Conflicting guidelines and onerous after-care requirements are barring “a huge amount” of women from accessing the abortion pill, say staff at Planned Parenthood Ottawa, as doctors try to wrap their heads around the logistical hurdles.
“Our abortion access co-ordinator has sat in a room full of doctors who just threw up their hands and said ‘There’s no way we’re going to take on that much work,’” said Catherine Macnab, the head of Planned Parenthood Ottawa, a non-profit that provides a range of sexual health and education services.
Health Canada had originally approved Mifegymiso — known as the “abortion pill” — in July 2015, and it became publicly available in January 2017. The two-medication drug, also known as RU-486, is taken to terminate an early pregnancy.
In August, the province touted improved access to safe abortions when it announced that women with a valid health card and prescription would be able to get Mifegymiso for free at participating pharmacies.
However, close to a year after the abortion pill became publicly available, some health-care providers are finding it too intimidating to tackle the logistical demands of providing the pill.
While nearly 800 people in Ontario have taken the voluntary training course for prescribing Mifegymiso, only 12 clinics are known to be willing to accept referrals, including one clinic in Ottawa.
“Our hypothesis is there’s a lot of logistical barriers that make it too difficult to turn the medical training into practice, into actual medical abortion being provided,” said Ariane Wylie, Planned Parenthood’s medical abortion access co-ordinator.
How one offers Mifegymiso depends on which guideline one follows. According to Wylie, Health Canada, The Society of Obstetricians and Gynaecologists of Canada, the National Abortion Federation, the Ontario College of Pharmacists, the College of Physicians and Surgeons of Ontario and the World Health Organization — to name just a few — all have guidelines for medical abortion, occasionally with major discrepancies in how care should be provided.
“There’s a sense that there’s a physician or nurse practitioner sitting in the middle being like, ‘I’m interested in providing this but six different sources are telling me information and a lot of it conflicts,’” said Wylie. “And even if they are interested … which (guideline) is going to protect them from a medical and legal perspective?
“Most of them just say, ‘No, I believe in this ideologically, but I think this is too much work and caught in too much of a maelstrom between all of our governing bodies.”
First, said Wylie, there’s the difference in guidelines.
On one hand, Mifegymiso’s “product monograph” approved by Health Canada — a document that outlines a drug’s regulations and conditions for use — states the pill is safe and effective up until seven weeks of the pregnancy.
But the Society of Obstetricians and Gynaecologists of Canada, the country’s medical experts in pregnancy and abortion care, extends that period to 10 weeks.
The three-week difference, Wylie said, is a problem because the turnaround for a medical abortion is so tight.
Typically, a woman only finds out she’s pregnant four or five weeks into it, said Wylie. If Health Canada guidelines are followed, the woman must then make the difficult to decision to have an abortion, then find a doctor willing to prescribe, then get referred for ultrasound and blood work, then come back and take the medication — all within three weeks. The 10-week option affords a crucial bit of extra time.
“(The guideline confusion) is barring a huge amount of people from accessing medical abortion,” she said.
Then there’s the issue of defining what the guidelines mean by the “emergency care” that’s mandated after a woman has taken the pill.
Health Canada says physicians need to “ensure patients have access to emergency medical care in the 14 days following administration of (the abortion pill).” The Society of Obstetricians and Gynaecologists of Canada says patients must receive “detailed info about how to recognize serious complications and access emergency medical care either directly or by telephone,” with no timeline. The National Abortion Federation requires that the patient have access to 24-hour telephone emergency care, again with no timeline specified.
“There’s a deep confusion here about what emergency care means,” said Wylie. Calls to doctors during business hours aren’t a problem, she said. It’s after-hours, with some providers interpreting the guidelines to mean they must carry a cellphone and pager with them 24/7.
“That is a huge burden for the average provider to give,” said Wylie.
Some clinics have collaborated to create “call groups,” with different providers offering emergency care in a rotation.
One practitioner at a clinic in Ottawa, who asked not to be named because of privacy concerns, wondered who should be in charge of the 24-hour emergency care.
“Do you just say, ‘Oh, now me, as an individual (doctor), will have to give my personal cellphone to the patient for the next two weeks?’”
Wylie said many Ottawa providers use Telehealth Ontario — a 24/7 emergency medical hotline run by the province — as their emergency care referral, but there’s no guarantee the registered nurse on the phone will know about medical abortion.
Mifegymiso-specific training is important, said Wylie — symptoms such as bleeding, vomiting, diarrhea or fever, for example, are usually signs of an infection, but those symptoms are “normal” in the first 24 hours after a medical abortion.
Wylie said the province could help fill a “huge gap” by training Telehealth workers on medical abortion, or even setting up a separate emergency line. More ultrasound machines — and more technicians trained on them — would also help speed up the turnaround for an abortion.
A spokesperson for the Ministry of Health and Long-Term Care said it will “continue to support our health care partners involved in prescribing and dispensing Mifegymiso.”
“We will continue to work with the Society of Obstetricians and Gynaecologists of Canada to closely monitor the roll out of Mifegymiso and provide training and other supports where needed.”
Wylie said a new product monograph is expected to be released Nov. 7 that brings Health Canada’s approved guidelines closer to the SOGC’s.
When the pill was first made available, one clinic and one practitioner in Ottawa were prescribing, but that number is expected to expand by one more clinic by next week, then to three more in the near future.