Almost eight months after the abortion pill became available in Canada, three provinces have yet to decide whether to fund the medication, while three others have opted to provide only limited coverage, primarily for low-income women, according to a Globe and Mail survey.
The patchwork approach to coverage for Mifegymiso, a two-drug combination that retails for about $300, has contributed to the slow uptake of the drug in those parts of the country where surgical abortions remain a cheaper option.
But in provinces with universal access – New Brunswick, Ontario and Alberta have already made Mifegymiso free to all women with a health card and Quebec has promised to follow suit this fall – more family doctors are stepping up to prescribe the drug for medical abortions, some of them in cities and towns with no other abortion services.
"As time rolls on, we're hearing of more providers taking up the call and becoming prescribers of Mifegymiso," said Sandeep Prasad, the executive director of Action Canada for Sexual Health and Rights, an Ottawa-based advocacy group that connects women with abortion providers. "It's becoming increasingly available in pharmacies. But all of that, unfortunately, is a slower-going process than one might like."
The introduction of Mifegymiso has also been marred by confusion around the rules for the controversial medication.
When Health Canada approved Mifegymiso two years ago, it did so with restrictions proposed by the drug's maker, including one that said women had to swallow the first pill in the package in front of a doctor and another that said doctors – not pharmacists – had to distribute the drug directly to their patients.
Health Canada has since eased those restrictions at the urging of pro-choice advocates who warned that forcing doctors to distribute the pills – which is not common practice in Canada – could discourage family physicians from prescribing Mifegymiso.
The federal department is now leaving it up to the regulatory bodies that govern doctors and pharmacists in each province to decide if pharmacists can hand out the abortion pill the way they do with most pharmaceuticals.
Health Canada issued a "Dear Healthcare Professional" letter in May that further clarified the conditions for prescribing Mifegymiso.
"I think if we had to do it all over again … the timing and the way that it was rolled out potentially could have been improved," said Supriya Sharma, Health Canada's chief medical adviser. "Having said that, I think we're really learning about the product and how it's being used once it's been out in the system."
Now that the protocol has become clearer, the uptake in primary care is "beyond what we'd hoped for" at this stage of the rollout, said Wendy Norman, a family doctor and University of British Columbia professor who is leading an independent research project on the launch of Mifegymiso.
"We've seen that about a quarter of the doctors who are part of our [Mifegymiso] community of practice are new to providing abortion, and 8 per cent of them are from communities that never had abortion care before," she said.
Persuading family doctors to prescribe Mifegymiso is critical to expanding abortion access outside of major cities and existing abortion clinics, Dr. Norman added.
Mifegymiso is comprised 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 those of a natural miscarriage.
Considered the gold standard in abortion medication, Mifepristone was not approved for sale in Canada until July, 2015, decades after it was approved in places such as France and China and 15 years after it received FDA approval in the United States. (Misoprostol was already available in Canada at the time.)
The combination kits became available in Canada in January.
It's difficult to say how many Canadian doctors are now prescribing Mifegymiso and how many pharmacies are stocking it.
As of the last week of August, 3,079 physicians and pharmacists had registered for or completed an online Mifegymiso training course run by the Society of Obstetricians and Gynaecologists of Canada (SOGC). More than half were from Ontario.
Although Quebec has promised universal funding of the drug, it is not yet available in the province, according to the medication's Canadian distributor, Celopharma Inc.
The ministries of health in Newfoundland and Labrador, Prince Edward Island and Nova Scotia all told The Globe they had not yet decided whether to cover the drug.
In the meantime, women in those provinces have to rely on private insurance or pay out of pocket if they want a medical abortion – assuming they can find a doctor willing to prescribe Mifegymiso in the first place.
Lianne Yoshida, a family doctor and the medical co-director of the Termination of Pregnancy Unit (TPU) at the Queen Elizabeth II Health Sciences Centre in Halifax, prescribed her first two kits of Mifegymiso just last month. The women found her through word-of-mouth referrals, she said.
Mifegymiso is not available at the TPU in Halifax, which provides more than 85 per cent of Nova Scotia's surgical abortions, or at the Summerside hospital that provides the only surgical abortions on the island.
Dr. Yoshida, who travels to PEI twice a month to perform abortions, is not aware of any doctors on the island prescribing the drug, although 55 doctors and pharmacists on the island had registered for or completed the SOGC course as of Aug. 3.
"Obviously, I'd like them [Nova Scotia and PEI] to follow New Brunswick and cover it for everyone with a health card – absolutely. That would be a huge step," she said.
Dr. Yoshida, with her provincial government's support, is also in the midst of crafting a plan to make surgical abortions more readily available in Nova Scotia, the last place in Canada where women still need a referral from a family doctor to access an abortion.
Three other provinces – Manitoba, Saskatchewan and British Columbia – have taken a partial approach to funding Mifegymiso.
Manitoba has made it free at places that already provide abortions in the Winnipeg and Brandon regions. The province has also added it to its drug-plan formulary, which means it is covered mainly for women poor enough to qualify for social assistance.
In Saskatchewan, where the drug will be added to the province's formulary effective Tuesday, low-income women who qualify will pay $2 or less for the drug.
And British Columbia has taken a similar approach, adding it to its hospital and drug-plan formularies. The three territories are providing partial coverage for Mifegymiso to women who otherwise qualify for public drug plans. The federal government's Non-Insured Health Benefits program, which covers eligible First Nations and Inuit people, also pays for Mifegymiso.
Dr. Norman said the partial funding is a "double whammy" that leaves out women who need access to affordable abortions most.
"What we're seeing [at abortion clinics] is the working poor. We're seeing single moms. We're seeing the people who are struggling to get through their life but aren't low[-income] enough that they're on social assistance," she said. "If they were, they could afford high-quality contraception and they wouldn't be having unintended pregnancies."
A spokeswoman for the Minister responsible for the Status of Women in Manitoba said via e-mail that "access to reproductive health services is important to women in Manitoba" and underscored that medical abortions will be free of charge at the province's existing abortion centres.
A spokesman for the B.C. Ministry of Health said the province's new NDP government "will be reviewing coverage of Mifegymiso to determine if the current approach works for B.C. women."