Slow implementation of mifepristone medical termination of pregnancy in Quebec, Canada: a qualitative investigation

Abstract

Objectives: Mifepristone for first-trimester medical termination of pregnancy (MTOP) became available in Quebec in 2018, one year after the rest of Canada. Using the theory of the Diffusion of Innovation (DOI) and the transtheoretical model of change (TTM), we investigated factors influencing the implementation of mifepristone MTOP in Quebec. Material and Methods: Semi-structured interviews were conducted with 37 Quebec physicians in early 2018. Deductive thematic analysis guided by the theory of DOI explored facilitators and barriers to physicians' adoption of mifepristone MTOP. We then classified participants into five stages of mifepristone adoption based on the TTM. Follow-up data collection one year later assessed further adoption. Results: At baseline, three physicians provided mifepristone MTOP (Maintenance) and two were about to start (Action). Thirteen physicians at Preparation and Advanced Contemplation stages intended to start while, within the Slow Contemplation, two intended to start and ten were unsure. Seven had no intention to provide mifepristone MTOP (Pre-Contemplation). Major reported barriers were: complexity of local health care organisations, medical policy restrictions, lack of support, and general uncertainty. One year later, ten physicians provided mifepristone MTOP (including three at baseline) and nine still intended to, while seventeen did not intend to start provision. Seven of sixteen participants (44%) who worked in TOP clinics at baseline were still not providing MTOP with mifepristone one year later. Conclusion: Despite ideological support, mifepristone MTOP uptake in Quebec is slow and laborious, mainly due to restrictive medical policies, vested interests in surgical provision and administrative inertia.

The perspective of Canadian health care professionals on abortion service during the COVID-19 pandemic

“…From December 2020 to January 2021, we conducted the survey (UBC-CW REB, H16-01006), which included a consent form and questions assessing brief demographics, monthly MA volume from January to September 2020, previous experience providing MA via telemedicine, and the impact of the COVID-19 pandemic on the provision of abortion services (see Supplementary Data ). We excluded respondents practicing in Quebec from analysis of MA-related questions, as restrictive medical policies sustained providers’ preference for surgical abortion and provincial/administrative inertia limit access to MA ( 15 , 25 ). This survey was available in English and French and we invited members of the Canadian Abortion Providers Support—Communauté de pratique canadienne sur l’avortement network (a national community of practice to support mifepristone abortion practice) via registered email ( 10 , 26 ).…”

“I just was really scared, because it's already such an uncertain time”: Exploring women's abortion experiences during the COVID-19 pandemic in Canada

“…Subsequently, Health Canada updated the product monograph and associated guidance to broaden eligibility to 63 days since the first day of the last menstrual period, expand prescribing authority, permit pharmacist dispensing, and allow individual clinicians to determine the need for an ultrasound [15][16]. As a result of these regulatory changes as well as the coverage of mifepristone/misoprostol by provincial and territorial health insurance schemes, medication abortion became increasingly accessible throughout most of the country [12][13][17][18][19].…”

Pharmacist checklist and resource guide for mifepristone medical abortion: User-centred development and testing

“…As medical abortion counselling may require additional time and resources inadequately reflected in a pharmacist's dispensing fee, our data indicate this may act as an additional barrier to provision for some pharmacists. Ongoing research 3,[32][33][34][35] suggests that 3 years since mifepristone/misoprostol for medical abortion entered the Canadian market in January 2017, uptake continues to be variable across Canada. Several pharmacy managers in our study reported using the Pharmacist Checklist and Resource Guide to train staff pharmacists for medical abortion provision. Indeed, a strength of our study was our integrated knowledge translation strategy for engaging knowledge users throughout the research process.…”

“…As medical abortion counselling may require additional time and resources inadequately reflected in a pharmacist’s dispensing fee, our data indicate this may act as an additional barrier to provision for some pharmacists. Ongoing research 3 , 32 - 35 suggests that 3 years since mifepristone/misoprostol for medical abortion entered the Canadian market in January 2017, uptake continues to be variable across Canada.…”