Why accessing medical abortions is so difficult in Ontario

The abortion drug Mifegymiso was approved by Health Canada in 2015, but many doctors are still reluctant to prescribe it. Here’s how one organization is trying to address the issue
By H.G. Watson - Published on Nov 07, 2019
Abortion drug packages
Mifegymiso can be prescribed in the first nine weeks of pregnancy by any doctor or nurse practitioner. (Linepharma International/cbc.ca)

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This is the final instalment in a three-part series on access to abortion in Ontario. Read Part 1 and Part 2.

Since 1997, Planned Parenthood Ottawa has offered a phone line that helps people get information and referrals related to reproductive care. In early 2017, Ariane Wylie, the organization’s medical abortion access coordinator, and other staff started noticing a growing number of calls from people wanting to know where they could get prescriptions for Mifegymiso — otherwise known as a medical abortion — which had just recently been made available in Canada.

Mifegymiso is considered by medical experts to be a game changer for medical-abortion access. “Medical abortion care plays a crucial role in providing access to safe, effective and acceptable abortion care,” a 2018 guide from the World Health Organization states. “In both high- and low-resource settings, the use of medical methods of abortion have contributed to task shifting and sharing and more efficient use of resources.” The pills can be prescribed in the first nine weeks of pregnancy by any doctor or nurse practitioner, and people can take them at home.

However, a recent Globe and Mail investigation found that doctors aren’t prescribing Mifegymiso at the rate they could be: “In eight provinces where detailed data was available, at least 69 per cent of the 10,092 Mifegymiso prescriptions dispensed last year came from abortion clinics located mainly in large urban centres. Interviews with clinic employees, physicians, researchers and abortion-rights advocates across the country suggest that many primary-care providers avoid prescribing the abortion pill.” As a result, people often still have to travel to access a medical abortion.

Planned Parenthood Ottawa does not have staff who prescribe medical abortions or perform surgical abortions — they refer clients to other primary-care providers. After looking at the number of people who wanted to access Mifegymiso, Wylie and the rest of the staff concluded that there was work to be done. “Then, there were appointments available at the two clinics in town that we knew of who were accepting patients outside their own practice,” Wylie says. “And we thought that was a problem — so we decided to fix it.” In spring 2017, the organization launched the Medical Abortion Access project to support local primary-care providers in prescribing medical abortions.

When Mifegymiso was approved by Health Canada in 2015, many abortion providers and pro-choice advocates hoped it would improve access across the board. A medical abortion requires fewer resources than a surgical abortion. “This means settings that maybe don’t have high resources — that are more rural and don’t have a lot of infrastructure — can still safely prescribe medical abortions,” says Wylie.

Surgical abortions are performed with suction or aspiration or, depending on how far along the pregnancy is, via dilation and evacuation — all procedures that require additional training for primary-care providers. A person who is pregnant may have to take the day off and require a localized anesthetic, depending on the procedure. They may find it invasive to have another person perform the procedure. It can also be extremely difficult to find a surgical-abortion provider in Ontario — most clinics are located in the southern part of the province, and only a few hospitals publicly indicate that they provide access to abortions.

Medical abortions are prescribed just like any other medication. Some primary-care providers require a blood test to confirm the pregnancy and an ultrasound to confirm gestational age and to ensure there are no complications, such as an ectopic pregnancy, that would pose a danger to the person who is pregnant.

Mifegymiso is actually two different medications — taking it is a two-step process. Mifepristone is the first pill: it stops the release of the hormone progesterone, preventing the pregnancy from further developing. Misoprostol is a set of four pills that dissolve in the patient’s mouth and effectively cause the body to mimic a miscarriage. The success rate is between 87 and 99 per cent, depending on when the drugs are taken. (Comparatively, surgical abortions are about 98 per cent effective.)

Sarah Warden, the lead physician of the medical-abortion program at the Bay Centre for Birth Control, in Toronto, says that more than 50 per cent of the people nine weeks pregnant and under seeking abortions at her clinic now opt to use Mifegymiso. Warden notes that the centre also used to see a significant number of out-of-province patients who’d come to Toronto to get medical abortions. “Now that’s gone down,” she says. More provinces now cover Mifegymiso under provincial health care (Ontario did so in 2017). At least one province, Quebec, suffered supply shortages after offering the pills free of charge.

Some medical professionals, though, are still reluctant to prescribe it. The Globe and Mail spoke to one Alberta-based doctor who had to prescribe the drug after her normal clinic hours because her colleagues didn’t want to be connected to abortions. Lyndsey Butcher, executive director of the SHORE Centre, in Kitchener-Waterloo, told the Globe that wait times for Mifegymiso can be from two to three weeks long because few area doctors will prescribe it.

Planned Parenthood Ottawa is working to improve access to medical abortions in two primary ways: it provides medical professionals and patients with access to plain-language information and is building a community of practice that connects primary-care providers with other medical-abortion practitioners. Wylie says that it’s important that primary-care doctors not feel isolated and that they have people who can provide mentorship through tough or complex cases. “That’s a really scary and isolating thing, to be embarking on a new type of care that you weren’t trained on,” says Wylie.

Since the project started, Wylie says, the number of Ottawa clinics that will prescribe Mifegymiso to people outside their own practice has gone from two to seven. “So we’ve dramatically increased the number of providers,” she says. As a result, wait times to get the prescription have dropped: two years ago, people usually had to wait one or two weeks to get Mifegymiso. Now, the typical wait time in Ottawa is about three to four business days. “To us, that seems like a pretty strong connection that what we’ve done has made a difference,” says Wylie. Planned Parenthood has also helped improve access for Quebecers and French-speaking Ottawans by working with francophone primary-care providers who will prescribe Mifegymiso.

But Wylie knows that, in many communities across Ontario, it can still be harder to get a medical abortion than a surgical one. “It’d be great if Ontario got to the state where, even if there wasn’t a freestanding abortion clinic or providers in the hospital setting that are trained to do in-clinic abortions, that there were primary-care providers ... who are comfortable to prescribe Mifegymiso and were able to let their community know they were out there,” she says. “That work is already happening.”

Wylie believes that the Medical Abortion Access project model could successfully be replicated across the province — and Planned Parenthood Ottawa is planning to fundraise for a pilot project that would include all of Ontario. “We’re very hopeful that that will occur,” she says, “and that we will be able to apply this model in other regions.”

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