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Abortion-pill obstacles: How doctors’ reluctance and long-distance travel stop many Canadians from getting Mifegymiso

The Globe and Mail with Lyndsey Butcher 13 July 2019

Doctors across Canada are refusing to write prescriptions for the abortion pill, forcing many women to travel to out-of-town clinics to get a prescription, according to a Globe and Mail analysis that reveals provincial access barriers and widespread reluctance on the part of medical professionals to provide abortion care.

Mifegymiso is the name for two oral medications, mifepristone and misoprostol, that safely and effectively terminate pregnancies in 95 per cent to 98 per cent of cases. When the medication first came on the market in Canada in 2017, it was heralded by abortion-rights advocates as a safe, less invasive way to terminate a pregnancy compared to surgery. And since any family doctor or, in most provinces, nurse practitioner can prescribe the abortion pill, many believed its arrival would make abortions more accessible – fewer women would need to travel to a clinic, pay out of pocket for costs or take time off work to end a pregnancy.

But The Globe’s investigation shows that in eight provinces where detailed data was available, at least 69 per cent of the 10,092 Mifegymiso prescriptions dispensed last year came from abortion clinics located mainly in large urban centres. Interviews with clinic employees, physicians, researchers and abortion-rights advocates across the country suggest that many primary-care providers avoid prescribing the abortion pill.

While ethical objections to abortion are a factor for some physicians, nearly two dozen people, including the heads of 10 abortion clinics, said the most significant issues are a professional reluctance to be seen as an abortion provider and a perception that the pill is too complex to administer.

Health Canada introduced the drug with a number of onerous restrictions, including a requirement that the first of five pills be swallowed in the presence of a doctor. These restrictions have since been lifted, but clinic directors, abortion providers and abortion-rights advocates said that many still believe the process to be too complicated.

Abortion-pill access is not tracked in Canada, so The Globe and Mail collected raw data from each provincial government and contacted more than 80 publicly known abortion clinics in Canada to determine how many prescriptions they wrote since Mifegymiso came on the market.

Some provinces have more severe access issues than others. In Alberta, 73 per cent of all abortion-pill prescriptions last year came from a single abortion clinic in Calgary, hundreds of kilometres from many of the province’s cities and towns.

And in New Brunswick, at least 72 per cent of prescriptions came from three urban hospital-based abortion clinics, according to the data collected by The Globe. (The actual figure is likely higher, as the province’s private clinic declined to provide its prescribing figures.)

In some provinces, government policy is an added barrier.

Manitoba only covers the cost of the abortion pill for women who get it from one of three abortion clinics: two in Winnipeg and one in Brandon, large cities that encompass 60 per cent of the province’s population. As a result, last year, 95 per cent of all Mifegymiso prescriptions in Manitoba came from those three clinics, meaning women who live in one of the province’s four dozen other population centres would have had to travel to a clinic – in many cases, hundreds of kilometres away. (Statistics Canada defines a population centre as a community with more than 1,000 residents.)

The Globe’s data set is incomplete because some abortion providers refused to provide data or did not have it available. Most abortion clinics in Ontario and Quebec did not provide information. But interviews with about a dozen clinic employees and primary-care providers suggest women in those provinces also face access barriers.

Three Ontario abortion clinics that agreed to speak to The Globe said they regularly see women travelling from hundreds of kilometres away to get an abortion-pill prescription after they were unable to obtain one from a primary-care provider closer to home.

In Quebec, which has the highest number of abortion clinics of any province, about 90 per cent of pregnancy terminations are still surgical and prescribing rates of Mifegymiso are low. There were 253 abortion-pill prescriptions dispensed from community pharmacies in Quebec last year, although that number does not include pills dispensed directly by abortion clinics. Still, experts say access to the abortion pill is difficult, in part because the Quebec regulatory college for doctors requires physicians to attend an in-person training course before becoming a prescriber.

With doctors across the country turning away women’s requests for the pill, many abortion clinics say it is increasingly challenging to keep up with the patient load, resulting in wait lists and delays of up to three weeks in some cases. This is a serious problem because the pill can only be prescribed in the first nine weeks of pregnancy, and research shows most women don’t discover they are pregnant until around six weeks. After nine weeks, surgery becomes the only option. (Across Canada, surgery remains the most common way to end a pregnancy, representing approximately 80 per cent of the 97,000 abortions performed in 2018.)

Access barriers to abortion care also pose health risks. Research shows the greater distance a woman has to travel to get an abortion, the higher the likelihood of carrying an unwanted pregnancy to term, getting an unsafe abortion outside of the health-care system or having an abortion at a later gestational age. Some abortion clinics are already developing workarounds, finding ways to offer the pill to women in smaller, rural and remote communities by introducing new services such as phone-in prescriptions. But most agree that the medical community – including the professional colleges that oversee provincial standards – needs to do more to ensure universal access.

“It should be something we’re all comfortable with prescribing,” said Michelle Cohen, a family doctor in Brighton, Ont., who has publicly advocated for better abortion-pill access. “It should absolutely be part of the basic education for anyone going into the primary-care specialty.”

Canada was one of the last developed countries in the world to approve Mifegymiso, which came onto the market in China and France in 1988 and in the United States in 2000.

Alberta’s government has covered 100 per cent of the cost of the pill since it was first introduced, which abortion-rights advocates say should help broaden access to women throughout the province. But The Globe’s data shows that more than 70 per cent of the 2,826 Mifegymiso prescriptions dispensed in Alberta last year were written at one facility in Calgary: the Kensington Clinic. (The province has two other abortion clinics – one in Edmonton that prescribes the pill in small numbers and another in Calgary that doesn’t prescribe it.)

Women in other communities struggle to access Mifegymiso. Hibo Farah, a 26-year-old University of Lethbridge student, is a real-world example of how challenging it can be to get a prescription for the abortion pill without having to travel out of town. Ms. Farah discovered she was pregnant last November and went to her doctor seeking a prescription. She says her doctor refused to write one, citing ethical beliefs, and suggested Ms. Farah travel to the Kensington Clinic, more than two hours away by car.

“As a patient, I felt judged and I felt unsafe,” Ms. Farah said in a recent interview. “I shouldn’t have had to go or be told to go two hours into Calgary to get this pill.”

At the time, Ms. Farah belonged to an abortion-rights group in Lethbridge, so she reached out to her contacts to see if they knew of another provider in the area that could help. Through word of mouth, they eventually found Jillian Demontigny, a physician based in Taber, about a 30-minute drive from Lethbridge.

Dr. Demontigny decided to start writing prescriptions for Mifegymiso in the fall of 2017 after she learned how difficult it is for many women in Alberta to get the drug. “I’ve seen people coming from Lethbridge who have been turned down by doctors with varying levels of empathy for the patient,” she said. “The patient is left with nowhere to go.”

She said she typically offers abortion services after the regular clinic hours, as her colleagues don’t want to be affiliated with pregnancy terminations. “Some of my colleagues feel that it’s a bad reflection on our group for me to be pro-choice and actively speaking about this and doing the work,” Dr. Demontigny said. “They say it takes away from my regular clinic work, they’ll see that as ammunition to get me to stop doing it.”

The current situation is unlikely to change, she said, unless more doctors step up and take leadership over this issue.

“I think we, as individual prescribers, can do a better job as a group putting our patients’ care needs ahead of our own,” she said.

Most of those interviewed say that one of the biggest disincentives to prescribing the pill is the perception that it’s an involved process that’s better left to abortion clinics.

It takes skill and training to prescribe the pill. Primary-care providers must understand the risks, ensure there is a system in place for patients who may experience excessive bleeding or other serious side effects and be available for the necessary follow-up care. But many in the abortion community say these issues are relatively easy to deal with if someone is interested in taking time to learn.

The Society for Obstetricians and Gynaecologists of Canada has an online training course on the abortion pill that offers step-by-step prescribing advice (the course used to be mandatory, but is now optional, although Health Canada recommends prescribers complete it). But as of June, only 505 family physicians out of the roughly 43,000 in Canada had completed the training.

Dr. Demontigny said prescribing the abortion pill is easier and carries fewer risks than caring for patients who are pregnant or postpartum, something that family providers regularly do.

Michael Kam, chief executive of Onyx Urgent Care in Kitchener, Ont., said there was an initial learning curve involved with prescribing, but his clinic easily made the necessary adjustments. He started prescribing the abortion pill out of his walk-in clinic when he saw a “deficit” of prescribers in the community. The demand for the pill has been high since they started prescribing in 2017, said Cait Desilets, the clinic’s director of operations.

“We have women that travel sometimes two hours to come to us,” she said.

Lyndsey Butcher, executive director of the Shore Centre, a sexual-health resource centre in Kitchener that offers the abortion pill, said the prescribing rules are straightforward and could easily be done by any primary-care provider. But her clinic routinely sees women travelling from around the region, up to a few hours away, because their family doctor wouldn’t prescribe it.

“It’s been incredibly disappointing to see the lack of primary-care providers willing to learn about Mifegymiso and provide the prescriptions for their patients,” Ms. Butcher said.

The lack of prescribing means clinics such as the Shore Centre often struggle to meet demands for service.

Because the Shore Centre faces such high demand, typical wait times for an appointment to get the abortion pill at the clinic is two weeks, but can stretch to three weeks.

Ms. Butcher said she has spoken to dozens of physicians who have referred patients to her clinic and tried to persuade them to prescribe the abortion pill themselves. In almost every case, the doctors have turned her down.

“I talk to them about the hardship and the burden of travelling into our community, in some instances from two hours away,” Ms. Butcher said. “There’s no physician exam. There’s nothing magical that happens in our clinic that couldn’t happen in any primary-care office across the province.”

Ms. Butcher and other women’s health advocates say in order for the situation to change, the country’s medical leadership bodies should make abortion care a priority.

“There is a role to play for the medical community,” she said. “There’s no reason why a primary-care provider should be reluctant to provide it to their own patient.”

Some say abortion care should be part of medical school curriculum and that residency programs should include a training component to help physicians feel comfortable prescribing it. Dr. Cohen said not every doctor will go on to prescribe the pill, but since it is a common medical service, it makes sense to offer education and training.

It’s unclear whether any medical organization is prepared to take leadership to encourage more doctors to prescribe the pill.

Provincial regulatory colleges are responsible for setting and maintaining physician practice standards, but many said it’s not their responsibility to ensure doctors are familiar with the abortion pill or how to prescribe it.

The College of Physicians and Surgeons of Saskatchewan, for instance, declined an interview but said in an e-mail statement that the abortion pill “is a clinical decision between physicians and their patients.”

The College of Family Physicians of Canada (CFPC) is responsible for creating standards for training and offers continuing medical education courses for doctors throughout their careers. The college has offered some training courses for physicians interested in prescribing Mifegymiso.

Sally Mahood, a Regina-based abortion provider, said she regularly sees women travelling from eight to 10 hours away and that more needs to be done to improve access. Dr. Mahood co-authored a letter published in the CFPC’s medical journal last year calling on the organization to incorporate abortion training in medical residency programs in Canada.

College spokeswoman Jayne Johnston declined an interview request. When asked about the reluctance of some physicians to prescribe the pill and what should be done about it, Ms. Johnston said it “is not something that we have information about, nor is it part of the CFPC’s mandate to monitor family physician prescribing trends.”

Dr. Cohen said she is “especially disappointed” in the CFPC’s response because their mandate includes improving education.

“The leadership on this issue is definitely lacking,” she said.

When the abortion pill became available in Canada in 2017, patients were told they had to swallow the first pill in the presence of their doctor, and physicians had to register with the drug company before they could prescribe it. Those, and a series of other restrictions, were removed months later following a public backlash. But the head of the Society of Obstetricians and Gynaecologists of Canada (SOGC) said they added to the atmosphere of confusion and uncertainty that has contributed to the reluctance by physicians to prescribe the pill.

“It does create an aura,” said Jennifer Blake, CEO of the SOGC. “Once you’ve created an aura, it’s really hard to undo it.”

Earlier this year, more rules were relaxed – ones that abortion-rights advocates say have the potential to help expand pill access outside of abortion clinics. Manitoba and Saskatchewan pledged to cover the cost of the pill, meaning the medication will soon be funded in every province. Health Canada also announced that women are no longer required to undergo an ultrasound before getting the pill. This is a significant change because in many communities, wait times to get an ultrasound can stretch for weeks and in some places, there is no immediate access to an ultrasound machine.

In the meantime, some abortion clinics are finding ways to work around the lack of community-based physician prescribing to ensure women that want the abortion pill can get it in time.

In B.C., like other provinces, most of the abortion-pill prescribing is done at urban abortion clinics. In that province last year, two-thirds of the Mifegymiso prescriptions were written at three out of five abortion clinics that offer the pill (two clinics declined to release their figures).

But unlike in most provinces, women don’t necessarily have to leave town to pick up a prescription from one of the clinics. That’s because the Willow Women’s Clinic in Vancouver has developed a robust telemedicine service that connects patients to care providers. All of the necessary counselling and prescribing is done over a secure video conference that allows patients to remain at home and still get the medication.

“I see people in their cars and homes,” said Ellen Wiebe, director of the Willow Women’s Clinic. “It works for all of us.”

She said other provinces could follow suit, but the system only works if there is the will to develop such a network and if there are billing codes in place that physicians can use to charge for their time. One easy solution would be to create a universal licence for doctors in Canada, which would allow the Willow Women’s Clinic to prescribe across the country. Under the current system, doctors must get licensed in every province where they want to practice, which is a costly and time-consuming endeavour.

Another way to increase Mifegymiso access is for more nurse practitioners to start prescribing. Claire Betker, president of the Canadian Nurses Association, said the organization supports abortion-pill prescribing, but that more work may be needed to ensure they feel comfortable prescribing.

The Athena Health Centre in St. John’s has created an ad hoc system to help women avoid travel. Rolanda Ryan, the clinic’s owner and manager, said she often encounters doctors that don’t want to prescribe the abortion pill. So instead, she asks them to order the patient’s blood work and ultrasound. The clinic’s doctor takes care of the prescribing, and the clinic ships the medication to patients by mail or an interprovincial bus line. Ms. Ryan gives patients her cellphone number and acts as the 24-hour emergency line they can call in the event of excessive bleeding or another problem.

Ms. Ryan said the lack of prescribing isn’t a big issue, as long as doctors do the necessary groundwork. “There are doctors out there … who are very supportive of women’s choice,” Ms. Ryan said. “They just don’t personally want to prescribe it.”

Despite these solutions, abortion rights advocates say what’s needed is better abortion access across the country. Sandeep Prasad, executive director of Action Canada for Sexual Health and Rights, said abortions should be viewed as any other health service, with providers trained and equipped to provide the service. “We’re talking about every primary health professional as a provider,” he said. “That’s what we need to be moving toward.”

In Alberta, Ms. Farah hopes for the same thing. She was able to obtain the abortion pill before the cutoff of nine weeks. But if access was a challenge for her, someone with connections in the abortion-advocacy community, she wonders how much worse the situation may be for others.

“It actually makes me very angry and worried,” she said. “If we become a little bit too complacent, people start to take away rights, bit by bit.”