Regulatory Landscape
Abortion is legal in Canada, and patients do not require consent from partners or parents to seek an abortion. It is the second most common reproductive health service: one in three Canadian pregnancy-capable persons will seek abortion in their lifetime[1,2].
Medication abortion uses medication pills to end a pregnancy. In Canada, the medication abortion pills are packaged and sold as Mifegymiso.
- Mifegymiso is approved by Health Canada for gestational age up to 63 days, but has been shown by SOGC to be safe and effective for up to 70 days.
- It is provided free-of-charge to all patients with provincial health insurance and several categories of federal health insurances.
- Patients eligible for healthcare in one province, who attempt to access Mifegymiso in another province or territory, are eligible for counselling, assessments and follow-up but not for the medication itself.
- It can be prescribed through in-person visits or virtual consultations, or a combination of the two.
Scope of practice: At the time of this writing, physicians and nurse practitioners in Canada are authorized to prescribe Mifegymiso. In most cases, pharmacists are in charge of dispensing the medication to patients, but some clinics are also authorized to dispense the medication directly to patients. With the exception of Quebec, midwives are currently not authorized to prescribe Mifegymiso but can provide medication abortion care by working closely with nurse practitioners or physicians.
Province-specific requirements: Healthcare providers should check specific guidelines and scope of practices in their provinces or territories. For example, provinces may differ in their requirements on who can pick up the medication and whether pharmacists have to register with Celopharma, the manufacturer of Mifegymiso. Click here to see the summary of some province-specific regulations for dispensing Mifegymiso.
Training requirement: Completing a training course is no longer required before prescribing or dispensing Mifegymiso, but healthcare providers may find the online courses below useful in learning about MA care.
Facility Setup
Below is a general guide of the steps to be taken when initiating medication abortion (MA) services in your facility. Some of these may not apply, depending on your facility[12].
Review protocol:
- Review guidelines for MA.
- Prepare your protocol and invite the clinical team to review and give feedback on the protocol.
- Determine if purpose of offering MA is for occasional support for current primary care caseload or if it will be made available as a service in the community.
- Evaluate related protocols including contraception, STI testing and treatment and other sexual and reproductive healthcare services, and integrate them with the abortion protocols if appropriate.
Review regulations and compensation processes:
- Review provincial and territorial regulations and scope of practice for physicians and nurse practitioners, and assess the potential involvement of registered midwives in providing MA.
- For physicians, get familiar with provincial billing codes for provision of MA, including codes for any testing that you would be doing on-site.
- For nurse practitioners and registered midwives, review the compensation processes from the professional associations in your jurisdiction.
Address abortion concerns among your team:
- Explore the willingness to provide MA among all staff, address their concerns and determine how to best incorporate abortion services into your practice (see the next module).
Prepare plans to support underserved populations:
- Evaluate your services for its ability to serve underserved population such as non-insured patients, patients from Indigenous communities and patients identified as 2SLGBTQI+.
- Consider incorporating trauma-informed care and harm-reduction approaches in your services.
- Prepare plans to provide low-barrier MA services for underserved populations, and review these plans with your staff.
Review staffing and administrative capacity:
- Review current clinic capacity to provide MA.
- Determine key person or team to be primarily responsible for MA patients.
- Assess best times for scheduling MA patients.
- Review your clinic's on-call schedule or your local hospital's call service to connect with obstetricians.
- For clinical staff, arrange in-depth training on counselling, provision of Mifegymiso, and complication management.
- For support staff, prepare phone scripts and other resources for them to review and use.
Set up your facility:
- Assess the design of waiting rooms, reception areas and counselling rooms to ensure they promote patient privacy.
- Review arrangements with a lab or in-house capacity for a quantitative βhCG test and Rhesus testing and administration.
- Identify ultrasound facilities in your community, if not available on-site.
- Determine what additional supplies or equipment are needed.
Identify clinics for referral:
- Find procedural abortion clinics if you do not provide procedural abortion service.
- Identify abortion clinics in your area who can accept prompt referrals if your schedule cannot accommodate patients in a timely manner to ensure that your patients do not miss the window for MA.
- Find pharmacies that regularly stock Mifegymiso and develop relationships with local pharmacies who could stock Mifegymiso.
Prepare communication materials:
- Obtain or develop patient education materials, consent forms and other charting forms.
- Develop, print and distribute posters to let your clients know that you prescribe MA.
Addressing Abortion Concerns
Below are suggestions on how to address opposition and concerns about medication abortion (MA) among your staff and colleagues, which will facilitate smooth integration of MA services into your practices[16].
- First, identify providers, administrators and support staff within your setting, who might be interested and committed to offering abortion services.
- Initiate informal discussions with colleagues about offering the service.
- Consider implementing an anonymous staff survey and patient survey to get an idea of people’s thoughts and feelings about MA.
- Consider organizing a workshop to clarify abortion beliefs, address opposition or discomfort, and determine ways for working together to provide MA. Abortion belief clarification workshop can be adapted using:
- Consider establishing a planning committee to discuss goals, tasks, timelines, obstacles and solutions.
- Find out about other local health centres or providers who have successfully integrated abortion services into their practice and invite them to meetings, workshops and planning sessions, or invite them to provide feedback and consult on your process.
- Develop a protocol for staff members who feel that they are unable to participate in providing abortion services.
- When interviewing applicants for staff vacancies, discuss the idea of abortion. Include in the job posting that applicant should be open to all aspects of reproductive care including pregnancy termination.
Federal Insurance Schemes
Patients who are covered through Federal programs, may request a prescription for Mifegymiso and fill it at a pharmacy of their choice and it will be fully covered when the pharmacy submits the billing to the Federal Plan assuming all other requirements for utilizing Mifegymiso are met.
Non-Insured Health Benefits (NIHB) Program
Eligible First Nations and Inuit clients are covered fully for the cost of Mifegymiso for medication abortion. The claim process follows the normal submission process for other prescription drugs.
Link: https://nihb-ssna.express-scripts.ca/en/0205140506092019/16/160407
Veterans Affairs Canada
Mifegymiso is currently listed as a standard benefit on the Veterans Affairs Canada (VAF) drug benefit list. This means that it is readily accessible to eligible clients with a valid prescription.
VAC clients have a VAC healthcare identification card on which "A" and/or "B" is indicated under the heading "Program number 10". Group A clients may only use their card to obtain health benefits directly related to the treatment of their VAC pensioned medical condition.
Group B clients are eligible for approved benefits if they have demonstrated a health need and the benefits are not available to them under a provincial health plan.
In addition, since veterans are covered for basic healthcare coverage through the provincial or territorial healthcare system, their access to Mifegymiso will follow the same provincial or territorial process as other residents.
Link: https://www.veterans.gc.ca/en/financial-programs-and-services/medical-costs/coverage-services-prescriptions-and-devices
Canadian Forces Health Services
Mifegymiso is a regular benefit on the Canadian armed forces drug benefit list; no special authorization is required.
Link: http://www.cmp-cpm.forces.gc.ca/hs/en/drug-benefit-list/index.asp
Royal Canadian Mounted Police (RCMP) Health Benefits Program
RCMP officers are considered insured persons and receive basic healthcare through the healthcare system in the province or territory in which they reside, their access to Mifegymiso will follow the provincial or territorial process as other residents. Additionally, private plans that cover the cost of prescription drugs is also an option.
Link: https://bc-cb.rcmp-grc.gc.ca/ViewPage.action?siteNodeId=2234&languageId=1&contentId=58416
Interim Federal Health Program (IFHP)
Coverage for Mifegymiso with IFHP is available in provinces and territories that have the medication listed on their public drug formularies.
Link: https://www.canada.ca/en/immigration-refugees-citizenship/services/refugees/help-within-canada/health-care/interim-federal-health-program/coverage-summary.html
Programs from Correctional Services of Canada
Service for people incarcerated in federal penitentiaries is provided directly from the pharmacy within the facility.
Non-Insured Patients
Providers can support non-insured patients by:
- Determining the cost of Mifegymiso and medication abortion (MA) consultations fees as out-of-pocket expenses. Make a list of community health centers and discount reproductive health clinics where patients can get a MA prescription at low or no cost.
- Exploring processes for waiving fees or developing cost-sharing agreements with partner organizations or other service providers.
- Ensuring administrative and supporting staff are aware of the plan.
- Referring patients to the Emergency Fund by National Abortion Federation (NAF) Canada and Action Canada:
2SLGBTQIA+ Patients
Below are some suggestions to help clinicians create an inclusive environment where the needs of 2SLGBTQIA+ patients can be met. These suggestions are not exhaustive and providers are encouraged to consider other manuals and cultural competency training opportunities to provide inclusive care.
These suggestions were reproduced from Gender Inclusive Language by Trans Care BC, The Trans-inclusive Abortion Services by the SHORE Centre and Fédération du Québec pour le planning des naissances, and the Handbook for Healthcare Providers Working with Clients from Diverse Communities by Action Canada for Sexual Health & Rights. For more information on the myths about reproduction of LGBTQ2S+, the vocabulary and glossary to use and avoid, and case studies and recommendations to overcome obstacles, please refer to these manuals.
Do's and Don'ts:
- Do have accessible bathrooms for multiple genders by removing “Male” and “Female” signs from washrooms, or replacing them with an “All Gender Bathroom” sign.
- Do display 2SLGBTQIA+ inclusive posters, pamphlets, and other materials to let your patients know that they are welcome.
- Do use inclusive clinical forms (e.g., intake forms) that are inclusive of all sexual orientations and gender identities. Consider whether the questions you are asking are necessary to ask for clinical purposes, or if they are asked out of curiosity only.
- Do ask which pronouns patients prefer and use them consistently throughout their care.
- Do ask patients and observe what words they use to refer to their body parts, and mirror their language.
- Do respect trans patients’ rights to educate on trans issues or speak on behalf of the needs of trans patients.
- Do seek to remove barriers for 2SLGBTQIA+ patients.
- Do NOT use labels and terms derived from older versions of DSM and ICD such as transgenderism, transsexualism and gender identity disorder.
- Do NOT use derogatory terms and expressions even if your patient does.
Gender-inclusive language:
Say this |
Instead of |
Person (person in the pink shirt, pregnant person) |
Man, woman, girl, boy, ladies, gentlemen, sir, ma'am (pregnant women, guy in pink shirt) |
Parenthood |
Motherhood, fatherhood |
Assigned female, assigned male |
Biological female, biological male |
Cisgender |
Not trans, normal, real |
Chestfeeding |
Breastfeeding |
Transgender men, transgender women |
A transgender, transgenders |
External condom, internal condom |
Male condom, female condom |
Receptive intercourse, insertive intercourse |
Vaginal sex |
Monthly bleeding |
Period, menses |
Sexual health screening, internal exam, cervical screening |
Pelvic exam, woman's exam |
Internal reproductive organs |
Female reproductive organs |
Internal gonads |
Ovaries |
External gonads |
Testes, testicles |
Internal genitals, genitals |
Vagina |
External genitals, erectile tissue, genitals |
Penis |
Indigenous Patients
Below are suggestions to help non-Indigenous healthcare professionals create an inclusive environment for Indigenous patients. These suggestions are not exhaustive and providers are encouraged to consider other manuals and cultural competency training opportunities to provide inclusive care.
A variety of factors and realities may affect how Indigenous Peoples access health services, including geographical access barriers, the unavailability of language and translation services, a lack of culturally safe health care settings or past experiences of racism, stigma, shame, fear or discrimination. Be mindful that being Indigenous is not a risk factor in itself, what actually puts people at risk are systemic issues like racism, colonialism, inter-generational trauma, and a lack of access to culturally safe care, treatment and supports.
These recommendations were reproduced from The Indigenous Ally Toolkit by the Montreal Urban Aboriginal Community Strategy Network, and the Handbook for Healthcare Providers Working with Clients from Diverse Communities by Action Canada for Sexual Health & Rights.
Quick tips for clinicians:
- Offer translation services, and where possible, translated resources.
- Connect with, and advocate for the involvement of, Indigenous patient navigators in your area.
- When hearing about difficult or violent experiences from patients, affirm their experiences and stories. Avoid shaming them for the feelings they have, or the ways they use to cope.
- Create and maintain a list of available resources and cultural supports within your region, including social services.
- Support your patients to participate in the creation of their treatment plans, including the incorporation of traditional and cultural resources and methods.
- Avoid saying “Canada’s Indigenous Peoples” or “Our Indigenous Peoples” – The Indigenous Peoples are not owned by Canada or by any individual.
- Avoid saying “The Indigenous culture” – this phrase does not recognize that there are hundreds of Indigenous communities, nations, languages and cultures existing in Canada. Instead of singular, try using plural forms “Indigenous cultures” or even better, being specific about the nation to avoid pan-Indigenizing.