Changing mifepristone to a normal prescription: effect on primary care abortion provision

Problem

In Canada, mifepristone became available for medical abortion in January 2017. Previously all abortions were provided by physicians, mainly as a focussed practice or specialty in urban areas, and >96% were surgical. By November 2017 restrictive regulations were removed so that mifepristone could be provided as a regular prescription by any primary care physician or nurse-practitioner (NP), dispensed by any pharmacist, without requirements for certification or observed dosing. We investigated trends for abortion rate, method, and workforce, examining all most responsible professionals (MRP) providing abortion in the province with 40% of Canada’s population.

Approach

We defined all medication and surgical abortion events from January 1, 2012 to March 15, 2020, by examining Ontario government linked health administrative data, including practitioner visits, hospital, emergency and ambulatory care admissions, and dispensed pharmaceuticals. For each abortion we identified one MRP. We examined temporal trends and rates for the number and characteristics of MRP, including age, sex, specialty, rural vs urban practice, and abortion method.

Findings

Among all 315,447 abortions we identified a MRP for 311,742 (98.3%). The abortion rate remained approximately 11 per 1000 female residents aged 15-49 throughout the study period, while the proportion of all abortions provided by medication increased from 2.2% to 31.4%. In the pre-mifepristone period (2012-2016), the number of providers of abortion each quarter was relatively stable and under 330, with 20.6% providing only medication abortion (‘medication-only’). The number of providers trebled rapidly once mifepristone could be prescribed as a normal prescription, reaching 1104 by the end of the study period, with 877 (79.5%) providing ‘medication-only’. By 2020, MRPs were mostly general practitioners (66.5%) with obstetrician gynecologists (O&G) and NPs as 23.2% and 9.1%, of the workforce respectively. For each discipline, the proportion of members providing abortion rose (GPs 0.5% to 1.9%; O&G 11.2% to 15.6%; NPs 0% to 2.5%). The number of abortion providers working in rural areas rose from 9 to 111 after restrictions were lifted, representing a 12-fold increase, while the proportion of all physicians working in rural areas remained unchanged. Providers’ mean age fell 6.9 years. The proportion of female providers rose from 39.5% to 63.4% overall, increasing among both ‘medication-only’ (53.5% to 65.2%) and ‘surgical-only’ providers (27.1% to 42.6%).

Consequences

Mifepristone availability without restrictions on distribution, prescribing and dispensing was associated with a rapid increase in primary care and rural provision of services. We observed a tripling of the overall number of most-responsible-professionals offering abortion care, while the abortion rate remained stable. New abortion providers were predominantly younger, female, primary care providers.