The Promise of Mifepristone
It’s been 50 years since Canada first legalized hospital abortions in 1969 and 30 years since mifepristone, the “abortion pill” first received approval in France with promises to change the way women access safe abortion care. In the years since, access to abortion care continues to be a fight central to women’s reproductive freedom.
On March 8th, International Women’s Day, 2019, the Ottawa Branch of the Federation of Medical Women of Canada and Canadian Women in Medicine co-hosted a presentation by Dr. Angel Foster, Associate Professor in the Interdisciplinary School of Health Sciences at the University of Ottawa and 2011-2016 Endowed Chair in Women’s Health Research. Dr. Foster spoke on the global journey of mifepristone and whether it lived up to the promise that it would “change everything”…
Abortion, politics, and the pill that promised to change everything: The global journey of mifepristone
According 2018 data, there are over 50 million users of mifepristone globally. It is registered in more than 60 countries worldwide. In some of those countries, over 80% of abortions are undertaken with mifepristone. Access to mifepristone is not available in many countries in the Southern Hemisphere due to cultural and religious restrictions. Even where abortion is legal, barriers exist that limit access and availability to women who need it.
Many abortions occur in settings where abortion is prohibited or legally restricted. Laws restricting abortion do not decrease abortion rate, but do increase the abortion death rate; lack of access to safe abortion care accounts for 8% - 18% of maternal deaths. Mifepristone combined with misoprostol is 98% effective when used through 10 weeks; it is extremely safe with few contraindications, tolerable side effects, and with time to manage complications should they arise. WHO recommendations support provision in low resource settings and by a range of clinicians and health workers.
Dr. Foster argues that mifepristone has been subject to over-regulation, particularly in the US and Canadian context. Canada legalized hospital abortions in 1969, which decriminalized abortion, but put restrictions on access; while the US legalized abortion in 1973 with the ruling of Roe vs Wade. Despite Canada’s early gain, it wasn’t until the Supreme Court ruled on R v. Morgentaler in 1988 that Canadian women gained access to abortion care across the country. Although legal, there continues to be a host of laws and regulations that limit access to abortion care, both surgical and medical. From “Physician Only” laws that target the regulation of care providers, to Risk Evaluation and Mitigation Strategies (REMS) that restrict dispensing privileges to clinicians who must register in advance with the distributor, to “label” laws that require US patients to sign an FDA-approved medication guide; accessing mifepristone isn’t as simple as it could be.
In order to understand the potential for full health system integration, Dr. Foster looked at the situation in Tunisia, which introduced family planning clinics in 1952 and legalized abortion in 1973. The Tunisian government created the Office National de la Famille et de la Population (ONFP), a division of public health dedicated to reproductive health. Tunisia has the safest and most comprehensive abortion care; unsafe abortion is virtually non existent, and Tunisia has fully integrated mifepristone into their health system. Tunisia is an example of a low- to middle-income country where medical abortion has been successfully integrated. Mifepristone does not have to be exceptionalized or have cumbersome regulatory requirements, its use can reduce health care costs associated with abortion care, while integrated services are less susceptible to political interference.
What do we have to learn from de-medicalized strategies in countries where abortion remains restricted, such as Poland where, according to official statistics, only 700-900 abortions take place per year. To serve the gap in services, Polish women turned to Women Help Women, an online/telemedicine network of organizations and individuals committed to providing safe abortion care to women in need. Dr. Foster examined the role of Women Help Women in Poland through questionnaires and qualitative interviews with women who used the service. She found that the care provided through Women Help Women was very well-received by the women using the program. She found that the participants were overwhelmingly satisfied; that they valued the privacy, confidentiality and convenience of the telemedicine service, and they felt strongly that the service should expand. Dr. Foster’s research proves that the online/telemedicine provision of mifepristone is an acceptable way to increase access. It also supports the argument that de-medicalized strategies are safe, effective, accessible and acceptable to women.
Dr. Foster asked the audience to consider questions that challenge the orthodoxy of unsafe abortions: the language, frames and priorities for action. How does medical abortion, and de-medicalized strategies in particular, fit with dominant definitions of unsafe abortion? Who provides the medical abortion? What might it mean if we re-conceptualize where the locus of control lies?
Mifepristone has the promise to change how abortion care is delivered, in particular, moving it from behind- to over-the-counter, as women return to the concept of a very, very early abortion - “Bring down your period” pill; contragestive, unpregnancy pill, or a monthly “baby be gone” pill.
Mifepristone has a long history and a safe record internationally and is on the WHO List of Essential Medicines. Dr. Foster’s presentation and her research with Women Help Women highlights first and foremost, the unrelenting fact that in the absence of legal and safe abortion care, women will still find a way to have an abortion.
In Canada, where Mifegymiso was approved for use in January 2017, barriers to access continue to hamper women’s reproductive freedom. Over-regulation has been challenged by physicians and with some success. Recently, Health Canada announced the removal of the ultrasound requirement which limited access to rural and isolated women. However, training requirements not required of other medications and dispensing directives that infantilize women remain that cause undue hardship for these patients. Despite the overwhelming positives that accompany mifepristone, cultural and religious attitudes continue to infiltrate the discussion around women’s reproductive freedom in subtle and sometimes and not so subtle ways. Some sections of the population persevere in advocating for abortion care restrictions, in part fuelled by religious conviction. Abortion care does not receive mandatory coverage in the medical school curriculum, and practitioners can conscientiously object and refuse treatment. In a community with limited health personnel, that could be all it takes to create an insurmountable travel barrier.
Geography is a major barrier in accessing abortion care, especially for rural and isolated women. Health providers are in great demand in northern and rural communities. De-medicalizing abortion care by utilizing the services of non-physician health care providers in support roles can improve access for rural and isolated women in circumstances where physician resources are scarce. While access to Mifegymiso was granted at the federal level, provincial jurisdiction over health care means that access varies by province, with some provinces refusing to provide cost coverage (Nunavut, Saskatchewan and Manitoba). Activists across the country have been leading the charge for full prescription coverage. Due to their efforts, cost coverage is available in most Canadian provinces.
Are there lessons to be learned in Canada from Plan B, an over the counter “morning after” pill that must be taken within 72 hours of unprotected sex? Plan B is available on pharmacy shelves in most provinces, except Quebec and Saskatchewan where it is held behind the counter. Support is provided online via the manufacturer, complete with a medical information line.
Certainly for some women, access to mifepristone has changed everything for them in terms of access to abortion. This is particularly relevant in those countries where upwards of 80% of abortions are medical such as Norway and Sweden. When are women in Canada going to given full access to medical abortion care, no matter where they live? It’s time for Canada to let women have equal access across the country to Mifepristone.
Dr. Bev Johnson, MD, CCFP
Ottawa Branch President
Federation of Medical Women of Canada
Dr. Tonja Stothart, MD, BSc, BEd, CCFP, FCFP
Canadian Women in Medicine