The Canadian launch of the abortion pill is proceeding more slowly than expected, with only five abortion clinics and a handful of big-city pharmacies across the country ordering the medication since its debut in January.
Abortion providers say confusion over distribution rules and a lack of public drug coverage are partly behind the sluggish introduction of Mifegymiso, a $300 pill combination that supporters hope will eventually make it easier for rural and small-town women to end their unwanted pregnancies.
"It's been terribly slow," Ellen Wiebe, the medical director of the Willow Women's Clinic in Vancouver, said of the abortion pill's roll-out. "We're the big customer. That shouldn't be. It should be all over the country."
Dawn Fowler, the Canadian director of the National Abortion Federation (NAF), said many of the abortion providers her organization represents are waiting for provincial drug programs to begin reimbursing the cost of Mifegymiso, something that will not happen until after a committee of experts releases its final recommendation on the drug's cost effectiveness in the spring.
"The clinics are very reluctant to start offering [Mifegymiso] because they're not sure that women will be willing to pay the $300-plus for the medication," Ms. Fowler explained.
Still, there are signs that Mifegymiso will soon become more widely available – even before the public-reimbursement issue is resolved.
Dr. Wiebe, for example, recently presided over her first telemedicine abortion using Mifegymiso.
Nearly 500 doctors and pharmacists have registered for the six-hour online course they need to take before prescribing or distributing Mifegymiso; 210 have finished the course so far, according to the Society of Obstetricians and Gynaecologists of Canada.
The self-regulatory colleges for doctors and pharmacists in Ontario are preparing to follow the lead of British Columbia by telling their members that pharmacists can distribute Mifegymiso, despite contentious Health Canada guidelines that say physicians should give the pills to women directly.
Health Canada has received correspondence from other provinces on the distribution issue, too, a spokeswoman for the federal department said.
Meanwhile, hospitals in at least one province, B.C., plan to begin offering Mifegymiso to women free of charge in the spring.
Three major private-insurance companies have also agreed to cover the pills and another four are considering it, according to the president of Celopharma Inc., the Canadian distributor for Mifegymiso.
"I cannot say for sure if providers in towns and cities where abortion has not previously been available will offer this service, but it certainly is our hope that this will in fact happen," Paula Tenenbaum, the president of Celopharma, said by e-mail. "After all, one of our goals is to make this necessary [and] essential service available not only in the urban areas but in the rural areas."
Aside from Dr. Wiebe's Vancouver clinic, four other abortion clinics are offering Mifegymiso, in Calgary, Ottawa, Toronto and St. John's.
Ms. Tenenbaum said her company has shipped pills to pharmacies in Vancouver, Victoria, Whitehorse, Saskatoon, Winnipeg and Toronto, which suggests that at least some doctors in those cities are willing to prescribe the pills.
But Sandeep Prasad, the executive director of Action Canada for Sexual Health and Rights, an Ottawa-based advocacy organization that connects women to abortion services, said he is not aware of any physicians outside of abortion clinics prescribing Mifegymiso.
"My worry remains that the roll-out of Mifegymiso will remain only amongst existing abortion providers," he said. "We really need large numbers of family physicians … that is one of the elements that is needed to ensure that we are realizing the game-changing potential of Mifegymiso."
Mifegymiso is made up of two medications, sold together in a combination pack. The first, mifepristone, blocks the hormone progesterone, causing the lining of the uterus to break down. The second drug, misoprostol, is taken 24 to 48 hours later, and induces contractions similar to a natural miscarriage.
Considered the gold standard in abortion medication, mifepristone was not approved in Canada until July of 2015, decades after it was approved in places such as France and China, and 15 years after it was approved in the United States.
When Health Canada licensed Mifegymiso, it did so with a list of conditions proposed by Celopharma, including a requirement that doctors distribute the pills directly to patients whose pregnancies are no further along than 49 days.
Celopharma has already applied to Health Canada to extend the upper limit of use to nine weeks, and to allow pharmacists to distribute Mifegymiso directly to women as they do with most prescription drugs.
At the few abortion clinics that are offering Mifegymiso, uptake has been brisk. Dr. Wiebe in Vancouver has given the medication to 180 women since Jan. 23. The $325 price, which includes painkillers, does not seem to be deterring patients, she added.
At the Kensington Clinic in Calgary, where executive director Celia Posyniak managed to persuade the province to include coverage of the pills in her facility's most recent contract, Mifegymiso is free to women.
The clinic has given out more than 100 doses since January.
"For women who want to avoid the surgical process and all it entails, it's an excellent option," Ms. Posyniak said. "It's too bad that we had to wait so long to offer it to women."