Dawn Fowler is the executive director of the Vancouver Island Women’s Clinic
Those of us who have been advocating for medical abortions – those done by taking pills – know they improve access and provide a safe, effective and less invasive option for those who need to terminate an unplanned pregnancy. Women could have their abortions in the privacy of her home rather than have a surgical aspiration with anesthetic.
In 2015, after much deliberation, cost and determination, approval in Canada was granted to combine two medications (mifepristone and misoprostol) in order to end a pregnancy. The result was Mifegymiso, which has technically been available for four years in this country – but efforts to ensure access are still under way, as reported in The Globe and Mail this weekend.
The reasons for the challenging access is that physician training is needed to ensure appropriate use of Mifegymiso, the abortion pill. The National Abortion Federation, of which many Canadian abortion providers are members, provides training in safe abortion care, and I have increased training opportunities for members during the approval process.
The College of Family Physicians of Canada did not develop a training program, nor work to ensure awareness among their membership. This was done by the Society of Obstetrics and Gynecologists of Canada for their membership. Not surprisingly, the first to offer Mifegymiso were the facilities and clinicians who provided abortion procedures. Many were responsible for developing more training and education materials.
The demand for this new option has been so significant in B.C. that the Vancouver Island Women’s Clinic no longer needed to provide any procedures in the clinic. Over 60 per cent of those eligible are choosing the abortion pill, so the remainder are assessed and followed up in the clinic, but have the procedure in the hospital.
In Calgary, the uptake is similar. In Quebec and Ontario, the demand is far less and the reasons are unclear and complicated. Some facilities may be reluctant to offer medical abortion, perhaps because incorporating a new sequence of assessment and follow up is both intimidating and overwhelming.
It involves significant staffing and scheduling changes. For some, contracts or operative time is allocated for surgery specifically. For others, there is a negative perception of using medication, because despite clear safety and efficacy data, some argue that they would not support a drug company.
The lack of rapid uniform uptake is a complex issue. The use of Mifegymiso across the country has increased significantly, but not uniformly. The hope was also that most family physicians would incorporate Mifegymiso use into their practice – but so far, the rate of uptake among physicians has been disappointing.
A few may be morally opposed to abortion. Some would rather refer the person to an experienced physician or facility because they do not feel adequately trained themselves. Others are not willing to take the responsibility for appropriate screening and follow up.
Many may be unaware that their patient has accessed their care by self-referral to an abortion facility rather than waiting for an appointment with their family doctor who may be unfamiliar with the process.
The concerns of inappropriate prescribing are real: We have had women call our clinic having obtained the prescription elsewhere, yet still having many questions about how and when to take it, what to expect and how to manage the pain and bleeding, and they have no follow-up arrangements.
Safe and effective use of Mifegymiso requires thorough assessment, management and follow-up. Even when appropriately used, fertility returns quickly, so discussion and timely access to effective contraception is very important. Appropriately training all family physicians will take time.
Not all pharmacies stock the abortion pill. There are various reasons for this. While a few pharmacists may have ethical objections to abortions, the main reason is perceived lack of demand for the medication in that area.
We can expect more changes in the coming years. I am confident that more and more physicians will seek training and develop ways to incorporate this option into regular practice.
I am heartened by the new graduates I meet who are very committed to reproductive health. It may sound simple: Take a pill and your unplanned pregnancy will end. But prescribing this option safely and appropriately with immediate access to better contraception takes good training.
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