What does the story of mifepristone reveal about healthcare equity in Canada? This episode explores how one medication reshaped care, the barriers that persist, and what it reveals about equity in reproductive health.
What does the story of mifepristone reveal about healthcare equity in Canada? This episode explores how one medication reshaped care, the barriers that persist, and what it reveals about equity in reproductive health.
Dr. Liz Darling is a professor and the assistant dean, midwifery at McMaster University, an adjunct scientist at ICES, and a registered midwife with graduate training in epidemiology and population health. Her research expertise includes midwifery services, novel care models, health equity, access to care, mixed methods, and administrative health data, and she has particular expertise in the midwifery data collected in Ontario’s perinatal registry (BORN-Ontario). Her CIHR-funded research program focuses on how the expansion of midwifery in Canada can help improve equitable access to sexual and reproductive healthcare for equity-deserving groups.
Dr. Laura Schummers is an epidemiologist and health policy researcher and Assistant Professor in the Collaboration for Outcomes Research and Evaluation in the Faculty of Pharmaceutical Sciences at the University of British Columbia (UBC). She completed her doctorate in Epidemiology at the Harvard School of Public Health in 2018 and a postdoctoral fellowship with the British Columbia Ministry of Health and UBC’s Contraception and Abortion Research Team from 2018-2021. Dr. Schummers’s program of research uses population-based health administrative data and draws heavily on causal inference methods to evaluate impacts of health policy and practice changes on service use, access, and health outcomes.
TK Pritchard (they/them) is the Executive Director of Abortion Care Canada. TK was previously the Executive Director of a regional Planned Parenthood and has held several leadership roles in related sectors. In other notable work, TK has authored educational curricula, including sexual health and anti-human trafficking programs, and served as a consultant related to trans and disability inclusion. TK is queer/trans/non-binary, physically disabled, neurodivergent, a survivor of sexual violence, a parent and active community member, and brings this lens to all of their work.
Research you heard about
ICES | Trends in abortion rates in Ontario, Canada
ICES | Abortion safety and use with normally prescribed mifepristone in Canada
Learn more about Abortion Care Canada
Misty Pratt
It was 1967 when Justice Minister Pierre Elliott Trudeau introduced a bill legalizing some abortions in Canada. The Criminal Law Amendment Act passed two years later, and abortions were allowed to take place in hospitals, but only if the pregnancy posed a danger to the health of the patient, as determined by a committee of doctors. It would be another two decades before abortions became decriminalized in Canada, yet equitable access to abortion and contraception remained challenging, even without criminal restrictions. In 2017, the abortion medication, mifepristone, was introduced, and access rapidly expanded across the country, but has it had the impact that researchers and advocates had hoped for? I'm your host, Misty Pratt, and this is In Our VoICES, the podcast that brings you the health data without the drama. To help us understand the data, the decisions and the advocacy work that got us to where we are today, we are joined by three guests. Dr Liz darling is an ICES Scientist and Assistant Dean of Midwifery at McMaster University, and her research interests include midwifery care and health policy. Dr Laura Schummers is an Assistant Professor at the University of British Columbia, and researches abortion and contraception policy. And last but definitely not least is TK Prichard, Executive Director at Abortion Care Canada, an organization that offers inclusive services to improve abortion access as well as public education and community building. So, everyone, welcome to In Our VoICES.
Liz Darling
Thank you.
Misty Pratt
Liz, I'll start with you. Can you walk us through the journey of mifepristone and why it was such a game changer in Canada?
Liz Darling
Canada was actually really, really late to the game in terms of the availability of medication abortion. So, the medication that's now available, mifepristone was actually developed in the 1980s, and it first started being used in other countries in the 1980s. It was introduced in the US in 2000. So, we've been waiting a really, really long time in Canada to have medication abortion available more widely and up until the point that mifepristone became available in 2017 the vast majority of abortions that were happening here in Canada were what we would call procedural or surgical abortions. And so that required having a care provider who did a procedure in order to conduct the abortion. And medication abortions open up the option of people basically being able to take a medication in the form of a couple of pills and have the miscarriage complete outside of a hospital in a way that mimics a natural miscarriage more closely than the other forms of abortion care. And in your introduction, you talked about how there was really inequitable access to abortion in Canada before medication abortion became available. And I think that's really the biggest impact that we've seen is that now that we have medication abortion available, it's something that can be accessed by people outside of a center where there's an abortion clinic. It means that people in smaller communities don't necessarily need to travel in order to access their abortion care. And we've also seen some unique things happen in Canada that have really helped to enhance the accessibility of medication abortion. So, in a lot of other countries where medication abortion is regulated, there are fairly tight controls on where people can actually access the medication. So, they have to go to a special clinic with a special provider, often the medication has to be available on site, and people have to be dispensed the medication by a physician who watches them consume the medication. And in Canada, when mifepristone first became available in 2017 we had tighter restrictions on it, but over the course of that first year, through really good collaborative work between policymakers and researchers and clinicians, we identified a number of constraints that were occurring in how people were able to access medication abortion and there were changes made to the policy. So now in Canada, we have a really unique situation where medication abortion can actually be accessed from a range of care providers, not just physicians. So, we have nurse practitioners also prescribing the medication; we have midwives working in collaboration with other providers and providing medication abortion care. And people can get their medication from a pharmacy. And so, it means that any pharmacist is able to actually dispense the medication, and then people are able to take the medication on their own. They don't actually have to have somebody watching them when they consume the medication. So, all of those things have made it a lot more accessible.
Misty Pratt
And we'll definitely talk a bit more about that access. But first I just wanted to ask TK, I know there's obviously still a lot of stigma and misinformation about abortion. What do you wish the public understood about mifepristone and how it works?
TK Pritchard
Yeah. I mean, I think that there's a lot of misconceptions about the safety of medication abortion and what that looks like, and I mean, across the forms of abortion. I think really wanting people to understand that it is relatively safe in terms of when you look at other healthcare access, that a lot of the risks or concerns about medication abortion that are named in the public or about abortion as a whole are actually myths and not true. But I think the other piece outside of the safety is that I think medication abortion is actually a really good example, a recent example, of how the availability of abortion has not always equaled access. So even when we had the approval of medication abortion in Canada, the uptake on it was relatively slow. Our projects, as well as partners that I talked to across the country, have involved working with clinicians to become prescribers, but also working with pharmacies to become carriers of medication abortion. We spent months and months after it was approved, calling pharmacies, asking them to carry it, asking them to stock it, and explaining why here in Ontario and so I think that that piece around once something is approved, particularly in the world of abortion, it doesn't necessarily actually equal access, and that's why there's this kind of continued need and focus and real need to look at what does it actually look like to have an abortion here.
Misty Pratt
And you mentioned some of those myths. So, what are the common myths that people have about having an abortion?
TK Pritchard
Yeah. I mean, there's a number, and I think that one of the most predominant ones that people talk about across forms of abortion is that you would not be able to get pregnant in the future, which is not the case. Also, conversations about increased risks of breast cancer, also your impacts on your mental health, and time and time again, research shows us that these are false narratives, and that you're not seeing those kinds of outcomes when people are accessing medication abortion or other forms of abortion.
Misty Pratt
And Laura to bring you into the conversation as well. What have we learned from the data so far about the safety and about the effectiveness of this drug?
Laura Schummers
As Liz mentioned, when mifepristone first came to Canada, we already had decades of safety information, but under the very strict, controlled conditions under which mifepristone was generally available across the globe. At that time, clinicians, not only in Canada, but actually globally, believed that all of those restrictions were really unnecessary and were ideologically driven and not really based on preserving safety. But we didn't actually have data in the context where that was the case. But the question was, now we have the first country in the world to actually make mifepristone available as a normally prescribed prescription, where you could just take the medication at home, or, you know, a patient could take the medication wherever they choose, wherever they would be most comfortable, and the pathways for follow up care would just follow sort of typical health care provision. And so that was the big question that we sought to answer right out of the gate when we sort of accrued enough data after mifepristone availability in Canada. And so, using Ontario's administrative health data through ICES, we examined the sort of specific safety outcomes that are generally used across the world to study the safety of abortion services under a range of models. And so, we looked first of all at things like severe adverse events. So, this kind of outcome is used across clinical domains in healthcare to identify, you know, things like ICU admission or someone becoming severely ill, perhaps from something like an infection or a hemorrhage, you know, these kinds of very rare but potential worst case scenario outcomes following abortion. And because of the manner in which mifepristone became available in Canada, we were able to study this using what's called a quasi-experimental approach, which gives us really quite a bit of confidence in the results of our data to compare what happened when all abortions basically were provided procedurally before mifepristone availability, what was the frequency of these adverse events then? And then did that change when we saw- yes, there were some access issues, but there still was quite a big jump. You know, almost a third of abortions within two years were provided by using mifepristone in Ontario, and we saw no change at all in the in the risk of these severe adverse events. We also looked at other complications that are just casting a wider net to look at, really, the, you know, any sort of risk, or, you know, poor outcomes that can occur even if it's able to be managed simply. And again, we found no increase at all after mifepristone was available under this model, and that led to the conclusion that this model is actually safe, and that was the big question internationally. You know, this paper was published in one of the world's like, leading medical journals, because we were the first in the world to do this, and really, to a large extent, based on those results, a similar model of abortion provision, and mifepristone provision has now been implemented in Australia. Which is really hats off to Canada for leading the way there. But in from the Canadian perspective, this model was not undertaken to change safety outcomes. This model was undertaken to improve access. And so, access really still remained the burning question. From the Canadian context, where access had really been quite poor and it's much harder for all health services to be provided to Canada's geographically distributed population. And abortion is no exception and has some specific barriers for access that TK has outlined.
Misty Pratt
Yeah, and I definitely want to talk about those barriers, but first I was just thinking of and maybe Liz, you could speak to this. The idea is not necessarily that we want everyone to have medication abortion. The idea is like that the choice is there; that procedural abortions could still be happening alongside medication abortion. Is that right?
Liz Darling
That's a really great point. Yeah, I think ideally, we would want everybody to be able to choose and to have the type of abortion that works best for them in their circumstances and there are pros and cons to each of them. For some people, you know, having a medication abortion is a process that takes a little bit of time, and so for somebody who doesn't have a home or a safe space to do that, that might be a barrier. And so, in that case, for them, it actually might be advantageous to have access to a procedural abortion. For other people, the benefit of being able to be on their own, maybe just with a support person, and have the privacy of not having to be interacting in a big way with the health system might be a big plus for them in terms of accessing a medication abortion. And I think the requirement for people to travel and actually be at a clinic or be at a particular hospital where procedural abortions are offered, historically, was a really big barrier for people, and for some people, just the cost of having to, you know, get themselves to a different city in order to find somewhere where they could access a procedural abortion really prevented people from having abortions. And so, medication abortion addresses that, but it doesn't actually address access to procedural abortion. So, it is something that we need to pay attention to. And it's actually, I think, a question that clinicians have around, how do we set this up in a way where we ensure that there is a balance and that we also maintain a high enough level of procedural abortions happening that people do have access to them when they need them, and that we don't see a decrease in the availability of procedural abortion just because we now have medication abortion available.
Misty Pratt
And to talk a bit about what happened after 2017 and the abortion rates. Laura, your recent ICES study showed that our rates increased slightly and then kind of stabilized. Wouldn't we expect to see this, like, really big spike in abortions if this drug, mifepristone is now available? You know, we're saying there are there are barriers, but access wise, we're saying it's kind of everywhere, meaning that a lot of people can access it. So, what did we see with those rates?
Laura Schummers
I think the backdrop here is that abortion rates have been declining in Canada and in most of most high-income settings across the globe for about the past 50 years. And so that's the sort of circumstance that we came into this through. And why is that the case? Because of improved access to effective contraception, and, you know, increasing availability of better methods for preventing unintended pregnancy to start with. And so that's really the background here. So, in our study looking at abortion rates, we did see that there was a decline in the abortion rate from before mifepristone was introduced. So, starting in 2012 until 2016, we saw a year over year decline in the abortion rate in Ontario. And then we saw that when mifepristone was increased, that decline slowed down, which meant that we did see more abortions than we expected to see without this policy change, but it was fairly small, and we saw that that increase was, you know, something in the neighborhood of a 10% increase after two years of mifepristone availability. And so, then you really just have competing forces working together. So, on the one hand, we still have expanding access to contraception in Ontario. In particular that was the same year that contraception became free to access for youth through OHIP plus. So, you know that may have helped to continue bringing the abortion rate down. And on the other hand, we have unmet need for abortion, in some cases, prevented people from having an abortion that they wanted as Liz described leading to an increase in the rate. But what we did not see, and what we might sometimes see in the anti-choice world about what happens if you make abortion easy to access, as we would see, like a tripling of the abortion rate, and that is nonsense. And we saw nothing like that. We saw a very small increase that we really think reflects the magnitude of unmet need for abortion before mifepristone was available. We expect abortions will never be zero, and you'll have kind of a slow and steady rate of abortion.
Misty Pratt
And so, what's super interesting is when you compare that trend in Canada then to some other countries, like, let's say our neighbour in the States or the UK, you see a big difference. You actually do see a spike, which is like, why would that be happening? If you know, they don't particularly have better access than us?
Laura Schummers
I think in general with reproductive health outcomes, it's hard to identify what a target rate should be. You know, we can't say how many births there should be, how many abortions there should be how many people should be using contraception. What we can say is compare how health systems are performing in terms of providing access to those essential services so that as people's lives change and socio-cultural contexts change, health system barriers and costs are not what drive those choices, but other circumstances are what drive those choices. You know, these are all very deeply personal, and the role of the health system is to make sure that people have true choice. So, when we're looking at at a place like, well, the US right now has a lot going on in this space, the UK, maybe provides a little bit more of a clear comparison where provision of contraception services really collapsed during the COVID-19 pandemic across the UK. At the same time, you know, there's now even more emerging evidence on real societal changes in perceptions of certain methods of contraception, or maybe all methods of hormonal contraception, and the extent to which people want to use those, especially in the sort of prime reproductive years younger than age 30. And so when we see a drop in contraception use and a collapse in service provision for primary care, including contraception, that is a recipe for increasing the number of abortions needed in a population, which is what we're seeing across the UK, with rates in abortion that are higher in 2022 to 2023 than ever on record before, since they started surveillance in the 1970s. And in Canada, yes all of our primary care services also suffered during the pandemic, including, to some extent, contraception provision. But we didn't see this major collapse that was seen elsewhere. And instead, we actually saw during this period, substantial efforts to improve access to contraception. And as far as these sort of socio cultural forces and fear mongering about contraception, I cannot say that we're immune to that like this is a globalized world where these sources of mis and disinformation are available in Canada and elsewhere, so I don't know what the future will hold there.
Misty Pratt
Yeah, and this is, as you said, you're, you're kind of speculating a bit on these socio-cultural forces. But you know, my own two kids have brought up that you've seen TikTok videos about the dangers of the birth control pill, that they're like, depression, anxiety, like all these bad things are going to happen to them if they take it. And I come from the generation where we didn't have that. In fact, I think the majority of me and my group of friends probably used the pill at some point. So yeah, I wonder if it's a bit of that too. As you said, the fear mongering that you know people are being scared from actually using certain forms of contraception.
Laura Schummers
Yes, and I think when we first spoke about this, like when our ICES paper that was looking at the abortion rates was published, I was speculating on this more than I am now, because there is now more evidence out there, published this summer on really the content of social media overall, in terms of perceptions of contraception and how contraception is discussed on various social media platforms. We can't link those data to say, "oh, this person stopped using contraception after watching this video," but we can really see a surge in misinformation and disinformation about contraception that happens to coincide with the declining trend in use in some cases, and then, unsurprisingly, a subsequent jump in abortion frequency.
TK Pritchard
Laura, I love listening to you speak, and I think that's so interesting, looking at how this data comes to be, particularly in the context, as you've named, with the pandemic, and what those impacts might look like. And I think that one of the challenges around trying to understand abortion rates and why people make decisions on methods and what that, we have data around that, but it is also deeply impacted by so many external factors. You know, I was still in a community clinic at the start of the pandemic, and we saw a lot of clients who were quite a bit further along in their pregnancies than we typically would have, because there was a fear of accessing health care at the time, a fear of going out in public, a number of things that made it difficult to get into their family doctor. And so, you know, there was significant impacts there. But then we also saw such an uptake in virtual care that allowed more access to a medication abortion in many cases, but then you watch the policies in the US and the fears that that sometimes create for folks here, that mean people are sometimes trending towards, "well, I want a more private experience" or "what does it mean if more people know I have an abortion?" Similarly, I worked with post-secondary students, and we were working with the clinics on site to become medication abortion providers. And when I talked to students, it was a real split experience of, "yes, I want to be able to get this abortion at my university, and medication one is great," or "No, I don't, because I am afraid that this will impact my academics, that people will find out somehow." And so, because the stigma and the fear impacts the policies and the legislative changes internationally have an impact on where people are. It'll be interesting to see how these things continue to play out, because there is so much impacting how people are making these choices and which method is going to work for them. And there is a big component about that, that's, you know, personal choice and autonomy, but we can't also disregard that there's so many external factors that are really impacting and playing with those numbers too.
Misty Pratt
And I guess that's what makes it challenging to study, the fact that there are so many factors impacting that choice.
Liz Darling
We need very different kinds of research right in order to be able to address all of these questions. So the research that we're talking about today, that we've done at ICES is quantitative research, and it's incredible for us to have large data sets, to be able to look at what's happened and look at outcomes like safety outcomes, but in order to understand some of these other factors, like what is influencing people's decisions? It's also helpful to have qualitative research where we start to explore some of those things, and we can use quantitative methods to get at some of those questions too, but really digging into the why and what are the factors that are influencing people requires lots of different methods to be kind of exploring those questions.
Misty Pratt
Mixed methods all the way, my favorite.
Liz Darling
Yeah.
Misty Pratt
So, TK, you work really closely, obviously, with people seeking abortion care as you've said. Can you share what it looks like on the ground today? So, we mentioned barriers. What are people's experiences and what are some of those key barriers that they're facing today?
TK Pritchard
Abortion access in Canada and the experiences of folks seeking it is complicated. You know, I would start by saying that I personally and organizationally, and I think many of us within this work talk about abortion as healthcare, and it is, but it's also not actually experienced as healthcare by many people, because the access looks different because there is a lot of stigma, because there's still, in a lot of places this sort of, like neutral "we're fine that abortion exists, but we don't really want to dig into what it needs to be better." Or there's not the same kind of focus but keeping up with the standards as they change. A good example when we kind of connect earlier, when Laura was talking about the really great work that took away the some of the restrictions on medication abortion, one of the challenges is that those restrictions were dropped, but not everyone kept up to date with that. And so, for example, in the past few years, I've worked with a number of clinicians who still were requiring ultrasounds for every client accessing a medication abortion, even though that's not clinically indicated. But on the other side of that, we have so many clients who are in rural and remote communities where occasionally someone does need an ultrasound while it's not indicated most of the time, there are sometimes a limited number of reasons that someone might need one, and then they can't get an ultrasound in their community, and so that becomes the barrier to them getting care, or there's a really long wait list to getting one, and that itself can be a challenge. We also still struggle with having enough providers in many communities. Virtual care has made a big difference here and where folks can access but it is still a really challenging experience for someone who, for example, goes to their trusted family doctor and asks about it, and their doctor says, "Oh, I don't do that." And while people have to give a good referral, that doesn't always happen, and even that first experience of "but this is just kind of standard healthcare. Why can't I get it from my family doctor? Why are they referring me for such a basic process?" Even that contributes to the stigma, and that's not an uncomplicated issue. Similarly, people will go to their pharmacy, and their pharmacy will say, "we don't stock that." I had a client who was in a small town there was not another pharmacy for more than an hour drive away. The client was a teenager, and the pharmacy in the town said, "No, we won't bring it in." And now we're trying to figure out how to get a medication abortion for a 17 year old with no close pharmacy access for them. Those pieces alone, that, like logistics, can be really difficult in accessing. And then obviously, you add on, you know, people experiencing intimate partner violence or family violence, we still really struggle with having culturally inclusive care, trans inclusive care, that those pieces can cause a significant amount of issue as well. And I think it's really important, coming back to what you had said earlier, Liz, that that choice too, between having access to procedural care and medication abortion has been shown to be incredibly important in client experience and satisfaction. And so sometimes we're struggling with keeping the same resources around procedural care as well. And so, folks are not also kind of getting that true choice. The last thing I would say, because, to be honest, there are so many barriers we could spend the whole time together just on this, is that we talk about in a lot of the provinces and territories, right, that medication abortion is covered, and that people will have access to it. And that is true. However, there are a number of times when folks are not having it covered, in which case they're being stuck with a four to $500 bill, sometimes more. And in those cases, yes, we're often talking about folks who are newcomers, refugees, who for a number of reasons, it's not being billed through the federal plan. There's also a challenge around international students, where sometimes international student plans, for a number of reasons, won't cover medication abortion. But then there's also times where a young person, for example, or a person who is on their partner's insurance and can't have them know, if they go to their pharmacy, where they normally bill through their insurance, their pharmacy is still often going to try and run it through their private insurance before they'll run it through the provincial or territorial insurance. And if folks know that, or if they don't know that, that can also cause a significant issue. But there's a real fear of 'is my primary insurance holder can access this information," and this deeply impacts young people, but also within the domestic violence piece as well. And so, I think that it's challenging, because it sounds really straightforward, and in theory, it should be, but there's a lot of folks that still are really struggling to actually have safe, supported access to care.
Misty Pratt
Just to go back to that point of, you know, you talked about the small town, I also imagine, like, privacy could be an issue if, like, say, you're going to the pharmacy and it's your friend's mom or something, who's the pharmacist, like that would be probably a barrier for someone wanting to go in and actually trying to get the prescription filled.
TK Pritchard
Yeah, absolutely. In terms of, you know that privacy and support access piece, and I think that, again, similar to if you go to your doctor and they say, "I don't do that," I think also imagining, okay, well, I'm gonna go to my pharmacy where I get my antibiotics and my regular meds, and you walk in and they say, "well, we won't fill that." There's not a lot of other medications where you're going to have that experience. You know, occasionally they don't stock something for one reason or the other, but most pharmacies will order in the vast majority of drugs. The two predominant drugs that I've heard around this experience is one- if you're accessing hormone replacement therapy, there are, particularly as a trans or non-binary person, that there are pharmacies that will say no, but more commonly, it's around medication abortion. And so, I think that that alone says something pretty concerning about abortion access, that it is those two pieces.
Misty Pratt
Are there any laws to improve access, to really encourage pharmacies to be carrying these and dispensing these drugs?
Laura Schummers
So yes, there are college guidelines. So, all of the laws surrounding health care provision, including abortion, go generally through provincial bodies that govern clinical practice, as well as colleges and the members of a college like the College of Pharmacists or College of Physicians, the members are beholden to follow their sort of standards of practice. There are exceptions where providers are allowed to decide not to offer specific services if they feel morally conflicted in doing so. The best term for this would be belief based denial of care as an idea that moving from the terminology of conscientious objectorship, which sort of presumes maybe a value about whether that's a good or a bad decision to make. But it's about denying a specific type of care because it is in conflict with the provider's belief. And that is allowed for colleges across clinical types across Canada, with the caveat that the provider is meant to offer a referral. In my view, having done a bit of a deeper dive of this in some professional practice context, there could be more depth in how referral is defined. Whose job is it to be sure that the provider that you were being referred to, in fact, will offer the service? Have you checked this? Who is the onus on? And I think there is a bit of gray zone there where sometimes patients are the ones left to sort that out. I think in the context of mifepristone from pharmacies. This gets back to something that TK mentioned earlier, where I think one of the challenges is that initially, when mifepristone was introduced, pharmacists and pharmacies needed to be certified as dispensers of mifepristone. And although this was done away with within the first year as a regulation for mifepristone, you know, pharmacists have a very broad practice, and they would see an alert of a new medication, especially if it has any sort of special considerations around practice or dispensing. But they may or may not always follow every update to those if it doesn't seem relevant. And you know, in the abortion space, mifepristone is very common now as a fraction of all abortion but compared with the volumes for many other classes of medications, it's a fairly low volume drug for most community pharmacies. And so, it's not something where pharmacists would necessarily be getting enough questions to go and see if there was an update, and, you know, it might just be squirreled in the back of their mind. Like, "oh, we had to do this special certification, and we didn't do it. So no, sorry. Like, sorry, that's not a thing we do." Even leaving aside any belief-based denial of care, but from a more logistical standpoint, and, you know, I think that is a much easier to overcome issue than the, I think, very small fraction of providers would deny abortion services from a belief-based standpoint.
Misty Pratt
It sounds like it's more of an education issue, of just educating these pharmacies and pharmacists
Laura Schummers
Exactly. And I think that the other, like terminology, recommendation I would make, is that I don't think we actually care about stocking at all. I think we care about the willingness to rapidly order and acquire this medication along with others to dispense. Because the nature of how this medication came to be provided in Canada, it's very expensive and it doesn't have a super long shelf life from this pharmacy standpoint. And so, there's some qualitative work that's been published within Canada about reasons for not having mifepristone, and one of them is cost. And if you need to have it on hand and in stock, it might expire because it's low volume before anyone comes in to dispense and then you might decide to not carry it, even again, if this is not a belief-based decision. This is not about stocking it's about can you reasonably order this on the time-sensitive timeline under which patients need it.
Misty Pratt
Right, so I guess if you're a very remote or rural pharmacy, you could run into issues of timeliness?
Laura Schummers
Because medications are so time sensitive for many areas, antibiotics, you know many, many things. In general, pharmacies can get medications quickly when they need to, including like a network of pharmacies to order from one another, within a community or across communities, and so I think the timeline should be okay as long as there is rapid action at the point of seeing a script.
Misty Pratt
What's the best part about your advocacy work? TK, I'll start with you.
TK Pritchard
I worked for years in Downstream work, right in trying to get, like a client, access to care, and we still do that in the work now, and it is really meaningful and I don't want to downplay what that experience is like. You know, setting someone up with care is a really big deal. But the work that I get to do now with Abortion Care Canada, so we actually don't define ourselves as an advocacy organization. We're a bit more of like a we're doing, kind of the operationalizing abortion care, so trying to support, how does that policy, how does the research come into play in the actual provision? How do you work through the barriers of when people don't want to provide care, and how do you make sure teams are supported. And getting to do that work, where we're training new providers, where we're helping support new program development, where we're looking at a barrier, even, as you know, simple sounding as a province not reimbursing enough money for people who are traveling for abortion care. When we're looking at removing those types of barriers, and where I get to see, oh my gosh, we maybe don't have to do all of this downstream work in this community anymore, because now there's actual access, and people might actually be able to go and not need to call us. Getting to do that kind of upstream or preventative or access work is so thrilling, and it feels less like I'm just constantly trying to fight against a system and get clients into care everywhere. And yes, we do that, but we're also trying to do the work so that we don't have to do that anymore, and that people don't have to have such a barrier-filled experience. And that is really motivating.
Misty Pratt
I can hear it in your voice that, yeah, it's, it's exciting work for you. Liz, how about you, what's, what's the best part of your work?
Liz Darling
Yeah, I mean, I think similar to TK, I came from, like, initially, in a very direct, clinical role, and the rewards that you get when you're doing work that way are immediate, right? Like, you see the impact you have on every person that you interact with. But I think for me, the like, the greatest reward in doing this work is when you have these moments where, like, the paper that Laura mentioned, that was published in the New England Journal of Medicine, is, you know, was used as evidence at a federal level in the United States, and then we see it helping to support a change in an entire country, in Australia, in the way in which their policies work, and that really broad impact that that research can have when it does kind of hit the nail on the head and provide the right piece of convincing evidence to show why we need to make changes, and yeah, and helps to lead to improved access or better care for people.
Misty Pratt
Laura, how about you?
Laura Schummers
You know, I came into doing abortion and contraception policy work from a very different background of really highly academic studying birth outcome epidemiology, which I also still love and still do sometimes, but the just like really the direct effect of seeing research translated into policy, and then also being able to share back to policymakers who made a change. "Hey, these are the results of the change you made. And look at that impact." Is just a really exciting place to be. And then getting to take that work elsewhere, internationally, and think about what other countries can learn from Canada has actually kind of paved my career path of like, how I see my role as an academic that can use these data and translate findings into something meaningful for stakeholders or interest holders in a range of roles, is something I feel really lucky to be able to do, because it's fun and exciting and feels really important every day.
Misty Pratt
Liz, when you look to the future, what needs to happen to improve equitable access to abortion in Canada?
Liz Darling
I mentioned earlier that we have a in Canada, we do have a unique situation in that we don't restrict the prescription of medication abortion to physicians, but we do, however, still in most jurisdictions, have restrictions that limit midwives from being able to prescribe medication abortion. And midwives are ideally suited to be providing this care. Midwives are sexual and reproductive health care providers who provide comprehensive, holistic care, excellent follow up, availability 24/7, if people have complications when they're having their medication abortion, and there are midwives across the country now who are actively engaged in providing medication abortion. In many contexts, they need to do that in collaboration with somebody else who's providing a medical directive or writing the prescription themselves. But midwives can do the counseling for about abortion, they can do all the follow up care that people need. And we do have some research, some that's just been published, some that will be coming out soon, that demonstrates just how successful and effective it can be to have midwives providing abortion care. We were talking a little bit earlier about regulations and how healthcare professionals are regulated and midwives are regulated jurisdiction by jurisdiction across the country. And there is some variation in how that works in the different provinces and territories, and there is more flexibility in some jurisdictions than in others. So actually, we do have a province already in Quebec, where midwives can provide medication abortion prescriptions on their own authority. We have changes in a couple of other provinces that are about to enable that. Things are shifting across the landscape. In some settings, we have regulations that have been set up that where, even though the regulator themselves might be supportive and in general, other research that I've been doing suggests that there is broad support across regulators to be supporting this as being part of midwives scope. The regulators themselves can't make those changes without also having some kind of change happen at a legislative level, and those processes can be extremely slow. So, we need buy in, in some cases, from provincial governments, in order to be able to make the changes that would enable expansions to the pharmacopeia for midwives so that they can provide that kind of care. But midwives are ready. It's included in you know what midwives learn as part of their training. They have they practice those skills because they support people through early pregnancy loss, which in many ways can be more complicated. In my mind, that would be one of the things that I'm looking to most in the future in terms of just really helping to improve access. The other thing is, we have midwives well distributed as well. So, I think in some communities where we don't have the availability of obstetrician gynecologists, or we might even have limited access to other primary health care providers, like family physicians. There often are midwifery services available, and so it's just another way of helping to make better use of the resources that we have in our health systems.
Misty Pratt
I may be a little biased, but I 100% agree with that having had midwifery care in the past, yeah,
Laura Schummers
And contraception too.
Liz Darling
Yeah, yeah.
Misty Pratt
Yeah, yeah.
Laura Schummers
Beyond the six weeks.
Misty Pratt
Anything else to add to that in terms of the future and what needs to happen?
Laura Schummers
Another ongoing study that we have is a global collaboration to understand, you know, one of the restrictions that does remain on the package label for mifepristone in Canada, and with some variation, is also on the package label for mifepristone across the globe, is about needing to have easy access to emergency services for some period of time after taking mifepristone. Which sounds like a simple and straightforward kind of requirement to have, but in practice, especially again in the Canadian context, geographically, this means that people in the most remote locations are actually not able to have an at home medication abortion and be compliant with the approval of mifepristone in Canada. And this is something that through an international quite large team funded by CIHR to examine this specific question from a range of perspectives together, we're seeking to understand if that is actually evidence based or not, or if it might be that the package labels globally could be revised to take away that requirement. And I think in the Canadian context, with such a such ongoing and persistent and really intractable issues for providing all services, including emergency services for rural and remote communities, this could make quite a sizable impact in for those folks that still don't have great access to abortion despite the gains that we've made.
TK Pritchard
I think that the kind of big piece for us in thinking about the future is just really, how do we build a more sturdy and inclusive system that provides access to abortion care. Often, when I talk about abortion in Canada, I talk about it as kind of flimsy in terms of people's access and relying on sometimes key individuals in communities that if they're no longer in those roles, will bring down the abortion access there. And this is more when we step back and talk about abortion as a whole, and again, thinking about people having choice and within that, that understanding that one all healthcare in Canada needs some more support. Of course, I think we hear lots about our healthcare system, and also recognizing that abortion is an urgent issue to some degree, right? Because it has time limits on when you can access different forms of care, and thinking about when people find out, typically, that they're pregnant, and how much time they have to get into care, get access to the medication and or access another form of procedural care. When you have a system that's not well supported it's difficult to work within that. And then when we look at pieces like individuals who are accessing procedural care at later gestations, it's really hard in Canada. A big part of what we do at abortion care Canada is supporting people at later gestations to actually go to the US to access their abortions, because we do struggle with that aspect of care. And in lot of times when folks can access care in Canada at a later gestation, there's like a few clinicians who are doing it. So, for example, in the summer, when people are on vacation, which is very fair, we might not actually be able to get someone in for a procedural abortion where we could have at another point in time. And that's what I mean when I say it's flimsy and sometimes reliant on particular individuals. And so these pieces around more providers, more access to training, more options, more structural and systemic work to really look at solidifying access because it is urgent, because it is layered and complicated, and because we can be taken down in a community sometimes by just one little change.
Misty Pratt
Well, I can't believe that we're done. We're out of time, but I just want to thank all three of you for being here. This has been a really great conversation, I feel like we could have maybe gone on another hour, and I appreciate all of your expertise and all of your work towards building a much stronger system. So, thank you.
TK Pritchard
Thank you.
Laura Schummers
Thanks so much for having us.
Liz Darling
Thanks Misty,
Misty Pratt
Thanks for joining me for this episode of In Our VoICES. Check out the show notes for links to research and any other information that we've referenced in this episode. A reminder that the opinions expressed in this podcast are not necessarily those of ICES. Please be sure to follow and rate us on your favorite podcast app. If you have feedback or questions about anything you've heard on In Our VoICES, please email us at communications@ices.on.ca and we will get back to you. All of us at ICES wish you strong data and good health.