No choice: Canada’s abor­tion pill prob­lem

The Globe and Mail Metro (Ontario Edition) - - FRONT PAGE - FO­LIO A12- 13

Two years af­ter Cana­di­ans got ac­cess to Mif­e­gymiso, some re­gions have seen thou­sands of pre­scrip­tions, but oth­ers have had hardly any, ac­cord­ing to fig­ures ob­tained by The Globe and Mail. The num­bers point to deeply rooted prob­lems in re­gional abor­tion care

Women’s health ad­vo­cates have hailed the abor­tion pill as the key to elim­i­nat­ing bar­ri­ers to abor­tion in Canada be­cause it can be pre­scribed by a fam­ily doc­tor and taken at home, no mat­ter where a woman lives. Yet, nearly two years af­ter Mif­e­gymiso be­came avail­able, many women still have to travel to abor­tion clin­ics, en­dure lengthy waits and pay outof-pocket if they want to use it to end their preg­nan­cies.

Pre­scrib­ing data pro­vided to The Globe and Mail show large re­gional dis­par­i­ties in ac­cess to the abor­tion pill, which the World Health Or­ga­ni­za­tion says is a safe and ef­fec­tive method of ter­mi­nat­ing preg­nan­cies in the first nine weeks. In Man­i­toba, where nearly 4,000 abor­tions are per­formed ev­ery year, no pre­scrip­tions for Mif­e­gymiso have been dis­pensed from re­tail phar­ma­cies since it came on the mar­ket, ac­cord­ing to the data. But in On­tario, which has about 40,000 abor­tions ev­ery year, more than 6,600 pre­scrip­tions were dis­pensed last year and this year, up to Au­gust, 2018.

The fig­ures, pro­vided by IQVIA, a phar­ma­ceu­ti­cal an­a­lyt­ics firm, don’t re­flect pre­scrip­tions dis­pensed from abor­tion clin­ics. But low num­bers in prov­inces such as Man­i­toba sug­gest that for some women, get­ting a pre­scrip­tion from a fam­ily doc­tor and hav­ing it filled at a lo­cal phar­macy are a chal­lenge.

Bar­ri­ers to abor­tion in Canada are com­plex and vary by re­gion, ac­cord­ing to women’s health ad­vo­cates, who say timely ac­cess to abor­tions is im­por­tant. De­lays can af­fect the type of abor­tion a woman can re­ceive – Mif­e­gymiso can only be pre­scribed to women in the first nine weeks of preg­nancy – and wait­ing also ex­poses women to preg­nancy-re­lated symp­toms, such as nau­sea, vom­it­ing, stress and anx­i­ety.

“This is a med­i­cal pro­ce­dure that should hap­pen in a short win­dow of time. It im­pacts health if you wait,” said Frédérique Chabot, di­rec­tor of health pro­mo­tion with Ac­tion Canada for Sex­ual Health and Rights, an Ot­tawabased ad­vo­cacy group. “There are piece­meal ef­forts made, but a sys­temic strat­egy must come from the pub­lic health sys­tem.”

Last month, The Globe and Mail high­lighted ac­cess bar­ri­ers in Nova Sco­tia, where women reg­u­larly wait a week or more for abor­tions be­cause of an ul­tra­sound back­log. But it’s not the only province with bar­ri­ers.

COV­ER­AGE, BUT ONLY AT A CLINIC

The poli­cies in Man­i­toba are more re­stric­tive. The gov­ern­ment added Mif­e­gymiso to its Phar­ma­care pro­gram, an in­come-based pro­gram that pro­vides med­i­ca­tion to those who pay a de­ductible. The pro­gram helps low-in­come women get pre­scrip­tion drugs for free. Oth­er­wise, the province only cov­ers the cost of Mif­e­gymiso at one of three abor­tion clin­ics − two in Win­nipeg and one in Bran­don − and wait­lists are typ­i­cally long. Women who live out­side of those cities must deal with the lo­gis­tics and costs of travel.

Shaun Gau­thier, vice-pres­i­dent of med­i­cal and di­ag­nos­tic ser­vices for Prairie Moun­tain Health, which over­sees Bran­don’s abor­tion ser­vices, said many women wait about a week for an abor­tion. If they are near the ges­ta­tional age limit for Mif­e­gymiso, they can be ex­pe­dited.

The Women’s Health Clinic in Win­nipeg de­scribed a more chal­leng­ing sit­u­a­tion. The clinic has enough fund­ing to open only twice a week and it can’t keep up with pa­tient loads, said Na­dine Sook­er­many, the ex­ec­u­tive di­rec­tor. The cur­rent wait for an abor­tion us­ing Mif­e­gymiso is two weeks; for a sur­gi­cal abor­tion, it’s three.

“It is an ac­cess is­sue, for sure,” Ms. Sook­er­many said. “It does put clients in a po­si­tion where they may feel they’re not be­ing sup­ported, they’re not be­ing heard.”

Gov­ern­ment spokes­woman An­drea Slo­bo­dian said in an email that 587 women have re­ceived Mif­e­gymiso in Man­i­toba from the time it came on the mar­ket un­til June this year. While the IQVIA fig­ures say no women have re­ceived pre­scrip­tions from re­tail phar­ma­cies, Ms. Slo­bo­dian said 29 pre­scrip­tions for the abor­tion pill have been dis­pensed from re­tail phar­ma­cies as of June.

Wendy Nor­man, as­so­ci­ate pro­fes­sor in the de­part­ment of fam­ily medicine at the Uni­ver­sity of Bri­tish Columbia, said Man­i­toba’s pol­icy “ap­pears to be more po­lit­i­cal than mak­ing sense for the health of the peo­ple.”

Sta­tus of Women Min­is­ter Rochelle Squires, who over­sees abor­tion ser­vices, said in an in­ter­view the province may be open to chang­ing its poli­cies.

“We’re watch­ing the up­take for pa­tients ac­cess­ing the drug and look­ing at what other ju­ris­dic­tions are do­ing,” she said.

Like Man­i­toba, Prince Ed­ward Is­land cov­ers the cost of Mif­e­gymiso for women who go to the is­land’s Women’s Well­ness Pro­gram for their abor­tion. But Au­tumn Tre­mere, a spokes­woman for Health PEI, said in an e-mail all doc­tors on the is­land can re­quest Mif­e­gymiso free of charge through the well­ness pro­gram. Wait­ing times for drug-in­duced abor­tions are about a week be­cause of an ul­tra­sound back­log.

NO COV­ER­AGE IN SASKATCHEWAN

On Sept. 1, New­found­land and Labrador be­came the lat­est province to of­fer universal Mif­e­gymiso cov­er­age. Now, Saskatchewan is the only province with no cov­er­age out­side of its pro­vin­cial drug plan for low-in­come res­i­dents. Shelley Svedahl, a spokes­woman with the province’s Health Min­istry, said women who can’t pay for the drug can ask their phar­ma­cist for emer­gency as­sis­tance and they may get a re­duced price.

RE­LUC­TANCE TO PRE­SCRIBE

Even in prov­inces where the drug is fully cov­ered, some women have trou­ble get­ting it be­cause few health providers are will­ing to pre­scribe. The SHORE Cen­tre, a sex­ual health clinic based in Kitch­ener-Water­loo, Ont., reg­u­larly sees women com­ing to get a Mif­e­gymiso pre­scrip­tion from small towns hun­dreds of kilo­me­tres away, as well as from large cities such as Hamil­ton, be­cause their fam­ily doc­tors would not pre­scribe it.

Lyn­d­sey Butcher, the clinic’s ex­ec­u­tive di­rec­tor, said she has called many of the doc­tors to ask why they won’t pre­scribe. In most cases, the doc­tors say they aren’t com­fort­able do­ing it.

“I think it’s this idea that abor­tions have to be done at a clinic,” Ms. Butcher said. “It’s get­ting over that bar­rier.”

It’s un­clear how many health pro­fes­sion­als are pre­scrib­ing Mif­e­gymiso, but signs sug­gest it’s a rel­a­tively small num­ber. Only 537 fam­ily physi­cians and 134 nurse prac­ti­tion­ers have com­pleted the So­ci­ety of Ob­ste­tri­cians and Gy­nae­col­o­gists of Canada’s on­line train­ing course for pre­scrib­ing the abor­tion pill. The train­ing course, which was manda­tory from Jan­uary un­til Novem­ber, 2017, is now op­tional.

Jeff Sisler, ex­ec­u­tive di­rec­tor of pro­fes­sional de­vel­op­ment and prac­tice sup­port with the Col­lege of Fam­ily Physi­cians of Canada, said there are ef­forts to en­cour­age physi­cian pre­scrib­ing of the abor­tion pill, in­clud­ing a ses­sion at the group’s an­nual con­fer­ence in Novem­ber and an on­line sup­port group where fam­ily doc­tors can ac­cess the guide­lines and have ques­tions an­swered anony­mously. He said doc­tors are busy and the abor­tion pill is new to Canada, which ex­plains why rates of pre­scrib­ing among fam­ily doc­tors may not be very high. A mi­nor­ity of doc­tors might refuse to pre­scribe on the ba­sis of con­sci­en­tious ob­jec­tion, he said.

“It’s fair to say that for most physi­cians, tak­ing the time and en­ergy to get into a new type of care is some­thing that they would do af­ter some con­sid­er­a­tion,” Dr. Sisler said. “It’s kind of a new drug, it’s got some spe­cial train­ing in­volved and it takes a while to hap­pen.”

ARE UL­TRA­SOUNDS NEC­ES­SARY?

Health Canada’s prod­uct mono­graph for Mif­e­gymiso says ul­tra­sounds must be done to ver­ify

the ges­ta­tional age of the fe­tus and en­sure the preg­nancy is in the uterus. But prod­uct mono­graphs are not bind­ing and Health Canada does not have ju­ris­dic­tion over how doc­tors de­liver care.

In many parts of Canada, health of­fi­cials say ul­tra­sounds are re­quired be­fore a drug-in­duced abor­tion. But some health providers, such as Dustin Costescu, lead au­thor of Canada’s phar­ma­ceu­ti­cal abor­tion guide­lines, say too much em­pha­sis on ul­tra­sounds can leave some women wait­ing days or weeks for an abor­tion, which he said is not ideal. Canada’s guide­lines rec­om­mend ul­tra­sounds, but if a ma­chine isn’t read­ily avail­able, health providers can use blood tests and pelvic ex­ams in­stead. Dr. Costescu, also a fam­ily plan­ning spe­cial­ist, noted the ma­jor­ity of phar­ma­ceu­ti­cal abor­tions in France are done with­out ul­tra­sounds.

In Nova Sco­tia, women wait about a week for an abor­tion be­cause they have to have an ul­tra­sound done at the hos­pi­tal’s di­ag­nos­tic imag­ing de­part­ment, which has a back­log of pa­tients. The province’s only abor­tion clinic re­cently pur­chased its own ul­tra­sound ma­chine, but the Nova Sco­tia Health Author­ity (NSHA) says clin­i­cians can’t use it for dat­ing ul­tra­sounds. The NSHA has not ex­plained why this is the case.

Ac­cess to an ul­tra­sound can also be lim­ited in smaller, more re­mote com­mu­ni­ties, which may be con­tribut­ing to abor­tion de­lays, said Joyce Arthur, ex­ec­u­tive di­rec­tor of the Abor­tion Rights Coali­tion of Canada.

“Fam­ily doc­tors are not go­ing to have an ul­tra­sound ma­chine in their of­fice. If they are in a smaller com­mu­nity, it’s go­ing to be an is­sue,” she said.

IS TRAIN­ING IN QUE­BEC NEC­ES­SARY?

Que­bec is home to about half of the abor­tion clin­ics in Canada and has a rep­u­ta­tion for pro­vid­ing ac­cess to sur­gi­cal pro­ce­dures. But from Jan­uary to Au­gust this year, only 144 Mif­e­gymiso pre­scrip­tions have been dis­pensed from re­tail phar­ma­cies there, ac­cord­ing to IQVIA. One rea­son could be the province’s Col­lege of Physi­cians re­quires doc­tors to take a one- or two-day train­ing course at an abor­tion clinic be­fore pre­scrib­ing Mif­e­gymiso.

Yves Robert, sec­re­tary of Que­bec’s Col­lege of Physi­cians, said the course helps doc­tors un­der­stand how to use the ul­tra­sound ma­chine and other as­pects of drug-in­duced abor­tions. He said be­tween 20 and 30 physi­cians have un­der­gone train­ing and that “we don’t see that a ma­jor bar­rier to ac­cess.”

But Dr. Nor­man said the train­ing course is “un­nec­es­sary” and is an ex­am­ple of how pro­vin­cial poli­cies are get­ting in the way of timely ac­cess to drug-in­duced abor­tions.

Mif­e­gymiso presents an op­por­tu­nity to en­sure all women in Canada have timely abor­tion ac­cess, but the piece­meal ap­proach to mak­ing the drug avail­able sug­gests much more work needs to be done, Ms. Arthur said.

“The prob­lem is … lack of proac­tive ac­tion by many prov­inces, by pro­fes­sional med­i­cal or­ga­ni­za­tions,” she said. “It should be a re­spon­si­bil­ity of the pro­vin­cial gov­ern­ment to en­sure ac­cess.”

PHO­TOS BY FRED LUM/THE GLOBE AND MAIL

Lyn­d­sey Butcher, top, ex­ec­u­tive di­rec­tor of the SHORE Cen­tre in Kitch­ener-Water­loo, Ont., says many doc­tors tell her they're un com­fort­able pre­scrib­ing the abor­tion drug Mif­e­gymiso.

IL­LUS­TRA­TION BY MATT FRENCH

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