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^[2,14,15,18].

Medication abortion uses medication pills to end a pregnancy. In Canada, the medication abortion pills are packaged and sold as Mifegymiso. It is approved by Health Canada for gestational age up to 63 days, but has been shown to be safe and effective up to 70 days by the Society of Obstetricians and Gynaecologists of Canada and 77 days by the World Health Organization. The counselling and the medication are provided free-of-charge to all patients with provincial health insurance and several categories of federal health insurances. However, it is important to note that patients eligible for healthcare in one province, who attempt to get medication abortion in another province or territory, are covered for counselling but not for the medication itself.

Mifegymiso typically comes in two boxes: a green box containing mifepristone 200 mg (MIFE) and an orange box containing misoprostol 800 mcg (MISO). MIFE helps stop a pregnancy from growing and prepares the body to empty the uterus by softening the cervix and helping the lining of the uterus to break down. MISO causes the cervix to dilate and the uterus to contract, which makes the pregnancy tissues leave the body. It is also used for abortion and for other conditions (e.g., miscarriage, postpartum hemorrhage)^[14].

Indication:

MIFE / MISO is indicated by Health Canada for pregnancy termination up to 63 days as counted from the first day of the last menstrual period (LMP) in a presumed 28-day cycle. The Society of Obstetricians and Gynaecologists of Canada indicates safe use up to 70 days after LMP. There is no absolute lower gestational age limit^[5].

Contraindications^[6]:

• Ectopic pregnancy
• Chronic adrenal failure
• Inherited porphyria
• Uncontrolled asthma
• Hemorrhagic disorder or concurrent anticoagulant therapy
• Anemia (Hb level < 9.5 g/dL)
• Long-term systemic corticosteroid therapy
• Allergy or hypersensitivity to product ingredients
• IUD in situ (no longer a contraindication once removed)
• Serious systemic illnesses such as liver disease, cardiac disease, renal failure and seizure disorders (these illnesses should be evaluated individually)
• Uncertain gestational age
• Decisional uncertainty

Breastfeeding / Chestfeeding^[6]:

Oral MISO is excreted into human breast milk in small amounts which are rapidly eliminated. No interruption of breastfeeding or chestfeeding is necessary when misoprostol is given by any route.

Gestational Age > 63 days

The Society of Obstetricians and Gynaecologists of Canada and the National Abortion Federation both endorse medication abortion (MA) with MIFE / MISO up to 70 days after LMP. They also recommend a second dose of MISO 800mcg four hours after the first dose of MISO 800mcg to increase the effectiveness of MA^[5,13].

The Society of Obstetricians and Gynaecologists of Canada also recommends a MIFE / MISO regimen from 70-84 days gestational age, with mifepristone 200mg followed in 24-48 hours with two doses of MISO 800mcg (buccal or vaginal), 4 hours apart.

The effectiveness decreases as the gestational age approaches 70 days. Prescribers should counsel patients that this is off-label use, that there is a possibility of expelling and seeing an intact fetus, and that there are higher rates of bleeding and incomplete or failed abortion.

Patients between 15 to 18 years of age

Data is insufficient to establish efficacy and safety in patients younger than 15 years old. However, in patients aged between 15 and 18 years, safety and efficacy have been demonstrated with vomiting and pain being reported more frequently than in adults^[11]. Thus, special considerations for patients in this age range can include counselling to prepare them for vomiting and pain, as well as psychosocial supports through the medication abortion process.

At the time of this writing, physicians and nurse practitioners in Canada are authorized to prescribe Mifegymiso. Midwives in all provinces and territories, except for Quebec, are not authorized to prescribe Mifegymiso but can provide medication abortion care when working closely with nurse practitioners or physicians.

Providers of medication abortion can be found through:

• Find medication abortion services portal by Action Canada for Sexual Health and Rights (please click the hyperlink and then select the option “Medical Abortion”)
• The list of abortion clinics by Action Canada for Sexual Health and Rights.
• The Choice Connect Abortion Referral App.

Counselling and clinical assessments are required prior to prescribing Mifegymiso. Counselling is to help patients make an informed decision by understanding their options (abortion versus term pregnancy, and medication abortion versus procedural abortion). Clinical assessments are to confirm that the gestational age does not exceed the threshold (63 days by Health Canada, 70 days by the Society of Obstetricians and Gynaecologists of Canada), rule out serious conditions such as ectopic pregnancy and anemia, and determine the need for bloodwork such as Rhesus testing^[6].

In cases of virtual or hybrid provision of medication abortion (also called no-touch or low-touch medication abortion), the number of visits is minimized by carrying out counselling, screening and follow- up appointments virtually over the phone or through video. The purpose is to reduce the need for patients to travel long distance or wait for days or weeks to receive abortion. However, the virtual provision of medication abortion may put patients at risk due to the lack of ultrasound screening that can provide accurate assessment of the gestational age or about the presence of ectopic pregnancy. In addition, virtual medication abortion may involve more frequent (phone) follow- up to monitor the symptoms and risk of ongoing pregnancy and ectopic pregnancy, and thus it often requires more clinical resources. For these reasons, whether virtual provision of medication abortion is possible depends on prescribers’ experiences, clinical resources, patients’ needs and patients’ safety^[7].

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. Specific guidelines by the College of Pharmacies may differ between provinces and territories about whether patients need to be present in- person to pick up the medication, or whether the medication can be delivered to patients via postage services.