Access to abortion care in Canada is uneven and often inadequate. And the long-delayed arrival of the abortion pill has not yet done much to improve the situation.
Mifegymiso is the pill; it’s a combination of two medications that are highly effective in terminating a pregnancy. For patients, it is less invasive than a surgical abortion; for the health-care system, it’s easier and cheaper to deliver. It’s on the World Health Organization’s list of essential medicines and has been available in other countries for years, where a majority of women choose the medication over surgery.
But the pill can be prescribed only during the first nine weeks of pregnancy. Time is essential.
A recent Globe and Mail investigation found access to the abortion pill is limited in many parts of Canada because numerous doctors will not prescribe it. Women then have to seek medical care from specialized abortion clinics, often located far from the patient’s home. For example, about three-quarters of all prescriptions for the abortion pill in Alberta in 2018 came from a single clinic in Calgary.
The problem appears to be more of a medical issue than a political one. Big gaps in access to the abortion pill exist across the country, from Alberta, which for the last four years was governed by New Democrats, to Quebec, which until last year had a Liberal government. The story of Mifegymiso in Canada has been one of reluctance, stemming from the years it wasn’t available, through its slow approval and, now, the widespread hesitancy among doctors to prescribe it.
From the start, Canada has been behind. Health Canada approved Mifegymiso four years ago this month, after an unusually long review. The medicine, first available in 2017, was initially burdened with onerous conditions. Those have since been eased, although it was only this April when Health Canada removed a mandatory ultrasound from its rules, conceding to “concerns that some patients may have been facing unnecessary barriers or delays in accessing this product.”
Still, a spectre around the medicine had been established, that it is unduly challenging for physicians and is not routine medical care. The Globe investigation found a big reason doctors refuse to deal with Mifegymiso is these perceived complexities.
Family doctors on a daily basis provide care for women through pregnancy and after birth. They provide advice on, and prescriptions for, contraception. It does not make sense for family doctors to shunt off access to abortion care to a limited number of already overburdened clinics, when a prescription pad is in their hands and they are best positioned to monitor patients in the weeks after they take the medication.
To improve access to abortion care, it is doctors – and the organizations that guide doctors – that need to step up.
The College of Family Physicians of Canada is in charge of education. It establishes standards of training, certification and lifelong education, and thus has a direct hand in the shaping of young doctors coming into the profession (it accredits family medicine at Canada’s 17 medical schools) and those who are practising.
The college’s stated mission is “to improve the health of all people in Canada.” Its first principle is that a family doctor is a skilled clinician, with expert knowledge of a wide range of issues, who bases decisions on the best science available.
But the college has been mostly absent on educating doctors about the best science on medical abortions. The college insists it does not control how doctors prescribe medicine. That is technically true. It also dodges the college’s mission and principles.
Lack of access to the abortion pill also highlights bigger questions in Canadian medicine. A single abortion clinic in Vancouver is serving patients throughout British Columbia via telemedicine – a technology that erases the problem of distance. But because doctors must be licensed in the province where they practise, a woman in rural Alberta or Northern Ontario can’t “visit” the Vancouver clinic. Further, why is the ability to prescribe Mifegymiso limited to doctors? Could nurse practitioners not prescribe it?
Abortion care for too long has existed outside the mainstream of day-to-day medicine in Canada. The whole idea behind Mifegymiso is to improve access to a type of abortion that is easier, safer and cheaper than a surgical procedure. The pill works. But it only works if patients can get it.