Explaining slow implementation of mifepristone in Quebec with the transtheoretical model of change

Abstract

<h3>Objectives</h3> 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. <h3>Methods</h3> 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. <h3>Results</h3> 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. <h3>Conclusions</h3> 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.