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October 29, 2020
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Q&A: Physicians in Canada share experiences after deregulation of abortion services

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In the United States, the FDA required that the drug mifepristone, an approved medication for nonsurgical abortion, be dispensed only in hospitals, clinics or physician offices, even during the pandemic.

On behalf of medical experts and advocates, the ACLU has sued to lift that restriction — suggesting that it jeopardizes the health of patients and clinicians, particularly in communities of color — and the case has since made its way to the Supreme Court.

The quote is: "Due to COVID-19, it may be difficult or unsafe for some patients to access their abortion provider in person." The source of the quote is  Sarah Munro, PhD.

In a paper published in Annals of Family Medicine, researchers in Canada recently described physician experiences with medical abortion services and the recent deregulation of mifepristone. In the study, they conducted one-on-one semi-structured interviews with 90 health care employees from rural and urban areas.

Healio Primary care spoke with one of the authors, Sarah Munro, PhD, an assistant professor in the department of obstetrics and gynecology at the University of British Columbia, about the findings and what the researchers learned.

Q: How comfortable are primary care physicians with prescribing mifepristone? What were their concerns?

A: When mifepristone was first approved in Canada, primary care providers were initially concerned about the regulations to dispense the medication out of their offices and observe patients swallowing the medication. Requiring Canadian physicians to purchase, stock, sell and dispense the medication was an exceptional burden, since physicians frequently did not have the training or the infrastructure to meet stock management and dispensing standards. High-volume sexual health and abortion clinics can handle stocking and dispensing, but it is not feasible for primary care practices. These conditions limited access to abortion in rural, remote and smaller centers. Our research shows that, in the face of anti-abortion attitudes, it is critical to remove policy and institutional barriers to make it as easy as possible for physicians to prescribe.

Once those restrictions were removed, physicians described how providing mifepristone was straightforward. One physician told us that after prescribing the abortion pill for the first time, they were shocked at how simple it was, remarking, "That was so crazy easy.”

Another participant told us, "We’re not set up to dispense medications from our office. We would not have been able to dispense it just through the clinic that I work in. I think that it is better, that it’s not dispensed by physicians. I don't know of any other medication that is dispensed by physicians.” Another described the requirement to watch the patient ingest the drug "was interpreted to mean that the patient would have to be in the presence of a doctor, in front of the doctor to take the drug, which was kind of unheard of for any drug to be handled that way. It was perceived as being very paternalistic, with one participant saying, ‘Women can’t be trusted’."

When Health Canada removed its initial regulations, we learned that there were still pockets of people who held anti-choice attitudes that influenced physician behavior. Some physicians reflected that it can be uncomfortable letting people know they prescribe the abortion pill. One participant told us that “Some of the abortion providers have to sneak their way into the clinic so people picketing outside don't see them or they don’t let their extended family know that they are abortion providers since they don’t feel like they can do it openly. If you look at the high support for abortion among Canadians, it’s unfortunate that physicians still have to do it in the dark.”

Q: Were patients comfortable receiving the pill in a primary care setting?

A: We did not interview patients, but we did hear from primary care providers about their experiences of abortion care and their perceptions of patient satisfaction. One rural physician who had never provided abortions before remarked she had seen one of her patients “three times since her abortion and she hugged me each time. She’s so happy.”

Another physician we interviewed right after mifepristone had become available talked about how her patient had to travel 12 hours from the northern part of the province for a surgical procedure, leaving her four children in her home community. The physician said, “if there had been a provider in her community or a nurse practitioner who could have done a medical abortion,” that would have made it possible for the patient to stay in her home community and have control over when and where the abortion took place. The physician started providing the abortion pill the next month. We spoke to her a year and a half later and learned that she had started to train and support general practitioners in rural communities to offer the abortion pill too.

Q: What needs to be done to improve access to mifepristone in Canada?

A: There needs to be greater consumer awareness. Our interviews with physicians indicate that the Canadian public may not be aware of this relatively new option, its pros and cons, and how it can be prescribed by their family doctor or nurse practitioner.

To improve access at the community level, we are designing and testing a patient decision aid for method of abortion. We aim to help the public become informed about their options and choose the method that best matches their values and preferences.

Q: What type of follow-up care is required for patients who receive the pill?

A: Patients are seen by a health professional 7 to 14 days after taking mifepristone to confirm safety and complete pregnancy termination. Due to COVID-19, it may be difficult or unsafe for some patients to access their abortion provider in person. As a result, Canadian clinical practice guidelines support telemedicine provision of medical abortion and follow-up.

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