Five years ago, Melanie Mackenzie got pregnant. Her birth control had failed, and the then 29-year-old knew she didn't want to have a baby. She wanted an abortion.

"I found out I was pregnant almost immediately. You just get that feeling," the Halifax resident said in an interview. "I hadn't even missed a period yet."

After taking a positive home pregnancy test, Mackenzie went to her family doctor — Nova Scotia is the only province in Canada where women must obtain a physician's referral before making an abortion appointment.

"I said flat out 'I'm pregnant and I don't want to be. I want an abortion.'"

Mackenzie was told there was a waiting period, and was sent for a battery of tests including blood work and an ultrasound. It took two months for her to finally obtain an abortion, at nearly 12 weeks pregnant.

"It was the worst two months of my life," she said. "The whole thing felt like a punishment."

Advocates say Nova Scotia is now one of the most difficult provinces in the country in which to access abortion, with women requiring a referral for a surgical abortion, lengthy wait times for the time-sensitive procedure and no provincial coverage for medical abortions using pills.

The province also has no private or freestanding abortion clinics located outside of a hospital. Halifax's Morgentaler clinic, where women had to pay out-of-pocket, closed in 2003.

The Termination of Pregnancy Unit at Halifax's QEII Health Sciences Centre — where more than 85 per cent of the province's abortions are performed — will only book appointments for women who are at least eight weeks pregnant.

With few doctors prescribing the abortion pill Mifegymiso — and no universal coverage of the costly medication in the province — women seeking to terminate early pregnancies are forced to wait.

"Nova Scotia is one of the worst places in Canada to get an abortion. The situation for abortion access is extremely grim," said Darrah Teitel, public affairs officer for Action Canada for Sexual Health and Rights.

After her blood work came back positive, Mackenzie recalled the nurse congratulating her on the pregnancy in front of other patients.

"I never regretted my decision to have an abortion," she said. "But it felt like that waiting period and all those tests were to shame me, to make me feel like an irresponsible slut, to punish me. It felt like it was a price I had to pay to obtain an abortion in a country where my right to choose is legally protected."

In Canada, abortion care is a patchwork of widely differing degrees of accessibility and options depending on the province and region. Abortion access is largely provided in big urban centres, leaving women in small communities or rural areas footing the bill for travel and accommodation.

Nova Scotia once had the region's least restrictive abortion access, but both New Brunswick and Prince Edward Island have changed their policies in the last three years.

In 2014, New Brunswick lifted the so-called two-doctor rule requiring two physicians to certify an abortion as medically necessary.

Abortions became available in P.E.I. for the first time earlier this year. Women on the Island can call a toll-free number to make an appointment without the need for a referral.

Women in Nova Scotia still require a referral and tests before obtaining an appointment for an abortion.

"We do require our patients to get referred to our clinic," Lianne Yoshida, medical co-director of the QEII's Termination of Pregnancy Unit, said in an interview. "It's been identified as a barrier and it's an issue we're working on. The issue of referral and ultrasound does delay a woman's ability to see us."

It also may be unconstitutional, said Teitel.

She said the provincial rule requiring a physician's referral is at odds with the Supreme Court's 1988 R v. Morgentaler decision. Evidence presented during the trial showed that the unnecessary wait times involved in physician referrals were creating unsafe conditions for women, Teitel said.

"These delays are still being forced on women in Nova Scotia, and there is no earthly reason why abortions cannot be granted upon self-referral, as in the rest of the country," she said.

In addition to the referral rule, it's unclear whether delays are exacerbated by a policy enforcing a wait time, restrictions on early abortions or simply a lack of sufficient resources.

While Yoshida said there are surgical issues with abortions performed too early, she said that tends to be around four weeks gestational age.

Still, a receptionist reached at the QEII clinic said abortions are not scheduled before eight weeks — something confirmed in multiple interviews.

Nova Scotia does not appear to keep statistics on how long it takes women to obtain an abortion after a referral.

Several women interviewed for this story spoke on condition of anonymity out of fear of the stigma surrounding abortions and the backlash they could face at work or in the community.

Their stories had recurrent themes. The condom broke. The pill didn't work. The IUD shifted. Contraception fails. Accidents happen.

While some were referred for an abortion by a family doctor without delay, others describe having to "jump through hoops" to get a referral. Wait times tended to be four to six weeks, a delay they described as "agonizing" and "cruel."

Jennifer Fishman, associate professor in the Biomedical Ethics Unit of the Social Studies of Medicine Department at McGill University, said the ethical problems that arise from making women wait for an abortion are enormous.

"The idea that there is differential access to abortions across the provinces, given that abortion is funded and legal and a medical procedure covered under the Canada Health Act, which operates under principles of universality and accessibility, is incredibly problematic," Fishman said. "It's unjust and inequitable to make some women wait while others don't have to."

Another ethical problem is the mental health impact of waiting, she said.

"There is definitely a psychological cost to carrying an unwanted pregnancy," Fishman said. "Some research shows women will even consider some kind of self-induction, which can be dangerous."

One woman told The Canadian Press she had four appointments with her family doctor before she obtained a referral for an abortion. Her doctor quizzed her on her knowledge of the fetus and sent her to a psychologist before finally agreeing to refer her.

"At some point, before my doctor agreed to write the referral, I remember standing in the kitchen with a pair of scissors, thinking maybe I'd just cut it out. I considered going to the emergency room and saying I would commit suicide if they wouldn't give me an abortion. The waiting, and the threat of not being able to access an abortion, was emotionally traumatic."

Fishman said another troubling issue with making women wait until later in their pregnancy to obtain an abortion are the physical health risks.

"Second trimester abortions have much higher rates of complications," Fishman said. "It's a much more complicated procedure. They are higher risk and they are more expensive."

Meanwhile, a new method has emerged that would give Nova Scotia women another option in early pregnancy.

Mifegymiso, an alternative to surgical abortion, is an abortion pill that can be used to terminate a pregnancy of up to 49 days.

Advocates say the two-step process using the drugs mifepristone and misoprosto could increase access, provide women with more choices and shorten wait times.

The Society of Obstetricians and Gynaecologists of Canada says 171 physicians and pharmacists in Nova Scotia have either registered for or taken a training course on Mifegymiso.

But at a cost of about $350, the pill remains out of reach for many women.

While Alberta, Manitoba, Ontario, Quebec and New Brunswick have all said they would provide at least some coverage for the drug, Nova Scotia has stayed silent on the issue.

A Health Department spokeswoman said the Nova Scotia government is looking at coverage for Mifegymiso, but a decision has not yet been made.

Meanwhile, it's unclear why women in Nova Scotia must obtain a referral.

Health spokeswoman Sarah Levy MacLeod confirmed that a referral and an ultrasound are required before an abortion can be booked, but she referred questions on the policy to the Nova Scotia Health Authority.

The health authority referred questions to the co-director of the QEII Termination of Pregnancy Unit — the same doctor, Lianne Yoshida, who called the need for a referral a barrier to access that needs to be addressed.

"I don't think it's necessarily political. It's sort of just the way it's always been," Yoshida said. "It's recognized as a problem."

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