Abstract
BackgroundDirect 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.MethodsIn 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.ResultsWe 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.ConclusionsOur 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.
Highlights
Direct primary care provision of first-trimester medical abortion could potentially address inequitable abortion access in Canada
Prior to January 2017 when mifepristone became available in the Canadian market, we developed and pilot-tested a survey to investigate health policy, health system, and health care delivery factors that influenced the uptake and implementation process for mifepristone first-trimester medical abortion practice
In phase 2, the panel of physician experts provided their perceptions of the impact of facilitators and barriers on abortion services throughout Canada which further informed the content we aimed to cover in our survey instrument
Summary
We explored expert, stakeholder, and physician perceptions of the impact of facilitators and barriers on abortion services throughout Canada. Abortion services are accessed in Canada either by selfreferral to an abortion/reproductive health care facility or through a referral from their family physician to an abortion provider [4, 5]. In Canada, geography is a significant barrier to accessing abortion facilities; for example, in the province of British Columbia, 90% of all abortions are provided in large urban cities, despite the fact that 43% of reproductive-aged women live outside these metropolitan areas [6]. Having abortion services limited to urban centers significantly impacts access to care for almost half of the population of reproductive-aged women in Canada [4]
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