RSS-Feed abonnieren
DOI: 10.1055/s-0042-1760213
Advancing Reproductive Health through Policy-Engaged Research in Abortion Care
Funding Canadian Institutes of Health Research (CPP-329455-107837, 2014-2024); Canadian Institutes of Health Research (PHE 148161); Michael Smith Foundation for Health Research 16743 (SBM), 18270 (SBM), 2012-5139 HSR (WVN).![](https://www.thieme-connect.de/media/srm/20220506/lookinside/thumbnails/10-1055-s-0042-1760213_2200005-1.jpg)
Abstract
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.
Publikationsverlauf
Artikel online veröffentlicht:
06. Februar 2023
© 2023. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
-
References
- 1 United Nations Population Fund. State of the World Population: Seeing the Unseen - The Case for Action in the Neglected Crisis of Unintended Pregnancy. New York, NY: United Nations Population Fund (UNFPA); 2022
- 2 United Nations Committee on Civil and Political Rights. General Comment No. 36 (2018) on Article 6 of the International Covenant on Civil and Political Rights, on the Right to Life. United Nations; 2018
- 3 Gynuity Health Projects. . Map of the years in which mifepristone was approved by country [Internet]. 2017. Accessed December 5, 2022 at: http://gynuity.org/downloads/mapmife__en.pdf
- 4 World Health Organization. . WHO Model List of Essential Medicine [Internet]. March 2017. Report No.: 20th edition. Accessed December 5, 2022 at: http://www.who.int/medicines/publications/essentialmedicines/en/
- 5 Kulier R, Gülmezoglu AM, Hofmeyr GJ, Cheng LN, Campana A. Medical methods for first trimester abortion. Cochrane Database Syst Rev 2004; (02) CD002855
- 6 Kapp N, Whyte P, Tang J, Jackson E, Brahmi D. A review of evidence for safe abortion care. Contraception 2013; 88 (03) 350-363
- 7 Raymond EG, Shannon C, Weaver MA, Winikoff B. First-trimester medical abortion with mifepristone 200 mg and misoprostol: a systematic review. Contraception 2013; 87 (01) 26-37
- 8 Barnard S, Kim C, Park MH, Ngo TD. Doctors or mid-level providers for abortion. Cochrane Database Syst Rev 2015; 2015 (07) CD011242
- 9 Cleland K, Smith N. Aligning mifepristone regulation with evidence: driving policy change using 15 years of excellent safety data. Contraception 2015; 92 (03) 179-181
- 10 Abbas D, Chong E, Raymond EG. Outpatient medical abortion is safe and effective through 70 days gestation. Contraception 2015; 92 (03) 197-199
- 11 Chen MJ, Creinin MD. Mifepristone with buccal misoprostol for medical abortion: a systematic review. Obstet Gynecol 2015; 126 (01) 12-21
- 12 Finer L, Fine JB. Abortion law around the world: progress and pushback. Am J Public Health 2013; 103 (04) 585-589
- 13 Raymond EG, Blanchard K, Blumenthal PD. et al; Mifeprex REMS Study Group. Sixteen years of overregulation: time to unburden Mifeprex. N Engl J Med 2017; 376 (08) 790-794
- 14 Blaze Baum K. . Health Canada eases restrictions on abortion pill Mifegymiso. The Globe and Mail [Internet]. November 7, 2017; Accessed December 5, 2022 at: https://www.theglobeandmail.com/news/national/health-canada-eases-restrictions-on-abortion-pill-mifegymiso/article36860275/
- 15 Health Canada. . MIFEGYMISO (mifepristone and misoprostol tablets) - Canadian Distribution and Administration Program [Internet]. Government of Canada. 2017 [cited May 4, 2018]. Accessed December 5, 2022 at: http://healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2017/63330a-eng.php
- 16 Guilbert E, Costescu D, Wagner MS. et al. Canadian Protocol for the Provision of Medical Abortion Via Telemedicine [Internet]. April 2020. Accessed December 5, 2022 at: https://sogc.org/common/Uploaded%20files/CANADIAN%20PROTOCOL%20FOR%20THE%20PROVISION%20OF%20MA%20VIA%20TELEMEDICINE-%20FINAL2.pdf
- 17 Costescu D, Guilbert E, Wagner MS. et al. Induced Abortion: Updated Guidance during Pandemics and Periods of Social Disruption [Internet]. Society of Obstetricians and Gynaecologists of Canada; 2020. Accessed December 5, 2022 at: https://sogc.org/common/Uploaded%20files/Induced%20Abortion%20-%20Pandemic%20Guidance%20-%20FINAL.PDF
- 18 Health Canada. MIFEGYMISO (mifepristone and misoprostol tablets) - Updates to Product Monograph and Risk Management Plan [Internet]. Healthy Canadians - Government of Canada. 2017 [cited November 17, 2017]. Accessed December 5, 2022 at: http://healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2017/65030a-eng.php
- 19 Stevenson T. Self-Managed Abortion in Canada: A Status Report. Toronto, Ontario; 2022
- 20 World Health Organization. Abortion care guideline [Internet]. Geneva: World Health Organization; 2022. Accessed December 5, 2022 at: https://www.who.int/publications-detail-redirect/9789240039483
- 21 Guttmacher Institute. Counselling and Waiting Periods for Abortion [Internet]. 2016. Accessed December 5, 2022 at: https://www.guttmacher.org/state-policy/explore/counseling-and-waitingperiods-abortion
- 22 Acosta L. Abortion Legislation in Europe [Internet]. Library of Congress. 2015 [cited November 20, 2017]. Accessed December 5, 2022 at: https://www.loc.gov/law/help/abortion-legislation/europe.php
- 23 Human Reproduction Program. . The Global Abortion Policies Database [Internet]. World Health Organization. 2017. Accessed December 5, 2022 at: https://abortion-policies.srhr.org
- 24 Marie Stopes Australia. . Nurse-led medical termination of pregnancy in Australia: legislative scan. 2nd Edition [Internet]. Melbourne: Marie Stopes Australia; 2022. Accessed December 5, 2022 at: https://www.mariestopes.org.au/wp-content/uploads/Nurse-led-MToP-in-Australia-legislative-scan.pdf
- 25 U.S. Food and Drug Administration. . Questions and Answers on Mifeprex [Internet]. U.S. Department of Health and Human Services.; 2021. Accessed December 5, 2022 at: https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/questions-and-answers-mifeprex
- 26 Jones RK, Witwer E, Jerman J. Abortion Incidence and Service Availability in the United States, 2017 [Internet]. Guttmacher Institute. 2019. Accessed December 5, 2022 at: https://www.guttmacher.org/report/abortion-incidence-service-availability-us-2017
- 27 Guttmacher Institute. . Medication Abortion Now Accounts for More Than Half of All US Abortions [Internet]. February 2022 [cited May 31, 2022]. Accessed December 5, 2022 at: https://www.guttmacher.org/article/2022/02/medication-abortion-now-accounts-more-half-all-us-abortions
- 28 Aiken ARA, Starling JE, Gomperts R. Factors associated with use of an online telemedicine service to access self-managed medical abortion in the US. JAMA Netw Open 2021; 4 (05) e2111852
- 29 Upadhyay UD, Koenig LR, Meckstroth KR. Safety and efficacy of telehealth medication abortions in the US during the COVID-19 pandemic. JAMA Netw Open 2021; 4 (08) e2122320
- 30 Chong E, Shochet T, Raymond E. et al. Expansion of a direct-to-patient telemedicine abortion service in the United States and experience during the COVID-19 pandemic. Contraception 2021; 104 (01) 43-48
- 31 Munro S, Guilbert E, Wagner MS. et al. Perspectives among Canadian physicians on factors influencing implementation of mifepristone medical abortion: a national qualitative study. Ann Fam Med 2020; 18 (05) 413-421
- 32 Schummers L, Darling EK, Dunn S. et al. Abortion safety and use with normally prescribed mifepristone in Canada. N Engl J Med 2022; 386 (01) 57-67
- 33 Norman WV, Darling E, Dunn S, Law M, Kaczorowski J, Schummers L. Mifepristone's effect on the abortion workforce and rural services in Ontario. J Obstet Gynaecol Can 2022; 44 (05) 622
- 34 Munro S, Wahl K, Soon JA. et al. Pharmacist dispensing of the abortion pill in Canada: diffusion of innovation meets integrated knowledge translation. Implement Sci 2021; 16 (01) 76
- 35 Soon JA, Levine M, Osmond BL, Ensom MHH, Fielding DW. Effects of making emergency contraception available without a physician's prescription: a population-based study. CMAJ 2005; 172 (07) 878-883
- 36 Soon JA, Whelan AM, Yuksel N, Rafie S. Enhancing access to contraception through pharmacist prescribing across Canada. Can Pharm J 2021; 154 (06) 356-362
- 37 Cameron ST, Glasier A, McDaid L. et al. Use of effective contraception following provision of the progestogen-only pill for women presenting to community pharmacies for emergency contraception (Bridge-It): a pragmatic cluster-randomised crossover trial. Lancet 2020; 396 (10262): 1585-1594
- 38 Norman WV, Soon JA. Requiring physicians to dispense mifepristone: an unnecessary limit on safety and access to medical abortion. CMAJ 2016; 188 (17-18): E429-E430
- 39 Canada Health Act. R.S.C. Sect. c. C-6. 1985
- 40 Leeson H. Constitutional jurisdiction over health and health care services in Canada. Gov Health Care Can Romanow Pap 2004; 3: 50-82
- 41 Kingdon JW. How do issues get on public policy agendas. In: Sociology and the Public Agenda. London: Sage; 1993: 40-50
- 42 Kingdon JW, Stano E. Agendas, Alternatives, and Public Policies. Little, Brown; Boston: 1984
- 43 Kaposy C. Improving abortion access in Canada. Health Care Anal 2010; 18 (01) 17-34
- 44 Norman WV, Guilbert ER, Okpaleke C. et al. Abortion services in Canada: results of a 2012 national survey. Can Fam Phys 2016; 62 (04) e209-e217
- 45 Statistics Canada. . Access to a regular medical doctor, 2014 [Internet]. Government of Canada. 2015. Accessed December 5, 2022 at: https://www.statcan.gc.ca/pub/82-625-x/2015001/article/14177-eng.htm
- 46 Sethna C, Doull M. Spatial disparities and travel to freestanding abortion clinics in Canada. Womens Stud Int Forum 2013; 38: 52-62
- 47 Dunn S, Cook R. Medical abortion in Canada: behind the times. CMAJ 2014; 186 (01) 13-14
- 48 Kirkey S. Home abortion pill about to hit market in Canada, but has already garnered criticism. National Post [Internet]. April 19, 2016. Accessed December 5, 2022 at: http://news.nationalpost.com/news/canada/0420-na-abortion
- 49 Citizen O. Editorial: What is Health Canada thinking on the abortion pill? Ottawa Citizen [Internet]. April 20, 2016; Accessed December 5, 2022 at: http://ottawacitizen.com/opinion/editorials/editorial-what-is-health-canada-thinking-on-the-abortion-pill
- 50 Britten L. ‘Abortion pill’ restrictions go too far, professor says. CBC News [Internet]. April 2016. Accessed December 5, 2022 at: http://www.cbc.ca/beta/news/canada/british-columbia/abortion-pill-restrictions-mifegymiso-1.3547582
- 51 Toronto Star. . Editorial: Ease restrictions on abortion pill. Toronto Star [Internet]. April 25, 2016; Accessed December 5, 2022 at: https://www.thestar.com/opinion/editorials/2016/04/24/ease-restrictions-on-abortion-pill-editorial.html
- 52 Muldoon M. The Abortion Debate in the United States and Canada: A Source book. New York: Routledge; 2021
- 53 Norman WV, Munro S, Brooks M. et al. Could implementation of mifepristone address Canada's urban-rural abortion access disparity: a mixed-methods implementation study protocol. BMJ Open 2019; 9 (04) e028443
- 54 Dineley B, Munro S, Norman WV. Leadership for success in transforming medical abortion policy in Canada. PLoS One 2020; 15 (01) e0227216
- 55 Grossman D, Goldstone P. Mifepristone by prescription: a dream in the United States but reality in Australia. Contraception 2015; 92 (03) 186-189
- 56 Baird B. Decriminalization and women's access to abortion in Australia. Health Hum Rights 2017; 19 (01) 197-208
- 57 Dawson A, Bateson D, Estoesta J, Sullivan E. Towards comprehensive early abortion service delivery in high income countries: insights for improving universal access to abortion in Australia. BMC Health Serv Res 2016; 16 (01) 612
- 58 College of Pharmacists of British Columbia. Frequently Asked Questions: Will pharmacies dispense mifepristone? [Internet]. College of Pharmacists of British Columbia. [cited June 3, 2022]. Accessed December 5, 2022 at: http://www.bcpharmacists.org/faq
- 59 Grant K. BC regulators plan to let pharmacists distribute abortion pills. The Globe and Mail [Internet]. October 17, 2016 [cited June 3, 2022]. Accessed December 5, 2022 at: https://www.theglobeandmail.com/news/national/bc-regulators-plan-to-let-pharmacists-distribute-abortion-pills/article32385496/
- 60 Mifegymiso [Internet]. College of Pharmacists of British Columbia. 2017 [cited 2017 Mar 9]. Accessed December 5, 2022 at: http://www.bcpharmacists.org/mifegymiso
- 61 Public Drug Programs. Frequently Asked Questions for Health Care Providers: Dispensing of Mifepristone/ misoprostol (Mifegymiso) and Claims Submission using the Health Network System [Internet]. Ministry of Health and Long-Term Care, Ontario; December 2017. Accessed December 5, 2022 at: https://www.health.gov.on.ca/en/pro/programs/drugs/opdp_eo/notices/fq_exec_office_20170803_1.pdf
- 62 College of Physicians and Surgeons of Nova Scotia. Revised Professional Standards Approved by Council & Retirement of Mifegymiso Prescribing Standard [Internet]. 2017 [cited June 3, 2022]. Accessed December 5, 2022 at: https://cpsns.ns.ca/revised-professional-standards-approved-by-council-retirement-of-mifegymiso-prescribing-standard/
- 63 Alberta College of Pharmacists. New guidelines for dispensing Mifegymiso® [Internet]. [cited June 3, 2022]. Accessed December 5, 2022 at: https://abpharmacy.ca/articles/new-guidelines-dispensing-mifegymiso?redirect
- 64 Oved M. Trudeau's new ‘feminist’ plan commits 95% of foreign aid to gender, women and girls by 2022. Toronto Star [Internet]. June 9, 2017. Accessed December 5, 2022 at: https://www.thestar.com/news/canada/2017/06/09/trudeaus-new-feminist-plan-commits-95-of-foreign-aid-to-gender-women-and-girls-by-2022.html
- 65 Norman WV, Soon JA, Maughn N, Dressler J. Barriers to rural induced abortion services in Canada: findings of the British Columbia Abortion Providers Survey (BCAPS). PLoS One 2013; 8 (06) e67023
- 66 Zilio M. Trudeau defends abortion position after graphic flyers target Liberal leader. CTV News [Internet]. May 13, 2015; Accessed December 5, 2022 at: http://www.ctvnews.ca/politics/trudeau-defends-abortion-position-after-graphic-flyers-target-liberal-leader-1.2371906
- 67 CTV News Staff. Abortion opponents not welcome to run for Liberals in 2015, Trudeau says. CTV News [Internet]. May 7, 2014. Accessed December 5, 2022 at: http://www.ctvnews.ca/politics/abortion-opponents-not-welcome-to-run-for-liberals-in-2015-trudeau-says-1.1810805
- 68 R. v. Morgentaler, [1988] 1 S.C.R. 30, 44 D.L.R. (4th) 385 (Supreme Court of Canada)
- 69 United Nations Office of the High Commissioner on Human Rights. Convention on the Elimination of All forms of Discrimination against Women: Concluding observations on the combined eighth and ninth periodic reports of Canada. [Internet]. 2016 Nov [cited June 11, 2019] p. 15. (Committee on the Elimination of Discrimination against Women). Accessed December 5, 2022 at: https://www.ohchr.org/en/NewsEvents/Pages/DisplayNews.aspx?NewsID=20708&LangID=E
- 70 Ennis M, Renner R, Guilbert E. et al. Provision of First-trimester Medication Abortion in 2019: Results from the Canadian Abortion Provider Survey. Contraception 2022; 113: 19-25
- 71 Dunn S, Munro S, Devane C. et al. A virtual community of practice to support physician uptake of a novel abortion practice: mixed methods case study. J Med Internet Res 2022; 24 (05) e34302
- 72 L'avortement médical pratiqué à l'aide de la pilule abortive (Mifegymiso): des précisions s'imposent! [Internet]. Collège des médecins du Québec. [cited May 31, 2022]. Accessed December 5, 2022 at: http://www.cmq.org/page/fr/avortement-medical-pilule-abortive-mifegymiso.aspx
- 73 Wagner MS, Munro S, Wilcox ES. et al. Barriers and facilitators to the implementation of first trimester medical abortion with mifepristone in the province of Québec: a qualitative investigation. J Obstet Gynaecol Can 2020; 42 (05) 576-582
- 74 Guilbert E, Wagner MS, Munro S. et al. Slow implementation of mifepristone medical termination of pregnancy in Quebec, Canada: a qualitative investigation. Eur J Contracept Reprod Health Care 2020; 25 (03) 190-198
- 75 Guilbert E, Wagner MS, Munro SB. , et al. La pilule abortive au Québec en 2019–Pourquoi n'est-elle pas plus accessible? Rapport de recherche de la CART-MIFE-Study. Quebec; 2019
- 76 Bojovic N, Stanisljevic J, Giunti G. The impact of COVID-19 on abortion access: insights from the European Union and the United Kingdom. Health Policy 2021; 125 (07) 841-858
- 77 Remez L, Mayall K, Singh S. Global developments in laws on induced abortion: 2008–2019. Int Perspect Sex Reprod Health 2020; 46 (Suppl. 01) 53-65
- 78 Erdman JN, Johnson Jr BR. Access to knowledge and the global abortion policies database. Int J Gynaecol Obstet 2018; 142 (01) 120-124
- 79 French RS, Shawe J, Palmer MJ, Reiter J, Wellings K. SACHA Study Team. Are we prepared for change? The need for evidence on healthcare practitioner readiness for current and future trends in abortion provision in the UK. BMJ Sex Reprod Health 2022; 48 (02) 149-151
- 80 Johnson Jr BR, Norman WV, Keogh L, Sheldon S. Decriminalisation of abortion in New Zealand and Australia. N Z Med J 2019; 132 (1501): 93-95
- 81 Code de déontologie des médecins du Québec. [Internet]. 2015. Accessed December 5, 2022 at: http://www.cmq.org/publications-pdf/p-6-2015-01-07-fr-code-de-deontologie-des-medecins.pdf?t=1511371300670
- 82 Dragoman M, Fofie C, Bergen S, Chavkin W. Integrating self-managed medication abortion with medical care. Contraception 2022; 108: 1-3
- 83 Kerestes C, Murayama S, Tyson J. et al. Provision of medication abortion in Hawai'i during COVID-19: practical experience with multiple care delivery models. Contraception 2021; 104 (01) 49-53
- 84 Reynolds-Wright JJ, Johnstone A, McCabe K, Evans E, Cameron S. Telemedicine medical abortion at home under 12 weeks' gestation: a prospective observational cohort study during the COVID-19 pandemic. BMJ Sex Reprod Health 2021; 47 (04) 246-251
- 85 Aiken A, Lohr PA, Lord J, Ghosh N, Starling J. Effectiveness, safety and acceptability of no-test medical abortion (termination of pregnancy) provided via telemedicine: a national cohort study. BJOG 2021; 128 (09) 1464-1474