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Second- and Third-Trimester Medical Abortion Providers and Services in 2019: Results From the Canadian Abortion Provider Survey

  • Regina Renner
    Correspondence
    Corresponding author: Regina Renner
    Affiliations
    Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC

    Contraception Abortion Research Team, Women’s Health Research Institute, BC Women’s Hospital and Health Centre, Vancouver, BC
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  • Madeleine Ennis
    Affiliations
    Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC

    Contraception Abortion Research Team, Women’s Health Research Institute, BC Women’s Hospital and Health Centre, Vancouver, BC
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  • Edith Guilbert
    Affiliations
    Contraception Abortion Research Team, Women’s Health Research Institute, BC Women’s Hospital and Health Centre, Vancouver, BC

    Department of Obstetrics, Gynecology, and Reproduction, Laval University, Québec City, QC
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  • Geneviève Roy
    Affiliations
    Contraception Abortion Research Team, Women’s Health Research Institute, BC Women’s Hospital and Health Centre, Vancouver, BC

    Department of Obstetrics and Gynaecology, University of Montréal, Montréal, QC
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  • Jon Barrett
    Affiliations
    Contraception Abortion Research Team, Women’s Health Research Institute, BC Women’s Hospital and Health Centre, Vancouver, BC

    Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON
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Open AccessPublished:February 16, 2022DOI:https://doi.org/10.1016/j.jogc.2022.01.016

      Abstract

      Objectives

      Mifepristone became available in Canada in 2017. Updated national guidelines recommend its off-label use for second/third-trimester medical abortion (STMA/TTMA) by labour induction. The objective of this study was to explore STMA/TTMA provision in Canada and the role of mifepristone.

      Methods

      We conducted a national, cross-sectional, web-based, self-administered, anonymized survey, available in English and French. The survey was distributed through health professional organizations and recruited physicians who provided abortion care in 2019. We used a modified Dillman technique to maximize participation. The survey included sections on workforce and clinical care, including mifepristone use. We used R statistical software to produce descriptive statistics.

      Results

      Four hundred sixty-five clinicians responded to the survey, of whom 112 reported providing STMA and 63, TTMA, for a total of 115 respondents providing at least 1 of the 2 services. Two-thirds of respondents were general obstetrician–gynaecologists or family physicians and the remainder were maternal–fetal medicine subspecialists. The majority (64.7%) provided STMA/TTMA in an academic hospital, and 59.4% performed fewer than 5 STMAs (maximum 50) and 76.1%, fewer than 5 TTMA (maximum 15) in 2019. Fifty-nine percent of respondents reported having used mifepristone/misoprostol for STMA. Among mifepristone users, 48.6% used it for TTMA. Most required an indication beyond patient request to provide STMA/TTMA (82.1%/95.5%).

      Conclusions

      STMA/TTMA care is provided by multiple (sub-) specialties, and mifepristone has not yet been universally implemented. Our results will inform knowledge translation activities aimed at facilitating collaboration between STMA/TTMA providers and health policy and service delivery leaders and will further increase mifepristone use for STMA/TTMA in Canada.

      Résumé

      Objectifs

      La mifépristone est arrivée sur le marché canadien en 2017. La mise à jour des lignes directrices nationales recommande son utilisation hors indication pour l’avortement médicamenteux au deuxième ou troisième trimestre (AMDT/AMTT) par déclenchement du travail. L’objectif de cette étude était d’explorer la prestation de services d’AMDT/AMTT au Canada et le rôle de la mifépristone.

      Méthodologie

      Nous avons mené un sondage national, transversal, en ligne, autonome et anonyme, disponible en anglais et en français. Le sondage a été distribué par l’intermédiaire d’associations de professionnels de la santé pour recruter des médecins ayant prodigué des soins d’avortement en 2019. Nous avons utilisé une méthode de Dillman modifiée pour maximiser la participation. Le sondage comprenait des sections sur le personnel et les soins cliniques, y compris l’utilisation de la mifépristone. Nous avons utilisé le logiciel de statistiques R pour produire des statistiques descriptives.

      Résultats

      Des 465 cliniciens ayant répondu au sondage, 112 ont déclaré fournir des services d’AMDT et 63, d’AMTT, pour un total de 115 répondants fournissant au moins l’un des deux services. Les deux tiers des répondants étaient des obstétriciens-gynécologues généraux ou des médecins de famille, et le reste étaient des surspécialistes en médecine fœto-maternelle. En 2019, la majorité des répondants (64,7 %) ont fourni des services d’AMDT/AMTT dans un hôpital universitaire, 59,4 % ont effectué moins de 5 AMDT (maximum de 50) et 76,1 %, moins de 5 AMTT (maximum de 15). En tout, 59 % des répondants ont indiqué avoir utilisé la combinaison mifépristone-misoprostol pour l’AMDT. Parmi les utilisateurs de mifépristone, 48,6 % l’ont utilisée pour l’AMTT. La plupart ont fourni des services d’AMDT ou d’AMTT qu’en cas d’indication autre que la demande de la patiente (82,1 % et 95,5 %).

      Conclusions

      Les services d’AMDT/AMTT sont fournis dans plusieurs (sur)spécialités et la mifépristone ne fait pas encore l’objet d’une utilisation universelle. Nos résultats enrichiront les activités de transfert des connaissances visant à faciliter la collaboration entre les fournisseurs d’AMDT/AMTT et les responsables des politiques et de la prestation des services de santé ainsi qu’à augmenter l’utilisation de la mifépristone pour l’AMDT/AMTT au Canada.

      Keywords

      Introduction

      Approximately 84 000 medical and surgical abortions are provided in Canada each year,
      Canadian Institutes for Health Information
      Induced abortions performed in Canada in 2019.
      and one-third of females will have an abortion in their lifetime.
      • Norman W.V.
      Induced abortion in Canada 1974–2005: trends over the first generation with legal access.
      In 2019, the Canadian Institute for Health Information
      Canadian Institutes for Health Information
      Induced abortions performed in Canada in 2019.
      reported 1519 medical and surgical hospital-based abortions at 17 or more weeks gestation. Although second- and third- trimester medical abortions (STMA and TTMA, respectively), also referred to as termination inductions of labour, are less common than first-trimester abortions, they require time-sensitive, more complex, and often multidisciplinary care in the hospital.
      • Costescu D.
      • Guilbert É.
      No. 360-induced abortion: surgical abortion and second trimester medical methods.
      • Kerns J.L.
      • Turk J.K.
      • Corbetta-Rastelli C.M.
      • et al.
      Second-trimester abortion attitudes and practices among maternal-fetal medicine and family planning subspecialists.
      • Lappen J.R.
      • Vricella L.K.
      • Andrews V.
      • et al.
      Society for maternal-fetal medicine special statement: maternal-fetal medicine subspecialist survey on abortion training and service provision.
      • Sénéchal M.
      • Taillefer C.
      • Payot A.
      The medical process in pregnancy terminations for fetal anomaly: an analysis of counselling and bereavement.
      • Hull D.
      • Davies G.
      • Armour C.M.
      Survey of the definition of fetal viability and the availability, indications, and decision making processes for post-viability termination of pregnancy for fetal abnormalities and health conditions in Canada.
      Little evidence has been published on the STMA/TTMA Canadian workforce or the care they provide. In 2015, 73.1% of obstetrics and gynaecology (OB-GYN) residents reported that STMA training was available, and 61.1% expected competency at the end of residency.
      • Liauw J.
      • Dineley B.
      • Gerster K.
      • et al.
      Abortion training in Canadian obstetrics and gynecology residency programs.
      A 2012 survey focusing on recruitment of abortion clinics described fewer than 300 abortion providers in Canada,
      • Norman W.V.
      • Guilbert E.R.
      • Okpaleke C.
      • et al.
      Abortion health services in Canada: Results of a 2012 national survey.
      with only 22 respondents providing STMA (unpublished data). Additionally, rural/urban abortion access disparities were reported.
      • Norman W.V.
      • Guilbert E.R.
      • Okpaleke C.
      • et al.
      Abortion health services in Canada: Results of a 2012 national survey.
      The United Nations Human Rights commissioner expressed concern in 2016 over inequitable access to abortion services in Canada and called on the Canadian government to improve equitable access across the country.
      United Nations High Commissioner on Human Rights
      Committee on the elimination of discrimination against women: concluding observations on the combined eighth and ninth periodic reports of Canada.
      Several important health system and service changes have occurred since then in Canada. In 2017, mifepristone became available, and in the following year the Society of Obstetricians and Gynaecologists of Canada (SOGC) issued evidence-based clinical practice guidelines on STMA, including a recommendation for off-label mifepristone use to shorten the labour induction time interval.
      • Costescu D.
      • Guilbert É.
      No. 360-induced abortion: surgical abortion and second trimester medical methods.
      Evidence assessing the impact of these changes and their knowledge translation into practice is limited.
      • Munro S.
      • Guilbert E.
      • Wagner M.-S.
      • et al.
      Perspectives among Canadian physicians on factors influencing implementation of mifepristone medical abortion: a national qualitative study.
      ,
      • Shaw D.
      • Norman W.V.
      When there are no abortion laws: a case study of Canada.
      We conducted a national survey of abortion providers in Canada to assess the characteristics and distribution of the health workforce and the services they provide.

      Methods

      From July to December 2020, we recruited for a national survey of health care professionals who provided abortion services in the calendar year 2019.

      Survey Instrument

      The 2019 Canadian Abortion Provider Survey was developed by modifying our 2012 survey instrument,
      • Norman W.V.
      • Guilbert E.R.
      • Okpaleke C.
      • et al.
      Abortion health services in Canada: Results of a 2012 national survey.
      incorporating the latest evidence and expert opinions, to explore our study aims and expand the STMA/TTMA section.
      • Renner R.
      • Wagner M.-S.
      • Dunn S.
      • et al.
      Development and testing for a national survey: the Canadian abortion provider survey (CAPS).
      Our national, cross-sectional, self-administered survey was web-based, anonymized, and available in both English and French. Our survey included a consent statement, followed by sections on provider demographics and clinical characteristics of abortion provision. This article includes the results of the survey for the STMA/TTMA workforce and the abortion care they provide.
      We built in complex skip pattern logic so that respondents only saw relevant questions. The Canadian Abortion Provider Survey included mandatory questions when critical for skip pattern logic and data analysis. Respondents could request remuneration ($50 gift certificate) upon survey completion. We collected data through the secure server of the British Columbia Children’s Hospital Research Institute Research Electronic Data Capture platform.
      BC Children's Hospital Research
      BCCHR REDCAP data system.
      BC Children’s and Women’s University of British Columbia research ethics board approved this survey (H18-03313).

      Recruitment

      Physicians who provided abortion services in 2019 were eligible to participate. To reach potential participants for an exploratory sample of this unknown workforce, we distributed a generic survey link through multiple collaborating health care professional networks and organizations, including the SOGC and the Canadian Society for Maternal Fetal Medicine. Additionally, we recruited via publicly available sources such as hospital departments of OB-GYN, as well as family medicine, Canadian abortion clinics, and our web-based community of abortion practice platform (www.caps-cpsa.ubc.ca). We employed a modified Dillman technique to maximize the response rate, which included recruitment partners emailing survey reminders 1, 2, and 4–6 weeks after the initial invitation.
      • Dillman D.
      Mail and internet surveys: the tailored design method.

      Data Cleaning and Analysis

      Data cleaning included removing noneligible and fraudulent respondents (M. Ennis, unpublished data, September 2021). Using R Statistical Software, we generated descriptive statistics and report proportions or medians with interquartile ranges (IQR), where appropriate.
      • Team R.
      Rstudio: integrated development environment for r.

      Results

      Sample Description

      The flow of respondents from recruitment to data analysis is depicted in Figure 1. Four hundred sixty-five clinician respondents reported providing medical or surgical abortions in 2019. Of these, 24.7% indicated in the demographic section that they provided STMA/TTMA and are included in the analysis of this manuscript. Sixty percent of them started the subsequent STMA/TTMA survey section, which included clinical care–related questions. The majority of those who exited (82.6%) were general OB-GYNs and family physicians (FPs) who provided multiple types of abortion care and therefore had more survey sections to complete before reaching the STMA/TTMA section. We found similar proportions of respondents exiting by geographic region, facility type, and rural versus urban status.
      Figure thumbnail gr1
      Figure 1Respondent flow chart for second/third-trimester medical abortion (STMA/TTMA) providers. This flow chart is informed by the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).
      Statistics Canada
      Table 17-10-0135-01 population estimates, July 1, by census metropolitan area and census agglomeration, 2016 boundaries.
      • Eysenbach G.
      Improving the quality of web surveys: the checklist for reporting results of internet e-surveys (cherries).
      aConsent statement view recorded on Research Electronic Data Capture (REDCap) platform.
      BC Children's Hospital Research
      BCCHR REDCAP data system.
      bThe participation rate was 95.1%.
      cThe initial mandatory survey questions verified respondents’ eligibility. If responses did not match the eligibility criteria, respondents were automatically exited from the survey. This included a question confirming that they had not taken the survey before.
      dManual removal of respondents who exited the survey prior to completing mandatory eligibility questions.
      eDuplicate analysis was conducted using R Statistical software, flagging matching demographics, followed by manual review of all flagged respondents. We did not collect IP addresses or use cookies, as per our research ethics board request, to maintain respondents’ anonymity.
      fCompleted the survey (n = 64), defined as completing the last survey section. Completing the survey took 30–80 minutes, depending on the range of abortion services respondents provided, programmed using skip pattern logic based mostly on mandatory questions. Respondents could change answers on their current screen but could not go back to prior screens. The completion rate was 55.7%. The completion rate among respondents who started the second/third-trimester medical abortion section (n = 69) was 92.8%. The survey contained mandatory and nonmandatory questions (to increase the survey completion rate). We included questions with missing responses in the analysis.
      STMA: second-trimester medical abortion; TTMA: third-trimester medical abortion.
      Among respondents, 97.5% provided STMA and 54.8% TTMA. The respondents comprised 67 OB-GYNs (58.3%), 39 maternal-fetal medicine subspecialists (MFMs; 33.9%), and 9 FPs (7.8%). The majority of respondents were in urban centres (79.3%) and provided STMA/TTMA in an academic (64.7%) as opposed to a community hospital. Table 1 further describes demographics, including a breakdown by specialty.
      Table 1Demographics of second/third-trimester medical abortion respondents by specialty
      Group, no. (%)
      MFM subspecialists; n = 39 (33.9%)General OB-GYNs and FPs
      Due to the small number of FPs, we combined them with OB-GYNS when reporting results by specialty in this table.
      ; n = 76 (66.1%)
      Total; n = 115 (100%)
      Sex
       Male12 (30.8)11 (14.5)23 (20)
       Female27 (69.2)65 (85.5)92 (80)
      Age group, y
       <40<524 (33.3)
       40–4917 (50)23 (31.9)40 (37.7)
       50>13 (38.2)25 (34.7)38 (35.8)
      Region
      To maintain respondent anonymity, we reported geographic results by regions (British Columbia, the Prairies, Ontario, Quebec, the Atlantic Provinces, and the Territories), combining some low respondent number provinces.
       British Columbia
      To maintain respondent anonymity, we reported geographic results by regions (British Columbia, the Prairies, Ontario, Quebec, the Atlantic Provinces, and the Territories), combining some low respondent number provinces.
      9 (23.1)9 (11.8)18 (15.7)
       Prairie provinces
      Prairies include Alberta, Manitoba, and Saskatchewan.
      <511 (14.5)
       Ontario11 (28.2)18 (23.7)29 (25.2)
       Québec12 (30.8)30 (39.5)42 (36.5)
       Atlantic Provinces
      Atlantic Provinces include New Brunswick, Nova Scotia, Newfoundland and Labrador, and Prince Edward Island. We defined urban providers and facilities as those located within Statistics Canada's defined census metropolitan areas27.
      <56 (7.9)
       Territories
      Territories include North West Territories, Yukon, and Nunavut.
      0<5
      Type of abortion care
      Respondents could select more than 1 answer option.
       STMA38 (97.4)74 (97.4)112 (97.5)
       TTMA33 (84.6)30 (39.4)63 (54.8)
       Exclusively STMA/TTMA24 (61.5)<5
      Combined with other types of abortion care
       First-trimester medical abortion7 (18)56 (73.7)63 (54.8)
       First-trimester surgical abortion11 (28.2)65 (85.6)76 (66.2)
       Second-trimester surgical abortion10 (25.6)44 (57.9)54 (47.0)
      All types of care<515 (19.7)
      STMA/TTMA experience, y
       <57 (23.3)7 (23.3)15 (22.1)
       5–107 (23.3)7 (23.3)
       11–15<5<5
       16–20<5<58 (11.8)
       >209 (30)9 (30)17 (25)
      Guidelines
      Respondents could select more than 1 answer option.
       SOGC36 (100)68 (98.5)104 (99.1)
       NAF5 (13.9)28 (40.5)33 (31.5)
      Percentages were calculated based on the total number of respondents for the individual variable (based on skip pattern logic and nonmandatory questions). A dash indicates that totals are not reported to maintain respondents’ anonymity.
      FP: family physician; MFM: maternal–fetal medicine; NAF: National Abortion Federation; OBGYN: obstetrician-gynaecologist; SOGC: Society of Obstetricians and Gynaecologists of Canada; STMA: second-trimester medical abortion; TTMA: third-trimester medical abortion.
      a Due to the small number of FPs, we combined them with OB-GYNS when reporting results by specialty in this table.
      b To maintain respondent anonymity, we reported geographic results by regions (British Columbia, the Prairies, Ontario, Quebec, the Atlantic Provinces, and the Territories), combining some low respondent number provinces.
      c Prairies include Alberta, Manitoba, and Saskatchewan.
      d Atlantic Provinces include New Brunswick, Nova Scotia, Newfoundland and Labrador, and Prince Edward Island. We defined urban providers and facilities as those located within Statistics Canada's defined census metropolitan areas
      Statistics Canada
      Table 17-10-0135-01 population estimates, July 1, by census metropolitan area and census agglomeration, 2016 boundaries.
      .
      e Territories include North West Territories, Yukon, and Nunavut.
      f Respondents could select more than 1 answer option.

      Demographics by Specialty and by Rural Versus Urban Status

      MFMs predominantly worked in academic hospitals (90.0%) and exclusively in urban centres, whereas OB-GYNs/FPs were more commonly in community hospitals (55.3%) and rural areas (31.1%). Exclusive STMA/TTMA provision was more common among urban (26.1%) than rural respondents (8.6%). Most respondents, regardless of rural versus urban status, reported that first- trimester surgical abortion was also provided in their facility (87.3%), whereas second-trimester surgical abortion was provided less frequently (61.3%).

      Labour Induction Regimen

      Labour induction regimens by specialty are presented in Table 2. A mifepristone-misoprostol regimen for STMA was reported by 58.5% of respondents. It was more frequently used by MFMs (75.0%) and in urban areas (66.0%). Among mifepristone users, 48.6% used it for TTMA. Respondents reported using a mifepristone-misoprostol regimen in most patients at <28 weeks gestation (median 80.0%, IQR 0%–100%), in 45.0% (0%–100%) at ≥28 to ≤316 weeks, and in 25.0% (0%–100%) ≥32 weeks. The majority of respondents waited 24 hours between mifepristone and misoprostol administration (60.5%). Table 3 shows the breakdown of misoprostol regimen details (dose and frequency) by gestational age (GA) and by unscarred versus scarred uterus. Most respondents administered misoprostol vaginally (74.6%). Respondents used lower doses of misoprostol as GA increased and in the setting of a uterine scar, but 66.7% did not change use between patients with one versus multiple prior uterine surgeries/scars. Overall, 56.2% of respondents reported barriers to providing a mifepristone-misoprostol regimen. More urban than rural respondents reported barriers (61.7% and 40.0%, respectively). Barriers included lack of availability at the hospital or patients’ local pharmacies and lack of financial coverage for mifepristone.
      Table 2Clinical care characteristics by specialty
      Group, no. (%)
      Unless otherwise specified.
      MFM subspecialists; n = 31 (44.9%)
      The reported sample size in this table is based on the respondents who started the STMA/TTMA survey section.
      General OB-GYNs and FPs
      The reported sample size in this table is based on the respondents who started the STMA/TTMA survey section.
      ,
      Due to the small number of FPs, we combined them with OB-GYNs when reporting results by specialty in this table.
      ; n = 38 (55.1%)
      Total; n = 69
      Denominator is based on the respondents who started the STMA/TTMA clinical care section.
      (100%)
      STMA regimen
      Respondents could select more than one answer option.
       Mifepristone-misoprostol21 (75.0)17 (45.9)38 (58.5)
       Misoprostol12 (42.9)31 (83.8)43 (66.2)
       Prostaglandin E20<5
       Oxytocin drip5 (17.9)11 (29.7)16 (24.6)
       Osmotic dilators<57 (20.0)
       Intracervical catheter
      Use only reported after 32 weeks.
      <5<57 (10.8)
       Intra-amniotic saline/urea<50
       Rupture membranes
      Use only reported after 32 weeks.
      <55 (14.3)
      Maximum GA for mifepristone-misoprostol
       Patient request
      Do not provide24 (82.8)25 (73.5)49 (77.8)
      No limit<50
      Up to certain GA<59 (26.5)
      Median (IQR), wk24.0 (23.9–26.0)23.9 (20.0–24.0)
       Maternal medical indication
      Do not provide0<5
      No limit22 (75.9)19 (54.3)41 (64.1)
      Up to certain GA7 (24.1)14 (40)21 (32.8)
      Median (IQR), wk25.0 (24.4–25.0)23.9 (23.9–24.0)
       Fetal indication
      Do not provide0<5
      No limit24 (82.8)23 (63.9)47 (72.3)
      Up to certain GA5 (17.2)11 (30.6)16 (24.6)
      Median (IQR), wk24.9 (24.9–25.0)23.9 (23.9–23.9)
      Consult services
      Respondents could select more than one answer option.
       Ethics5 (16.7)6 (16.2)11 (16.4)
       Social work22 (73.3)21 (56.8)43 (64.2)
       Specialists for newborn22 (73.3)17 (45.9)39 (58.2)
       Genetic counsellor25 (83.3)28 (75.7)53 (79.1)
       Psychiatry<5<54 (6)
       Psychology5 (16.7)10 (27)15 (22.4)
       Other
      Most often reported consulting MFM subspecialists.
      <57 (18.9)
       None<5<5
      Ultrasound access
      Respondents could select more than one answer option.
       Diagnostic imaging<527 (75)
       MFM/perinatology26 (89.7)23 (63.9)49 (75.4)
       In clinic7 (24.1)6 (16.7)13 (20.0)
      Feticidal injection
       Never performed<524 (64.9)28 (43.1)
       Starting at specific GA24 (85.7)13 (35.1)37 (56.9)
       Injection GA, wk, median (IQR)20.5 (20.0–23.0)20.0 (20.0–22.0)20.0 (20.0–23.0)
      Percentages were calculated based on the total number of respondents for the individual variable (based on skip pattern logic and nonmandatory questions). A dash indicates that totals are not reported to maintain respondents’ anonymity.
      FP: family physician; GA: gestational age; IQR: interquartile range; MFM: maternal-fetal medicine; OB-GYN: obstetrician-gynaecologist; STMA: second-trimester medical abortion; TTMA: third-trimester medical abortion.
      a Unless otherwise specified.
      b The reported sample size in this table is based on the respondents who started the STMA/TTMA survey section.
      c Due to the small number of FPs, we combined them with OB-GYNs when reporting results by specialty in this table.
      d Denominator is based on the respondents who started the STMA/TTMA clinical care section.
      e Respondents could select more than one answer option.
      f Use only reported after 32 weeks.
      g Most often reported consulting MFM subspecialists.
      Table 3Misoprostol dose and frequency of administration
      Gestational age, no. (%)
      <246 wk25–276 wk≥28 wk
      Unscarred uterus
       Misoprostol dose, μg
      40047 (77.0)19 (31.7)9 (15.3)
      20012 (19.7)27 (45.0)17 (28.8)
      1000<519 (32.2)
      50<5<56 (10.2)
      Not used07 (11.7)8 (13.6)
       Frequency, h
      314 (23.0)9 (15.3)7 (12.1)
      445 (73.8)38 (64.4)36 (62.1)
      6<55 (8.5)7 (12.1)
      Not used07 (11.7)8 (13.6)
      Scarred uterus
       Misoprostol dose, μg
      40021 (35.0)<5<5
      20025 (41.7)18 (30.5)7 (11.7)
      10010 (16.7)24 (40.7)19 (31.7)
      50<5<59 (15.0)
      Not used<58 (13.6)22 (36.7)
       Frequency, h
      313 (21.7)7 (12.1)6 (10.2)
      438 (63.3)32 (55.2)24 (40.7)
      67 (11.7)8 (13.8)8 (13.6)
      Not used<511 (19.0)21 (35.6)
      Table results are based on the 69 respondents who started the STMA/TTMA clinical care section. Percentages were calculated based on the total number of respondents for the individual variable (based on skip pattern logic and nonmandatory questions).
      STMA: second-trimester medical abortion; TTMA: third-trimester medical abortion.

      Indications

      Figure 2 depicts abortion indications among all STMA/TTMA respondents. OB-GYNs/FPs more often reported offering an abortion by patient request alone (21.6% for STMA, 5.4% for TTMA) compared with MFMs (13.3% for STMA, 3.3% for TTMA). Among respondents under 50 years old, 26.3% offered STMA for any indication, whereas 4.8% of those aged ≥50 provided it for any indication; respective percentages for TTMA were 8.1% and 0%. Facility regulations were the most commonly reported reason for maximum GA (86.7%). Table 2 shows a further breakdown for maximum GA by indication.
      Figure thumbnail gr2
      Figure 2Reported indications for second/third-trimester medical abortion providers.
      Anomaly refers to both genetic and congenital fetal anomalies.
      PPROM: preterm premature rupture of membranes; STMA: second-trimester medical abortion; TTMA: third-trimester medical abortion.

      Clinical Care Characteristics

      Table 2 includes additional clinical care characteristics such as consultation services, ultrasound access, and feticidal injection. The majority of MFMs reported use of a feticidal injection before 24 weeks gestation based on patient preference (75%), whereas the majority of OB-GYNs/FPs reported never recommending injection at that GA (53.8%). Beyond 24 weeks gestation, the majority of both MFMs and OB-GYNs/FPs always recommended feticidal injection (70.8% and 69.2%, respectively). The most frequently used feticidal agent by MFMs (70.3%) was potassium chloride. Most OB-GYNs/FPs did not provide feticidal injections (71.6%), and less than 10% used digoxin. More rural than urban respondents (75.0 vs. 31.9%) reported never having provided a feticidal injection.
      In the setting of placenta praevia, 57.4% of respondents offered STMA and 22.2% TTMA. Pain management usually included an opioid; 85.9% reported using regional anaesthesia, 64.1% intravenous opioids, 59.4% patient-controlled analgesia, and 51.6% each oral and intramuscular opioids.
      Oxytocin was the most commonly reported prophylactic uterotonic agent used in the third stage of labour (56.5% at 14–236 weeks gestation, 68.4% at 24–276 weeks, and 82.5% at ≥28 weeks). Misoprostol for that indication was reported by 42.0%, 31.5%, and 24.6%, respectively. Approximately half (54.8%) of respondents waited >120 minutes for delivery of the placenta in the third stage of labour before intervening with a manual removal or dilation and curettage rather than intervening earlier. More urban than rural respondents reported having an STMA/TTMA protocol (86.7% vs. 64.3%). Most respondents offered insertion of a postplacental intrauterine device after STMA/TTMA (78.9%).

      Number of STMA/TTMAs

      Twenty-four MFMs reported 222 (56.4%) of the overall 394 STMA deliveries (median number of deliveries per respondent 10.0; IQR 4.5–15.0), whereas 33 OB-GYNs/FPs reported 172 (median 3.0; IQR 2.0–5.0) for the year of 2019. Twenty-one MFMs reported 110 of 160 TTMA deliveries (median 5.0; IQR 3.0–6.0), whereas 13 OB-GYNs/FPs reported 50 (median of 3.0; IQR 1.0–5.0). Urban respondents reported a higher median of STMA deliveries (5.0; IQR 3.0–10.0) than rural respondents (2.0; IQR 1.0–3.0). Respondents reported the percentage of their practice focused on contraception and abortion care as a median of 10.0% (IQR 5.0%–20.0%).

      Discussion

      Respondents to our national survey on STMA and TTMA consisted of 115 clinicians from across Canada. Years of experience were evenly distributed among the workforce, suggesting ongoing rejuvenation. Although the majority of respondents were OB-GYNs/FPs, the 33.9% of MFM respondents provided 59.9% of all STMA/TTMAs. In our 2012 survey, 91% of STMA providers were OB-GYNs and reported that 31% of their facilities had MFMs and 14% had family planning subspecialists providing this type of care (unpublished data). The difference in specialty distribution likely reflects the change in our recruitment strategy to invite MFMs to participate in the survey. We were unable to identify other published data on this topic.
      Although our data indicate that rural respondents provided multiple types of abortion care as part of comprehensive reproductive care, there was a concentration of STMA/TTMA services in urban areas. Our survey further included surgical abortion providers, and 55 respondents reported providing second-trimester surgical abortion but not STMA/TTMA. Their detailed characteristics will be described in a separate manuscript on surgical abortion (R. Renner, unpublished data, 2022). None were MFMs. They had a rural/urban (29.0%/71.1%) distribution similar to that of the STMA/TTMA respondents. These findings highlight the concentration of more complex care in academic and urban centres and suggest that patients may not be able to access second- or third-trimester abortion in their home community or with their prenatal care provider. Such access disparities have been described for other types of abortion care and are compounded by the large rural areas of Canada’s geography.
      • Norman W.V.
      • Guilbert E.R.
      • Okpaleke C.
      • et al.
      Abortion health services in Canada: Results of a 2012 national survey.
      ,
      United Nations High Commissioner on Human Rights
      Committee on the elimination of discrimination against women: concluding observations on the combined eighth and ninth periodic reports of Canada.
      As described in other Canadian surveys,
      • Sénéchal M.
      • Taillefer C.
      • Payot A.
      The medical process in pregnancy terminations for fetal anomaly: an analysis of counselling and bereavement.
      ,
      • Hull D.
      • Davies G.
      • Armour C.M.
      Survey of the definition of fetal viability and the availability, indications, and decision making processes for post-viability termination of pregnancy for fetal abnormalities and health conditions in Canada.
      most respondents used multidisciplinary consultation services. However, little is known about the detailed pathway of patients through the health care system when seeking an STMA/TTMA or the determinants of high-quality care. Second-trimester surgical abortion (dilation and evacuation [D&E]) training and services are not available in all academic hospitals,
      • Kerns J.L.
      • Turk J.K.
      • Corbetta-Rastelli C.M.
      • et al.
      Second-trimester abortion attitudes and practices among maternal-fetal medicine and family planning subspecialists.
      ,
      • Lappen J.R.
      • Vricella L.K.
      • Andrews V.
      • et al.
      Society for maternal-fetal medicine special statement: maternal-fetal medicine subspecialist survey on abortion training and service provision.
      ,
      • Liauw J.
      • Dineley B.
      • Gerster K.
      • et al.
      Abortion training in Canadian obstetrics and gynecology residency programs.
      a finding we confirmed in our survey, limiting patients’ choice on how to terminate a pregnancy. Twenty-nine percent of our survey respondents who provided D&Es without offering STMA/TTMA were non–hospital based, which might have improved patient access in some cities where hospitals did not provide D&E (R. Renner, unpublished data, 2022).
      Despite respondents following SOGC national and international guidelines recommending a mifepristone-misoprostol regimen, because it safely leads to significant reductions in time to expulsion by 2 to 10 hours,
      • Costescu D.
      • Guilbert É.
      No. 360-induced abortion: surgical abortion and second trimester medical methods.
      ,
      World Health Organization, Department of Reproductive Health and Research
      Safe abortion: technical and policy guidance for health systems.
      only 58.5% adopted mifepristone-misoprostol for STMA. This was associated with the majority reporting barriers to providing this regimen, including lack of coverage. Since 2019, changing provincial regulations have likely improved the cost coverage in the community.
      CART-GRAC (Contraception & Abortion Research Team-Groupe de recherche sur l’avortemont et la contraception)
      Canadian abortion providers support-communauté de pratique canadienne sur l’avortement (caps-cpca) community of practice Vancouver, British Columbia, Canada: University of British Columbia.
      Although more urban than rural respondents reported using a protocol, they reported more barriers than their rural counterparts, indicating that a protocol is only one component of the knowledge translation of guideline recommendations into practice. Only half of mifepristone users used it in TTMA, likely associated with the SOGC guideline
      • Costescu D.
      • Guilbert É.
      No. 360-induced abortion: surgical abortion and second trimester medical methods.
      not including TTMA-specific recommendations. However, its use in TTMA is recommended in the Royal College of Obstetricians and Gynaecologists guideline, and the World Health Organization also does not define an upper GA limit for mifepristone use.
      • Siassakos D.
      • Fox R.
      • Draycott T.
      • et al.
      Late intrauterine fetal death and stillbirth. Royal College of Obstetricians and Gynaecologists.
      ,
      • Siassakos D.
      • Fox R.
      • Draycott T.
      • et al.
      Late intrauterine fetal death and stillbirth. Royal College of Obstetricians and Gynaecologists.
      Consistent with national and international guidelines
      • Costescu D.
      • Guilbert É.
      No. 360-induced abortion: surgical abortion and second trimester medical methods.
      ,
      World Health Organization, Department of Reproductive Health and Research
      Safe abortion: technical and policy guidance for health systems.
      respondents decreased misoprostol dose in patients with increasing GA, especially in the setting of a uterine scar. However, not all respondents used the recommended 400 μg dose at <246 weeks gestation, which can be given independent of uterine scar status.
      • Costescu D.
      • Guilbert É.
      No. 360-induced abortion: surgical abortion and second trimester medical methods.
      ,
      World Health Organization, Department of Reproductive Health and Research
      Safe abortion: technical and policy guidance for health systems.
      Our data and prior publications indicate heterogeneous use of feticidal injection.
      • Costescu D.
      • Guilbert É.
      No. 360-induced abortion: surgical abortion and second trimester medical methods.
      ,
      • Maurice P.
      • Letourneau A.
      • Benachi A.
      • et al.
      Feticide in second- and third-trimester termination of pregnancy for fetal anomalies: results of a national survey.
      Similar to a national survey in France, it was more commonly used after 20 weeks.
      • Maurice P.
      • Letourneau A.
      • Benachi A.
      • et al.
      Feticide in second- and third-trimester termination of pregnancy for fetal anomalies: results of a national survey.
      Efficacy, safety, and acceptability of feticidal injections provided by multiple physician specialties, including those in training and using digoxin, is supported by evidence.
      • Tufa T.H.
      • Lavelanet A.F.
      • Belay L.
      • et al.
      Feasibility of intra-amniotic digoxin administration by obstetrics and gynecology trainees to induce fetal demise prior to medical abortion beyond 20 weeks.
      • Molaei M.
      • Jones H.E.
      • Weiselberg T.
      • et al.
      Effectiveness and safety of digoxin to induce fetal demise prior to second-trimester abortion.
      • Sharvit M.
      • Klein Z.
      • Silber M.
      • et al.
      Intra-amniotic digoxin for feticide between 21 and 30 weeks of gestation: a prospective study.
      Some providers offer feticide based on their or patient preferences to avoid a live birth, especially in the later second and the third trimester.
      • Costescu D.
      • Guilbert É.
      No. 360-induced abortion: surgical abortion and second trimester medical methods.
      However, feticidal injection has not been consistently shown to decrease the length of time for labour induction and might increase the risk for a retained placenta, requiring a dilation and curettage.
      • Costescu D.
      • Guilbert É.
      No. 360-induced abortion: surgical abortion and second trimester medical methods.
      ,
      • Şık A.
      • Bilecan S.
      • Kumbasar S.
      • et al.
      Does feticide shorten termination duration in second trimester pregnancy terminations?.
      The SOGC guideline states that more evidence is required to determine if feticide prior to STMA confers benefit.
      • Costescu D.
      • Guilbert É.
      No. 360-induced abortion: surgical abortion and second trimester medical methods.
      Use of analgesics increased (85.9% regional, 64.1% intravenous analgesics) compared with our 2012 survey (69% and 57%, respectively; unpublished data).
      Although Canada does not have a law restricting abortion access,
      • Shaw D.
      • Norman W.V.
      When there are no abortion laws: a case study of Canada.
      the majority of respondents required a maternal or fetal indication to offer STMA/TTMA. These restrictions on indications are consistent with other reports,
      • Hull D.
      • Davies G.
      • Armour C.M.
      Survey of the definition of fetal viability and the availability, indications, and decision making processes for post-viability termination of pregnancy for fetal abnormalities and health conditions in Canada.
      including an estimate of at least 150 people per year traveling from Canada to the United States to access abortion at ≥21 weeks gestation. Facility regulations were the most commonly stated reason for GA limits, but details on GA limits and other reasons for limiting patient access to STMA/TTMA, such as societal values, are poorly understood.
      The main limitation of our study is the limited ability to determine the representativeness of our exploratory sample. Owing to the sensitive nature of this work and lack of systematic recording, the true number of abortion providers in Canada is unknown. Therefore, we do not know the denominator of eligible respondents from which to calculate a response rate. We mitigated this with our broad recruitment strategy and by interpreting our data focusing on the internal consistency of the responses of our exploratory sample. Additionally, because of attrition, the clinical data are based on only the 60% of respondents who indicated they provided STMA/TTMA and started the subsequent STMA/TTMA survey section, with an overrepresentation of MFMs. Of these, however, 92.8% completed the STMA/TTMA section. This was likely due to survey fatigue, as more respondents who provided multiple types of services did not start the section. We detected fraudulent respondents in our survey and applied a rigorous fraud detection algorithm (M. Ennis, unpublished data, September 2021). We are confident that our final sample includes valid respondents. The strength of our study is the national sample collected by our extensive recruitment strategy engaging the key professional physician and nurse practitioner organizations in Canada, many of which collaborated on our study. Despite the unanticipated impact of coronavirus disease 2019, we recruited more providers than in our 2012 survey.

      Conclusion

      Access to high-quality STMA in Canada is limited by the lack of universal mifepristone implementation. Based on international guidelines, this applies to TTMA as well; however, more research on the benefits of mifepristone in TTMA would strengthen an argument for universal use in Canada. Knowledge translation activities aimed at facilitating collaboration and education among STMA/TTMA providers, health policy leaders, and service delivery leaders are needed to further improve STMA/TTMA care in Canada, including mifepristone use and access to D&E as an alternative.
      Disparities between rural and urban regions, as well as the importance of collaboration among multiple (sub-) specialties, health system managers, and patients are a call for qualitative research on abortion providers and patients to better understand service gaps, facilitators, and barriers to equitable access to high-quality abortion care regarding STMA and TTMA. Additionally, the use of large health administrative data can provide more complete data on the number of abortion providers and distribution of health services in Canada.

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