CMAJ Podcasts
CMAJ Podcasts
How mifepristone changed abortion access, and how to prescribe it
On this episode of the CMAJ Podcast, hosts Dr. Mojola Omole and Dr. Blair Bigham explore how changes to mifepristone regulation have reshaped abortion access in Ontario. Unlike most other countries, Canada allows the drug to be prescribed by any physician or nurse practitioner and dispensed by any community pharmacy, without additional restrictions or special certifications. The discussion draws on the article Changes in local access to mifepristone dispensed by community pharmacies for medication abortion in Ontario: a population-based repeated cross-sectional study, recently published in CMAJ.
Dr. Laura Schummers, reproductive epidemiologist and lead author of the study, explains how the 2017 policy change contributed to a significant shift in abortion access. Before mifepristone, abortion care in Ontario was concentrated in fewer than 100 clinics, most of them in urban centres. Within five years of the regulatory change, the percentage of Ontario abortion service users with local access rose from 37% to 91%. Dr. Schummers also notes that this shift happened even though only one in five pharmacies dispensed the drug. She describes how earlier work demonstrating the safety of medication abortion helped support these policy changes.
Dr. Wendy Norman, a professor of family practice at UBC and co-author on the CMAJ study, outlines what clinicians need to know about prescribing mifepristone. She explains that it can be safely offered without ultrasound or lab testing in many cases, and that virtual care is a viable model for appropriate patients. Dr. Norman also provides practical advice on gestational age limits, follow-up requirements, and how to identify patients at risk for ectopic pregnancy.
This episode offers physicians a clear picture of how a regulatory approach that treats mifepristone like any other prescription medication has expanded abortion access across Ontario—and what it takes to incorporate this care into practice.
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Dr. Mojola Omole
Hi, I am Mojola Omole.
Dr. Blair Bigham
I'm Blair Bigham. This is the CMAJ podcast.
Dr. Mojola Omole
So Blair, this is a phenomenal research article that was recently published in the CMAJ that's looking about medical abortion access across the country.
Dr. Blair Bigham
Absolutely. And this article is sort of the accumulation of quite a few years of work and what really drew us to it is how unique it is to Canada.
Dr. Mojola Omole
Very much. Like, with this article, I learned that we are world leaders when it comes to medical abortion access dispensed by community pharmacists across the country.
Dr. Blair Bigham
I don't want to give too much away right off the top, Jola, but this is pretty exciting. This is definitely a Canadian success story.
Dr. Mojola Omole
And of course, right now, given the fact that there's restrictions to access for abortions in our southern neighbor and maybe other parts in Europe will follow suit, this is actually very topical for us to be discussing. Having that we have access to medical abortions that's solely focused on patient outcomes is vastly important. And that we're the leaders in that is really important for us to highlight on this episode.
Dr. Blair Bigham
So we're going to speak to the researcher who has led some of this leading policy work here in Canada, and then we'll speak to an expert to help us sort of recap exactly how we can prescribe mifepristone to people seeking abortion. Dr. Laura Schumers is the lead author of the study titled, “Changes in local access to mifepristone dispensed by community pharmacies for medication abortion in ontario, a population-based repeated cross-sectional study.” She's a reproductive epidemiologist and health policy researcher at the University of British Columbia.
Laura, thanks for joining us today.
Dr. Laura Schummers
Thanks for having me, Blair.
Dr. Blair Bigham
So before we get started, I need a little bit of context here, and I'll be honest, I feel like I should probably know more about mifepristone as an emerg doc, but I am definitely deficient in knowledge. Tell me, how is mifepristone typically prescribed and dispensed in Canada?
Dr. Laura Schummers
Well, the way mifepristone is dispensed and prescribed in Canada is actually globally unique, which is a really important factor to consider when we talk through why we did this paper and why this is an important question. So here in Canada, mifepristone is prescribed and dispensed just like any routine prescription medication.
Dr. Blair Bigham
Like when I prescribe amoxicillin?
Dr. Laura Schummers
Exactly.
Dr. Blair Bigham
Okay, and how does that differ from the rest of the world?
Dr. Laura Schummers
In basically every other what we'll call pharmaceutically regulated nation, mifepristone has very specific restrictions that limit its use and mainly mean that the medication is available through purpose-specific reproductive health clinics that we would generally think about as contraception and abortion-providing clinics. So this means that they need to often have the medication on hand and actually have the physician who's prescribing mifepristone also dispense the medication. They, in many settings, need to have a specific manufacturer or government-mandated consent form signed by the patient.
This is true, for example, in the US with the FDA. In Canada, we don't have any of that. Here, this medication can be prescribed by any family doctor, nurse practitioners can prescribe.
Any pharmacist can dispense just like any other medication, just like amoxicillin.
Dr. Blair Bigham
So the barriers are low.
Dr. Laura Schummers
Indeed, that's right.
Dr. Blair Bigham
What about any other country? Does anywhere have something like this, the way Canada does it? Or are we really out there on our own?
Dr. Laura Schummers
Well, we were the first to do this. Since Canada took this step back in between 2017 and 2018, other countries have followed suit thus far, notably including Australia. During the pandemic, there were some big shifts where some of these restrictions were removed either temporarily or for a pandemic-related health service shift to enable fewer contacts with patients in the healthcare system.
For example, some of the restrictions on mandating that prescribers would actually observe ingestion were removed in the US. Some of the prescriber-specific dispensing restrictions were removed during the pandemic and also, to some extent, in response to an earlier paper from our team that found that this model of medication abortion provision was safe.
Dr. Blair Bigham
Got it. So mifepristone came to the Canadian market in 2015. How was it initially regulated?
And then what changed in 2017?
Dr. Laura Schummers
Yeah, so Health Canada first approved mifepristone in 2015. And then it took up a couple of years before the medication came to any of the provincial health system markets. So it was first actually available in Canada in 2017.
And then incrementally throughout 2017, many of these same barriers to use that I've just described were removed in Canada. So initially, we had a similar requirement for patients to sign a consent form, but that was done away with. We had the observed dosing mandate was removed in between approval by Health Canada and availability in 2017.
And then some of the specific regulations for pharmacists, for example, having to complete a training program through the manufacturer of the medication, that was also removed such that by November of 2017, mifepristone was available like a routinely prescribed prescription medication.
Dr. Blair Bigham
Got it. OK, so that's the policy backdrop here. We have Canada standing alone all the way back to 2017 as a place with relatively low barriers to access mifepristone.
It's prescribed just like any other drug. So now that we have that covered, talk to me about your study. What were you hoping to learn when you designed your study?
Dr. Laura Schummers
Yeah, so I think this context is really important for why we wanted to undertake this study at all. So because Canada was unique, there were a lot of questions about what would happen when mifepristone became available under this model. And stepping back even further, the background that matters here is that before mifepristone was introduced in Canada, almost all abortions were provided as procedures.
So over 96% of abortions across the country were provided in a small number of clinics, most of which were these purpose-specific reproductive health clinics. So there were under 100 clinics that provided abortion care across the entire country.
Dr. Blair Bigham
And when you say these were done in clinic, are we talking about medication-induced abortions?
Dr. Laura Schummers
No.
Dr. Blair Bigham
Are these all like DNCs?
Dr. Laura Schummers
Correct. Yeah.
Dr. Blair Bigham
Oh, so before 2017, everyone who wanted an abortion needed to have a DNC?
Dr. Laura Schummers
Just about. So we had some off-label use of other medications. Either methotrexate and misoprostol together or misoprostol alone were used.
But Canada was very late in bringing mifepristone to market. So mifepristone has been in use in the US since 2000, in some settings in Europe since the 1980s, 1990s. So Canada was very late to the game in terms of mifepristone becoming available at all.
But then by the time it did come to market, they undertook a very different approach to regulation. So why does this matter? Is that when all of the abortions that were provided were by procedure, so DNC being the most frequent but not the only procedure that's used for abortion, that meant that most people in Canada had pretty poor access to abortion services.
They needed to travel to one of these 100 clinics that are mostly in urban centers along the southern part of the country. And for rural and remote patients, clearly that's a huge barrier. And this meant that there was really inequitable and inadequate access.
So then when Canada, again late to the game, brought mifepristone to market, they wanted to first come up to modernize the way that abortion was being provided across the world. But also to really try to resolve this access issue. And it was clear that if they followed the same policy implementation approach for medication abortion that was used elsewhere, yes, we would now have another way to provide abortion services, but we would not solve the access gap.
And so in really close collaboration with physicians and researchers and professional organizations across the country, Health Canada changed the regulations alongside introduction of the medication to make this available as a routinely prescribed medication. So the first burning question was, is this safe? Because of course, all of the regulations that exist across the world purport to be keeping women safe by limiting abortion access.
And most abortion providers and health professional organizations have long thought that these are unnecessary and were actually not preserving safety, but we're instead really just exerting reproductive control. But we didn't have much data to really support that one way or the other. So our team first had to know, is this safe?
And we studied that back in 2020.
Dr. Blair Bigham
So great. We have a setting now, Canada, that has that condition. And so tell me, what did you actually find?
Dr. Laura Schummers
Yeah. So we found in that first paper, this was published a few years ago, abortion remains safe. Then the burning question is, did this achieve the policy goal of improving access? And that's what we still didn't know.
Dr. Blair Bigham
Before we run away into that, I want to dig into the word safe. Because if we're going to say the other places could have been safe without these extra burdens or restrictions, tell me, was there any signal for harm? Did anybody fall through the cracks with this?
Or was this just plain safe period?
Dr. Laura Schummers
Yeah. So this was just plain safe period. So what we're looking at is the frequency of complications and severe adverse events before mifepristone was available, when basically all abortions were provided by procedure versus in the very rapid uptake of medication abortion.
So in Ontario, we were up to over 30% of abortions provided by medication within two years of this policy implementation. So it was quick. In that context, there was no change in the frequency of complications or severe adverse events.
We published that paper in early 2021 in the New England Journal of Medicine. That then we were able to use some of that to implement some of those COVID-specific policy changes. Even before it was published, we were shopping that around to the FDA when some discussions were in process there.
Dr. Blair Bigham
Fascinating. OK. I have so many questions.
But first, anything else you found in your most recent study in CMAJ?
Dr. Laura Schummers
Yeah. So the CMAJ paper, this is the burning question in the Canadian context is, OK, it's safe. But did we succeed in improving access?
Because we were not trying to improve safety of abortion here. We were trying to improve access. And so this is really the first paper that's examined what happened to access after mifepristone became available in this globally unprecedented way.
Dr. Blair Bigham
I feel like there's a mic drop coming here.
Dr. Laura Schummers
Yeah, exactly. So what happened was, importantly, in this new model, the role of pharmacies and community pharmacists was newly added to the abortion landscape. And so we'd heard anecdotally some questions about how from prescribers saying, yeah, we're all willing to prescribe mifepristone, but it's the pharmacies that want to dispense.
And so we wanted to look to see, is this actually true? And what are we finding from the pharmacy perspective, both in terms of the number and the percent of pharmacies that have dispensed mifepristone and geographic clustering?
Dr. Blair Bigham
So prescribers weren't like, no, I need to observe this person, take it, or no, I need to watch and wait and see if they have any bleeding or complications. They were like, here's your prescription, go for it. But then people couldn't actually get a pharmacist to dispense.
Dr. Laura Schummers
I mean, so that was the question. And so bringing pharmacies into the landscape is completely new to abortion. Of course, pharmacists have no role in procedural abortion.
And so how to measure access is pretty complex, and it really takes a multi-pronged approach. And so in this paper, what we wanted to study is, do community pharmacies improve access to medication abortion in Canada?
Dr. Blair Bigham
All right. So we went from 100 clinics providing DNCs, essentially. What did you find?
Dr. Laura Schummers
What we found was that, yeah, we went from only 37% of abortion service users in Ontario living in a geographic region that had any local abortion provider up to 90. That was true as of 2017. Up to 91% of abortion service users having local access to either a procedural abortion provider or local mifepristone dispensing as of 2022.
Dr. Blair Bigham
So I mean, in my world of slow science, you basically solved the problem overnight.
Dr. Laura Schummers
I mean, I didn't solve anything, but I measured how other people solved it.
Dr. Blair Bigham
This regulatory approach, this is fascinating. OK. But there's still some problems, no?
Dr. Laura Schummers
Yeah. So I mean, I would never say we have now solved abortion access. Again, this is a really multi-pronged issue.
And getting access to even a prescriber and making sure that there's confidentiality and time away from perhaps even a spouse or a partner to have an abortion is complex. But in terms of the health system providing the scaffolding to make abortion services now more readily available, we've made huge strides in only a small number of years.
Dr. Blair Bigham
And tell me more about the pharmacies. Can I walk into any pharmacy and get this prescription? Or do I have to go to a special pharmacy?
Dr. Laura Schummers
So any community pharmacy can indeed order and dispense mifepristone. And in this study, what we were looking at is the number and percent of pharmacies that did dispense in each year. So of course, we did not see that they all did.
We saw that in 2022, we only got up to just over 20% of pharmacies that did dispense.
Dr. Blair Bigham
So only one in five pharmacies are dispensing this, and we still took that access gap from 37% to 91%.
Dr. Laura Schummers
Yes, because when we look at their geographic region, we can see not every pharmacy has to dispense every medication for access to be good. So we're looking at within a geographic region defined by postal code, what fraction of the geography of Ontario has some way to access abortion? And we went from very few to almost all.
Dr. Mojola Omole
I have a question regarding rural, urban versus rural, because I'm someone who grew up in rural Ontario, and we had back then two pharmacists. And so I'm just thinking that if we talk about the urban-rural divide, what is that like for access? If you only have one or maybe two pharmacists in town, and they both don't carry, like, what does that look like for the rural people?
Like, what's the distance that they have to drive to get this medication?
Dr. Blair Bigham
Because a region can be big, right?
Like, we think of a region as being like, oh, Scarborough, Ottawa, but a region could be like... I'm from Wingham, Ontario. Half of Saskatchewan might be one region for all I know.
Dr. Laura Schummers
Yeah, and so it is indeed true that by looking... Regions that are defined by postal code, the size varies a lot by where you live. And so a postal code-defined region within Toronto is tiny geographically, whereas a northern region defined by postal code might be geographically quite large.
Dr. Blair Bigham
So a region was defined as the first three characters of a postal code?
Dr. Laura Schummers
Exactly.
Dr. Blair Bigham
Oh, wow, that's... Okay, so some of these regions were actually half the size of a province.
Dr. Laura Schummers
Some of them were large... Not half the size, but some of them were large. But none of those large regions had no access.
So within those areas, you may have to travel to... It might be hard to still find a pharmacy, and that's actually not something that this kind of policy change can affect. But in terms of looking by region, did they have at least one? All of those northern and remote regions did.
Dr. Mojola Omole
Well, I guess my question is, can we just order it from somewhere else? If you don't have... Is it possible to see an abortion provider virtually?
Because...
Dr. Laura Schummers
Yes.
Dr. Mojola Omole
And then get it mailed to you?
Dr. Laura Schummers
It is indeed possible. And that's something that within health administrative data in Ontario anyway, we actually can't do a great job at measuring virtual care. And so we know virtual care is irrelevant for procedural abortion, but is definitely relevant and important in the context of medication abortion.
And that was really accelerated during the pandemic, where depending on the clinical characteristics of each person seeking abortion care, even a no-touch medication abortion, where the person was never actually physically seen by a provider, is a plausible option in some cases. And we expect that did happen to some extent, but it's not something that's easy to measure or possible to measure in health administrative data. Some pharmacies do mail.
There is no reason that mifepristone could not be mailed from a brick and mortar or a virtual pharmacy to a patient's home.
Dr. Mojola Omole
So even with the progress that we have, what gaps still remain?
Dr. Laura Schummers
Yeah. So I think part of this is about awareness and knowledge of providers and pharmacists. So do people see this as somehow an exceptional medication that requires specific hoops that need to be jumped through?
Or is this seen by all health providers, including pharmacists as a typical prescription medication that they can dispense like normal? So I think some of that knowledge mobilization and knowledge translation facing physicians and potential prescribers as well as pharmacists is still an important aspect that could be improved.
Dr. Blair Bigham
So this is a little bit timely to have this conversation, given what's happening to our southern neighbors. How do your findings bring some context to some of the political discussions that are happening around the world?
Dr. Laura Schummers
Yeah, I think this is definitely timely and something that looking at the way Canada treats, the Canadian health systems treat abortion versus the U.S. makes it really clear that Canada is not just a middle of the road, not U.S. country. But we're actually a global leader in the way that abortion and to some extent contraception is being provided. And this is something that I really want to be highlighted and for Canadians to not lose sight of.
That in addition to being really pioneers in the way that medication abortion is provided with mifepristone, Canada is the only country in the world where there is no criminal law governing abortion provision at all. And that's been true since 1988 when the Supreme Court ruled that abortion is just health care. And this is something that comes up every couple of years about whether there should be a law put into place to protect abortion.
But in fact, the way we have this set up where abortion is just health care overseen by professional regulatory colleges is the best way to preserve access to health care and is really putting Canada in the global spotlight as how to follow the best practices and best evidence to provide abortion care.
Dr. Mojola Omole
It's amazing.
Dr. Blair Bigham
I cannot think of a better place to end this interview than right there. Laura, thank you so much for joining us today and congratulations on this study.
Dr. Laura Schummers
Thanks so much for having me.
Dr. Blair Bigham
Dr. Laura Schummers is the lead author of the study in CMAJ and a reproductive epidemiologist and health policy researcher at UBC.
Dr. Mojola Omole
Now we're going to take a closer look at what actually it takes to prescribe mifepristone. Dr. Wendy Norman is a leader in reproductive health and a co-author on the CMAJ paper. She's a professor in the Department of Family Practice at the University of British Columbia, Faculty of Medicine, and she founded and leads Canada's contraception and abortion research team.
Wendy, thanks so much for joining us from beautiful B.C. today.
Dr. Wendy Norman
Thanks, Jola. It's a pleasure to be here.
Dr. Mojola Omole
So we wanted to talk to you about just the process of prescribing mifepristone. So let's just start off with how safe is it, clinically speaking?
Dr. Wendy Norman
Oh, yes. This is a great question because this is a very safe medication. So mifepristone is one of the most safe medications that we have available and we have more than 40 years of data to show its safety, more than 30 years of data coming on, almost 40 years of data now to show the safety.
Dr. Blair Bigham
What are the bullet points here in terms of the actual process in prescribing it?
Dr. Wendy Norman
Yeah. So first of all, a person needs to be pregnant.
Dr. Blair Bigham
Yeah. No, this is a good place to start.
Dr. Wendy Norman
And they need to make a non-coerced choice on their own that they actually don't want to continue this pregnancy. And if they are in a stage where they haven't made the decision, they need the supports to be able to explore their options. But let's say you've got a person in front of you, and both you and the person coming to you are very certain this is what's the next step for them.
They need to stop this pregnancy. So the mifepristone is an antiprogesterone agent. It works at the syncytiotrophoblast, which is the layer that's available in the uterus between a pregnancy and in the placental as it's attaching to the uterus wall.
And it stops that syncytiotrophoblast from growing so that the pregnancy essentially becomes a miscarriage. But the syncytiotrophoblast, it's only active if it's an intrauterine pregnancy. So it has no effect on a pregnancy that would be ectopic.
Dr. Mojola Omole
So would there be any effects on the person if they took it and they had an ectopic pregnancy? Or would it be fine still?
Dr. Wendy Norman
No, not from the medicine. It has absolutely no effect. And this was the point that allowed Health Canada to take off the requirement that you must have an ultrasound before you get the medicine because the medicine has no effect either way on an ectopic pregnancy.
It just doesn't, it's not effective to stop it, but it hasn't done anything else. It's an antiprogesterone agent, and the pregnancy usually keeps on growing. So you can actually, if you've got a pregnancy of unknown location, you don't know if it's in the uterus or not, your chances are overwhelmingly that it's intrauterine because non-intrauterine pregnancies are very rare.
You can go through the historical questions to see if there are any signs or symptoms of ectopic pregnancy. And that's the main thing that you're ruling out before you give the medication. And in fact, whether you were giving mifepristone or not, you're seeing somebody in early pregnancy.
As the healthcare provider, you want to know, is this an early pregnancy that's ectopic or not? Because the ectopic is what's going to be a problem. The mifepristone and its action on the pregnancy is not a problem for an ectopic.
Dr. Blair Bigham
So if on exam and history, I'm pretty convinced they don't have an ectopic pregnancy, it's safe to give mifepristone without having any ultrasound?
Dr. Wendy Norman
Absolutely. But what you do need is a plan to be able to follow and ensure that the pregnancy comes out and that the person is no longer pregnant.
Dr. Blair Bigham
So if this person has never had any type of ultrasound on this pregnancy, I can just rely on a beta-HCG and prescribe?
Dr. Wendy Norman
You, in fact, by the guidelines, don't even need a beta-HCG. If you are not worried at all about ectopic pregnancy, and you've gone through the other checklist categories, what you want to do is ensure that after the mifepristone is administered, that it has been effective. And as you know, whether you've got an ectopic pregnancy or not, there's about between 1% and 3% of cases, depending on the gestational age, where the mifepristone, the first treatment dose, is not going to be sufficient to stop the pregnancy from growing.
So for all kinds of reasons, you need to ensure follow-up with the person to show that their pregnancy test is negative by two weeks or four weeks, or that they get beta-HCGs that are falling if they're still feeling pregnant symptoms. Now the vast majority of people, 97-98% of people, are going to tell you after a week, yes, I had several hours of cramping and about a day or two of bleeding, and then it all stopped, and now my pregnancy symptoms are gone. And I don't have that nausea.
There's no more breast tenderness. I'm feeling so great. And you say, yes, but we did ask you to pick up the highly sensitive urine pregnancy test.
We still want you to do that at two weeks or at four weeks, whichever your protocol has decided, so that you can ensure that that's fine. It's with the people who say, you know, I got some bleeding, but it wasn't as much as I expected, and I'm still feeling really nauseated. Then you want to zero in.
You want to get your beta-HCGs. You want to do that follow-up for them.
Dr. Mojola Omole
Is there a gestational window?
Dr. Wendy Norman
A gestational age? Yeah, when this was first approved, it was approved just for people up to 49 days for pregnancy. But that has been extended now, and the current clinical practice guidelines from the Society of Obstetricians and Gynecologists of Canada indicate that it's quite effective up to 70 days in the first 10 weeks of pregnancy.
Dr. Mojola Omole
Oh, wow. Okay.
Dr. Wendy Norman
And in fact, there are studies around the world showing that anywhere in the first trimester, you can use this. Each successive week of gestation, your completion rate with the single dose of mifepristone and the follow-up dose 24 to 48 hours later of the misoprostol that assists in the expulsion process, that first treatment becomes less effective.
So under seven weeks, you're going to have 98, 99% of people where that's all they need, and they've had complete treatment. As you go up eight, nine, 10 weeks, your success rate might be at 96, 95, 94%. And once you get to 11, 12, 13 weeks, you might be talking in the high 80s.
Now, as you sit down with your patient, and this is what the SOGC guidelines go, you're weighing the options they have. What other choices? Does this mean they'd have to leave their job, leave the kids they have at home, and travel 400 kilometers to a surgical site instead?
And would they like to take an 85% chance that this would work? So this is a case of judgment and go to the guidelines. They'll help you with being able to weigh those.
But essentially, there are trials now looking well into the second trimester for this and showing what kind of effectiveness rates they have. It's not as though the medicine doesn't work at some stage. It's always an antiprogesterone.
It's working at the level of the placenta. And as long as you can ensure that you've got the treatment your patient will need to be able to do an aspiration if the medication abortion doesn't work, then that's the important thing to go ahead with.
Dr. Mojola Omole
I guess, just to follow up on that, what type of follow-up care is needed after you prescribe the medication?
Dr. Wendy Norman
Yes. So again, making sure that the person knows where they have to go if they have any questions or anything is coming up in their symptoms is really important. So they do need a 24-hour emergency services contact, ideally you, that they can reach if they have any concerns.
Serious complications are very rare for this. About one person in 1,000 will have so much bleeding sometime in the first two to three weeks that they would need a blood transfusion. So this is a lower rate of requirement for hemorrhage or requirement for transfusion than for many other pregnancy conditions and outcomes.
But it's still a possibility. And because you've prescribed the medication that got this started, you have to make sure that if that one in 1,000 case comes up, you've got a way to be able to care for them. As the most common thing, of course, is that one or two percent of people, the mifepristone won't be effective and that you'll need to arrange either for a second dose a few weeks on or for procedural aspiration care to be able to complete that abortion procedure for them.
Dr. Mojola Omole
Are there any specific medical histories that physicians need to be aware of before prescribing it?
Dr. Wendy Norman
It's a good question. Most of those fall into the category of risk for ectopic pregnancy. So you want to know if they've had chronic PID, pelvic inflammatory disease, if they've got an IUD in place, particularly a copper device, where there are very few pregnancies with copper IUDs.
The copper IUD is most effective at preventing an intrauterine pregnancy. So the pregnancies that occur when a copper IUD is in place are very, very few, much fewer than normal, but they're more likely to be an ectopic than in the normal distribution of pregnancies. So copper IUDs don't cause ectopic pregnancies, but they prevent almost all the intrauterine ones.
They don't prevent the ectopic ones that were going to happen anyway. So those kinds of things you want to rule out beforehand.
Dr. Blair Bigham
Outside of primary care and sort of OB/GYN, are there roles for emergency doctors to be prescribing mifepristone? We see more and more people showing up to emerg just for any type of care. It's very hard for many people to find a family doctor.
Do emerg docs have to have confidence that this should be part of their repertoire?
Dr. Wendy Norman
It's an interesting way to describe that. What I can say is that when we set up our initial community of practice, about 2% of the practitioners were emerg docs.
Dr. Blair Bigham
Okay.
Dr. Wendy Norman
And pediatricians as well came into this. And I think that I'm not sure I would say that every emergency doc needs to bring this into their practice, but I would say certainly if you're practicing as an ER doc in a secondary or primary care environment that's smaller hospitals and rural hospitals, then probably this would be something that you would be handling in the ER as part of your regular care. If you're right down the road from a clinic where they're doing this or your hospital has a service, then possibly in the ER wouldn't be the place that you'd be managing the services. But it's certainly an area of care that is easily folded into most regular visit times for a single-episode visit in primary care.
Dr. Blair Bigham
So for people who choose to use telemedicine or maybe can't get in to see someone in person, totally safe to do this over the phone?
Dr. Wendy Norman
Yes, absolutely. There's solid evidence on that with about 10 years of data in countries all around the world now, yeah.
Dr. Mojola Omole
Amazing. Thank you so much.
Dr. Wendy Norman
Total pleasure.
Dr. Wendy Norman is a professor in the Department of Family Medicine at the University of British Columbia Faculty of Medicine. She's the founder and leader of Canada's contraception and abortion research team.
Dr. Mojola Omole
So, Blair, what are your first thoughts?
Dr. Blair Bigham
My first thoughts are unusually positive, Jola. Normally, I feel like you and I are out of the green.
I know we're all pessimistic. This Canadian healthcare system sucks. But this is actually a pretty amazing contribution, not only in Canada, but, I mean, these authors have previously been published in the New England Journal of Medicine.
This is world-changing information.
Dr. Mojola Omole
Absolutely. And for us to look at abortion, which for some have, just like the fact that people mix politics into it.
Dr. Blair Bigham
Oh, yeah. It is one of the particularly polarized topics in medicine.
Dr. Mojola Omole
But it shouldn't be. And what this article truly highlights is that if our focus is on delivering the highest quality of patient-centered care, medication abortion is absolutely safe. And right now in Canada, it is accessible to all Canadians who want an abortion.
Dr. Blair Bigham
I appreciate how people in the research community looked at the pandemic and said, hey, this is actually an opportunity, not just a threat, not just a problem, but we can actually use this to see how things are going and if our policies are working.
Dr. Mojola Omole
And the fact that they were able to push our government to make such different changes from other countries than what's been done before and improve outcomes for patients and people who are needing medical abortions, personally for me, I think is phenomenal. And all the work that they do really needs to be highlighted when we talk about the great research that comes out of Canada.
Dr. Blair Bigham
Jola, you and I just recently were speaking to Kirsten Patrick, the editor-in-chief of CMAJ, who mentioned that the strength of Canadian researchers is often in clarifying a problem, but not necessarily in finding a solution. And here we have a solution.
Dr. Mojola Omole
Exactly. And I do think that that is why it is so important for us to be talking about it.
Dr. Blair Bigham
So, here we have it. A very easy way to increase access is just treat the medication like any other medicine, let pharmacies dispense it, let physicians prescribe it.
Dr. Mojola Omole
And we can do virtual care for it in areas where it might not be as accessible, like in terms of being able to get in to see a primary care practitioner, you have the ability to do virtual care.
Dr. Blair Bigham
Or even just, I can imagine it's so much less stressful when you don't have to go for an ultrasound, wait for the ultrasound result, go back to the doctor's office. This is really about respecting patients and making their life as easy as possible and respecting their choice without throwing in all these punitive barriers that are really just meant to tick people off.
Dr. Mojola Omole
Well, instead of trying to, the paternalistic way of trying to restrict access to abortion, whether medical and prior to that, surgical, but now we actually have open access to it. And to me, that is something that we as healthcare providers should always be champions of.
Dr. Blair Bigham
And just so smart to prove that this is actually better than the way other places do it. I don't know, maybe other countries will follow suit.
Dr. Mojola Omole
Elbows up, Canada.
Dr. Blair Bigham
That's it for this week on the CMAJ Podcast. Thank you so much for listening. If you like what you heard, please help us spread the message by liking or sharing wherever you listen to your audio.
Or just tell your friends or colleagues when you're around the hospital. The CMAJ Podcast is produced by PodCraft Productions. Our producer is Neil Morrison, and our deputy editor at CMAJ is Catherine Varner.
I'm Blair Bigham.
Dr. Mojola Omole
I'm Mojola Omole. Until next time, be well.