CANADA – Canada removes access barriers to abortion with mifepristone + misoprostol

by Sarah Munro, PhD; Wendy V. Norman, MD, MHSc, University of British Columbia, Canada

On 8 April we reported that Canada had removed the requirement of an ultrasound scan prior to abortion up to 63 days LMP. But now we have learned more has been happening over the past 1-2 years to remove other access barriers:

In 2012, fewer than 300 physicians provided induced abortions in Canada. They worked largely in surgical facilities in large cities close to the Canada/United States border. With few abortion providers serving a small portion of the population, there was a critical need to enhance abortion access. In January 2017, a potential solution emerged. Medical abortion with mifepristone + misoprostol was made available for the first time in Canada. It had the potential to address geographic barriers to access, but Canada approved mifepristone with restrictions to prescribing and dispensing. Our research team anticipated that these restrictions would make it difficult to provide the drug in primary care and, in turn, improve. We set out to partner with Canadian decision makers to detect and change barriers to implementing provision in primary care.

Over the first year of mifepristone being available in Canada (2017-18), we conducted surveys and interviews with physicians and pharmacists and invited them to join a virtual Community of Practice. We explored their barriers to providing mifepristone – mandated physician-only dispensing and pharmacist training, inadequate coverage and payment, and confusion about changing regulations. We shared our research results with leaders from government, health system and professional organizations in real time. They increasingly requested evidence briefs, illustrative maps showing where in Canada mifepristone was available, and face-to-face meetings.

The rapid uptake of our study findings into practice and policy demonstrate the potential of partnering with decision makers. The impacts included removal of federal requirements for observed dosing, practitioner training, practitioner registration, physician-only prescribing and dispensing. Pharmacist dispensing and nurse-practitioner prescribing are now allowed in Canada.

As of 16 April 2019, Canada removed the last federal restriction on mifepristone. Practitioners are no longer required to order an ultrasound before prescribing mifepristone for medical abortion prior to 63 days of pregnancy.

Having researchers and decision makers collaborate on the same team has great potential to accelerate changes to abortion practice and policy and maximise the impact of research. In Canada, this means that women now have increased access to equitable, safe, confidential abortion care closer to home.

REFERENCE: Wendy V Norman,Sara Munro,Melissa Brooks, et al.Could implementation of mifepristone address Canada’s urban–rural abortion access disparity: a mixed-methods implementation study protocol.BMJ Open2019;9:e028443.DOI:10.1136/bmjopen-2018-028443 ; PHOTO: Wendy Norman