Shipments of the combination pack of the two pills, mifepristone and misoprostol, used for medical abortion finally began arriving in Canada at two clinics in Vancouver and Calgary during the week of 16 January 2017. Misoprostol has long been available in Canada, but not mifepristone. For a long time, methotrexate has been prescribed by some providers in Canada with misoprostol instead, but this combination was never approved by WHO.
When the pharmaceutical company Celopharma finally agreed to apply to provide the medications, the approval process took three years and was finally completed in July 2015. It has taken since then for the government and the company to negotiate the indications, a public sector price and reimbursement via provincial insurance plans and make the pills available.
In Canada, 90% of abortions happen before 12 weeks of pregnancy. Although the approval is only for up to 7 weeks LMP, the first clinics to launch the service will go beyond that off-label, up to 9 or 10 weeks LMP, for which there is excellent evidence of safety and efficacy. The US Food & Drug Administration currently allows home use up to 10 weeks. The fact that off-label prescribing is common and accepted practice has been crucial for medical abortion, given that so many governments have been ultra-conservative in regulating its provision, including Canada, in spite of years of evidence that they could safely go further.
“Long-awaited” is an understatement according to those who have been campaigning for this for years. The homepage of the website of the medication contains a long list of the news articles from across 2016 announcing delays in the “imminent” arrival of the pills.
The Globe and Mail quote Celia Posyniak, Executive Director of Calgary’s Kensington Clinic, to say: “We were over the moon. There’s a few of us who’ve been here for 25 years or more and we’ve been waiting for it all that time. Canada was definitely a laggard.” According to the newspaper, the Willow Women’s Clinic in Vancouver have begun prescribing already and the Bay Centre for Birth Control in Toronto was getting ready to do so when the announcement was made. And this is just the beginning of what is expected to be a major change in how women in Canada have abortions.
Importantly for access to be achieved, the Society of Obstetricians & Gynaecologists Canada (SOGC) has launched two online courses for health professionals to prepare to provide the pills – an accredited self-assessment programme and a non-accredited course of six hours each. Pharmacists, a range of mid-level providers, e.g. nurses and midwives, and medical students are able to take the courses, as well as doctors. The accredited course fee is CAN$50; the programme modules are:
> Overview of medical abortion in Canada
> Pre-abortion care
> Assessment of unintended pregnancy
> Evidence-based medical abortion regimens
> Providing medical abortion as per Health Canada requirements
> Post-abortion care
The non-accredited course is free. It contains the following modules:
> Define and describe medical abortion (MA)
> Select appropriate patients for MA and identify contraindications
> Provide pre-abortion care for women eligible for MA
> Describe evidence-based medical abortion regimens
> Describe in detail the prescribing information for combination mifepristone/misoprostol as per Health Canada requirements
> Identify post-procedural complications arising from MA.