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OBJECTIVE: To explore the Canadian first-trimester medication abortion (MA) workforce and their clinical care following the introduction of mifepristone in 2017, updated national clinical practice guidelines and government approval of nurse practitioners (NPs) as first-trimester MA providers. STUDY DESIGN: We conducted a national, self-administered, cross-sectional survey of abortion providers in 2019. Our bilingual (French/English) survey collected information on demographics, abortion number, and clinical care characteristics. The true number of abortion providers is unknown thus we cannot calculate a survey response rate. To maximize identification of possibly eligible respondents, we widely distributed the survey between July and December 2020 through health professional organizations, using a modified Dillman technique. We used descriptive statistics to characterize the workforce and clinical practices. RESULTS: Four-hundred-sixty-five clinicians responded, of whom 388 provided first-trimester MA. Physicians (n = 358) and NPs (n = 30) reported providing 13,429 first-trimester MAs in 2019 which represented 27.7% of all reported abortions in the survey. The majority of first-trimester MA respondents were primary care physicians (n = 245, 63.1%), had less than five years' experience (n = 223, 61.3%) and practiced outside of hospitals (n = 228, 66.5%). Forty-three percent (n = 165) practiced rurally, and 44.0% (n = 136) used telemedicine for some abortion care. Ninety-nine percent (n = 350) used a guideline-recommended mifepristone/misoprostol regimen while 14.5% (n = 51) sometimes used methotrexate. Patients most commonly received mifepristone/misoprostol at community pharmacies (median 100.0%; interquartile range 50.0%-100.0%). CONCLUSION: Our results suggest that there are many new first-trimester MA providers, an increase in the proportion of MAs since 2012 and a shift to primary care settings. Respondents widely adopted mifepristone. IMPLICATIONS STATEMENT: Our results highlight that, following mifepristone introduction, many new primary care practitioners started providing first-trimester medication abortion throughout Canada, including the first non-physicians. This increased access to abortion particularly in rural and underserved communities. These results could inform future directions in policy, guidelines, and abortion access initiatives.

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.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.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%).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.

Objective To provide guidance on culturally competent contraception counselling that is free of coercion and promotes shared decision-making and patient autonomy. Target population Individuals of reproductive age who seek contraception or counselling for family planning. Options Contraception counselling is provided within a rights-based family planning framework, where the individual's beliefs, culture, preferences, and ability to use the chosen method are respected. Outcomes To promote patient autonomy in decision-making surrounding family planning, including the right to access and use their contraceptive method of choice, to decline contraception or use less effective methods of contraception, and to freely choose to discontinue a method of contraception, as well as the right to unbiased, non-coercive contraception counselling and evidence-based information from their health care provider Benefits, Harms, and Costs Implementation of these recommendations would reduce real or perceived coercive contraceptive care, particularly among vulnerable populations, resulting in improved patient autonomy and a better patient experience in health care settings. Evidence Databases searched: MEDLINE, Cochrane, PubMed, and CanLII. Medical terms used: contraception, family planning services, informed consent, coercion, decision making, sterilization, permanent contraception, counselling. Legal terms searched: forced sterilization, and aboriginal. Initial search conducted in 2020 and updated in 2021. Intended Audience This committee opinion is intended for health care providers (obstetricians, gynaecologists, family physicians, general surgeons, nurse practitioners, nurses, midwives, undergraduate/postgraduate medical trainees, and other health care providers) who provide sexual and reproductive health services.

RESUME Objectif Fournir des recommandations pour que le counseling contraceptif soit adapte a la culture, n'exerce aucune coercition et favorise la prise de decision partagee et l'autonomie de la patiente. Population cible Les personnes en âge de procreer qui consultent afin d'adopter une methode contraceptive ou d'obtenir des conseils en planification familiale. Options Le counseling contraceptif est offert dans un cadre de planification familiale fonde sur les droits de la personne, dans le respect des croyances, de la culture et des preferences individuelles et de la capacite de la personne a utiliser la methode choisie. Resultats Promouvoir l'autonomie de la patiente dans la prise de decisions concernant la planification familiale, y compris le droit d'obtenir et d'utiliser la methode contraceptive de son choix, de refuser la contraception ou d'utiliser une methode contraceptive moins efficace et de choisir librement de cesser l'utilisation d'une methode contraceptive, tout en s'assurant que le fournisseur de soins de sante lui offre un counseling contraceptif impartial et non coercitif ainsi que des renseignements fondes sur des donnees probantes. Benefices, risques et couts La mise en œuvre des recommandations limiterait la prestation de soins contraceptifs coercitifs, reels ou percus, en particulier chez les populations vulnerables, ce qui se traduirait par une amelioration de l'autonomie et de l'experience de la patiente dans les milieux de soins. Donnees probantes Bases de donnees utilisees : Medline, Cochrane, PubMed et CanLII. Termes medicaux utilises : contraception, family planning services, informed consent, coercion, decision making, sterilization, permanent contraception, counselling. Termes juridiques utilises : forced sterilization et aboriginal. La recherche initiale a ete effectuee en 2020 et mise a jour en 2021. Professionnels concernes : Cette opinion de comite est destinee aux fournisseurs de soins de sante (obstetriciens, gynecologues, medecins de famille, chirurgiens generalistes, infirmieres praticiennes, infirmieres, sages-femmes, stagiaires en medecine [externat, residence et monitorat] et autres fournisseurs de soins) qui offrent des services de sante sexuelle et reproductive.

Since 2016, abortion care has undergone several important changes, particularly related to the provision of medical abortion using mifepristone. We aimed to document characteristics of the abortion care workforce in Canada after the update of clinical practice guidelines of mifepristone use for medical abortion.We conducted a national, web-based, anonymized, bilingual (English/French) survey. We collected demographics and clinical care characteristics of physicians and nurse practitioners who provided abortion care in 2019. Between July and December 2020, we distributed the survey through professional organizations, including The College of Family Physicians of Canada and The Society of Obstetricians and Gynaecologists of Canada. We present descriptive statistics.Overall, 465 respondents representing all 10 provinces and 3 territories in Canada completed the survey. Of these, 388 (83.4%), including 30 nurse practitioners, provided first-trimester medical abortion, of which 350 (99.4%) used mifepristone. Two hundred and nineteen (47.1%) respondents provided first-trimester surgical abortion, 109 (23.4%) provided second-trimester surgical abortion and 115 (24.7%) provided second- or third-trimester medical abortion. Half of respondents reported fewer than 5 years of experience with any abortion care. Respondents reported providing a total of 48 509 abortions in 2019, including 32 345 (66.7%) first-trimester surgical abortions and 13 429 (27.7%) first-trimester medical abortions. In Quebec, only 1918 (12.5%) of reported abortions were first-trimester medical abortions. Primary care providers provided 34 540 (71.2%) of the total abortions. First-trimester medical abortions represented 44.4% (in/i= 2334) of all abortions in rural areas, as opposed to 25.6% (in/i= 11 067) in urban areas.The increased availability of medical abortion facilitates abortion access, especially in primary care and rural settings, and where surgical abortion is not available. Rejuvenation of the workforce is a critical contributor to equitable access to abortion services.

Background The COVID-19 pandemic and pandemic response created novel challenges for abortion services. Canada was uniquely positioned to transition to telemedicine because internationally common restrictions on abortion medication were removed before the pandemic. Objective We sought to characterize the experiences of abortion health care professionals in Canada during the COVID-19 pandemic and the impact of the pandemic response on abortion services. Methods We conducted a sequential mixed methods study between July 2020 and January 2021. We invited physicians, nurse practitioners and administrators to participate in a cross-sectional survey containing an open-ended question about the impact of the pandemic response on abortion care. We employed an inductive codebook thematic analysis, which informed the development of a second, primarily quantitative survey. Results Our initial survey had 307 respondents and our second had 78. Fifty-three percent were family physicians. Our first survey found respondents considered abortion access essential. We identified three key topicss: access to abortion care was often maintained despite pandemic-related challenges (e.g. difficulty obtaining tests, additional costs); change of practice to low-touch medication abortion care and provider perceptions of patient experience, including shifting demand, telemedicine acceptability and increased rural access. The second survey indicated uptake of telemedicine medication abortion among 89% of participants except in Quebec, where regulations meant procedures were nearly exclusively surgical. Restrictions did not delay care according to 76% of participants. Conclusions Canadian health care professionals report their facilities deemed abortion an essential service. Provinces and territories, except Quebec, described a robust pandemic transition to telemedicine to ensure access to services. Podcast An accompanying podcast is available in the Supplementary Data, in which the authors Dr Madeleine Ennis and Kate Wahl discuss their research on how family planning care and access to abortion services have changed during the COVID-19 pandemic., Lay Summary Access to abortion care was challenged by the response to COVID-19. Canada had fewer restrictions on medical abortion than many other countries when the pandemic began. The goal of this study was to describe the experiences of health care practitioners providing abortion in Canada and the impact of the pandemic and the pandemic response measures on abortion services. We conducted two surveys of physicians, nurse practitioners and administrators between July 2020 and January 2021. Most of the health care practitioners who participated reported that medical and surgical abortion care were essential and that, except in the province of Quebec, there was a rapid transition to virtual telemedicine care for first trimester abortions. Several practitioners said that virtual care made abortion more accessible. Other practitioners reported that it was challenging to order certain tests, access operating room facilities or make referrals for late second trimester cases. Practitioners felt that patients had strong fears about COVID-19 exposure and reported that limited contraception access was increasingly a reason for seeking abortion care. The results of the study suggested that abortion was considered essential and that the pandemic instigated a transition to virtual care in all provinces and territories except Quebec.

In 2020, 11.9% of abortions in Quebec were medication abortions, compared with 32.4% in Ontario. The objective of this evaluation was to assess the quality of access to medication abortion in abortion clinics of Quebec, where 91% of these abortions are performed.Quebec abortion clinics were contacted by two mystery client clinical profiles between October 8 and November 17, 2021. Descriptive analyses and statistical tests were performed, as well as a qualitative analysis of collected comments.Medication abortion up to 63 days of gestational age or less was available in 39/47 abortion clinics, more in rural and remote areas than in urban or suburban areas (p = 0.013). The mean time from first call to first appointment was 6.2 calendar days (standard deviation [SD] 4.0), shorter in rural and remote areas (p = 0.005) and in clinics affiliated with a hospital or local community service center (p = 0.010). The mean number of visits required for medication abortion was higher than for surgical abortion (2.9 [SD] 0.9 vs. 2.3 [SD] 1.1) (p0.001). For one in three clinical profiles (26/78, 33%), a telemedicine visit was possible. Medication abortion entirely accessible through telemedicine was not available. Unfavorable comments about medication abortion were frequent.Access to medication abortion is difficult in Quebec and access through telemedicine is almost non existent. Restrictions imposed by the Collège des médecins du Québec and constraints imposed on patients limit access.

Objective Mifepristone became available in Canada in January 2017, but provincial medical policy delayed its use for medical abortion (MA) in Quebec for 1 year. The objective of this study was to identify barriers and facilitators experienced by physicians who could potentially provide this newer abortion practice in Quebec. Methods This study was part of the Canadian Contraception and Abortion Research Team-Mifepristone Implementation Study, an observational, prospective, mixed-methods study. Interviews were conducted with physicians representing all health regions of Quebec. Using thematic analysis guided by diffusion of innovation theory, the study identified key barriers and facilitators to implementation. Results From January 2017 to March 2018, study investigators interviewed 25 family physicians and 12 obstetrician-gynaecologists. Most were women (81%), over 40 years old (65%), with >20 years in practice since residency (49%). Less than half of the sample provided abortion services (41%), and only 8% provided MA with mifepristone. Key barriers to implementation were: (1) uncertainty or confusion about policies regarding MA, (2) lack of human resources or support from colleagues, (3) uncertainty about product distribution, (4) confusion about professional collaboration, and (5) lack of local infrastructure. Key facilitators were: (1) perception of support and influence from colleagues, (2) previous experience with provision of first trimester MA, (3) requests for first trimester MA by patients or other physicians, and (4) knowledge of research on mifepristone MA. Conclusion Despite Health Canada's approval of mifepristone in Canada and supportive federal policies for provision of MA in primary care, physicians in the province of Quebec face onerous barriers to the practice of mifepristone MA.

Objectives: Mifepristone for first-trimester medical termination of pregnancy (MTOP) became available in Quebec in 2018, one year after the rest of Canada. Using the theory of the Diffusion of Innovation (DOI) and the transtheoretical model of change (TTM), we investigated factors influencing the implementation of mifepristone MTOP in Quebec.Material and Methods: Semi-structured interviews were conducted with 37 Quebec physicians in early 2018. Deductive thematic analysis guided by the theory of DOI explored facilitators and barriers to physicians' adoption of mifepristone MTOP. We then classified participants into five stages of mifepristone adoption based on the TTM. Follow-up data collection one year later assessed further adoption.Results: At baseline, three physicians provided mifepristone MTOP (Maintenance) and two were about to start (Action). Thirteen physicians at Preparation and Advanced Contemplation stages intended to start while, within the Slow Contemplation, two intended to start and ten were unsure. Seven had no intention to provide mifepristone MTOP (Pre-Contemplation). Major reported barriers were: complexity of local health care organisations, medical policy restrictions, lack of support, and general uncertainty. One year later, ten physicians provided mifepristone MTOP (including three at baseline) and nine still intended to, while seventeen did not intend to start provision. Seven of sixteen participants (44%) who worked in TOP clinics at baseline were still not providing MTOP with mifepristone one year later.Conclusion: Despite ideological support, mifepristone MTOP uptake in Quebec is slow and laborious, mainly due to restrictive medical policies, vested interests in surgical provision and administrative inertia.

BACKGROUND Virtual communities of practice (VCoPs) have been used to support innovation and quality in clinical care. The drug mifepristone was introduced in Canada in 2017 for medical abortion. We created a VCoP to support implementation of mifepristone abortion practice across Canada. OBJECTIVE The aim of this study was to describe the development and use of the Canadian Abortion Providers Support-Communauté de pratique canadienne sur l’avortement (CAPS-CPCA) VCoP and explore physicians’ experience with CAPS-CPCA and their views on its value in supporting implementation. METHODS This was a mixed methods intrinsic case study of Canadian health care providers’ use and physicians’ perceptions of the CAPS-CPCA VCoP during the first 2 years of a novel practice. We sampled both physicians who joined the CAPS-CPCA VCoP and those who were interested in providing the novel practice but did not join the VCoP. We designed the VCoP features to address known and discovered barriers to implementation of medication abortion in primary care. Our secure web-based platform allowed asynchronous access to information, practice resources, clinical support, discussion forums, and email notices. We collected data from the platform and through surveys of physician members as well as interviews with physician members and nonmembers. We analyzed descriptive statistics for website metrics, physicians’ characteristics and practices, and their use of the VCoP. We used qualitative methods to explore the physicians’ experiences and perceptions of the VCoP. RESULTS From January 1, 2017, to June 30, 2019, a total of 430 physicians representing all provinces and territories in Canada joined the VCoP and 222 (51.6%) completed a baseline survey. Of these 222 respondents, 156 (70.3%) were family physicians, 170 (80.2%) were women, and 78 (35.1%) had no prior abortion experience. In a survey conducted 12 months after baseline, 77.9% (120/154) of the respondents stated that they had provided mifepristone abortion and 33.9% (43/127) said the VCoP had been important or very important. Logging in to the site was burdensome for some, but members valued downloadable resources such as patient information sheets, consent forms, and clinical checklists. They found email announcements helpful for keeping up to date with changing regulations. Few asked clinical questions to the VCoP experts, but physicians felt that this feature was important for isolated or rural providers. Information collected through member polls about health system barriers to implementation was used in the project’s knowledge translation activities with policy makers to mitigate these barriers. CONCLUSIONS A VCoP developed to address known and discovered barriers to uptake of a novel medication abortion method engaged physicians from across Canada and supported some, including those with no prior abortion experience, to implement this practice. CLINICALTRIAL INTERNATIONAL REGISTERED REPORT RR2-10.1136/bmjopen-2018-028443

Resume Objectif Fournir des lignes directrices aux fournisseurs de soins quant a l'utilisation de modes de contraception pour la prevention de la grossesse et quant a la promotion d'une sexualite saine. Issues Orientation des praticiens canadiens en ce qui concerne l'efficacite globale, le mecanisme d'action, les indications, les contre-indications, les avantages n'etant pas lies a la contraception, les effets indesirables, les risques et le protocole de mise en œuvre des modes de contraception abordes; planification familiale dans le contexte de la sante sexuelle et du bien-etre general; methodes de counseling en matiere de contraception; et accessibilite et disponibilite des modes de contraception abordes au Canada. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans MEDLINE et The Cochrane Library entre janvier 1994 et janvier 2015 au moyen d'un vocabulaire controle (p. ex. contraception, sexuality, sexual health) et de mots cles (p. ex. contraception, family planning, hormonal contraception, emergency contraception) appropries. Les resultats ont ete restreints aux analyses systematiques, aux etudes observationnelles et aux essais comparatifs randomises / essais cliniques comparatifs publies en anglais entre janvier 1994 et janvier 2015. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en juin 2015. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats a ete evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). Chapitre 7 : Contraception intra-uterine Declarations sommaires 1Les contraceptifs intra-uterins sont aussi efficaces que les modes de contraception permanente. (II-2) 2L'utilisation du systeme intra-uterin a liberation de levonorgestrel 52 mg par des patientes prenant du tamoxifene n'est pas associee a la recurrence du cancer du sein. (I) 3Les contraceptifs intra-uterins comptent un certain nombre d'avantages n'etant pas lies a la contraception. L'utilisation du systeme intra-uterin a liberation de levonorgestrel 52 mg entraine une attenuation significative de la perte sanguine menstruelle (I) et de la dysmenorrhee. (II-2) Le dispositif intra-uterin au cuivre et le systeme intra-uterin a liberation de levonorgestrel entrainent tous deux une baisse significative du risque de cancer de l'endometre. (II-2) 4Bien que le risque de perforation uterine soit inversement proportionnel a l'experience du fournisseur de soins procedant a l'insertion, il est accru pendant la periode postpartum et l'allaitement. (II-2) 5Bien que le risque de syndrome inflammatoire pelvien soit legerement accru au cours du premier mois suivant l'insertion d'un contraceptif intra-uterin, le risque absolu est faible. La manifestation d'un syndrome inflammatoire pelvien apres le premier mois d'utilisation est attribuable a une exposition a des infections transmissibles sexuellement et non a la presence meme du contraceptif intra-uterin. (II-2) 6La nulliparite n'est pas associee a un risque accru d'expulsion du contraceptif intra-uterin. (II-2) 7Bien qu'il soit rare de constater une grossesse ectopique en presence d'un contraceptif intra-uterin in situ, de 15%a 50% des grossesses qui en viennent tout de meme a se manifester sont de nature ectopique. (II-2) 8Chez les femmes qui en viennent a connaitre une grossesse malgre la presence d'un contraceptif intra-uterin in situ, le retrait precoce de ce dernier entraine une amelioration des issues de grossesse, mais ne mene pas a une elimination integrale des risques. (II-2) 9Les contraceptifs intra-uterins n'entrainent pas une hausse du risque d'infertilite. (II-2) 10L'insertion immediate d'un contraceptif intra-uterin a la suite de la tenue de l'accouchement ou d'une cesarienne (de 10 minutes a la suite de la delivrance du placenta a 48 heures) est associee a des taux accrus de poursuite de l'utilisation, par comparaison avec l'insertion a six semaines postpartum. (I) 11L'insertion immediate d'un contraceptif intra-uterin a la suite de la tenue de l'accouchement ou d'une cesarienne (de 10 minutes a la suite de la delivrance du placenta a 48 heures) est associee a un risque accru d'expulsion. (I) Les avantages de l'insertion d'un contraceptif intra-uterin immediatement a la suite de la tenue de l'accouchement ou d'une cesarienne l'emportent sur les desavantages d'une telle pratique (soit des risques accrus de perforation et d'expulsion). (II-C) 12L'insertion d'un contraceptif intra-uterin chez une femme qui allaite est associee a un risque accru de perforation au cours de la premiere annee suivant l'accouchement. (II-2) 13L'insertion d'un contraceptif intra-uterin immediatement a la suite d'un avortement entraine une baisse significative du risque de devoir proceder a un autre avortement (II-2) et une hausse significative des taux de poursuite de l'utilisation d'un contraceptif intra-uterin a six mois. (I) 14La mise en œuvre d'une antibioprophylaxie au moment de l'insertion d'un contraceptif intra-uterin n'entraine pas une attenuation significative de l'infection pelvienne postinsertion. (I) Recommandations 1Les fournisseurs de soins devraient prendre soin d'eviter de restreindre l'acces aux modes de contraception intra-uterins en raison de risques theoriques ou non etablis. (III-A) Les professionnels de la sante devraient considerer les contraceptifs intra-uterins comme etant des modes de contraception de premiere intention pour leurs patientes tant nullipares que multipares. (II-2A) 2Dans le cas des femmes qui cherchent a obtenir une contraception intra-uterine et qui connaissent des saignements menstruels abondants et/ou une dysmenorrhee, les professionnels de la sante devraient envisager de privilegier l'utilisation du systeme intra- uterin a liberation de levonorgestrel 52 mg. (I-A) 3Les patientes atteintes du cancer du sein qui prennent du tamoxifene pourraient envisager l'utilisation d'un systeme intra- uterin a liberation de levonorgestrel 52 mg, a la suite d'une consultation aupres de leur oncologue. (I-A) 4Les femmes qui demandent la mise en place d'un systeme intra- uterin a liberation de levonorgestrel ou d'un dispositif intra-uterin au cuivre devraient beneficier de services de counseling traitant du risque d'infection transmissible sexuellement, des modifications du cycle menstruel et de la duree d'utilisation. (III-A) 5Le professionnel de la sante devrait etre raisonnablement sur que sa patiente n'est pas enceinte avant de proceder a l'insertion d'un contraceptif intra-uterin. (III-A) 6Les fournisseurs de soins devraient envisager de proceder a l'insertion d'un contraceptif intra-uterin immediatement a la suite d'un avortement provoque, plutot que d'attendre de proceder a une insertion d'intervalle. (I-B) 7Chez les femmes qui en viennent a connaitre une grossesse en presence d'un contraceptif intra-uterin in situ, le diagnostic de grossesse ectopique devrait etre ecarte des que possible. (II-A) Une fois la possibilite d'une grossesse ectopique ecartee, le contraceptif intra-uterin devrait etre retire sans avoir recours a une intervention effractive. Le contraceptif intra-uterin pourrait etre retire au cours de la tenue d'une interruption de grossesse chirurgicale. (II-2B) 8En presence d'un syndrome inflammatoire pelvien, il n'est pas necessaire de retirer le contraceptif intra-uterin pendant le traitement, sauf en l'absence d'une amelioration clinique de 48 a 72 heures a la suite de la mise en œuvre d'une antibiotherapie appropriee. (II-2B) 9La mise en œuvre systematique d'une antibioprophylaxie n'est pas indiquee pour l'insertion d'un contraceptif intra-uterin. (I-B) Chez les femmes qui sont exposees a des risques eleves d'infections transmissibles sexuellement, les fournisseurs de soins devraient proceder au depistage de ces dernieres au moment de l'insertion du contraceptif intra-uterin. Lorsque des resultats positifs sont obtenus en ce qui concerne la chlamydiose et/ou la gonorrhee, la patiente en question devrait faire l'objet d'un traitement post- insertion adequat et son CIU peut demeurer in situ. (II-2B) 10Chez les utilisatrices de contraceptifs intra-uterins, les saignements imprevus, lorsqu'ils sont persistants ou associes a des douleurs pelviennes, devraient faire l'objet d'une exploration visant a ecarter la possibilite d'une infection, d'une grossesse, d'une pathologie gynecologique, d'une expulsion ou d'un mauvais positionnement. (III-A)

BackgroundSince Canadian drug regulatory approval of mifepristone for medical abortion in 2015 and its market availability in January 2017, the role of pharmacists in abortion provision has changed rapidly. We sought to identify the factors that influenced the initiation and provision of medical abortion from the perspectives of Canadian pharmacists, bridging two frameworks — Diffusion of Innovation in Health Service Organizations and integrated knowledge translation.MethodsWe conducted one-on-one semi-structured interviews with pharmacists residing in Canada who intended to stock and dispense mifepristone within the first year of availability. Our data collection, analysis, and interpretation were guided by reflexive thematic analysis and supported by an integrated knowledge translation partnership with pharmacy stakeholders.ResultsWe completed interviews with 24 participants from across Canada: 33% had stocked and 21% had dispensed mifepristone. We found that pharmacists were willing and able to integrate medical abortion care into their practice and that those who had initiated practice were satisfied with their dispensing experience. Our analysis indicated that several key Diffusion of Innovation constructs impacted the uptake of mifepristone, including: innovation (relative advantage, complexity and compatibility, technical support), system readiness (innovation-system fit, dedicated time, resources), diffusion and dissemination (expert opinion, boundary spanners, champions, social networks, peer opinions), implementation (external collaboration), and linkage. Participants’ experiences suggest that integrated knowledge translation facilitated evidence-based changes to mifepristone dispensing restrictions, and communication of those changes to front line pharmacists.ConclusionsWe illustrate how Diffusion of Innovation and integrated knowledge translation may work together as complimentary frameworks for implementation science research. Unlike in the USA, UK, and other highly regulated settings globally, pharmacists in Canada are permitted to dispense mifepristone for medical abortion. We contribute to literature that shows that mifepristone dispensed outside of hospitals, clinics, and medical offices is safe and acceptable to both patients and prescribers. This finding is of particular importance to the current COVID-19 pandemic response and calls for continued and equitable access to abortion care in primary practice.

Objectives: Canada was positioned to transition to telemedicine abortion care during the COVID-19 pandemic because REMs-like mifepristone restrictions were removed previously. We sought to characterize the impact of the pandemic response on Canadian clinical practice and abortion care access from the provider perspective. Methods: This was a sequential mixed methods study conducted between July 2020 and January 2021. A national sample of abortion providers completed a survey containing an open-ended question about the impact of the pandemic response. We took an inductive thematic approach to analysis that informed a second, primarily quantitative, survey. Results: The first survey was completed by 307 participants and the second by 78. Overall, 85% were physicians, 6% were nurse practitioners, and the remainder were pharmacists or administrators. Our thematic analysis identified 3 topics: access to abortion care, which was usually maintained despite pandemic-related challenges (eg difficulty obtaining tests, reduced operating time, limited referral pathways, new costs);change of practice to low- and no-touch medication abortion care;and provider perceptions of the patient experience, including shifting demand, good telemedicine acceptability, and increased rural access. The second survey showed uptake of telemedicine medication abortion among 89% of participants outside the province of Quebec, where uptake was 33%. Pandemic-related restrictions did not delay care according to 76% of participants. Conclusions: The pandemic led to a robust transition to telemedicine abortion care in most of Canada, facilitated by prior removal of mifepristone restrictions and consideration of abortion as essential. Our findings could inform innovation in medication abortion service delivery in the US setting.

Objective This guideline reviews evidence relating to the provision of surgical induced abortion (IA) and second trimester medical abortion, including pre- and post-procedural care. Intended Users Gynaecologists, family physicians, nurses, midwives, residents, and other health care providers who currently or intend to provide and/or teach IAs. Target Population Women with an unintended or abnormal first or second trimester pregnancy. Evidence PubMed, Medline, and the Cochrane Database were searched using the key words: first-trimester surgical abortion, second-trimester surgical abortion, second-trimester medical abortion, dilation and evacuation, induction abortion, feticide, cervical preparation, cervical dilation, abortion complications. Results were restricted to English or French systematic reviews, randomized controlled trials, clinical trials, and observational studies published from 1979 to July 2017. National and international clinical practice guidelines were consulted for review. Grey literature was not searched. Values The quality of evidence in this document was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology framework. The summary of findings is available upon request. Benefits, Harms, and/or Costs IA is safe and effective. The benefits of IA outweigh the potential harms or costs. No new direct harms or costs identified with these guidelines.

Resume Objectif La presente directive clinique examine les donnees probantes sur l'avortement chirurgical et l'avortement medical au deuxieme trimestre, y compris les soins prodigues avant et apres l'intervention. Utilisateurs cibles Gynecologues, medecins de famille, infirmieres, sages-femmes, residents et autres fournisseurs de soins de sante qui pratiquent ou enseignent, ou ont l'intention de pratiquer ou d'enseigner, l'avortement provoque (AP). Population cible Femmes dont la grossesse de premier ou de deuxieme trimestre est non desiree ou anormale. Evidence Des recherches ont ete menees dans PubMed, Medline et la base de donnees Cochrane a l'aide des mots-cles « first-trimester surgical abortion », « second-trimester surgical abortion », « second-trimester medical abortion », « dilation and evacuation », « induction abortion », « feticide », « cervical preparation », « cervical dilation » et « abortion complications ». Nous n'avons tenu compte que des revues systematiques, des essais cliniques randomises, des essais cliniques et des etudes observationnelles de langue anglaise ou francaise publies entre 1979 et juillet 2017. Des directives cliniques nationales et internationales ont ete consultees. Nous n'avons pas effectue de recherches dans la litterature grise (non publiee). Valeurs La qualite des donnees probantes a ete evaluee au moyen de l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation). Le resume des conclusions peut etre fourni sur demande. Avantages, inconvenients et couts L'AP est sur et efficace. Les avantages en surpassent les dommages et les couts potentiels. Aucun nouveau dommage ou cout direct n'a ete associe a la presente directive clinique.

Background Direct primary care provision of first-trimester medical abortion could potentially address inequitable abortion access in Canada. However, when Health Canada approved the combination medication Mifegymiso® (mifepristone 200 mg/misoprostol 800 mcg) for medical abortion in July 2015, we hypothesized that the restrictions to distribution, prescribing, and dispensing would impede the uptake of this evidence-based innovation in primary care. We developed and pilot-tested a survey related to policy and practice facilitators and barriers to assess successful initiation and ongoing clinical provision of medical abortion service by physicians undertaking mifepristone training. Additionally, we explored expert, stakeholder, and physician perceptions of the impact of facilitators and barriers on abortion services throughout Canada. Methods In phase 1, we developed a survey using 2 theoretical frameworks: Greenhalgh’s conceptual model for the Diffusion of Innovations in health service organizations (which we operationalized) and Godin’s framework to assess the impact of professional development on the uptake of new practices operationalized in Légaré’s validated questionnaire. We finalized questions in phase 2 using the modified Delphi methodology. The survey was then tested by an expert panel of 25 nationally representative physician participants and 4 clinical content experts. Qualitative analysis of transcripts enriched and validated the content by identifying these potential barriers: physicians dispensing the medication, mandatory training to become a prescriber, burdens for patients, lack of remuneration for mifepristone provision, and services available in my community. To assess the usability and reliability of the online survey, in phase 3, we pilot-tested the survey for feasibility. Results We developed and tested a 61-item Mifepristone Implementation Survey suitable to study the facilitators and barriers to implementation of mifepristone first-trimester medical abortion practice by physicians in Canada. Conclusions Our team operationalized Greenhalgh’s theoretical framework for Diffusion of Innovations in health systems to explore factors influencing the implementation of first-trimester medical abortion provision. This process may be useful for those evaluating other health system innovations. Identification of facilitators and barriers to implementation of mifepristone practice in Canada and knowledge translation has the potential to inform regulatory and health system changes to support and scale up facilitators and mitigate barriers to equitable medical abortion provision.

PURPOSE Access to family planning health services in Canada has been historically inadequate and inequitable. A potential solution appeared when Health Canada approved mifepristone, the gold standard for medical abortion, in July 2015. We sought to investigate the factors that influence successful initiation and ongoing provision of medical abortion services among Canadian health professionals and how these factors relate to abortion policies, systems, and service access throughout Canada. METHODS We conducted 1-on-1 semistructured interviews with a national sample of abortion-providing and nonproviding physicians and health system stakeholders in Canadian health care settings. Our data collection, thematic analysis, and interpretation were guided by Diffusion of Innovation theory. RESULTS We conducted interviews with 90 participants including rural practitioners and those with no previous abortion experience. In the course of our study, Health Canada removed mifepristone restrictions. Our results suggest that Health Canada’s initial restrictions discouraged physicians from providing mifepristone and were inconsistent with provincial licensing standards, thereby limiting patient access. Once deregulated, remaining factors were primarily related to local and regional implementation processes. Participants held strong perceptions that mifepristone was the new standard of care for medical abortion in Canada and within the scope of primary care practice. CONCLUSION Health Canada’s removal of mifepristone restrictions facilitated the implementation of abortion care in the primary care setting. Our results are unique because Canada is the first country to facilitate provision of medical abortion in primary care via evidence-based deregulation of mifepristone.

Objective Abortion is one of the most common medical procedures a woman experiences in her lifetime. Even though overall rates of abortion are decreasing slightly, medical abortion rates are expected to increase in Canada following approval by Health Canada of a combination of mifepristone and misoprostol for use in medical abortion. Methods We conducted a literature review as part of the development of the 2016 Society of Obstetricians and Gynaecologists of Canada's Clinical Practice Guidelines on medical abortion. We searched the PubMed, MEDLINE, and Cochrane databases for articles published between 1986 and 2015 using the MeSH terms "induced abortion," "medical abortion," "mifepristone," "misoprostol," "methotrexate," and "prostaglandin." Additionally, we reviewed existing international medical abortion guidelines and searched reference lists. Results The most commonly studied medical abortion regimens are combinations of mifepristone and misoprostol, methotrexate and misoprostol, mifepristone and prostaglandin, and misoprostol only. Each of these regimens is a potential therapeutic choice; the advantages and disadvantages of each regimen are discussed. Conclusion Drugs used for medical abortion are safe; however, clinicians who provide medical abortion and those who provide care to women who have undergone medical abortion should have an understanding of the pharmacokinetics and clinical effects of the medications used to improve outcomes and mitigate risk.

This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care.Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services.Women with an unintended first trimester pregnancy.Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required.The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1).Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability.Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion careIntroduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care.

Objective To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. Outcomes Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada. Evidence Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Chapter 8: Progestin-Only Contraception Summary Statements 15.Progestin implants have failure rates as low as permanent contraception. (II-2) 16.The use of a progestin implant immediately postpartum and post-abortion is an effective way of decreasing repeat pregnancy in adolescents and repeat abortions. (II-2) 17.The most common side effect of progestin-only contraceptive methods is menstrual cycle disturbances. (II-2) Amenorrhea is very common with depot medroxyprogesterone acetate and progestin implant use. (II-2) 18.The use of progestins given at contraceptive doses does not appear to increase the risk of venous thromboembolism, myocardial infarction, or stroke. (II-2) 19.The efficacy of progestin implants or depot medroxyprogesterone acetate is not decreased in overweight and obese women. (II-2) 20.Early weight gain with depot medroxyprogesterone acetate use is predictive of continued weight gain. (II-2) 21.Depot medroxyprogesterone acetate use is associated with a delay in resumption of ovulation. (II-2) 22.The use of depot medroxyprogesterone acetate (DMPA) is associated with a decrease in bone mineral density. This decrease is most rapid in the first 2 years of use and appears to be largely reversible once DMPA is discontinued. (I) There is no strong evidence that the use of DMPA causes osteoporosis (II-2) or increases the risk of fracture. (II-2) 23.The use of progestin-only preparations has not been shown to decrease breast milk production. (I) The small amounts of steroid hormones secreted in breast milk do not have an adverse effect on infant growth and development. (II-2) 24.Depot medroxyprogesterone acetate use is associated with a decreased risk of endometrial and ovarian cancer. (II-2) Recommendations 12.Progestin-only methods of contraception should be considered in women with medical conditions where estrogen is contraindicated or less appropriate, such as women who are recently postpartum, breastfeeding, or in smokers over age 35. (III-A) 13.There should be no restriction on the use of depot medroxy-progesterone acetate (DMPA), including duration of use, among women of reproductive age who are otherwise eligible to use the method. The overall risks and benefits of continuing DMPA use should be discussed with DMPA users at regular intervals throughout the course of treatment. (III-A) 14.Counselling regarding menstrual cycle disturbances should be done prior to initiating a progestin-only method of contraception. (I-A) 15.Health care providers should inform patients of the potential effects of depot medroxyprogesterone acetate on bone mineral density and counsel them on "bone health," including calcium and vitamin D supplementation, smoking cessation, weight-bearing exercise, and decreased alcohol and caffeine consumption. (III-A) 16.If prolonged and/or frequent bleeding occurs in users of progestin-only contraceptives, pregnancy, sexually transmitted infection, and genital pathology should be ruled out. (III-B) 17.Ectopic pregnancy should be ruled out if a pregnancy occurs in a woman using a progestin-only method of contraception. (III-A)

Resume Objectif Fournir des lignes directrices aux fournisseurs de soins quant a l'utilisation de modes de contraception pour la prevention de la grossesse et quant a la promotion d'une sexualite saine. Issues Orientation des praticiens canadiens en ce qui concerne l'efficacite globale, le mecanisme d'action, les indications, les contre-indications, les avantages n'etant pas lies a la contraception, les effets indesirables, les risques et le protocole de mise en œuvre des modes de contraception abordes; planification familiale dans le contexte de la sante sexuelle et du bien-etre general; methodes de counseling en matiere de contraception; et accessibilite et disponibilite des modes de contraception abordes au Canada. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans MEDLINE et The Cochrane Library entre janvier 1994 et janvier 2015 au moyen d'un vocabulaire controle (p. ex. contraception , sexuality , sexual health ) et de mots cles (p. ex. contraception , family planning , hormonal contraception , emergency contraception ) appropries. Les resultats ont ete restreints aux analyses systematiques, aux etudes observationnelles et aux essais comparatifs randomises / essais cliniques comparatifs publies en anglais entre janvier 1994 et janvier 2015. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en juin 2015. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats a ete evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). Chapitre 8 : Contraception a progestatif seul Declarations sommaires 15.Les implants de progestatif comptent des taux d'echec aussi faibles que ceux de la contraception permanente. (II-2) 16.L'insertion d'un implant immediatement a la suite d'un accouchement ou d'un avortement constitue une facon efficace d'abaisser les taux de nouvelle grossesse chez les adolescentes et de nouvel avortement. (II-2) 17.Les perturbations du cycle menstruel constituent l'effet indesirable le plus courant des modes de contraception a progestatif seul. (II-2) L'amenorrhee est tres courante dans le cadre de l'utilisation d'acetate de medroxyprogesterone-retard et d'implants de progestatif. (II-2) 18.L'utilisation de progestatifs administres selon des doses contraceptives ne semble pas accroitre le risque de thromboembolie veineuse, d'infarctus du myocarde ou d'accident vasculaire cerebral. (II-2) 19.L'efficacite des implants de progestatif (ou de l'acetate de medroxyprogesterone) n'est pas amoindrie chez les femmes obeses ou presentant une surcharge ponderale. (II-2) 20.La constatation d'un gain ponderal precoce dans le cadre de l'utilisation d'acetate de medroxyprogesterone-retard permet de predire la poursuite du gain ponderal. (II-2) 21.L'utilisation d'acetate de medroxyprogesterone-retard est associee a un delai quant a la reprise de l'ovulation. (II-2) 22.L'utilisation d'acetate de medroxyprogesterone-retard est associee a une baisse de la densite minerale osseuse. Cette baisse atteint sa rapidite maximale au cours des deux premieres annees d'utilisation et semble etre largement reversible a la suite de l'abandon du traitement a l'acetate de medroxyprogesterone-retard. (I) Nous ne disposons pas de donnees probantes solides indiquant que l'utilisation d'acetate de medroxyprogesterone-retard cause l'osteoporose (II-2) ou qu'elle entraine une hausse du risque de fracture. (II-2) 23.Il n'a pas ete demontre que l'utilisation de preparations a progestatif seul entraine une baisse de la production de lait maternel. (I) Les petites quantites d'hormones steroidiennes secretees dans le lait maternel n'exercent pas un effet indesirable sur la croissance et le developpement du nouveau-ne. (II-2) 24.L'utilisation d'acetate de medroxyprogesterone-retard est associee a une baisse des risques de cancer de l'endometre et de cancer de l'ovaire. (II-2) Recommandations 12.Le recours a des modes de contraception a progestatif seul devrait etre envisage chez les femmes qui presentent des troubles medicaux dans le cadre desquels la prise d'œstrogenes est contre-indiquee ou moins souhaitable, comme dans le cas des femmes qui ont recemment connu un accouchement, qui allaitent ou qui fument et qui sont âgees de plus de 35 ans. (III-A) 13.Aucune restriction ne devrait etre imposee quant a l'utilisation d'acetate de medroxyprogesterone-retard (y compris en ce qui a trait a la duree d'utilisation) chez les femmes en âge de procreer qui sont autrement admissibles a l'utilisation de ce mode de contraception. Les risques et les avantages globaux de la poursuite de l'utilisation d'acetate de medroxyprogesterone-retard devraient faire l'objet de discussions avec les utilisatrices a intervalles reguliers tout au long du traitement. (III-A) 14.Des services de counseling traitant des perturbations du cycle menstruel devraient etre offerts avant la mise en œuvre d'un mode de contraception a progestatif seul. (I-A) 15.Les fournisseurs de soins devraient aviser leurs patientes des effets potentiels de l'acetate de medroxyprogesterone-retard sur la densite minerale osseuse et leur offrir des conseils en matiere de « sante osseuse » (y compris en ce qui concerne la supplementation en calcium et en vitamine D, l'abandon du tabagisme, la pratique d'exercices de port de poids et l'attenuation de la consommation d'alcool et de cafeine). (III-A) 16.En presence de saignements prolonges et/ou frequents chez des utilisatrices de contraceptifs a progestatif seul, la presence d'une grossesse, d'une infection transmissible sexuellement ou d'une pathologie genitale devrait etre ecartee. (III-B) 17.La possibilite d'une grossesse ectopique doit etre ecartee lorsqu'une grossesse en vient a se manifester chez une femme qui utilise un mode de contraception a progestatif seul. (III-A)

Objectives We sought to investigate the factors that influence successful initiation and ongoing provision of medical abortion services among Canadian health professionals, and how these factors relate to abortion policies, systems, and service access throughout Canada. Methods We conducted one-on-one semi-structured interviews at baseline (2017) and follow-up (2018) with a national sample of abortion providing and non-providing physicians and health system stakeholders in Canadian health care settings. Our data collection, thematic analysis, and interpretation were guided by Diffusion of Innovation theory. Results We conducted interviews with 90 participants including rural practitioners and those with no previous abortion experience. Our results suggest that Health Canada's initial approval included restrictions that were perceived as time-consuming, discouraging to physicians interested in the new practice, in breach of professional privacy, and inconsistent with provincial licensing standards, thereby limiting patient access. After Health Canada's restrictions were removed, implementation challenges revolved around confusion about the changing regulations, waiting for billing codes, varying subsidies for patients in each province, and navigating the unique challenges of practice in low-resource, rural environments. Conclusions In the first two years since mifepristone was made available in Canada, rapid regulatory revisions greatly assisted primary care practitioners to implement closer to home abortion care. These changes have led to health care professional perceptions that there are minimal regulatory barriers to medical abortion practice. Our results are unique internationally as Canada is the first nation to facilitate provision of medical abortion in primary care settings through evidence-based deregulation of mifepristone.

Objectives To create a questionnaire able to explore changes in abortion services, workforce, and clinical practices compared to our 2012 Canadian survey, particularly in relationship to the 2017 introduction of mifepristone medical abortion and updated SOGC clinical guidelines. We aimed to create a cross-sectional online survey capturing demographics, clinical care and provider experiences among healthcare professionals providing abortion care either independently or in collaborative care agreements. Methods After completing a literature search, we held expert working-group meetings to revise the 2012 survey instrument. We convened expert focus groups across Canada engaging clinicians and researchers from many sectors, and subsequently piloted the survey instrument. Results We held 7 expert working groups of 5–10 participants each. Input from participants including family physicians, obstetricians & gynaecologists, maternal–fetal–medicine specialists, midwives, nurses, and researchers ensured relevant and concise questions. Due to the complexity of some of the identified topics, such as interdisciplinary collaboration and differences between provinces, some of the survey sections underwent an iterative process of meetings and revisions until we reached consensus on constructs to include. The resulting instrument underwent pilot testing among additional experts representing the study population. We confirmed content validity, clarity of language and usability of the survey instrument. Conclusions The new national survey instrument is the product of a rigorous revision and testing process. We plan to implement the survey in 2020 to assess practice factors and their relationship to recent SOGC guidelines.

Objectives Mifepristone for first-trimester medical abortion (MA) became available in Quebec in 2018, one year after the rest of Canada. Using the transtheoretical model of change (TTM), we investigated factors influencing the implementation of mifepristone MA by physicians in Quebec. Methods Semi-structured interviews were conducted with 37 Quebec physicians in early 2018. Deductive thematic analysis guided by the TTM explored facilitators and barriers to physicians’ adoption of mifepristone MA. We classified participants into five stages of mifepristone adoption based on the TTM. Follow-up data collection one year later assessed further adoption. Results At baseline, three physicians provided mifepristone MA (Maintenance) and two were about to start (Action). Fifteen physicians at Preparation and Contemplation stages intended to start while ten were unsure (Slow Contemplation) and seven did not intend to provide (Pre-Contemplation). Barriers such as complexity of local health care organizations, uncertainty/confusion about medical policy restrictions, and uncertainty about organizational flexibility were present at all stages. Availability of surgical abortion services was a barrier for participants in the Contemplation and Pre-contemplation stages while the presence of a surgical culture was mentioned by participants in the Maintenance and Action stages. One year later, ten physicians provided MA (including the three at baseline), with a range of 3 to 50 prescriptions per provider. Seventeen either lost their intention or never intended to start provision. Conclusions Despite ideological support, mifepristone MA uptake in Quebec is slow and laborious, mainly due to restrictive medical policies, resistance to abortion practice diversification and administrative inertia.

Objectives To assess whether first-trimester aspiration abortion practices of US providers agree with evidence-based policy guidelines. Study design We sent surveys by mail or electronically to all abortion facilities in the United States identified via professional networks and websites from June through December 2013. Administrators reported on the volume of procedures performed at their site(s) through 13 weeks 6 days' gestation and on clinic services. Clinicians reported on personal demographic characteristics and abortion practices. We reviewed guidelines from key US professional organizations to determine how well reported practices aligned with available recommendations and the extent to which guidelines have changed since the time of the survey. Results We identified 703 clinical sites in the United States; 383 (54%) sites responded, 256 of which offer first-trimester aspiration abortions. Most providers identified as obstetrician-gynecologists (74%) and female (64%); 52% were less than 50 years old compared to 36% in 2002. Overall, reported practices follow evidence-based guidelines, including routine administration of periprocedure antibiotics (85%), use of misoprostol for cervical ripening in the late first trimester (94%), pain management practices, and same-day contraception provision (98%) including long-acting devices (76%). Less evidence-based practices include routine preprocedure ultrasound (99%), not providing abortion before 5 weeks' gestation (66%), restrictive fasting policies, and prolonged and postprocedure antibiotic provision. Conclusion Overall, the first-trimester aspiration abortion practices revealed in our survey agree with professional evidence-based policy guidelines, though some related to preprocedure ultrasound use, very early abortion provision, preanesthesia fasting protocols, and antibiotic regimens deserve attention. Implications In this third cross-sectional survey of US abortion practices (prior surveys 1997 and 2002), first-trimester aspiration abortion providers are younger than before, reflecting an improvement in the “graying” of the abortion provider workforce. Research and education are needed to further improve evidence-based practice in abortion care.

Objective To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. Outcomes Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada. Evidence Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Chapter 7: Intrauterine Contraception Summary Statements 1.Intrauterine contraceptives are as effective as permanent contraception methods. (II-2) 2.The use of levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg by patients taking tamoxifen is not associated with recurrence of breast cancer. (I) 3.Intrauterine contraceptives have a number of noncontraceptive benefits. The levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg significantly decreases menstrual blood loss (I) and dysmenorrhea. (II-2) Both the copper intrauterine device and the LNG-IUS significantly decrease the risk of endometrial cancer. (II-2) 4.The risk of uterine perforation decreases with inserter experience but is higher in postpartum and breastfeeding women. (II-2) 5.The risk of pelvic inflammatory disease (PID) is increased slightly in the first month after intrauterine contraceptive (IUC) insertion, but the absolute risk is low. Exposure to sexually transmitted infections and not the IUC itself is responsible for PID occurring after the first month of use. (II-2) 6.Nulliparity is not associated with an increased risk of intrauterine contraceptive expulsion. (II-2) 7.Ectopic pregnancy with an intrauterine contraceptive (IUC) is rare, but when a pregnancy occurs with an IUC in situ, it is an ectopic pregnancy in 15% to 50% of the cases. (II-2) 8.In women who conceive with an intrauterine contraceptive (IUC) in place, early IUC removal improves outcomes but does not entirely eliminate risks. (II-2) 9.Intrauterine contraceptives do not increase the risk of infertility. (II-2) 10.Immediate insertion of an intrauterine contraceptive (10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher continuation rate compared with insertion at 6 weeks postpartum. (I) 11.Immediate insertion of an intrauterine contraceptive (IUC; 10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher risk of expulsion. (I) The benefit of inserting an IUC immediately postpartum or post-Caesarean section outweighs the disadvantages of increased risk of perforation and expulsion. (II-C) 12.Insertion of an intrauterine contraceptive in breastfeeding women is associated with a higher risk of uterine perforation in the first postpartum year. (II-2) 13.Immediate insertion of an intrauterine contraceptive (IUC) post-abortion significantly reduces the risk of repeat abortion (II-2) and increases IUC continuation rates at 6 months. (I) 14.Antibiotic prophylaxis for intrauterine contraceptive insertion does not significantly reduce postinsertion pelvic infection. (I) Recommendations 1.Health care professionals should be careful not to restrict access to intrauterine contraceptives (IUC) owing to theoretical or unproven risks. (III-A) Health care professionals should offer IUCs as a first-line method of contraception to both nulliparous and multiparous women. (II-2A) 2.In women seeking intrauterine contraception (IUC) and presenting with heavy menstrual bleeding and/or dysmenorrhea, health care professionals should consider the use of the levonorgestrel intrauterine system 52 mg over other IUCs. (I-A) 3.Patients with breast cancer taking tamoxifen may consider a levonorgestrel-releasing intrauterine system 52 mg after consultation with their oncologist. (I-A) 4.Women requesting a levonorgestrel-releasing intrauterine system or a copper-intrauterine device should be counseled regarding changes in bleeding patterns, sexually transmitted infection risk, and duration of use. (III-A) 5.A health care professional should be reasonably certain that the woman is not pregnant prior to inserting an intrauterine contraceptive at any time during the menstrual cycle. (III-A) 6.Health care providers should consider inserting an intrauterine contraceptive immediately after an induced abortion rather than waiting for an interval insertion. (I-B) 7.In women who conceive with an intrauterine contraceptive (IUC) in place, the diagnosis of ectopic pregnancy should be excluded as arly as possible. (II-2A) Once an ectopic pregnancy has been excluded, the IUC should be removed without an invasive procedure. The IUC may be removed at the time of a surgical termination. (II-2B) 8.In the case of pelvic inflammatory disease, it is not necessary to remove the intrauterine contraceptive unless there is no clinical improvement after 48 to 72 hours of appropriate antibiotic treatment. (II-2B) 9.Routine antibiotic prophylaxis for intrauterine contraceptive (IUC) insertion is not indicated. (I-B) Health care providers should perform sexually transmitted infection (STI) testing in women at high risk of STI at the time of IUC insertion. If the test is positive for chlamydia and/or gonorrhea, the woman should be appropriately treated postinsertion and the IUC can remain in situ. (II-2B) 10.Unscheduled bleeding in intrauterine contraception users, when persistent or associated with pelvic pain, should be investigated to rule out infection, pregnancy, gynecological pathology, expulsion or malposition. (III-A)

Objective Unintended pregnancies (UPs) are associated with a significant cost burden, but the full cost burden in Canada is not known. The objectives of this study were to quantify the direct cost of UPs in Canada, the proportion of cost attributable to UPs and imperfect contraceptive adherence and the potential cost savings with increased uptake of long-acting reversible contraceptives (LARCs). Methods A cost model was constructed to estimate the annual number and direct costs of UP in women aged 18 to 44years. Adherence-associated UP rates were estimated using perfect-and typical-use contraceptive failure rates. Change in annual number of UPs and impact on cost burden were projected in three scenarios of increased LARC usage. One-way sensitivity analyses were conducted to assess the impact of key variables on scenarios of increased LARC use. Results There are more than 180 700 UPs annually in Canada. The associated direct cost was over $320 million. Fifty-eight percent (58%) of UPs occurred in women aged 20 to 29years at an annual cost of $175 million; 82% of this cost ($143 million) was attributable to contraceptive non-adherence. Increased LARC uptake produced cost savings of over $34 million in all three switching scenarios; the largest savings ($35 million) occurred when 10% of oral contraceptive users switched to LARCs. The minimum duration of LARC usage required before cost savings was realized was 12months. Conclusion The cost of UPs in Canada is significant and much of it can be attributed to imperfect contraceptive adherence. Increased LARC uptake may reduce contraceptive non-adherence, thereby reducing rates of UP and generating significant cost savings, particularly in women aged 20 to 29.

Resume Objectif Fournir des lignes directrices aux fournisseurs de soins quant a l'utilisation de modes de contraception pour la prevention de la grossesse et quant a la promotion d'une sexualite saine. Issues Orientation des praticiens canadiens en ce qui concerne l'efficacite globale, le mecanisme d'action, les indications, les contre-indications, les avantages n'etant pas lies a la contraception, les effets indesirables, les risques et le protocole de mise en œuvre des modes de contraception abordes; planification familiale dans le contexte de la sante sexuelle et du bien-etre general; methodes de counseling en matiere de contraception; et accessibilite et disponibilite des modes de contraception abordes au Canada. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans MEDLINE et The Cochrane Library entre janvier 1994 et janvier 2015 au moyen d'un vocabulaire controle (p. ex. contraception , sexuality , sexual health ) et de mots cles (p. ex. contraception , family planning , hormonal contraception , emergency contraception ) appropries. Les resultats ont ete restreints aux analyses systematiques, aux etudes observationnelles et aux essais comparatifs randomises / essais cliniques comparatifs publies en anglais entre janvier 1994 et janvier 2015. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en juin 2015. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats a ete evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau).

Objective To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. Outcomes Guidance for Canadian practitioners on overall effectiveness, mechanism of action, indications, contraindications, non-contraceptive benefits, side effects and risks, and initiation of cited contraceptive methods; family planning in the context of sexual health and general well-being; contraceptive counselling methods; and access to, and availability of, cited contraceptive methods in Canada. Evidence Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis and incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

Objective To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. Outcomes Guidance for Canadian practitioners on overall effectiveness, mechanism of action, indications, contraindications, non-contraceptive benefits, side effects and risks, and initiation of cited contraceptive methods; family planning in the context of sexual health and general wellbeing; contraceptive counselling methods; and access to and availability of cited contraceptive methods in Canada. Evidence Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis and incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

Objective To assess whether second-trimester surgical abortion practices of U.S. providers agree with evidence-based policy guidelines. Study Design We conducted a cross-sectional survey of abortion facilities in the U.S. identified via publicly available resources and professional networks from June through December 2013. Results Of 703 identified facilities, 383 (54%) participated, including 172 clinicians providing second-trimester surgical abortions (dilation and evacuations [D&Es]). The majority of clinicians were obstetrician–gynecologists (87%), female (67%), and less than 50 years old (62%). Most clinicians (93%) ever use misoprostol as a cervical preparation agent, including in the setting of a uterine scar (87%). Some clinicians refer to a hospital-based provider if the patient has a placenta previa and a history of cesarean section (31%) or a complete previa alone (17%). Many clinicians have weight or body mass index restrictions for cases performed under iv moderate sedation (32/97, 33%) or deep sedation (23/50, 46%). Most clinicians (69%) who report performing D&Es at 18 weeks last menstrual period or greater do not routinely induce fetal demise preoperatively. Clinicians employ routine intraoperative ultrasound (79%) more commonly than routine postoperative ultrasound (47%), with no difference by years of provider experience. Most clinicians routinely use prophylactic uterotonic agents, most often postoperatively. Most clinicians (80%) routinely give perioperative antibiotics, most often doxycycline (75%). Conclusion Overall, the second-trimester surgical abortion practices revealed in our survey agree with professional evidence-based policy guidelines. Wider variability was reported for practices lacking a strong evidence base. Implications In this third cross-sectional survey of U.S. abortion practices (prior 1997 and 2002), second-trimester surgical abortion providers are younger than before, reflecting an improvement in the “graying” of the abortion provider workforce. Facility restrictions on gestational age along with hospital restrictions on referrals pose barriers to outpatient abortion access.

Objectives In 2012, only 60 doctors provided medical abortion in Canada. Mifepristone-based medical abortion is a gold standard that has now been available in Canada since 2016. While no longer mandatory, the Health Canada/SOGC/CFPC/CPhA Medical Abortion Training Program is the only comprehensive training program in the country, and this program meets the Health Canada definition of "appropriate training". We will provide the current data on training across Canada. Methods This is a descriptive study of the participants in the SOGC Medical Abortion Training Program. Data is classified by province/territory of practice, as well as membership/practice type. Updated information to May 31, 2019 will be provided at the time of presentation. Results As of September 2018, there were 1324 prescribers (physicians and nurse practitioners) as well as 2273 pharmacists trained to prescribe and dispense mifepristone. There were prescribers in every province and territory, including PEI, where there were, until recently, no surgical abortion services. Only Nunavut does not have a pharmacist trained in medical abortion. In comparison to the number of OB/GYNs in Canada, approximately 11.7% of Obstetrician/Gynaecologists were trained in Canada within the first 18 months of availability of mifepristone. Conclusions There has been an over 2200% increase in the number of possible medical abortion providers in Canada since the approval of combination mifepristone-misoprostol. This is reflective of a successful launch of the Medical Abortion Training Program, as well as a coordinated integrated Knowledge Translation (iKT) program and community of practice.

IntroductionIn January 2017, mifepristone-induced medical abortion was made available in Canada. In this study, we will seek to (1) understand facilitators and barriers to the implementation of mifepristone across Canada, (2) assess the impact of a ‘community of practice’ clinical and health service support platform and (3) engage in and assess the impact of integrated knowledge translation (iKT) activities aimed to improve health policy, systems and service delivery issues to enhance patient access to mifepristone.Methods and analysisThis prospective mixed-methods implementation study will involve a national sample of physicians and pharmacists recruited via an online training programme, professional networks and a purpose-built community of practice website. Surveys that explore constructs related to diffusion of innovation and Godin’s behaviour change frameworks will be conducted at baseline and at 6 months, and qualitative data will be collected from electronic interactions on the website. Survey participants and a purposeful sample of decision-makers will be invited to participate in in-depth interviews. Descriptive analyses will be conducted for quantitative data. Thematic analysis guided by the theoretical frameworks will guide interpretation of qualitative data. We will conduct and assess iKT activities involving Canada’s leading health system and health professional leaders, including evidence briefs, Geographical Information System (GIS)maps, face-to-face meetings and regular electronic exchanges. Findings will contribute to understanding the mechanisms of iKT relationships and activities that have a meaningful effect on uptake of evidence into policy and practice.Ethics and disseminationEthical approval was received from the University of British Columbia Children’s and Women’s Hospital Ethics Review Board (H16-01006). Full publication of the work will be sought in an international peer-reviewed journal. Findings will be disseminated to research participants through newsletters and media interviews, and to policy-makers through invited evidence briefs and face-to-face presentations.

J Obstet Gynaecol Can 2015;37(11):955–957 L de la pilule anticonceptionnelle et la legalisation subsequente de la contraception au Canada dans les annees 1960 ont marque les debuts d’une ere dans le cadre de laquelle les femmes pouvaient enfin avoir le dernier mot en ce qui a trait aux efforts visant a eviter les grossesses non planifiees. La capacite de planifier et d’espacer les grossesses confere de nombreux avantages indeniables en matiere de sante, de formation, de travail et de gestion economique aux femmes, a leurs collectivites et a l’ensemble de la societe1. Et pourtant, en 1957, la pilule n’etait prescrite que pour contrer les irregularites menstruelles et le marketing ou la vente de contraceptifs exposaient les personnes trouvees coupables a des amendes ou a des peines de prison, sauf dans les cas ou l’on estimait qu’elles avaient ainsi agi pour le « bien public ». Bien que cela puisse paraitre incomprehensible aux yeux de bon nombre d’entre nous en 2015, la Loi de 1968-69 modifiant le droit penal, qui prevoyait la legalisation de la contraception et des avortements « therapeutiques », n’a ete promulguee qu’en 19692. Il est interessant de souligner que cette loi n’a pas ete promulguee sans soulever une opposition feroce a la legalisation de la contraception.

A prospective study in this journal issue compares the effects on maternal bone turnover during lactation of subdermal implant compared with copper intrauterine device (IUD) use.1 It is interesting because publications about the influence of hormonal contraceptives on the health of the lactating woman herself are rare. This study’s advantage is that bone mineral density mostly is measured using dual-energy X-ray absorptiometry or a similar modality rather than relying on biochemical analyses of serum and urine samples. Its weak points are the relatively small numbers of participating women and the fact that this is a single-centre study. However it does offer some reassurance regarding the safety for the mother of this highly effective type of long-acting reversible contraceptive (LARC) even during lactation. Most studies of hormonal contraceptives in lactating women have focused on the effect of the contraceptive on lactation itself and on infant growth and well-being. A systematic review of progestogen-only contraception found no adverse effects on breastfeeding outcomes or outcomes related to infant growth health or development. This lack of negative outcomes was maintained when progestogen-only implants were started within the first 6 weeks postpartum. In addition breastfeeding duration did not differ between users of an etonogestrel implant compared with Cu-IUD users over 3 years. LARCs including the etonogestrel subdermal implant and the levonorgestrel-releasing intrauterine system are the most effective methods of contraception even more effective than female sterilisation. In a 3-year prospective study comparing LARC methods with non-LARC methods LARC methods were 20 times more effective than the non-LARC methods over all time periods. In keeping with this the American College of Obstetricians and Gynecologists (ACOG) recently published a report encouraging the application of LARCs immediately postpartum. It recommends among other things that women should be counselled prenatally about the option of immediate postpartum application of a LARC method. However as well as clinicians health authorities need to be more aware of the power of LARC methods to provide safe and effective contraception reduce teenage pregnancies unintended pregnancy unsafe abortion and maternal deaths. In addition to their harm to womens health they also impact detrimentally on social well-being. Providing contraception including LARCs at no cost to the user should be standard for all women after they have received adequate counselling to ensure that the chosen contraceptive method meets their needs. (full-text)