In 2015, Health Canada approved the use of the medical abortion drug RU-486 (also known as Mifepristone). In Canada, the Mifepristone (RU-486) and Misoprostol drug regimen is sold under the name Mifegymiso.
This medication is now available to the public and, since November 1st, 2017, is accessible for free for Nova Scotia residents.
Making it available to people in Canada is an important step in ensuring access to the best possible care when it comes to sexual and reproductive health services.
Here are some frequently asked questions about Mifegymiso and medical abortion.
What is medical abortion?
How does Mifegymiso work?
Mifegymiso is the Canadian brand name for the combination of the medications Mifepristone and Misoprostol. Mifepristone is a medication that blocks the effect of progesterone, a hormone that is needed for a pregnancy to continue. Misoprostol is a prostaglandin and causes contractions of the uterus and relaxation of the cervix. This helps push out the contents of the uterus. Mifepristone and Misoprostol work together to end a pregnancy.
In Canada, Mifepristone is packaged in a combination box, 1- Mifepristone 200Mg tablet and 4 – 0.2Mg Misoprostol tablets. First a Mifepristone tablet is taken and then 24 to 48 hours later, Misoprostol tablets are taken. 4 Misoprostol tablets are taken at the same time.
Health Canada has fixed the gestational limit for on-label use at 63 days or 9 weeks. Evidence from other countries (including the United States) indicates that Mifepristone can safely be used beyond the mandated 63 days of gestation. In many countries, this medication is commonly used for medical abortion for pregnancies of up to 10 weeks of gestation (and beyond), which providers can do off-label in Canada.
The Mifepristone and Misoprostol regimen is on the World Health Organization’s list of essential drugs. It is considered the “gold standard” for medical abortion.
Is Mifepristone safe?
Mifepristone is already available in 60 countries. Its use was approved in France and in China in 1988 (almost 30 years ago) and since then, it has maintained an outstanding safety record throughout the world. In some of the countries where Mifepristone is used for medical abortion care, most people choose medical abortion. For example, in France, upward of 58% of abortions are done using medication, in Switzerland, 70% and in Norway, 84%.
Mifepristone and misoprostol has been used safely millions of time over a long period of time, have been formally studied and the rates of possible complications are very low. According to the World Health Organization (WHO), most people can use abortion pills safely. There are very few absolute contraindications to medical abortion.
Who can prescribe Mifegymiso?
Initially, the Health Canada decision had limited prescribing to physicians but this restriction has since been relaxed. The language of the regulations has been changed to “health professional” rather than "physician", accounting for the appropriate prescribing and dispensing scope of practice of among pharmacist, nurse practitioner, nursing and midwifery groups.
The Canadian Nurses Association has publicly shared their support for Nurse Practitioners prescribing of Mifegymiso.
The College of Nurses of Ontario was the first nursing governing body to support their NPs to prescribe Mifegymiso. In Since December of 2017, Nurse practitioners in Nova Scotia are also able to prescribe Mifegymiso.
Here is the December 6, 2017 decision from CRNNS in regards to Mifegymiso prescribing by NPs:
Is special training required to prescribe Mifegymiso?
Initially, Health Canada had mandated a training for prescribing physicians and pharmacists but this restriction was lifted in May 2017.
Mandated health professional training is no longer required: The new language (as for all health professional care) indicates, "health care professionals should have the appropriate knowledge."
The training is still available and offered through the Society of Obstetricians and Gynaecologists of Canada (SOGC) for interested health care providers to get better acquainted with medical abortion service provision. Find this training here: https://sogc.org/online-courses/courses.html/event-info/details/id/229
Who dispenses Mifegymiso?
The Nova Scotia College of Pharmacists produced guidelines in support of pharmacists and pharmacy technicians' involvement in dispensing directly to patients which means that Nova Scotia residents who receive a prescription from their doctor can go fill it at their local pharmacies.
Who pays for Mifegymiso?
In September 2017, Nova Scotia announced its intention to offer universal coverage in the coming fall. The province is following the lead of provinces like Alberta and Ontario in ensuring that people who need Mifegymiso and get a prescription for it from their health care provider can access it free of charge upon presenting their health card at the pharmacy. This was put in place to ensure equitable access to this important medication despite its high price tag which ranges from 300$-450$.
Coverage came into effect on November 1st 2017 and so, Nova Scotia residents can now access Mifegymiso free of charge.
Is there a billing code for medical abortion?
On May 23rd, 2018, the province of Nova Scotia officially announced a new billing code for mifepristone medical abortion services! To read more, click here
03.03V: Medical Abortion / Termination of Early Pregnancy, 45.7 units, Billing rate: $117.80
Follow up visits can be billed as regular office visits
Is an Ultrasound required?
Currently, the Health Canada approval of Mifegymiso includes a mandatory ultrasound.
Most of health care providers who operate in clinics do not have access to ultrasound machines on-site. The mandatory ultrasound requirement therefore requires multiple appointments, likely at different locations. This has the potential to result in serious delays in administering Mifegymiso within the 9-week gestation period, especially in regions where ultrasound services are few and far between, only accessible in hospitals, have long wait lists, etc.
In their April 2016 Medical Abortion guidelines, the Journal of Obstetrics and Gynaecology in Canada provided alternative means to confirm gestational age and rule out ectopic pregnancy when ultrasound is not available to the physician.
“In the absence of readily accessible ultrasound, gestational age can be estimated using last menstrual period (LMP), clinical history, and physical examination, in people who are certain of the date of their LMP. Ultrasound is needed when uncertainty remains. “
What does follow-up involve?
Seven to fourteen days after Mifepristone administration, a follow-up visit is required, which can be provided through an in person visit or remotely (e.g. telephone or telemedicine). When the patient first receives their prescription, a plan for this follow-up must be communicated to them, in addition to a plan should urgent care be needed beyond the hours of your clinic. This follow-up is needed to confirm completion of the abortion and for the person can be assessed for any complications, have any outstanding questions answered and for contraception planning if applicable. For more information, see the SOGC training on Mifegymiso.
What do I do when my first patient asks for Mifegymiso?
Barriers to abortion disproportionately affect young people and marginalized people, especially those who are low-income, people of color, migrants or refugees, people with precarious immigration status and those who do not speak English or French. These barriers are compounded for those living in rural or remote areas.
Making medical abortion more easily available is an important way to expand choice when it comes to terminating a pregnancy and could have an important impact on the accessibility of abortion in Canada. Therefore, it is important for health care providers to get informed about Mifegymiso to be ready to incorporate it in their practice. The SOGC training is a great first step in getting acquainted with what goes on during a medical abortion appointment.
Health care providers can also join communities of practice where they can get direct support from colleagues who prescribe Mifegymiso, including peer to peer workshops from local physicians. https://www.caps-cpca.ubc.ca/index.php/Main_Page
Some sexual and reproductive health organizations have developed materials to support prescribers in their regions. For example, you can reach out to Planned Parenthood Ottawa to ask about their Mifegymiso Project.
Who in Nova Scotia can help me prescribe Mifegymiso?
Health Care providers can reach out to the CAPS network to ask if there are any current medical abortion providers in their regions who would be willing to offer them guidance. CAPS has assisted health care providers in getting connected with one another to benefit from peer to peer support.
Health care providers can also call the toll-free number, 1-833-352-0719 to be linked to other Nova Scotia health care providers and advocates who can support them in integrating medical abortion into their practice and direct patients their way.
Does prescribing Mifegymiso put me and my staff at risk of harm?
While the likelihood of experiencing harassment and intimidation is rare in Canada, a larger barrier to health care providers opting to offer abortion care is the stigma they may experience within their work places. However, this can be mitigated by cultivating connectedness with colleagues, something that can be offered by communities of practice such as CAPS, by reaching out to supportive organizations like LEAF or the Halifax Sexual Health Center, as well as integrating abortion care into primary care and sexual health care more generally as opposed to offering it as a standalone service.
Also, Ontario is now leading the way in updating safe zones legislations to reflect the impact of Mifegymiso on abortion access points. These zones are designed to ensure that protesting activities do not happen in the immediate vicinity of clinics or points of service. Just this month, the government of Ontario passed a law banning protest activities outside of abortion clinics, creating a picket-free ‘bubble zone’ of between 50 and 150 metres around abortion facilities where it is forbidden to protest, advise a patient not to get an abortion, or intimidate or interfere with people passing in or out of the clinic. The bubble also includes 150 metres around the homes of providers and those who work in clinics. Hopefully, provinces and territories will follow this development promptly in implementing similar legislation.
For general inquiries about Mifegymiso and pregnancy options, please visit Action Canada for Sexual Health and Rights’ Mifegymiso website at www.mifegymiso.com, contact us at [email protected] or call the 24hr toll-free Access Line 1-888-642-2725