Written by: Jill Koebel (she/her).
Edited by: Etienne Maes (he/him).
Summary: In Canada, both medication and surgical abortions are legal, but legality does not guarantee accessibility. Over 70% of abortions in Canada are provided in abortion clinics which tend to be located in large urban centers. The abortion pill mifepristone, or a “medication abortion”, represents a revolutionary tool to increase abortion access in resource-limited settings. A major challenge to the implementation of mifepristone abortion in primary care settings is the willingness of family doctors to adopt this practice. Researchers, physicians, and advocates across Canada are working to make abortion as accessible as possible. In the present political climate, this work is more important than ever before. This article, inspired by a conversation with leading medication abortion researcher and clinician Dr. Sheila Dunn (she/her), will briefly review the history of medication abortion in Canada, identify current barriers and explore the work that is being done nationwide to increase accessibility.
Mifepristone approval:
The 2015 Health Canada approval of the medication abortion drug mifepristone represented a landslide victory for abortion advocates nationwide. This approval, which made the drug available to the public in the beginning of 2017, revolutionized the abortion landscape in Canada, says Dr. Sheila Dunn.
Dr. Dunn is a clinician scientist at Women’s College Research Institute in Toronto and the Associate Research Director of the Contraception and Abortion Research Team (CART), which is led by Dr. Wendy Norman at the University of British Columbia. The CART Team are regarded as experts and national leaders in reproductive health research.
Despite this approval, early on medication abortions remained largely inaccessible for the Canadian population due to restrictions that did not conform with the clinical guidelines or usual clinical practice (1), including (2):
- Physicians must observe the patient taking the medication
- Prescribers must take a mandatory training
- Patients must sign a manufacturer consent form
- Only physicians, not pharmacists, can dispense the drug directly to the patient
- Mandatory ultrasound before prescribing
- Medication could only be used up to seven weeks of pregnancy (rather than nine weeks, which is the standard outside of Canada)
Dr. Dunn and other abortion advocates across Canada lept to action; launching research programs that would explore the effect these restrictions had on abortion access. The CART-Mife study was launched, and surveys and interviews with providers indicated these restrictions were significant barriers to mifepristone prescribing (3).
Getting MDs on board:
As a result of this pushback, these restrictions were removed by Health Canada in 2017. But another challenge remained: even without these restrictions, providers needed support to adopt mifepristone prescription into practice. Since then, Dr. Dunn has played a critical leadership role in supporting primary care clinicians to provide medication abortion in their practice by identifying and alleviating policy and practice barriers through her research.
Dr. Dunn’s work with the CART research team has identified remaining individual and organization level barriers to introduction of mifepristone into primary care. Such barriers include provincial variation in physician billing codes, lack of motivation to provide due to the assumption that other physicians would, and provincial restrictions from the Quebec College of Physicians (4).
The Quebec Landscape:
While medication approvals are a federal responsibility, provinces are responsible for the delivery of healthcare and may impose their own restrictions (5). Although technically approved, until The College of Physicians of Quebec (CMQ) released its own guidelines in December 2017, mifepristone was not available in Quebec (5). The unique restrictions imposed by CMQ included in-person mandatory clinician training, unlike the online training initially required and removed by Health Canada in 2017.
However, things are looking up: In early July 2022, more than 300 Quebec physicians signed an open letter lobbying the removal of the prescription restriction (6). Excitingly, the CMQ announced on July 14th, 2022 that the mandatory training requirement has been removed in Quebec, and it is now “up to the physician to ensure they have the knowledge and skills necessary to prescribe this medication” (7). However, this will likely not result in a shift in practice overnight; in 2020, the CART team explored practice barriers for Quebec physicians, finding that several other barriers exist besides the training restriction. These included lack of local resources or support of colleagues and concerns about patient confidentiality (8). Additionally, providers were unsure if this was something that was their responsibility and believed there were other providers who would fill the gaps (8). Overall, confusion about practice policies and a lack of information access were critical findings, indicating CMQ should work to clarify and widely disperse information on these changes to Quebec physicians. Such an option is a virtual community of practice like Canadian Abortion Providers Support – Communauté de pratique canadienne sur l’avortement (CAPS-CPCA) VCoP, an on-line platform Dr. Dunn and colleagues created from 2017-2019 to support implementation of mifepristone abortion practice across Canada. A study of the VCoP found that members valued the information, practical resources to assist in delivering the service, and email announcements which kept them up to date with changing regulations (9).
Telemedicine/Low-touch:
The COVID-19 pandemic’s burden on the Canadian healthcare system reduced access to health care. Shortly after the pandemic was declared, Dr. Dunn and other members of the Society of Obstetricians and Gynecologists of Canada (SOGC) Sexual Health and Reproductive Equity (SHORE) Committee put out a statement providing best practice guidance in maintaining abortion access during the COVID-19 pandemic (8). It reaffirmed the essential nature of both medication and surgical abortion services and provided a list of clinical recommendations including extending gestational limits for medication abortions (8). The statement provided information on how to deliver abortion care through telemedicine and prescribing guidelines for medication abortions (8). Also at this time, Dr. Dunn collaborated on a study that explored the perspectives of over 300 Canadian healthcare professionals on abortion service disruption during the pandemic, which found providers in every province and territory except Quebec transitioned a significant amount of their practice to telemedicine to ensure access to services (10).
Current research:
Dr. Dunn continues to contribute to research aimed at improving abortion access in Canada and elsewhere through her work with CART. Current work with colleagues across Canada is examining the changes in abortion care and the distribution of abortion services in Ontario since the introduction of mifepristone.
References:
1. Abortion Rights Coalition of Canada. The Canadian Abortion Provider Shortage – Now and Tomorrow . Abortion Rights Coalition of Canada. https://www.arcc-cdac.ca/on-the-issues/.
2. Devane C, Renner RM, Munro S, et al. Implementation of Mifepristone Medical Abortion in Canada: Pilot and feasibility testing of a survey to assess facilitators and barriers. Pilot and Feasibility Studies. 2019;5(1). doi:10.1186/s40814-019-0520-8
3. UBC Faculty of Medicine. Easing restrictions on abortion pill greatly improved access to care in Canada. UBC Faculty of Medicine. https://www.med.ubc.ca/news/easing-restrictions-on-abortion-pill-greatly-improved-access-to-care-in-canada/. Published August 18, 2021.
4. Guilbert E, Wagner M-S, Munro S, et al. Slow implementation of mifepristone medical termination of pregnancy in Quebec, Canada: A qualitative investigation. The European Journal of Contraception & Reproductive Health Care. 2020;25(3):190-198. doi:10.1080/13625187.2020.1743825
5. College of Doctors of Quebec. Abortion pill rules updated: Voluntary termination of medical pregnancy – IVGM. College of Doctors of Quebec. http://www.cmq.org/nouvelle/fr/actualisation-regles-pilule-abortive.aspx. Published July 14, 2022.
6. Nerestant A. Quebec doctors demand abortion pill be made more accessible | CBC news. CBCnews. https://www.cbc.ca/news/canada/montreal/abortion-pill-access-quebec-restrictions-1.6509668. Published July 4, 2022.
7. Costescu D, Guilbert E, Wagner M-S, et al. Induced Abortion: Updated Guidance During Pandemics and Periods of Social Disruption. SOGC COVID-19 Resources. https://sogc.org/common/Uploaded%20files/Induced%20Abortion%20-%20Pandemic%20Guidance%20-%20FINAL.PDF. Published November 9, 2021.
8. Wagner M-S, Munro S, Wilcox ES, et al. Barriers and facilitators to the implementation of first trimester medical abortion with mifepristone in the province of Québec: A qualitative investigation. Journal of Obstetrics and Gynaecology Canada. 2020;42(5):576-582. doi:10.1016/j.jogc.2019.10.037
9. Dunn S, Munro S, Devane C, et al. A Virtual Community of Practice to Support Physician Uptake of a Novel Abortion Practice: Mixed Methods Case Study. J Med Internet Res. 2022;24(5):e34302. Published 2022 May 5. doi:10.2196/34302
10. Ennis M, Wahl K, Jeong D, et al. The perspective of Canadian health care professionals on abortion service during the COVID-19 pandemic. Family Practice. 2021;38(Supplement_1):i30-i36. doi:10.1093/fampra/cmab083
