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

Abstract

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.

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

“…Members of our team also conducted a national qualitative study of pharmacists, concurrent with this survey, which provides additional context for the implementation of mifepristone. 13 In that study, involving semi-structured interviews with 24 pharmacists who intended or had begun to dispense mifepristone, experiences in the first year of abortion pill availability (2017–2018) were characterised by the uncertainty of changing restrictive measures and self-organising and adapting to bring mifepristone dispensing in line with usual practice. Local implementation hinged on having a relationship between prescribers and community pharmacists, to ensure that there was a demand for pharmacy mifepristone supplies.…”

“…This research represents the baseline survey results of a cross-sectional study assessing the perspectives of community pharmacists when initiating mifepristone dispensing in various practice settings during the first 24 months of availability in Canada (January 2017 to January 2019) 10. This research is a component of our larger observational mixed-methods programme of research, the Contraception and Abortion Research Team Mifepristone Implementation Study10 that also investigated perspectives of physicians and policymakers 8 11–13…”

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

“…3,36,37 We noted substantial rejuvenation among the abortion provider workforce; almost half of respondents were younger than 40 years, and half of primary care providers and a third of obstetriciangynecologists indicated fewer than 5 years of abortion experience. Other evidence describing growth in the abortion workforce is emerging; 22,24,[38][39][40][41][42] this growth appears to be associated with the 2017 introduction of mifepristone in Canada and the subsequent removal of restrictive regulations. Our data indicate that nurse practitioners contribute to provision of firsttrimester medical abortions.…”

“…Documentation of the Canadian abortion workforce after these changes and the knowledge translation of these changes into practice is limited. [22][23][24] We conducted a national survey of abortion providers in Canada, aiming to explore the characteristics and distribution of the workforce and the services they provide.…”

Advancing Reproductive Health through Policy-Engaged Research in Abortion Care

“…Other factors—vocal champions, supportive interprofessional health provider networks, funding policies, and practice supports—were also critical across different levels of the health system to support uptake. 34 71 For instance, while the national outlook for abortion access in Canada is positive, there remain jurisdictional barriers to access of mifepristone medication abortion in the province of Quebec. The College of physicians of Quebec (CMQ) continues to require several of the restrictions at a provincial level that Health Canada removed federally, including mandatory clinical training in surgical abortion before providing mifepristone, restricting nurse practitioners from autonomous practice by requiring them to prescribe under the supervision of a physician who performs abortions, and the requirement for a mandatory dating ultrasound.…”