Medical abortion is an essential service during the pandemic

Changes in abortion demand owing to COVID-19

For many reasons, the unmet need for abortion during the COVID-19 pandemic might increase.

Difficulty accessing contraception. In March 2020, owing to concerns about drug supply-chain disruptions, the Canadian Pharmacists Association⁶ advised 30-day dispensing limits for all prescription medications, a restriction that lasted in some provinces into the summer. These restrictions increased the likelihood of missed doses of contraception. In addition, dispensing medication more frequently meant that patients paid dispensing fees more frequently, increasing the relative cost of using prescription contraception. For people who lost drug benefits owing to the economic downturn, the cost of contraception might also now be prohibitive.

Supply-chain disruptions risk many prescription contraceptives becoming unavailable for unknown periods of time. Shortages in supply can have a cascading effect if demand suddenly increases for the contraceptives still left on the market, much in the way that several recalls of ranitidine in the months before the pandemic led to increased demand and months-long shortages of other acid reflux medications.⁷ The global supply chain for condoms was also disrupted by COVID-19, with halted or reduced production prompting manufacturers to warn of impending shortages.⁸

Changes in abortion demand and access. Public health stay-at-home directives have forced many to shelter in place in dangerous environments. Reports of intimate partner violence and child abuse have increased, including rates of sexual assault in the home.⁹ As a consequence, we might see an increase in unintended pregnancy. To further complicate an already awful scenario, pregnancy is a well-established intensifier of intimate partner violence.^10-12 In ordinary times, a woman living in an abusive situation could more easily access her support system and her medical providers if pregnancy posed a threat to her safety. During the pandemic, however, the enormous pressure not to go out means that patients cannot access medical care in the same way, resulting in limited options for termination of pregnancy.

At the same time that we could see an increase in unintended pregnancies, abortion services themselves are being restricted. While Canadian health authorities have classed abortion as essential care, some clinics and hospitals have delayed procedures such as intrauterine device insertions and restricted abortion services. Abortion clinics continue to operate, but some have reduced their catchment area.¹³ For much of rural Canada, standalone clinics are inaccessible, particularly now that the pandemic has made travel more difficult. Travel out of communities to access these stand-alone abortion clinics might result in women having to isolate upon their return, which can present another barrier to access. School and day-care closures present yet another barrier, because most people seeking abortion have children and might now lack child care.¹⁴

How the abortion pill can help

The mifepristone and misoprostol regimen solves many of the abortion access issues created by COVID-19. The medications can be taken at home, thereby eliminating the need to travel and the many complications associated with travel during the pandemic. The cost of the prescription is covered by provincial or territorial health insurance and some national programs, so lack of drug benefits should not be a barrier.¹⁵ The tablets can be taken discreetly in unsafe environments and the pregnancy’s end passed off as a heavy period or spontaneous miscarriage by anyone facing an abuser’s scrutiny.

Unlike surgical abortion, which can involve imaging, multiple visits, and close contact between health care providers and patients, medical abortion generally requires less contact and can be done without imaging in many cases. In April 2020, the Society of Obstetricians and Gynaecologists of Canada (SOGC) released new guidelines for prescribing the mifepristone and misoprostol regimen via telemedicine,¹⁶ which are based on evidence that virtual prescribing and management of medical abortion is safe and effective.^17-20 The SOGC guidelines make these medications a viable option for patients needing a pregnancy termination, while respecting public health guidelines during the pandemic.

Primary care needs a culture shift

One of the important factors in patient access to the mifepristone and misoprostol regimen has been reluctance within primary care to prescribe it. Nearly one-third of all Canadian women will have an abortion, making it one of the most common health services in the country.²¹ The view that abortion is specialized, out-of-scope care persists, despite how fundamental a service it is.²² Medical abortion, in particular, has been hailed as a game changer in Canadian reproductive health care, a way to reverse our problem of extremely uneven access to abortion. The ability to have an abortion without traveling for hours or even days eliminates substantial geographic barriers for rural populations.²³ Primary care providers understand better than most how patients suffer when they cannot access geographically remote services. We should be embracing tools that prevent this type of suffering, especially during the pandemic when the need for abortion might be greater.

Family physicians uncertain about medical abortion should be aware of the resources and supports that exist. The SOGC offers an online course that reviews the basics of prescribing medical abortion as well as the management of complications. Although the course was once mandatory before prescribing combined mifepristone and misoprostol, the requirement has since been removed. The online community Canadian Abortion Providers Support (https://www.caps-cpca.ubc.ca/index.php?title=Main_Page) is backed by the SOGC and the College of Family Physicians of Canada and has downloadable resources such as patient handouts, checklists, and electronic medical record templates for primary care providers. An infographic published in early 2020 in Canadian Family Physician provides some basic information for both primary care providers and patients. Evidently, there is no shortage of resources to support the successful integration of medical abortion access into primary care practice (https://www.cfp.ca/content/66/1/42/tab-figures-data).²⁴

Medical abortion is a core primary care service, yet patients’ access to this service remains largely limited by the attitudes of many primary care providers. Conscientious objection and anti-choice attitudes among primary care physicians, refusal of clinic staff to clean clinic rooms in which medical abortion is provided, administrator reluctance to implement medical abortion protocol, and pharmacist refusal to dispense are some of the attitude barriers that increase the difficulty for patients to access medical abortion.²⁵ A culture shift within primary care regarding the provision of medical abortion is needed to realize the enormous potential that the mifepristone and misoprostol regimen has for reproductive health care, including in addressing geographic disparities of abortion services in Canada. Its discreet form, nearly universal Medicare coverage, and prescription accessibility via telemedicine allow it to surmount many of the barriers created by the COVID-19 pandemic. In this environment, family physicians have a duty to protect access to reproductive health care, and that means recognizing the importance of the abortion pill.