignancy or organ failure and seldom have unmet health care needs. This information could be used to enhance education and support for clinicians as they help patients with track 2 requests access their right to peaceful deaths.

Forced and chosen transfers for medical assistance in dying (MAiD) before and during the COVID 19 pandemic: A mixed methods study.

The purpose of this study was to describe the experience of people who transferred locations for MAiD. It used mixed methods with a chart review from one health authority and interviews with key informants across Canada. In the chart review, we found that of 444 MAiD deaths, 42 (9.5%) were forced to transfer due to the religious affiliation of the facility and 33 (7.4%) chose to transfer. In 23 interviews with 18 key informants we found that the most important theme was the suffering caused by forced transfers. COVID-19 restrictions led to fewer choices and more suffering.

The experience of volunteer witnesses for Medical Assistance in Dying (MAiD) requests.

Many jurisdictions with legal forms of assisted dying require that written requests be witnessed by independent witnesses. In Canada, a unique program of volunteers was founded to make such witnesses available. A total of 106 volunteers completed a questionnaire about their experiences, challenges, and perspectives; 24 were also interviewed. Although the witnesses felt well prepared for their roles, they encountered challenges including role uncertainty, communication difficulties, and the emotional impacts of being with suffering patients and their grieving families. Most felt that the requirement for independent witnesses is an intrusive and unnecessary barrier to accessing medical assistance in dying.

How can we improve the experiences of patients and families who request medical assistance in dying? A multi-centre qualitative study.

BACKGROUND: Medical assistance in dying has been available in Canada for 5 years, but it is unclear which practices contribute to high-quality care. We aimed to describe patient and family perspectives of quality of care for medical assistance in dying. METHODS: We conducted a multi-centre, qualitative descriptive study, including face to face or virtual one-hour interviews using a semi-structured guide. We interviewed 21 english-speaking patients found eligible for medical assistance in dying and 17 family members at four sites in Canada, between November 2017 and September 2019. Interviews were de-identified, and analyzed in an iterative process of thematic analysis. RESULTS: We identified 18 themes. Sixteen themes were related to a single step in the process of medical assistance in dying (MAID requests, MAID assessments, preparation for dying, death and aftercare). Two themes (coordination and patient-centred care) were theme consistently across multiple steps in the MAID process. From these themes, alongside participant recommendations, we developed clinical practice suggestions which can guide care. CONCLUSIONS: Patients and families identified process-specific successes and challenges during the process of medical assistance in dying. Most importantly, they identified the need for care coordination and a patient-centred approach as central to high-quality care. More research is required to characterize which aspects of care most influence patient and family satisfaction.

Perceptions and Experiences of Medical Assistance in Dying Among Illicit Substance Users and People Living in Poverty.

Since medical assistance in dying (MAiD) became legal in Canada in 2016, there have been concerns about vulnerable people feeling pressured to end their lives. It is important to understand what people in marginalized communities know and feel about MAiD in order to help prevent any pressure to hasten death and to prevent any barriers to accessing assisted death. This qualitative study explored the perceptions and experiences of MAiD and other end-of-life care options with 46 people who were illicit substance users, living in poverty, or who worked with marginalized people in these communities. Six broad themes were identified: the importance of family, friends, and community; the effects of the opioid crisis; barriers to accessing end-of-life care services; support for MAiD; the difference between suicide and MAiD; and what constitutes a good death. Findings from this research may be used to help inform future legislation, professional guidelines, and standards of best practice.

Suicide vs medical assistance in dying (MAiD): A secondary qualitative analysis.

This is a secondary analysis of three qualitative studies about MAiD in which researchers asked about the differences between suicide and MAiD. In all, researchers interviewed 52 Canadians; 7 were people who had requested MAiD and had been found ineligible, 6 were MAiD providers and 39 were socially and economically marginalized. The overwhelming response was that MAiD is better than suicide in the context of suffering at the end of life. Whereas these people perceived suicide as uncertain, difficult, and something that was usually done alone and without support, they thought MAiD was certain, painless, and more socially acceptable.

How Cannabis Alters Sexual Experience: A Survey of Men and Women.

INTRODUCTION: Cannabis is reported to enhance sexual function; yet, previous studies have shown that physiological and subjective indices of sexual arousal and motivation were associated with decreased availability of circulating endocannabinoid concentrations. AIM: To explain this contradiction, we evaluated which aspects of sexual experience were enhanced or diminished by cannabis use. METHODS: We used an online questionnaire with a convenience sample of people who had experience with cannabis. We asked questions regarding various aspects of sexual experience and whether they are affected by cannabis. We also asked about sexual dysfunction. MAIN OUTCOME MEASURE: Aspects of participant sexual experience enhanced by cannabis. RESULTS: We analyzed results from 216 questionnaires completed by people with experience using cannabis with sex. Of these, 112 (52.3%) said they used cannabis to alter their sexual experience. Eighty-two participants (38.7%) said sex was better, 34 (16.0%) said it was better in some ways and worse in others, 52 (24.5%) said it was sometimes better, and only 10 (4.7%) said it was worse. Of 202 participants, 119 (58.9%) said cannabis increased their desire for sex, 149 of the 202 participants (73.8%) reported increased sexual satisfaction, 144 of 199 participants (74.3%) reported an increased sensitivity to touch, and 132 of 201 participants (65.7%) reported an increased intensity of orgasms. Out of 199 participants, 139 (69.8%) said they could relax more during sex, and 100 of 198 participants (50.5%) said they were better able to focus. Of the 28 participants who reported difficulty reaching orgasm, 14 said it was easier to reach orgasm while using cannabis, but only 10 said that sex was better. CLINICAL IMPLICATIONS: The information in this study helps clarify which aspects of sexual function can be improved or interfered with by cannabis use. STRENGTHS & LIMITATIONS: We asked about specific sexual effects of cannabis and were therefore able to understand the paradox of how cannabis can both improve and detract from sexual experience. Limitations of this study include bias that may have been introduced because the sample included only people who responded to the advertisements; it may not represent the general population of people who use cannabis. Moreover, over one-third of our sample said they use cannabis daily and so represent heavier than average users. CONCLUSION: Many participants in our study found that cannabis helped them relax, heightened their sensitivity to touch, and increased intensity of feelings, thus enhancing their sexual experience, while others found that cannabis interfered by making them sleepy and less focused or had no effect on their sexual experience. Wiebe E, Just A. How Cannabis Alters Sexual Experience: A Survey of Men and Women. J Sex Med 2019; 16:1758-1762.

Reasons for requesting medical assistance in dying.

OBJECTIVE: To review the charts of people who requested medical assistance in dying (MAID) to examine their reasons for the request. DESIGN: Retrospective chart survey. SETTING: British Columbia. PARTICIPANTS: Patients who requested an assisted death and were assessed by 1 of 6 physicians in British Columbia during 2016. MAIN OUTCOME MEASURES: Patients' diagnoses and reasons for requesting MAID. RESULTS: Data were collected from 250 assessments for MAID: 112 of the patients had assisted deaths, 11 had natural deaths, 35 were assessed as not eligible for MAID, and most of the rest were not ready. For people who had assisted deaths, disease-related symptoms were given as the first or second most important reason for requesting assisted death by 67 people (59.8%), while 59 (52.7%) gave loss of autonomy, 55 (49.1%) gave loss of ability to enjoy activities, and 27 (24.1%) gave fear of future suffering. People who were assessed as eligible but who had not received assisted deaths were more likely to list fear of future suffering (33.7% vs 7.1%) and less likely to list disease-related symptoms (17.4% vs 40.2%) than those who received MAID were. There was a difference in reasons for MAID given by people with different diagnoses; disease-related symptoms were given as the most important reason by 39.0% of patients with malignancies, 6.8% of patients with neurological diseases, and 28.9% of patients with end-organ failure. Loss of autonomy was given as the most important reason by 16.0% of patients with malignancies, 36.4% of patients with neurological diseases, and 23.7% of patients with end-organ failure. CONCLUSION: This study shows that the reasons patients give for requesting an assisted death are similar to those reported in other jurisdictions with similar laws, but in different proportions. Loss of autonomy and loss of ability to enjoy activities were less common reasons among patients in this study compared with other jurisdictions. This might be related to the method of data collection, as in this study, the patients' reasons were recorded by physicians.

Experiences and perspectives of people who pursued medical assistance in dying: Qualitative study in Vancouver, BC.

OBJECTIVE: To explore the experiences, wishes, fears, and beliefs of people who requested and were eligible for medical assistance in dying (MAID) in Canada in the first year after legalization. DESIGN: Qualitative study using semistructured interviews. SETTING: A clinic in Vancouver, BC, that provides MAID. PARTICIPANTS: People requesting and eligible for MAID between February 6 and December 17, 2016. Family and friends who were identified as the patients' primary support people were also interviewed. METHODS: Semistructured interviews were conducted over the telephone, by e-mail, or in person. The interviews were audiorecorded and transcribed and then analyzed using thematic qualitative analysis. The investigators read the transcripts and created a coding scheme to identify themes in the patients' experiences. The identified themes were compiled and evaluated in the context of what is already known based on current literature. Basic demographic characteristics were recorded for context. MAIN FINDINGS: Of the 23 patients whose experiences were explored, most had a malignancy, a neurologic disorder, or organ failure. A main theme was that patients thought it was important to have autonomy and control over their own end-of-life decisions. Main reasons for requesting MAID were a self-perceived unacceptable quality of life, most commonly owing to loss of independence, mobility, ability to communicate, a sense of purpose, and participation in meaningful activity. Some people expressed fear of future suffering and future disability. Pain was seldom mentioned as a cause of suffering. Some participants believed they could discuss their decision with the people in their lives while others chose to keep it a private matter. Most people were not religious. CONCLUSION: The participants' reasons for choosing to pursue MAID were consistent with those of people in other jurisdictions that have been studied. They felt confident in their decision to pursue MAID and did not have fears about the process.

Exploring the experience of supporting a loved one through a medically assisted death in Canada.

OBJECTIVE: To explore the experience of family and close friends of patients seeking medical assistance in dying (MAID) in Canada. DESIGN: Qualitative study using semistructured interviews. SETTING: A clinic in Vancouver, BC, that provides MAID services. PARTICIPANTS: Eighteen support people for patients seeking MAID. METHODS: Clinic patients seeking MAID identified their primary support people during consultations for an assisted death evaluation. Identified support people were invited to participate in the study, and those who were interested were asked to contact the interviewers. Semistructured interviews were conducted, transcribed, coded, and subjected to content analysis to elucidate common themes. MAIN FINDINGS: All participants were supportive of their loved one's wish for assisted death and they provided emotional and practical support in preparation for MAID. Support persons talked about the journey they went through from their loved one's diagnosis to the MAID request to the actual death. Some were initially opposed but changed their minds after seeing the suffering their loved ones endured. The time before the assisted death involved saying goodbye and, for some, ceremonial rituals (celebration of life, poems, singing, etc). Those interviewed after their loved one's assisted death found the death peaceful and reported that it offered advantages compared with natural death in their loved one's individual circumstances. CONCLUSION: This study provides insight into experiences of support people coping with a loved one who is seeking or has sought MAID in the context of a country unfamiliar with the legal process of a planned and hastened death. Participants were supportive of their loved one's wishes for assistance in death to end suffering and found the process to be peaceful overall.

Providing medical assistance in dying: Practice perspectives.

OBJECTIVE: To explore the experiences of the first cohort of physicians to offer medical assistance in dying (MAID) in British Columbia. DESIGN: Qualitative study using semistructured, one-on-one interviews. SETTING: British Columbia. PARTICIPANTS: Eight physicians who offered MAID in British Columbia in 2016. METHODS: The physicians were interviewed by telephone or by e-mail between 4 and 6 months after MAID was made legal in Canada, with follow-up in January 2017. Interviews were audiorecorded, transcribed, and analyzed through qualitative thematic analysis. MAIN FINDINGS: Participants believed that MAID was rewarding and satisfying work. They explained that some of the structural and emotional challenges related to providing MAID included the following: the refusal of faith-based institutions to provide information about MAID to patients, as well as their refusal to allow assessments or deaths to occur on site; having to deny MAID to patients who did not qualify for it; disagreements with colleagues who did not support the provision of MAID; dealing with the grief of family and friends who were present at the death; and feeling like they were always on call. While a few participants thought that the legislative restrictions of Bill C-14 were appropriate in the beginning when MAID was first available in Canada, most would like to see changes to the legislation to make it more aligned with the intent of the Carter decision, including broadening the eligibility criteria to include mature minors and people with advanced psychiatric diagnoses, having the ability to honour advance directives, and removing the requirement of death being in the reasonably foreseeable future for patients with grievous and irremediable conditions. CONCLUSION: Physicians in this study explained that providing MAID is rewarding work; however, there are many challenges that complicate their ability to offer MAID to patients. The current MAID legislation in Canada should be updated to better serve the needs of patients.

Medical Abortion.

OBJECTIVE: This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care. INTENDED USERS: Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services. TARGET POPULATION: Women with an unintended first trimester pregnancy. EVIDENCE: Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1). BENEFITS, HARMS AND/OR COSTS: Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability. SUMMARY STATEMENTS: Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care RECOMMENDATIONS: Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care.

Exploring the experience of chronic pain among female Survival Sex Workers: a qualitative study.

BACKGROUND: The prevalence of self-identified chronic pain in Canadian adults is approximately one in five people. Marginalization and addictions have been shown to complicate chronic pain in vulnerable populations. This study aimed to understand the experience of chronic pain among female Survival Sex Workers in Vancouver's downtown eastside (DTES). METHODS: This study used an exploratory qualitative analysis with in-depth, semi-structured interviews. Members of PACE Society who self-identified as a current or former Survival Sex Worker and who had a chronic pain experience known to PACE support workers were invited to participate. Interviews were conducted, audio recorded and transcribed. The investigators met to read the transcripts and discuss emerging themes. The process continued until no new themes were observed. RESULTS: Participants ranged in age from 42 to 56 years old and all self- identified as females and Survival Sex Workers. Eleven of thirteen interviews were analyzed for themes. Drug use for pain management, both prescribed and illicit, was the most important theme. Poverty, the need to continue working and the lack of stable housing were barriers to adequately addressing the source of chronic pain. Participants felt judged for living in the downtown eastside, being a drug user and/or being Aboriginal and only two participants had been referred to a pain specialist. All participants were involved in support networks made up of other Sex Workers and all spoke of a sense of community and survival. CONCLUSIONS: Our study emphasizes the complex nature of chronic pain and addictions among a uniquely marginalized population. The study is unique in that it contributes the perspectives of a traditionally "hard-to-reach" population and demonstrates that Sex Workers should not only participate in but should lead development and implementation of research and programs for managing chronic pain in the setting of addiction.

Misperceptions about the risks of abortion in women presenting for abortion.

OBJECTIVE: Misinformation about the risks and sequelae of abortion is widespread. The purpose of this study was to examine whether women having an abortion who believe that there should be restrictions to abortion (i.e., that some other women should not be allowed to have an abortion) also believe this misinformation about the health risks associated with abortion. METHODS: We carried out a cross-sectional survey of women presenting consecutively for an abortion at an urban abortion clinic in Vancouver, British Columbia, between February and September 2012. RESULTS: Of 1008 women presenting for abortion, 978 completed questionnaires (97% response rate), and 333 of these (34%) favoured abortion restrictions. More women who favoured restrictions believed that the health risk of an abortion was the same as or greater than the health risk of childbirth (84.2% vs. 65.6%, P < 0.001), that abortion caused mental health problems (39.1% vs. 28.3%, P < 0.001), and that abortion caused infertility (41.7% vs. 21.9%, P < 0.001). Using multivariate logistic regression analyses, believing that abortion should not be restricted was found to be a significantly correlated with correct answers about health risks, mental health problems, and infertility. CONCLUSION: Misinformed beliefs about the risks of abortion are common among women having an abortion. Women presenting for abortion who favoured restrictions to abortion have more misperceptions about abortion risks than women who favour no restrictions.

Objectif : La désinformation au sujet des risques et des séquelles de l'avortement est généralisée. Cette étude avait pour objectif de tenter de déterminer si les femmes subissant un avortement qui estiment que des restrictions devraient être imposées en matière d'avortement (c.-à-d. qui estiment que certaines autres femmes ne devraient pas avoir le droit de subir un avortement) sont susceptibles de croire cette désinformation au sujet des risques pour la santé qui sont associés à l'avortement. Méthodes : Nous avons mené un sondage transversal auprès des femmes s'étant consécutivement présentées à une clinique urbaine d'avortement de Vancouver, en Colombie-Britannique, entre février et septembre 2012, en vue d'y obtenir un avortement. Résultats : Des 1 008 femmes s'étant présentées à cette clinique en vue d'y obtenir un avortement, 978 ont rempli le questionnaire (taux de réponse de 97 %) et 333 d'entre elles (34 %) favorisaient l'imposition de restrictions en matière d'avortement. Un nombre supérieur de femmes favorisant l'imposition de restrictions estimaient que les risques pour la santé associés à l'avortement étaient égaux ou supérieurs aux risques pour la santé associés à l'accouchement (84,2 % vs 65,6 %, P < 0,001), que l'avortement causait des problèmes de santé mentale (39,1 % vs 28,3 %, P < 0,001) et que l'avortement causait l'infertilité (41,7 % vs 21,9%, P < 0,001). En utilisant des analyses de régression logistique multivariées, nous avons constaté que le fait d'estimer que l'avortement ne devrait pas faire l'objet de restrictions était en corrélation significative avec l'offre de réponses exactes au sujet des risques pour la santé, des problèmes de santé mentale et de l'infertilité. Conclusion : Les opinions erronées au sujet des risques de l'avortement sont courantes chez les femmes qui subissent un avortement. Les femmes cherchant à obtenir un avortement qui favorisent l'imposition de restrictions à l'avortement sont plus susceptibles d'avoir des perceptions erronées, au sujet des risques de l'avortement, que les femmes qui ne favorisent pas l'imposition de telles restrictions.

Invited commentary: How can we reconcile the findings of Keyes et al.'s study with the experience of our patients in clinical practice?

Although the accompanying study by Keyes et al. (Am J Epidemiol. 2013;178(9):1378-1388) shows us that women currently using hormonal contraception (HC) have better scores on the Center for Epidemiologic Studies Depression Scale and report fewer suicide attempts, it does not show us that HC protects women from mood disorders or that HC is free of the mood-related side effects which cause high rates of discontinuation. The groups compared in the Keyes et al. study were different in many ways; the women using HC were younger, were more likely to engage in positive health behaviors, and had lower depression scores at each prior interview. Women with mood disorders are more likely to avoid or discontinue HC and more likely to experience worsening mood while on HC. The negative mood-related side effects experienced by women using HC (irritability and lability) are not captured by a screening tool for clinical depression, such as the depression scale used in this study. The database used in this study was longitudinal and multiwave, so the authors could have compared changes in depressive symptoms among women who switched from hormonal to nonhormonal contraceptive methods (and vice versa) across different waves. Only if the same women experienced greater levels of depressive symptoms after discontinuing HC and fewer symptoms when they restarted HC could we conclude that HC may protect women from mood disorders.

Contraceptive practices and attitudes among immigrant and nonimmigrant women in Canada.

OBJECTIVE: To compare experiences, attitudes, and beliefs of immigrant and nonimmigrant women presenting for abortion with regard to contraception, and to identify difficulties involved in accessing contraception in Canada. DESIGN: A survey of immigrant and nonimmigrant women asking about women's experiences with and attitudes toward contraceptives and any barriers to contraceptive access they have encountered. Demographic data including ethnicity, country of origin, and length of residence in Canada were collected. SETTING: Two urban abortion clinics. PARTICIPANTS: Women presenting for first-trimester abortion. MAIN OUTCOME MEASURES: Type of contraception used when the unwanted pregnancy was conceived, attitudes to contraceptives, and barriers to access of contraceptives. RESULTS: A total of 999 women completed questionnaires during the study period (75.9% response rate); 466 of them (46.6%) were born in Canada. Immigrant women presenting for abortion were less likely to be using hormonal contraception when they got pregnant (12.5% vs 23.5%, P < .001) and had more negative attitudes toward hormonal contraception (62.6% vs 51.6%, P < .003). They reported having more difficulties accessing contraception before the abortion (24.8% vs 15.3%, P < .001) than nonimmigrant women did. About half of all the women expressed fear about intrauterine device use. The longer immigrant women had lived in Canada, the more likely they were to have similar responses to those of Canadian-born women. CONCLUSION: The information provided by this study might be valuable for family doctors and other clinicians to improve contraceptive information resources for immigrants to address existing knowledge gaps and other culturally relevant concerns. As about half of all women presenting for abortion expressed negative attitudes toward the more effective methods of contraception, it is important that family doctors educate all women at risk for unintended pregnancies.