Perspectives Among Canadian Physicians on Factors Influencing Implementation of Mifepristone Medical Abortion: A National Qualitative Study

What do Australian primary care clinicians need to provide long-acting reversible contraception and early medical abortion? A content analysis of a virtual community of practice

BACKGROUND

Uptake of long-acting reversible contraception (LARC) is lower in Australia compared with other high-income countries, and access to early medical abortion (EMA) is variable with only 11% of general practitioners (GPs) providing EMA. The AusCAPPS (Australian Contraception and Abortion Primary Care Practitioner Support) Network is a virtual community of practice established to support GPs, nurses and pharmacists to provide LARC and EMA in primary care. Evaluating participant engagement with AusCAPPS presents an opportunity to understand clinician needs in relation to LARC and EMA care.

METHODS

Data were collected from July 2021 until July 2023. Numbers of online resource views on AusCAPPS were analysed descriptively and text from participant posts underwent qualitative content analysis.

RESULTS

In mid-2023 AusCAPPS had 1911 members: 1133 (59%) GPs, 439 (23%) pharmacists and 272 (14%) nurses. Concise point-of-care documents were the most frequently viewed resource type. Of the 655 posts, most were created by GPs (532, 81.2%), followed by nurses (88, 13.4%) then pharmacists (16, 2.4%). GPs most commonly posted about clinical issues (263, 49% of GP posts). Nurses posted most frequently about service implementation (24, 27% of nurse posts). Pharmacists posted most about health system and regulatory issues (7, 44% of pharmacist posts).

CONCLUSIONS

GPs, nurses and pharmacists each have professional needs for peer support and resources to initiate or continue LARC and EMA care, with GPs in particular seeking further clinical education and upskilling. Development of resources, training and implementation support may improve LARC and EMA provision in Australian primary care.

Defying the odds: Facilitating integration of abortion care into clinical practice in the United States

OBJECTIVES

We sought to describe the experiences of physicians who successfully incorporated abortion care into their practices in the United States. We explored facilitators of and barriers to abortion provision.

STUDY DESIGN

In this qualitative study, we conducted semistructured interviews with a national sample of obstetrician-gynecologists and family medicine physicians providing abortion care. Interviews addressed facilitators of and barriers to abortion provision, lessons learned and recommendations for future providers. We analyzed data using a content analysis approach.

RESULTS

We interviewed 14 obstetrician-gynecologists and 11 family medicine physicians providing abortion care as part of their practices. We identified four categories of facilitators and barriers: personal, community, training, and workplace factors. Major facilitators included supportive leadership and professional mentorship. Major barriers included antagonistic colleagues and leadership. Lessons learned included proactively assessing leadership support, identifying institutional allies, actively minimizing workplace conflict and being perceived as a team player. Recommended resources to increase abortion provision included clinical support, mentorship, funding, negotiation coaching, and access to clinical policies.

CONCLUSIONS

Institutional leadership support emerged as a critical facilitator for initiating and continuing to offer abortion care. Efforts to expand abortion access should include investments in supportive leadership, both in academic and community practices.

IMPLICATIONS

Maximizing abortion access is essential to counteract the legislative and political restrictions imposed on abortion care. Institutional support is a critical facilitator of abortion provision, and efforts to expand abortion access should include investments in supportive leadership and health care administration.

User-Centered Development of a Patient Decision Aid for Choice of Early Abortion Method: Multi-Cycle Mixed Methods Study

BACKGROUND

People seeking abortion in early pregnancy have the choice between medication and procedural options for care. The choice is preference-sensitive-there is no clinically superior option and the choice depends on what matters most to the individual patient. Patient decision aids (PtDAs) are shared decision-making tools that support people in making informed, values-aligned health care choices.

OBJECTIVE

We aimed to develop and evaluate the usability of a web-based PtDA for the Canadian context, where abortion care is publicly funded and available without legal restriction.

METHODS

We used a systematic, user-centered design approach guided by principles of integrated knowledge translation. We first developed a prototype using available evidence for abortion seekers' decisional needs and the risks, benefits, and consequences of each option. We then refined the prototype through think-aloud interviews with participants at risk of unintended pregnancy ("patient" participants). Interviews were audio-recorded and documented through field notes. Finally, we conducted a web-based survey of patients and health care professionals involved with abortion care, which included the System Usability Scale. We used content analysis to identify usability issues described in the field notes and open-ended survey questions, and descriptive statistics to summarize participant characteristics and close-ended survey responses.

RESULTS

A total of 61 individuals participated in this study. Further, 11 patients participated in think-aloud interviews. Overall, the response to the PtDA was positive; however, the content analysis identified issues related to the design, language, and information about the process and experience of obtaining abortion care. In response, we adapted the PtDA into an interactive website and revised it to include consistent and plain language, additional information (eg, pain experience narratives), and links to additional resources on how to find an abortion health care professional. In total, 25 patients and 25 health care professionals completed the survey. The mean System Usability Scale score met the threshold for good usability among both patient and health care professional participants. Most participants felt that the PtDA was user-friendly (patients: n=25, 100%; health care professionals: n=22, 88%), was not missing information (patients: n=21, 84%; health care professionals: n=18, 72%), and that it was appropriate for patients to complete the PtDA before a consultation (patients: n=23, 92%; health care professionals: n=23, 92%). Open-ended responses focused on improving usability by reducing the length of the PtDA and making the website more mobile-friendly.

CONCLUSIONS

We systematically designed the PtDA to address an unmet need to support informed, values-aligned decision-making about the method of abortion. The design process responded to a need identified by potential users and addressed unique sensitivities related to reproductive health decision-making.

First and Second-Trimester Surgical Abortion Providers and Services in 2019: Results From the Canadian Abortion Provider Survey

OBJECTIVE

Our objective was to explore the workforce and clinical care of first and second-trimester surgical abortion (FTSA, STSA) providers following the publication of the updated Society of Obstetricians and Gynaecologists of Canada (SOGC) surgical abortion guidelines.

METHODS

We conducted a national, cross-sectional, online, self-administered survey of physicians who provided abortion care in 2019. This anonymized survey collected participant demographics, types of abortion services, and characteristics of FTSA and STSA clinical care. Through healthcare organizations using a modified Dillman technique, we recruited from July to December 2020. Descriptive statistics were generated by R Statistical Software.

RESULTS

We present the data of 222 surgical abortion provider respondents, of whom 219 provided FTSA, 109 STSA, and 106 both. Respondents practiced in every Canadian province and territory. Most were obstetrician-gynaecologists (56.8%) and family physicians (36.0%). The majority of FTSA and STSA respondents were located in urban settings, 64.8% and 79.8%, respectively, and more than 80% practiced in hospitals. More than 1 in 4 respondents reported <5 years' experience with surgical abortion care and 93.2% followed SOGC guidelines. Noted guideline deviations included that prophylactic antibiotic use was not universal, and more than half of respondents used sharp curettage in addition to suction. Fewer than 5% of STSA respondents used mifepristone for cervical preparation.

CONCLUSION

The surgical abortion workforce is multidisciplinary and rejuvenating. Education, training, and practice support, including SOGC guideline implementation, are required to optimize care and to ensure equitable FTSA and STSA access in both rural and urban regions. GESTATIONAL AGE NOTATION: weeks, weeks' gestation, gestational age (GA), e.g., 116 weeks.

Canadian Newspapers Support Mifepristone Medication Abortion to Improve Fulfillment of the AAAQ Right to Health Framework (2015-2019)

BACKGROUND

In 2015, mifepristone in combination with misoprostol, the international gold standard for medication abortion, was approved for use in Canada. By 2019, all Canadian provinces had included the medication as a publicly insured health benefit.

METHODS

Our content analysis of Canadian newspaper coverage describes arguments in favor of or against medication abortion and the evolving regulatory framework for mifepristone from 6 months before regulatory approval until the last significant regulatory barrier to use was removed (2015-2019).

RESULTS

Our study found an exceptionally high level of support for the approval of, introduction of, and removal of regulatory barriers to mifepristone for medication abortion. Of 402 pieces, 67% were pro-medication abortion, 25% presented balanced or neutral coverage, and only 8% presented solely anti-medication abortion viewpoints. Of the 761 individuals quoted, more than 90% made positive or neutral statements about medication abortion. Most pieces discussed medication abortion as a health issue and described how liberalization of the regulatory framework would improve abortion availability (68%), accessibility (87%), acceptability (34%), and quality (28%).

CONCLUSIONS

Rather than formal balance, which presents contrasting arguments as equally valid even when the scientific evidence for one vastly outweighs the other, our study identified evidentiary balance, in which coverage aligned with the weight of evidence and expert opinion. Our results differ from analyses in other high-income countries (United Kingdom, United States) where media outlets frame abortion in relation to morality or electoral politics rather than as a health issue. The Canadian print media presented overwhelmingly favorable arguments toward the expansion of mifepristone medication abortion and framed the introduction and universal coverage of medication abortion as advancing the "Availability, Accessibility, Acceptability, and Quality" (AAAQ) Right to Health Framework that establishes international human rights standards for health information, facilities, goods, and services.

Seeking support for abortion care from national hotlines in Canada: Caller characteristics and call outcomes, 2019-2021

OBJECTIVES

Both the National Abortion Federation Canada and Action Canada for Sexual Health and Rights operate national toll-free hotlines that provide information, financial support, and travel assistance to abortion seekers. We aimed to characterize callers to both hotlines before and after the onset of the COVID-19 pandemic.

METHODS

Hotline personnel routinely document information about callers and type(s) of assistance needed and received. We received call logs from both organizations for a two-year period (April 1, 2019 through March 31, 2021). We exported these data to Microsoft Excel® and analyzed them using descriptive statistics. We analyzed case notes for content and themes.

RESULTS

Over the study period, the two hotlines worked with 270 unique callers. Nearly two-thirds of callers (n = 174) were seeking support to obtain abortion care for pregnancies after 14 weeks gestation, including 69 callers (26%) who were at or beyond 24 weeks gestation. Most callers were seeking support to obtain abortion care outside of their province of residence because services at their gestational age were not available. Caller needs were similar before and after the onset of the pandemic, but fewer traveled to the United States for abortion care in the COVID-19 era.

DISCUSSION

Assistance hotlines play an important role in helping some abortion seekers navigate the Canadian health system to obtain needed abortion care. The needs of those seeking care after the 14 weeks gestation points to gaps in current service availability. Identifying ways to expand later abortion care in Canada, particularly after 24 weeks, appears warranted.

Experience of stigma and harassment among respondents to the 2019 Canadian abortion provider survey

OBJECTIVE

We conducted a national survey to assess the experiences of stigma and harassment among physicians and nurse practitioners providing abortions and abortion service administrators in Canada.

STUDY DESIGN

We conducted an exploratory, cross-sectional, national, anonymized, online survey between July and December 2020. Subsections of the survey explored stigma and harassment experienced by respondents, including the 35-item Revised Abortion Providers Stigma Scale and open-ended responses. We analyzed the quantitative data to generate descriptive statistics and employed a reflexive thematic analysis to interpret open-ended responses.

RESULTS

Three hundred fifty-four participants started the stigma and harassment section of the survey. Among low-volume clinicians (<30 abortions/year, 60%, n = 180) 8% reported harassment; 21% among higher volume clinicians (≥30 abortions/year, 40%, n = 119) and 47% among administrators (n = 39), most commonly picketing. The mean stigma score was 67.8 (standard deviation 17.2; maximum score 175). Our qualitative analysis identified five themes characterizing perceptions of stigma and harassment: concerns related to harassment from picketing, protestors, and the public; wanting protestor "bubble zones"; aiming to be anonymous to avoid being a target; not providing an abortion service; but also witnessing a safe and positive practice environment.

CONCLUSIONS

Being a low-volume clinician compared to higher volume clinician and administrator appears to be associated with less harassment. Clinicians providing abortion care in Canada reported mid-range abortion-related stigma scores, and expressed strong concerns that stigma interfered with their abortion provision. Our results indicate that further de-stigmatization and protection of abortion providers in Canada is needed through policy and practice interventions including bubble zones.

IMPLICATIONS

While Canadian abortion care clinicians and administrators reported relatively low incidence of harassment, our results indicate that they are concerned about stigma and harassment. However, as this was an exploratory survey, these data may not be representative of all Canadian abortion providers. Our data identify a need to support abortion clinicians and to bolster protections for dedicated abortion services.

Dispensing mifepristone for medical abortion in Canada: Pharmacists' experiences of the first year

Background

Mifepristone for medical abortion was first dispensed by community pharmacists in Canada directly to patients in January 2017. We asked about pharmacists' experiences over their first year dispensing mifepristone in order to evaluate the frequency of the new practice and assess availability in urban/rural pharmacies.

Methods

From August to December 2019, we invited 433 community pharmacists who had completed a baseline survey at least 1 year prior to participate in a follow-up online survey. We summarized categorical data using counts and proportions and conducted a qualitative thematic analysis of open-ended responses.

Results

Among 122 participants, 67.2% had dispensed the product, and 48.4% routinely stocked mifepristone. Pharmacists reported a mean of 26 and median of 3 (interquartile range, 1, 8) mifepristone prescriptions filled in their pharmacies in the previous year. Participants perceived that the benefits of making mifepristone available in pharmacies included increased abortion access for patients (n = 115; 94.3%), reduced pressure on the health care system (n = 104; 85.3%), increased rural and remote abortion access (n = 103; 84.4%) and increased interprofessional collaborations (n = 48; 39.3%). Few participants reported challenges to maintaining adequate stock of mifepristone, but these challenges included low demand (n = 24; 19.7%), short expiry dating (n = 12; 9.8%) and drug shortages (n = 8; 6.6%). The overwhelming majority, 96.7%, reported that their communities did not resist the provision of mifepristone by their pharmacy.

Interpretation

Participating pharmacists reported many benefits and very few barriers to stocking and dispensing mifepristone. Both urban and rural communities responded positively to enhanced access to mifepristone in their community.

Conclusions

Mifepristone is well accepted by pharmacists within the primary care system in Canada.

Development and pilot testing of the 2019 Canadian Abortion Provider Survey

BACKGROUND

Substantial changes in abortion care regulations, available medications and national clinical practice guidelines have occurred since a 2012 national Canadian Abortion Provider Survey (CAPS). We developed and piloted the CAPS 2019 survey instrument to explore changes of the abortion provider workforce, their clinical care as well as experiences with stigma and harassment.

METHODS

We undertook development and piloting in three phases: (1) development of the preliminary survey sections and questions based on the 2012 survey instrument, (2) content validation and feasibility of including certain content aspects via a modified Delphi Method with panels of clinical and research experts, and (3) pilot testing of the draft survey for face validity and clarity of language; assessing usability of the web-based Research Electronic Data Capture platform including the feasibility of complex skip pattern functionality. We performed content analysis of phase 2 results and used a general inductive approach to identify necessary survey modifications.

RESULTS

In phase 1, we generated a survey draft that reflected the changes in Canadian abortion care regulations and guidelines and included questions for clinicians and administrators providing first and second trimester surgical and medical abortion. In phase 2, we held 6 expert panel meetings of 5-8 participants each representing clinicians, administrators and researchers to provide feedback on the initial survey draft. Due to the complexity of certain identified aspects, such as interdisciplinary collaboration and interprovincial care delivery differences, we revised the survey sections through an iterative process of meetings and revisions until we reached consensus on constructs and questions to include versus exclude for not being feasible. In phase 3, we made minor revisions based on pilot testing of the bilingual, web-based survey among additional experts chosen to be widely representative of the study population. Demonstrating its feasibility, we included complex branching and skip pattern logic so each respondent only viewed applicable questions based on their prior responses.

CONCLUSIONS

We developed and piloted the CAPS 2019 survey instrument suitable to explore characteristics of a complex multidisciplinary workforce, their care and experience with stigma on a national level, and that can be adapted to other countries.

Can youth-engaged research facilitate equitable access to contraception in Canada? The qualitative study protocol for the Ask Us project

INTRODUCTION

There is little to no evidence in Canada on the barriers that youth face when accessing contraception. We seek to identify the contraception access, experiences, beliefs, attitudes, knowledge, and needs of youth in Canada, from the perspectives of youth and youth service providers.

METHODS AND ANALYSIS

This prospective, mixed-methods, integrated knowledge mobilisation study, the Ask Us project, will involve a national sample of youth, healthcare and social service providers, and policy makers recruited via a novel relational mapping and outreach approach led by youth. Phase I will centre the voices of youth and their service providers through in-depth one-on-one interviews. We will explore the factors influencing youth access to contraception, theoretically guided by Levesque's Access to Care framework. Phase II will focus on the cocreation and evaluation of knowledge translation products (youth stories) with youth, service providers, and policy makers.

ETHICS AND DISSEMINATION

Ethical approval was received from the University of British Columbia's Research Ethics Board (H21-01091). Full open-access publication of the work will be sought in an international peer-reviewed journal. Findings will be disseminated to youth and service providers through social media, newsletters, and communities of practice, and to policy makers through invited evidence briefs and face-to-face presentations.

What skills do New Zealand clinicians have to provide first trimester abortion in primary care and are they willing?

OBJECTIVE

To determine the skills and intentions of health practitioners in New Zealand to provide first trimester abortion care.New Zealand achieved abortion law reform in 2020, changing how abortion could be delivered and experienced by pregnant people. However, little has changed in the way abortion care is provided.

STUDY DESIGN

This survey, which was deployed to a range of health practitioners via regulatory bodies and professional groups, used an online free text and tick box survey. Questions included demographics, scope of practice, abortion care experience, philosophical perspective on abortion, and skills transferable to abortion care. Data was analysed using descriptive statistics and deductive and inductive thematic analysis.

RESULTS

128 respondents included doctors, nurses, midwives, counsellors, and social workers from a range of practice settings, the majority from primary health (51%). Most respondents indicated competency or proficiency in clinical skills relevant to provision of early medical abortion. However, practitioners were more likely to indicate "I do not have this skill" or "support required" for: calculating gestational age by bimanual examination (42%), LARC (implant and IUC) insertion (36%), undertake a pregnancy related consultation using tikanga best practice guidelines (19%).Analysis of qualitative data showed three main themes; (1) support for abortion access and for abortion provision in primary care (2) levels of intention to provide abortion (3) critical components for an action plan for abortion in primary care.

CONCLUSION

Abortion care in the community has support from health practitioners. They identified needs including development of clinical skills, funding, and wider sector support.

Évaluation de l'information transmise sur l'avortement médicamenteux dans les cliniques d'avortement du Québec en 2021 - Partie 2

OBJECTIVE

Communication of information is a key component of quality family planning services. It allows for an informed choice between surgical and medication abortion.

METHODS

Québec abortion clinics were contacted by 2 mystery client clinical profiles (PC) between October 8 and November 17, 2021. Data collection was done simultaneously by a data collector. The unit of analysis was the PC. Descriptive analyses and statistical tests were performed, as well as a qualitative analysis of the collected comments.

RESULTS

Of the 17 information topics deemed necessary for an informed choice, 35% were obtained spontaneously. These included what tests to perform (78%), professionals to meet before the procedure (77%), gestational age limit (64%), side effects (49%) (especially alarming ones), and the number of visits required (42%). On a score of 12, the average information quality score was 7.2 (standard deviation [SD] 2.7). A score of less than 7/12 was obtained by 41% of PCs. A high information quality score was associated with a perceived friendlier attitude of the person responding to the call, and the unprompted transmission of more information. For 51/78 PCs, abortifacient medications were served at the clinic, and for 13 of them, the first medication had to be taken in front of the physician.

CONCLUSION

The information received when calling Québec abortion clinics for an appointment for abortion was often insufficient and made it difficult to make an informed choice between the 2 methods of abortion. This may explain the low proportion of medication abortion in Québec.

Barriers and enablers to nurse practitioner implementation of medication abortion in Canada: A qualitative study

In this study we explored nurse practitioner-provided medication abortion in Canada and identified barriers and enablers to uptake and implementation. Between 2020-2021, we conducted 43 semi-structured interviews with 20 healthcare stakeholders and 23 nurse practitioners who both provided and did not provide medication abortion. Data were analyzed using interpretive description. We identified five overarching themes: 1) Access and use of ultrasound for gestational dating; 2) Advertising and anonymity of services; 3) Abortion as specialized or primary care; 4) Location and proximity to services; and 5) Education, mentorship, and peer support. Under certain conditions, ultrasound is not required for medication abortion, supporting nurse practitioner provision in the absence of access to this technology. Nurse practitioners felt a conflict between wanting to advertise their abortion services while also protecting their anonymity and that of their patients. Some nurse practitioners perceived medication abortion to be a low-resource, easy-to-provide service, while some not providing medication abortion continued to refer patients to specialized clinics. Some participants in rural areas felt unable to provide this service because they were too far from emergency services in the event of complications. Most nurse practitioners did not have any training in abortion care during their education and desired the support of a mentor experienced in abortion provision. Addressing factors that influence nurse practitioner provision of medication abortion will help to broaden access. Nurse practitioners are well-suited to provide medication abortion care but face multiple ongoing barriers to provision. We recommend the integration of medication abortion training into nurse practitioner education. Further, widespread communication from nursing organizations could inform nurse practitioners that medication abortion is within their scope of practice and facilitate public outreach campaigns to inform the public that this service exists and can be provided by nurse practitioners.

Increasing the availability of long-acting reversible contraception and medical abortion in primary care: the Australian Contraception and Abortion Primary Care Practitioner Support Network (AusCAPPS) cohort study protocol

INTRODUCTION

Although primary care practitioners are the main providers of long-acting reversible contraception (LARC) and early medical abortion (EMA) in Australia, few provide these services. A professional community of practice (CoP) has the potential to improve LARC and EMA provision through evidence-based guidance, expert support and peer-to-peer engagement.The primary objective is to establish, implement and evaluate an innovative, multidisciplinary online CoP (AusCAPPS Network) to increase LARC and EMA services in Australian primary care. Secondary objectives are to (1) increase the number of general practitioners (GPs) and pharmacists certified to provide or dispense EMA, respectively, (2) increase LARC and EMA prescription rates and, (3) improve primary care practitioners' knowledge, attitudes and provision of LARC and EMA.

METHODS AND ANALYSIS

A stakeholder knowledge exchange workshop (KEW) will be conducted to inform the AusCAPPS Network design. Once live, we aim to reach 3000 GPs, practice nurses and community pharmacists members. Changes in the number of GPs and pharmacists certified to provide or dispense EMA, respectively, and changes in the number of LARCs and EMAs prescribed will be gleaned through health service data. Changes in the knowledge attitudes and practices will be gleaned through an online survey with 500 individuals from each professional group at baseline and 12 months after members have joined AusCAPPs; and experiences of the AusCAPPS Network will be evaluated using interviews with the project team plus a convenience sample of 20 intervention participants from each professional group. The project is underpinned by the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, and a realist framework will inform analysis.

ETHICS AND DISSEMINATION

Ethical approval was received from the Monash University Human Research Ethics Committee (No. 28002). Dissemination will occur through KEWs, presentations, publications and domestic and international networks.

TRIAL REGISTRATION NUMBER

ACTRN12622000655741.

Advancing Reproductive Health through Policy-Engaged Research in Abortion Care

Mifepristone medication abortion was first approved in China and France more than 30 years ago and is now used in more than 60 countries worldwide. It is a highly safe and effective method that has the potential to increase population access to abortion in early pregnancy, closer to home. In both Canada and the United States, the initial regulations for distribution, prescribing, and dispensing of mifepristone were highly restricted. However, in Canada, where mifepristone was made available in 2017, most restrictions on the medication were removed in the first year of its availability. The Canadian regulation of mifepristone as a normal prescription makes access possible in community primary care through a physician or nurse practitioner prescription, which any pharmacist can dispense. In this approach, people decide when and where to take their medication. We explore how policy-maker-engaged research advanced reproductive health policy and facilitated this rapid change in Canada. We discuss the implications of these policy advances for self-management of abortion and demonstrate how in Canada patients "self-manage" components of the abortion process within a supportive health care system.

Pharmacist direct dispensing of mifepristone for medication abortion in Canada: a survey of community pharmacists

INTRODUCTION

Pharmacists were acknowledged as the most appropriate healthcare professional to dispense mifepristone for medication abortion shortly after the prescription therapy became available in January 2017 in Canada.

OBJECTIVE

We aimed to identify the facilitators and barriers for successful initiation and ongoing dispensing of mifepristone among community pharmacists across Canada.

STUDY DESIGN

We surveyed community pharmacists from urban/rural practice settings across Canada by recruiting from January 2017 to January 2019 through pharmacist organisations, professional networks, at mifepristone training courses and at professional conferences. The Diffusion of Innovations theory informed the study design, thematic analysis and interpretation of findings. We summarised categorical data using counts and proportions, χ² tests, Wilcoxon rank-sum and proportional odds logistic regression.

RESULTS

Of the 433 responses from dispensing community pharmacists across 10/13 Canadian provinces and territories, 93.1% indicated they were willing and ready to dispense mifepristone. Key facilitators were access to a private consultation setting (91.4%), the motivation to increase accessibility for patients (87.5%) and to reduce pressure on the healthcare system (75.3%). The cost of the mifepristone/misoprostol product was an initial barrier, subsequently resolved by universal government subsidy. A few pharmacists mentioned liability, lack of prescribers or inadequate stock as barriers.

CONCLUSIONS

Pharmacist respondents from across Canada reported being able and willing to dispense mifepristone and rarely mentioned barriers to stocking/dispensing the medication in the community pharmacy setting. The removal of initial regulatory obstacles to directly dispense mifepristone to patients facilitated the provision of medication abortion in the primary care setting.

Telemedicine for First-Trimester Medical Abortion in Canada: Results of a 2019 Survey

Introduction: Telemedicine has the potential to improve abortion access disparities in Canada. We aimed to explore the provision of telemedicine for first-trimester medical abortion and related barriers in 2019. Methods: We conducted a national, cross-sectional, anonymized, web-based survey of clinicians who provided abortion care in 2019 in Canada. We distributed our survey through professional health organizations to maximize identification of possible eligible respondents and used a modified Dillman technique to foster responses. Questions elicited provider demographics, clinical characteristics, including telemedicine first-trimester medical abortion and perceived related barriers. Descriptive statistics were analyzed using R software. Results: Among 465 respondents, 388 reported providing first-trimester medical abortion across Canada; 44.0% reported experience using telemedicine for some components of care: 49.3% of primary care clinicians and 28.7% of specialists. Telemedicine was used for initial consultation (86.0%), prescription (82.2%), or follow-up (92.2%). The median percentage of telemedicine providers' patients who underwent a dating ultrasound was 90.0. The majority usually followed up with patients through quantitative human chorionic gonadotropin (hCG) (84.2%). Seventy-eight percent perceived barriers to telemedicine; the most common being inability to confirm gestational age with ultrasound (43.0%), and lack of provincial telemedicine abortion fee code to pay practitioners (30.2%), timely access to serum hCG testing (24.6%), and nearby emergency services (23.3%). Discussion: In 2019, fewer than half of respondents reported providing some aspects of first-trimester medical abortion through telemedicine and the majority perceived barriers. Our results can inform knowledge translation activities to reduce barriers and increase telemedicine abortion care in Canada.

Abortion services and providers in Canada in 2019: results of a national survey

BACKGROUND

Since 2016, abortion care has undergone several important changes, particularly related to the provision of medical abortion using mifepristone. We aimed to document characteristics of the abortion care workforce in Canada after the update of clinical practice guidelines of mifepristone use for medical abortion.

METHODS

We conducted a national, web-based, anonymized, bilingual (English/French) survey. We collected demographics and clinical care characteristics of physicians and nurse practitioners who provided abortion care in 2019. Between July and December 2020, we distributed the survey through professional organizations, including The College of Family Physicians of Canada and The Society of Obstetricians and Gynaecologists of Canada. We present descriptive statistics.

RESULTS

Overall, 465 respondents representing all 10 provinces and 3 territories in Canada completed the survey. Of these, 388 (83.4%), including 30 nurse practitioners, provided first-trimester medical abortion, of which 350 (99.4%) used mifepristone. Two hundred and nineteen (47.1%) respondents provided first-trimester surgical abortion, 109 (23.4%) provided second-trimester surgical abortion and 115 (24.7%) provided second- or third-trimester medical abortion. Half of respondents reported fewer than 5 years of experience with any abortion care. Respondents reported providing a total of 48 509 abortions in 2019, including 32 345 (66.7%) first-trimester surgical abortions and 13 429 (27.7%) first-trimester medical abortions. In Quebec, only 1918 (12.5%) of reported abortions were first-trimester medical abortions. Primary care providers provided 34 540 (71.2%) of the total abortions. First-trimester medical abortions represented 44.4% (n = 2334) of all abortions in rural areas, as opposed to 25.6% (n = 11 067) in urban areas.

INTERPRETATION

The increased availability of medical abortion facilitates abortion access, especially in primary care and rural settings, and where surgical abortion is not available. Rejuvenation of the workforce is a critical contributor to equitable access to abortion services.

"I just was really scared, because it's already such an uncertain time": Exploring women's abortion experiences during the COVID-19 pandemic in Canada

OBJECTIVE

Travel restrictions, physical distancing and quarantine requirements, lockdowns, and stay-at-home orders due to COVID-19 have impacted abortion services across Canada. We aimed to explore the decision-making and care experiences of those who obtained abortion services during the COVID-19 pandemic and understand recent abortion patients' perspectives on demedicalized models of medication abortion service delivery.

STUDY DESIGN

We conducted 23 semi-structured, in-depth interviews with women across Canada who obtained abortion care after March 15, 2020. We audio-recorded and transcribed the telephone/Skype/Zoom interviews and managed our data with ATLAS.ti. We analyzed the English-language interviews for content and themes using inductive and deductive techniques.

RESULTS

The COVID-19 pandemic, and the associated economic and social support uncertainties, factored into many of our participants' decisions to obtain an abortion. Participants expressed relief and gratitude for being able to secure abortion care during the pandemic. Although women in our study reflected positively on their abortion care experiences, many felt that service delivery changes initiated because of the public health emergency exacerbated pre-COVID-19 barriers to care and contributed to feelings of loneliness and isolation. Our participants expressed considerable enthusiasm for demedicalized models of medication abortion care, including telemedicine services and behind-the-counter availability of mifepristone/misoprostol.

CONCLUSIONS

For our participants, abortion care constituted an essential health service. Our findings demonstrate the importance of continuing to provide access to safe, effective, and timely abortion care during public health emergencies. Exploring additional models of demedicalized medication abortion service delivery to address persistent access barriers in Canada is warranted.

IMPLICATIONS

Policymakers and clinicians should consider patient experiences as well as clinical evidence when considering regulatory changes to facilitate access to abortion care during public health emergencies. Identifying a multitude of ways to offer a full range of abortion services, including demedicalized models of medication abortion care, has the potential to meet significant needs in the COVID-19 era and beyond. The COVID pandemic highlights the need for demedicalized models, not only for the sake of those seeking abortion care but also to ease the burden on medical professionals during public health emergencies.

A Virtual Community of Practice to Support Physician Uptake of a Novel Abortion Practice: Mixed Methods Case Study

Background

Virtual communities of practice (VCoPs) have been used to support innovation and quality in clinical care. The drug mifepristone was introduced in Canada in 2017 for medical abortion. We created a VCoP to support implementation of mifepristone abortion practice across Canada.

Objective

The aim of this study was to describe the development and use of the Canadian Abortion Providers Support-Communauté de pratique canadienne sur l’avortement (CAPS-CPCA) VCoP and explore physicians’ experience with CAPS-CPCA and their views on its value in supporting implementation.

Methods

This was a mixed methods intrinsic case study of Canadian health care providers’ use and physicians’ perceptions of the CAPS-CPCA VCoP during the first 2 years of a novel practice. We sampled both physicians who joined the CAPS-CPCA VCoP and those who were interested in providing the novel practice but did not join the VCoP. We designed the VCoP features to address known and discovered barriers to implementation of medication abortion in primary care. Our secure web-based platform allowed asynchronous access to information, practice resources, clinical support, discussion forums, and email notices. We collected data from the platform and through surveys of physician members as well as interviews with physician members and nonmembers. We analyzed descriptive statistics for website metrics, physicians’ characteristics and practices, and their use of the VCoP. We used qualitative methods to explore the physicians’ experiences and perceptions of the VCoP.

Results

From January 1, 2017, to June 30, 2019, a total of 430 physicians representing all provinces and territories in Canada joined the VCoP and 222 (51.6%) completed a baseline survey. Of these 222 respondents, 156 (70.3%) were family physicians, 170 (80.2%) were women, and 78 (35.1%) had no prior abortion experience. In a survey conducted 12 months after baseline, 77.9% (120/154) of the respondents stated that they had provided mifepristone abortion and 33.9% (43/127) said the VCoP had been important or very important. Logging in to the site was burdensome for some, but members valued downloadable resources such as patient information sheets, consent forms, and clinical checklists. They found email announcements helpful for keeping up to date with changing regulations. Few asked clinical questions to the VCoP experts, but physicians felt that this feature was important for isolated or rural providers. Information collected through member polls about health system barriers to implementation was used in the project’s knowledge translation activities with policy makers to mitigate these barriers.

Conclusions

A VCoP developed to address known and discovered barriers to uptake of a novel medication abortion method engaged physicians from across Canada and supported some, including those with no prior abortion experience, to implement this practice.

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2018-028443

A more accurate approach to define abortion cohorts using linked administrative data: an application to Ontario, Canada

Background

The shifting landscape of abortion care from a hospital-only to a distributed service including primary care has implications for how to identify abortion cohorts for research and surveillance. The objectives of this study were to 1) create an improved approach to define abortion cohorts using linked administrative data sets and 2) evaluate the performance of this approach for abortion surveillance compared with standard approaches.

Methods

We applied four principles to identify induced abortion cohorts when some services are delivered beyond hospital settings; 1) exclude early pregnancy losses and postpartum procedures; 2) use multiple data sources; 3) define episodes of care; 4) apply a hierarchical algorithm to determine abortion date to a population-based cohort of all abortion events in Ontario (Canada) from January 1, 2018-March 15, 2020. We calculated risk differences (RD, with 95% confidence intervals) comparing the proportion of medication vs. surgical, first vs. second trimester, and complication incidence applying these principles vs. standard approaches.

Results

Hospital-only data (versus multiple data sources) underestimated the frequency of medication abortion (16.1% vs. 31.4%; RD -15.3% [-14.3, -16.3]) and first-trimester abortion (82.1% vs. 94.5%; RD -12.8 [-11.4, 13.4]) and overestimated incidence of abortion complication (2.9% vs. 0.69%; RD 2.2% [1.8, 2.7]). An unlinked (versus linked) approach underestimated the frequency of abortion complications (0.19% vs 0.69%, -RD 0.50% [-0.44--0.56]). Including (versus excluding) abortions following early pregnancy loss or delivery events increased the estimated incidence of abortion complications (1.29% vs. 0.69%, RD 0.60% [0.51-0.69].

Conclusion

New methods are required to accurately identify abortion cohorts for surveillance or research. When legal or regulatory approaches to medication abortion evolve to enable abortion in primary care or office-based settings, hospital-based surveillance systems will become incomplete and biased; to continue valid and complete abortion surveillance, methods must be adjusted to ensure complete capture of procedures across all settings.

Provision of First-trimester Medication Abortion in 2019: Results from the Canadian Abortion Provider Survey

OBJECTIVE

To explore the Canadian first-trimester medication abortion (MA) workforce and their clinical care following the introduction of mifepristone in 2017, updated national clinical practice guidelines and government approval of nurse practitioners (NPs) as first-trimester MA providers.

STUDY DESIGN

We conducted a national, self-administered, cross-sectional survey of abortion providers in 2019. Our bilingual (French/English) survey collected information on demographics, abortion number, and clinical care characteristics. The true number of abortion providers is unknown thus we cannot calculate a survey response rate. To maximize identification of possibly eligible respondents, we widely distributed the survey between July and December 2020 through health professional organizations, using a modified Dillman technique. We used descriptive statistics to characterize the workforce and clinical practices.

RESULTS

Four-hundred-sixty-five clinicians responded, of whom 388 provided first-trimester MA. Physicians (n=358) and NPs (n=30) reported providing 13,429 first-trimester MAs in 2019 which represented 27.7% of all reported abortions in the survey. The majority of first-trimester MA respondents were primary care physicians (n=245, 63.1%), had less than five years' experience (n=223, 61.3%) and practiced outside of hospitals (n=228, 66.5%). Forty-three percent (n=165) practiced rurally, and 44.0% (n=136) used telemedicine for some abortion care. Ninety-nine percent (n=350) used a guideline-recommended mifepristone/misoprostol regimen while 14.5% (n=51) sometimes used methotrexate. Patients most commonly received mifepristone/misoprostol at community pharmacies (median 100.0%; interquartile range 50.0-100.0%).

CONCLUSION

Our results suggest that there are many new first-trimester MA providers, an increase in the proportion of MAs since 2012 and a shift to primary care settings. Respondents widely adopted mifepristone.

IMPLICATIONS STATEMENT

Our results highlight that, following mifepristone introduction, many new primary care practitioners started providing first-trimester medication abortion throughout Canada, including the first non-physicians. This increased access to abortion particularly in rural and underserved communities. These results could inform future directions in policy, guidelines, and abortion access initiatives.

Second- and Third-Trimester Medical Abortion Providers and Services in 2019: Results from the Canadian Abortion Provider Survey

OBJECTIVES

Mifepristone became available in Canada in 2017. Updated national guidelines recommend its off-label use for second/third-trimester medical abortion (STMA/TTMA) by labour induction. The objective of this study was to explore STMA/TTMA provision in Canada and the role of mifepristone.

METHODS

We conducted a national, cross-sectional, web-based, self-administered, anonymized survey, available in English and French. The survey was distributed through health professional organizations and recruited physicians who provided abortion care in 2019. We used a modified Dillman technique to maximize participation. The survey included sections on workforce and clinical care, including mifepristone use. We used R statistical software to produce descriptive statistics.

RESULTS

Four hundred sixty-five clinicians responded to the survey, of whom 112 reported providing STMA and 63, TTMA, for a total of 115 respondents providing at least 1 of the 2 services. Two-thirds of respondents were general obstetrician-gynaecologists or family physicians and the remainder were maternal-fetal medicine subspecialists. The majority (64.7%) provided STMA/TTMA in an academic hospital, and 59.4% performed fewer than 5 STMAs (maximum 50) and 76.1%, fewer than 5 TTMA (maximum 15) in 2019. Fifty-nine percent of respondents reported having used mifepristone/misoprostol for STMA. Among mifepristone users, 48.6% used it for TTMA. Most required an indication beyond patient request to provide STMA/TTMA (82.1%/95.5%).

CONCLUSIONS

STMA/TTMA care is provided by multiple (sub-) specialties, and mifepristone has not yet been universally implemented. Our results will inform knowledge translation activities aimed at facilitating collaboration between STMA/TTMA providers and health policy and service delivery leaders and will further increase mifepristone use for STMA/TTMA in Canada.

Integrating mifepristone into primary care in Canada's capital: A multi-methods exploration of the Medical Abortion Access Project

OBJECTIVES

Following the 2017 introduction of mifepristone in Canada and both ensuing regulatory changes and increased demand for medication abortion care, Planned Parenthood Ottawa created the Medical Abortion Access Project (MAAP). This study aimed to document outcomes, identify facilitators and barriers, and distill learnings from an initiative that sought to recruit and support primary care clinicians in providing mifepristone/misoprostol in Canada's capital.

METHODS

We employed a multi-methods evaluation strategy that included reviewing MAAP-related documents, evaluating the project log, and conducting in-depth interviews with clinicians at five sites. In the final analytic phase, we integrated the findings from the different evaluation components.

RESULTS

From May 2017 through July 2018, the MAAP helped 14 primary care facilities in Ottawa become medication abortion providers; nine began providing mifepristone/misoprostol to existing patients and five began offering mifepristone/misoprostol to the public. The program recruited four new pharmacies to stock the combination package and trained two sonography clinics in abortion-related protocols. Program participants identified patient demand as a key driver of medication abortion provision but required information and logistical support from the MAAP to operationalize service delivery. New abortion providers reflected positively on the community of practice that the MAAP created, which enabled them to offer and receive technical and emotional support from colleagues across the city.

CONCLUSIONS

A number of primary care clinicians in Ottawa were able to successfully integrate medication abortion care into their practices with MAAP support. Future research should explore whether this type of community-based intervention can be replicated in other settings.

IMPLICATIONS

Evidence-based regulation of mifepristone by health authorities is a critical step to increasing access to medication abortion care. However, deregulation alone was insufficient to integrate medication abortion services into primary care in Ottawa. Community-based programs like the MAAP can help providers make sense of shifting regulations and practice guidelines, overcome logistical barriers, and ultimately increase access to this medically necessary service. Establishing and facilitating communities of practice is especially important for new primary care providers.

Abortion Safety and Use with Normally Prescribed Mifepristone in Canada

BACKGROUND

In the United States, mifepristone is available for medical abortion (for use with misoprostol) only with Risk Evaluation and Mitigation Strategy (REMS) restrictions, despite an absence of evidence to support such restrictions. Mifepristone has been available in Canada with a normal prescription since November 2017.

METHODS

Using population-based administrative data from Ontario, Canada, we examined abortion use, safety, and effectiveness using an interrupted time-series analysis comparing trends in incidence before mifepristone was available (January 2012 through December 2016) with trends after its availability without restrictions (November 7, 2017, through March 15, 2020).

RESULTS

A total of 195,183 abortions were performed before mifepristone was available and 84,032 after its availability without restrictions. After the availability of mifepristone with a normal prescription, the abortion rate continued to decline, although more slowly than was expected on the basis of trends before mifepristone had been available (adjusted risk difference in time-series analysis, 1.2 per 1000 female residents between 15 and 49 years of age; 95% confidence interval [CI], 1.1 to 1.4), whereas the percentage of abortions provided as medical procedures increased from 2.2% to 31.4% (adjusted risk difference, 28.8 percentage points; 95% CI, 28.0 to 29.7). There were no material changes between the period before mifepristone was available and the nonrestricted period in the incidence of severe adverse events (0.03% vs. 0.04%; adjusted risk difference, 0.01 percentage points; 95% CI, -0.06 to 0.03), complications (0.74% vs. 0.69%; adjusted risk difference, 0.06 percentage points; 95% CI, -0.07 to 0.18), or ectopic pregnancy detected after abortion (0.15% vs. 0.22%; adjusted risk difference, -0.03 percentage points; 95% CI, -0.19 to 0.09). There was a small increase in ongoing intrauterine pregnancy continuing to delivery (adjusted risk difference, 0.08 percentage points; 95% CI, 0.04 to 0.10).

CONCLUSIONS

After mifepristone became available as a normal prescription, the abortion rate remained relatively stable, the proportion of abortions provided by medication increased rapidly, and adverse events and complications remained stable, as compared with the period when mifepristone was unavailable. (Funded by the Canadian Institutes of Health Research and the Women's Health Research Institute.).

The perspective of Canadian health care professionals on abortion service during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic and pandemic response created novel challenges for abortion services. Canada was uniquely positioned to transition to telemedicine because internationally common restrictions on abortion medication were removed before the pandemic.

OBJECTIVE

We sought to characterize the experiences of abortion health care professionals in Canada during the COVID-19 pandemic and the impact of the pandemic response on abortion services.

METHODS

We conducted a sequential mixed methods study between July 2020 and January 2021. We invited physicians, nurse practitioners and administrators to participate in a cross-sectional survey containing an open-ended question about the impact of the pandemic response on abortion care. We employed an inductive codebook thematic analysis, which informed the development of a second, primarily quantitative survey.

RESULTS

Our initial survey had 307 respondents and our second had 78. Fifty-three percent were family physicians. Our first survey found respondents considered abortion access essential. We identified three key topicss: access to abortion care was often maintained despite pandemic-related challenges (e.g. difficulty obtaining tests, additional costs); change of practice to low-touch medication abortion care and provider perceptions of patient experience, including shifting demand, telemedicine acceptability and increased rural access. The second survey indicated uptake of telemedicine medication abortion among 89% of participants except in Quebec, where regulations meant procedures were nearly exclusively surgical. Restrictions did not delay care according to 76% of participants.

CONCLUSIONS

Canadian health care professionals report their facilities deemed abortion an essential service. Provinces and territories, except Quebec, described a robust pandemic transition to telemedicine to ensure access to services.

PODCAST

An accompanying podcast is available in the Supplementary Data, in which the authors Dr Madeleine Ennis and Kate Wahl discuss their research on how family planning care and access to abortion services have changed during the COVID-19 pandemic.

Pharmacist dispensing of the abortion pill in Canada: Diffusion of Innovation meets integrated knowledge translation

BACKGROUND

Since Canadian drug regulatory approval of mifepristone for medical abortion in 2015 and its market availability in January 2017, the role of pharmacists in abortion provision has changed rapidly. We sought to identify the factors that influenced the initiation and provision of medical abortion from the perspectives of Canadian pharmacists, bridging two frameworks - Diffusion of Innovation in Health Service Organizations and integrated knowledge translation.

METHODS

We conducted one-on-one semi-structured interviews with pharmacists residing in Canada who intended to stock and dispense mifepristone within the first year of availability. Our data collection, analysis, and interpretation were guided by reflexive thematic analysis and supported by an integrated knowledge translation partnership with pharmacy stakeholders.

RESULTS

We completed interviews with 24 participants from across Canada: 33% had stocked and 21% had dispensed mifepristone. We found that pharmacists were willing and able to integrate medical abortion care into their practice and that those who had initiated practice were satisfied with their dispensing experience. Our analysis indicated that several key Diffusion of Innovation constructs impacted the uptake of mifepristone, including: innovation (relative advantage, complexity and compatibility, technical support), system readiness (innovation-system fit, dedicated time, resources), diffusion and dissemination (expert opinion, boundary spanners, champions, social networks, peer opinions), implementation (external collaboration), and linkage. Participants' experiences suggest that integrated knowledge translation facilitated evidence-based changes to mifepristone dispensing restrictions, and communication of those changes to front line pharmacists.

CONCLUSIONS

We illustrate how Diffusion of Innovation and integrated knowledge translation may work together as complimentary frameworks for implementation science research. Unlike in the USA, UK, and other highly regulated settings globally, pharmacists in Canada are permitted to dispense mifepristone for medical abortion. We contribute to literature that shows that mifepristone dispensed outside of hospitals, clinics, and medical offices is safe and acceptable to both patients and prescribers. This finding is of particular importance to the current COVID-19 pandemic response and calls for continued and equitable access to abortion care in primary practice.