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Access to abortion in Canada
In accordance with the 1988 Supreme Court of Canada decision R. v. Morgentaler, there are no criminal laws restricting access to abortion in Canada. In Canada, provincial and territorial governments are responsible for the administration, organization, and delivery of health care. The federal government has constitutional spending power through which it sets health standards across Canada. Funding for health systems under provincial jurisdiction are subject to provincial compliance with certain requirements set out in the 1984 Canada Health Act. It regulates the conditions to which provincial and territorial health insurance programs must adhere in order to receive the full amount of the Canada Health Transfer cash contribution. The Act states that provinces and territories must provide universal coverage for all insured persons for all medically necessary hospital and physician services, which abortion is considered to be.
Mifegymiso has the potential to close gaps in access to abortion in Canada
Continued advocacy for better access to Mifegymiso matters. Three decades have passed since abortion was decriminalized in Canada but those who wish to access this medical service often still face many barriers. This is of great concern as abortion is not only a very common procedure, with up to one third of women needing one in their lifetime, it is an integral part of a comprehensive package of reproductive health services. Making medical abortion more easily available is an important way to expand choice when it comes to terminating a pregnancy and could have an important impact on the accessibility of abortion in Canada. It could have such impact because it can be offered earlier than surgical abortion, has the potential to reduce wait times for surgical abortion procedures and wait times overall, can be offered to people who want to avoid an internal procedure for a number of reasons, and could be administered by different health care providers, including family doctors and professionals like nurse practitioners which could increase access in more remote and rural areas.
Medical abortion is currently offered in few clinics and hospitals across the country. Historically, it has not been widely available due to factors like lowered demand (because of lack of availability), the lack of formal billing codes for medical abortion in several provinces, the need to use an off-label regimen up until now (which may have deterred some health care providers) and the very slow roll-out of Mifegymiso, as well as the numerous Health Canada restrictions that hinder its use.
Forging ahead towards accessibility
As things stand right now, some of Health Canada’s restrictions on the use of Mifegymiso are standing in the way of realizing its potential. In response, the current restrictions are being publicly criticized by several physicians, colleges of pharmacists, researchers, activists, stakeholders and sexual and reproductive rights organizations, including Action Canada for Sexual Health and Rights.
Considering the critiques, Celopharma submitted a Supplemental New Drug Submission (SNDS) to have several of the restrictions reviewed, including the current gestational limit restriction of 7 weeks when Mifepristone is used safely up to 10 weeks (and beyond) in other contexts. Celopharma has requested that Health Canada allow physicians to prescribe Mifegymiso on label up to 9 weeks of gestation. They also requested that Health Canada remove the restrictions around pharmacist dispensing, to allow pharmacists to dispense directly to patients for them to take the product home for use, unless instructed otherwise by the prescribing physician.
While we continue to await the SNDS decision regarding the removal of restrictions imposed on the prescribing and distribution of Mifegymiso, changes are happening on many fronts. In May 2017, Health Canada announced that they no longer required a mandatory training to be able to prescribe and dispense Mifegymiso. They also clarified that Provincial and Territorial professional bodies representing doctors and pharmacists were to determine distribution systems which also alleviated barriers created by the physician only dispensing originally mandated by Health Canada.
On August 29th, 2017 the Saskatchewan College of Pharmacy Professionals became the 5th provincial governing body of pharmacist professionals to produce guidelines in support of pharmacists and pharmacy technicians involvement in dispensing Mifegymiso directly to patients. The other provinces having clarified their support for pharmacist dispensing are British Columbia, Ontario, Alberta and Nova Scotia.
On another front, while Health Canada still has not changed their language around who can prescribe Mifegymiso, professional bodies representing nurses and nurse practitioners are moving ahead with their recommendations in regards to nurse practitioners becoming prescribers.
The Canadian Nurses Association has publicly stated their opinion on Nurse Practitioners prescribing of Mifegymiso and what this could mean for individual access across Canada.
The College of Nurses of Ontario was the first nursing governing body to support their NPs to prescribe Mifegymiso. The college has stated those NPs with the knowledge, skill and judgment to prescribe Mifegymiso and who can manage all possible outcomes are legally authorized to prescribe it.
Other provinces are waiting for Health Canada to clarify who qualifies as 'prescriber', when it can administered and who can dispense it which points to the importance of continuing to put pressure on Health Canada to edit their language.
Health Canada also eased some of the initial restrictions included in their approval in regards to physicians having to watch patients ingest the drug though Action Canada still considers the current wording as falling short of what we wish to see. It leaves the decision of where the ingestion must happen with doctors instead of clearly putting it in the hands of patients.