Dispensing mifepristone for medical abortion in Canada: Pharmacists' experiences of the first year

Not here, not now: a mystery caller study of availability of mifepristone in community pharmacies in Alberta, Canada

OBJECTIVES

This study assessed same-day availability, dispensing practices, and information provision for mifepristone in Alberta pharmacies.

STUDY DESIGN

Cross-sectional data from 1620 pharmacies (>99% response) were collected from pharmacy respondents using a mystery caller approach (January-October 2024). Using a standardized script, team members inquired about mifepristone availability, Alberta's coverage plan, and dispensing. Outcomes included: (i) same-day stock availability, (ii) willingness to order, (iii) refusal to order (iv) conscientious objection. Accuracy of cost information, and adherence to regulatory standards were assessed. Geographic patterns and associations with the deprivation index of pharmacy location were explored.

RESULTS

Same day dispensing was available at 12.9% pharmacies, and 76.2% offered to order it, with delivery times estimated from next day to 10 days. A small number of pharmacies (n=86, 5·3%) did not offer to order with no reason given; conscientious objection was reported by 90 pharmacies (5·6%), of which only 10.0% (n=9) provided onward referrals. Awareness of Alberta's universal coverage for mifepristone was low; 71.1% of respondents incorrectly stated that uninsured patients must pay out of pocket. Mifepristone was less often in stock in Alberta's two major cities; pharmacies in high-deprivation areas were less likely to have mifepristone in stock and more often expressed conscientious objection.

CONCLUSION

Same-day mifepristone availability in Alberta pharmacies is limited, and adherence to referral standards among objectors is poor. Awareness of universal coverage is suboptimal, raising concern about overcharging. Enhancing access may require collaboration between abortion providers and pharmacies, increased communication about coverage policies, and innovative solutions related to dispensing.

IMPLICATIONS

Limited same-day access to mifepristone, compounded by poor adherence to regulatory standards and low awareness of public coverage, highlights equity gaps in abortion care across Alberta, Canada. Targeted policy reforms and pharmacist education are needed to improve timely, reliable access, particularly for socioeconomically disadvantaged communities.

Nurse practitioner medication abortion providers in Canada: results from a national survey

BACKGROUND

In 2017, nurse practitioners (NPs) became the first non-physician healthcare providers authorised to independently provide medication abortion (MA) in Canada. We aimed to report on demographic and clinical characteristics of NPs providing mifepristone/misoprostol MA in Canada and to identify context-specific barriers and enablers to NP provision of mifepristone/misoprostol MA in Canada among MA providers and non-providers.

METHODS

From August 2020 to February 2021, we invited Canadian NPs to complete a national, web-based, bilingual (English/French) survey. The survey was distributed through national and provincial nursing associations and national abortion health professional organisations. We collected demographic and clinical care characteristics and present descriptive statistics and bivariate analyses to compare the experiences of NP providers and non-providers of MA.

RESULTS

The 181 respondents represented all Canadian provinces and territories. Sixty-five NPs (36%) had provided MA at the time of the survey and 116 (64%) had not. Nearly half (47%) of respondents worked in rural or remote communities and 81% in primary care clinics. Significant barriers impacting non-providers' abilities to provide MA included limited proximity to a pharmacy that dispensed mifepristone/misoprostol, few experienced abortion providers in their community of practice, poor access to procedural abortion services, policy restrictions in NPs' places of employment, and no access to clinical mentorship. Some 98% of NPs providing MA services had never encountered anti-choice protest activity.

CONCLUSIONS

NPs appear prepared and able to provide MA, yet barriers remain, particularly for NPs in smaller, lower-resourced communities. Our findings inform the development of supports for NPs in this new practice to improve abortion access in Canada.

Changes in local access to mifepristone dispensed by community pharmacies for medication abortion in Ontario: a population-based repeated cross-sectional study

BACKGROUND

Although mifepristone for medication abortion has been available in Canada since a regulatory change in 2017, leading to its rapid uptake, the effects of this availability on regional access to abortion are unknown. We sought to examine how community pharmacy dispensation of mifepristone affected distribution of abortion services over time in Ontario, Canada.

METHODS

We used linked health administrative data to identify a cohort of all medication and procedural abortions provided in Ontario from 2017 to 2022, defined by outpatient mifepristone dispensations and abortion billing, diagnostic, and procedure codes. We evaluated changes over time in the annual proportion of community pharmacies that dispensed mifepristone and the availability and distribution of medication and procedural abortion services across geographic regions, defined by postal code forward sortation areas.

RESULTS

In 2017, 2% of Ontario pharmacies filled 1 or more prescriptions for mifepristone, which increased to 20% in 2022. In 2017, few regions contained a mifepristone-dispensing pharmacy (19%) or procedural abortion service (18%). By 2022, most regions had local access to a mifepristone-dispensing pharmacy (77%), with geographically distributed abortion services across Ontario. Although only 37% of abortion service users lived in a region with either a mifepristone-dispensing pharmacy or procedural provider in 2017, this increased to 91% by 2022.

INTERPRETATION

Access to medication abortion across Ontario increased substantially within 5 years of mifepristone's availability as a normally prescribed and dispensed medication. This regulatory approach appears successful for achieving widespread access to local abortion services.

Availability of mifepristone and misoprostol in Oregon pharmacies: A comparison by rural and urban status

OBJECTIVES

To evaluate the availability of mifepristone and misoprostol at pharmacies in a state with protective abortion legislation and variation in access by rurality.

STUDY DESIGN

Using a secret shopper survey, researchers attempted to contact all community pharmacies in Oregon and evaluate their mifepristone and misoprostol provisions.

RESULTS

Among the 444 pharmacies surveyed, mifepristone was planned at 19.2%. Misoprostol was available at 77.5%, but stocking issues and medication ordering impact access, without significant differences by rurality.

CONCLUSIONS

Pharmacy engagement and support are key to increasing access to these essential medicines, which may be improved through education and referral programs.

Willingness of Pharmacists to Prescribe Medication Abortion in California

Importance

Nearly half of US states have restricted abortion access. Policy makers are exploring pathways to increase access to abortion and reproductive health care more broadly. Since 2016, California pharmacists could prescribe hormonal birth control, providing an opportunity to learn about the implementation of pharmacist-provided reproductive health care.

Objective

To explore the feasibility of broadening pharmacist scope of practice to include prescribing medication abortion.

Design, Setting, and Participants

A cross-sectional online survey was conducted from October 11 to December 20, 2022, among a convenience sample of California licensed community pharmacists to examine their attitudes toward, knowledge of, and confidence in prescribing hormonal birth control and reports of pharmacy-level practices.

Main Outcomes and Measures

Descriptive analyses and log-binomial regression models were used to compare medication abortion and contraceptive provision attitudes by pharmacist and pharmacy characteristics.

Results

Among the 316 pharmacists included in the analysis who worked at community pharmacies across California (mean [SD] age, 40.9 [12.0] years; 169 of 285 [59.3%] cisgender women; and 159 of 272 [58.5%] non-Hispanic Asian individuals), most (193 of 280 [68.9%]) indicated willingness to prescribe medication abortion to pharmacy clients if allowed by law. However, less than half were confident in their knowledge of medication abortion (139 of 288 [48.3%]) or their ability to prescribe it (115 of 285 [40.4%]). Pharmacists who indicated that providing access to hormonal birth control as a prescribing provider was important (263 of 289 [91.0%]) and were confident in their ability to prescribe it (207 of 290 [71.4%]) were 3.96 (95% CI, 1.80-8.73) times and 2.44 (95% CI, 1.56-3.82) times more likely to be willing to prescribe medication abortion and to express confidence in doing so, respectively. Although most pharmacists held favorable attitudes toward hormonal birth control, less than half (144 of 308 [46.8%]) worked in a pharmacy that provided prescriptions for hormonal birth control, and 149 who did not reported barriers such as lack of knowledge or training (65 [43.6%]), insufficient staff or time to add new services (58 [38.9%]), and lack of coverage for services (50 [33.6%]).

Conclusions and Relevance

The findings of this cross-sectional survey study of California pharmacists suggest that most pharmacists were willing to prescribe medication abortion. However, future efforts to expand pharmacists' scope of practice should include training to increase knowledge and confidence in prescribing medication abortion. Pharmacy-level barriers to hormonal birth control prescription, such as insurance coverage for pharmacist effort, should also be addressed, as they may serve as barriers to medication abortion access.

Pharmacists' experiences dispensing misoprostol and readiness to dispense mifepristone

BACKGROUND

Mifepristone, followed by misoprostol, is commonly used for medication abortion and early miscarriage care. Since mifepristone's approval in 2000, the Food and Drug Administration (FDA) has placed restrictions on where and how it could be dispensed, including applying a Risk Evaluation and Mitigation Strategy in 2011. In December 2021, the FDA removed the in-person dispensing requirement and, in January 2023, began allowing certified pharmacies to dispense the drug directly to patients.

OBJECTIVES

To explore pharmacist knowledge about misoprostol and mifepristone, experience dispensing misoprostol, as well as comfort and readiness to dispense mifepristone should federal regulations allow.

METHODS

We conducted in-depth interviews with 21 U.S.-based pharmacists and pharmacy trainees between June and December of 2021, a time when few pharmacists were allowed to dispense mifepristone.

RESULTS

Participants reported varied knowledge about medications for miscarriage and abortion but described themselves as generally knowledgeable about medications and reported strategies for learning about new medications. Most said they would feel ready to dispense mifepristone, and many described dispensing misoprostol without difficulty. Potential challenges specific to mifepristone dispensing included employer hesitation and colleague refusals. To assure successful dispensing, participants recommended basic training and fact sheets; relationships with prescribers for follow-up; and policies for prescription transfers in the event of refusal.

CONCLUSIONS

We found that nearly all participants would feel ready to dispense mifepristone with some basic training. Pharmacists self-report having the skills and resources to learn about new medications quickly. Our findings support the FDA's rule change allowing pharmacist dispensing of mifepristone and suggest that most challenges would stem from individual or institutional refusals.