Put abortion pills into people’s hands and then provide them with the information and support to use them. Do this for every person who would need them. Do it for every person who could put them into the hands of another in need. That’s my policy advice for Canadian governments.

Abortion with pills is a safe and effective way to end an early pregnancy, and preferred by many. One tablet of mifepristone can be swallowed to block the hormone progesterone needed for pregnancy, followed 24 hours later by four tablets of misoprostol, a prostaglandin, to induce contractions. The abortion takes place over a period of days with cramping and bleeding stronger than a usual menstrual period and similar to an early miscarriage. These pills were first approved in Canada in 2015 as a combination pack under the trade name Mifegymiso® and became commercially available in 2017.

Would a commitment to pills in hand solve every abortion access problem in Canada? No. There will always be a need for safe clinical services including surgical abortion care, as well as supportive and available abortion-care professionals within our health-care system. Nonetheless, abortion with pills has radically changed the world of abortion rights, but have most Canadians, and our governments, heard the news?

Decades later, abortions in Canada are still hard to get

Regulatory risk mismanagement and the abortion pill

Abortion pill: One step forward, two steps back

Awakened by the leaked U.S. Supreme Court opinion that Roe v. Wade will likely be overturned, and the U.S. constitutional right to abortion would be no more, Canadians have vowed to defend their own. Prime Minister Justin Trudeau said that his government may legislate to protect abortion rights. It would enforce the Canada Health Act. The Liberals are prepared to do everything to protect abortion rights.

Among the most important acts that the Canadian government has ever taken to support abortion rights was Health Canada’s approval of Mifegymiso, eventually followed by relaxed regulation for its distribution through simple prescriptions and local pharmacy access. Provincial governments then provided public funding. This national framework proved critical during COVID-19 lockdowns, when telehealth consultations and no-touch care protocols allowed many people to access abortion pills without any clinic visit and close to home.

However, when the Globe and Mail published its report on abortion access, it included a map illustrating driving times to abortion clinics from cities across the country. The map was criticized as outdated, and it is a strange map to see in the era of abortion pills, which travel more easily than people. Perhaps we should have seen no map at all, but the floorplan of a bed or bathroom, showing the distance to the drawer or cabinet where people keep their abortion pills.

If you were a government committed to abortion rights, how would you put abortion pills into people’s hands? First, we can acknowledge that many physicians today still will not prescribe Mifegymiso and refer people to abortion clinics. What’s to blame? Provincial billing codes and other practice-related barriers such as training are routinely cited, with calls to address them. Yet the answer to physician barriers has largely been to expand the class of health-care professionals who can provide, or rather prescribe, abortion pills, including nurse practitioners and midwives. Let’s keep going.

What about pharmacists? As recommended by the World Health Organization’s 2022 abortion-care guideline, the skill and knowledge to manage abortion with pills in early pregnancy align with pharmacist competencies. Legislation in British Columbia, Saskatchewan and Quebec, for example, allowed pharmacists to prescribe emergency contraception before Health Canada reclassified it for over-the-counter (OTC) sale.

Let’s also make every encounter with a prescriber a meaningful one by introducing advanced provision, the provision of abortion pills before they are immediately needed and wraparound services to support a person to use the pills when they are needed. This would entail an obligation by Canadian governments to ensure a reliable supply if not production of the pills.

With advanced provision, we may come to rethink the clinical role in abortion care altogether as less supervisory and more supportive. Without the need for clinical supervision, perhaps we will also rethink prescription controls on the pills themselves. As a Schedule I drug, Mifegymiso cannot be lawfully sold in Canada without a prescription, and it’s generally an offence under the Food and Drugs Act to import prescription drugs for personal use.

What if we moved abortion pills over the counter? Moving abortion pills off-prescription typically requires information on whether a condition can be reasonably self-diagnosed, the overall safety of the medicine, and the likelihood of its misuse. This information, however, is known given the decades-long work of feminist organizations that have provided people with information on how to safely buy and use abortion pills, supported them throughout their abortions, and helped them to access clinical care when wanted or needed.

Making abortion pills available and affordable from any retail outlet, including internet platforms, would support these community-based distribution models of abortion pills, which have expanded access to safe abortion care for people around the world, especially those who have been marginalized from and mistreated within formal health-care systems.

In other words, rather than only improving abortion care from health professionals within clinical settings, what if our governments supported diverse networks of abortion care? Rather than only cutting the charity status of anti-abortion groups, why not also support and sustain the work of abortion doulas, abortion accompaniers and other community health workers who provide evidence-based information, emotional comfort, and logistical support for people to have abortions according to the values and needs most important to them? Why not support safe-abortion hotlines as information and counselling resources for people to self-manage their abortions with trust and confidence?

Let’s acknowledge that today a safe supply of abortion pills circulates in global markets and moves across borders and into people’s hands. Imagine that Canada would create a safe environment for every person to have the information and support to use these pills. More than simply opening borders, let’s create a safety network to catch Americans, too.

There is a bounty of research from diverse contexts that shows that when people are informed, resourced and supported, they can safely manage their abortions, as recently endorsed by the World Health Organization. For the first time, its 2022 guideline includes recommendations for self-managed abortion and service delivery approaches to support the practice.

Rather than any single law, the guideline endorses a policy framework to support a plurality of service-delivery approaches in abortion care, which together ensure that every individual has access to safe information and supplies (abortion pills and pain management, too), and back-up clinical support. We have yet to see any government fully implement these recommendations in a national context. Perhaps Canada would be the first.

In moments of crisis – constitutional crises, too – governments can do extraordinary things to protect the health and lives of people. We witnessed the mobilization for vaccines into arms. We can do the same to put abortion pills into people’s hands.

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Joanna Erdman
Joanna Erdman is an associate professor and the inaugural MacBain chair in Health Law and Policy at the Schulich School of Law, Dalhousie University, Nova Scotia. Her research focuses on sexual and reproductive health and human rights in a transnational context with a specialization in abortion law and policy. Twitter @joannaerdman

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