What motivates primary care providers to prescribe mifepristone medication abortion? Results of a qualitative investigation in Canada

Munro et al. BMC Primary Care (2025) 26:349 https://doi.org/10.1186/s12875-025-03043-1 BMC Primary Care Open Access RESEARCH What motivates primary care providers to prescribe mifepristone medication abortion? Results of a qualitative investigation in Canada Sarah Munro1*, Madeleine Ennis2, Kate Wahl2 and Aleyah Williams2 Abstract Background Mifepristone-misoprostol, the gold standard medication abortion drug regimen, became available in Canada in 2017. However, there is limited evidence regarding the factors that influence primary care providers to begin prescribing medication abortion. We aimed to explore perspectives of the behavioural, social, and system factors that influence implementation of medication abortion prescribing among primary care providers in Canada. Methods We led a qualitative investigation involving one-on-one interviews with primary care providers who were interested in becoming or already were low-volume medication abortion prescribers in Canada. We collected data at two time points: (1) in 2018 after the first year of mifepristone’s availability and (2) in 2023. We recruited participants through partner health organizations’ online platforms and listservs. We conducted reflexive thematic analysis to understand resolved, novel, and ongoing factors influencing the implementation of mifepristone in primary care and mapped our results to Diffusion of Innovation theory. Results We completed 18 interviews with primary care providers from across Canada. We identified 5 core Diffusion of Innovation factors that were important to primary care provider implementation of medication abortion care. These factors included adoption and assimilation (motivation), where prescriber pro-choice attitudes and commitment to provide abortion as part of generalist primary care were facilitators. The innovation (knowledge required to use it) and implementation (external collaboration) were interrelated constructs: after training in the knowledge and skills to offer medication abortion, prescribers needed ongoing collaboration and support with physician and pharmacist peers. System antecedents (a receptive context for change) included challenges with abortion-related stigma and harassment in professional and community settings. Finally, system readiness (dedicated time and resources) was necessary to ensure ease in the logistics of medication abortion care, including billing, counseling, and delays in timely care. Conclusions Our results highlight that, after five years, barriers still exist to providing mifepristone medication abortion in Canadian primary care. We illustrate the importance of addressing ongoing perceptions of logistical *Correspondence: Sarah Munro Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Munro et al. BMC Primary Care (2025) 26:349 Page 2 of 13 barriers to care, concerns about advertising abortion services to the community, and the need for robust mentorship and consultation pathways. Keywords Mifepristone, Medication abortion, Canada, Pregnancy, Primary care, Qualitative research Introduction First trimester induced abortions are a common and essential health care service, with over 90,000 abortions in Canada reported annually [1]. In Canada, there are no laws governing abortion care, and people have the right to access abortions [2]. In 2017, the gold standard of medication abortion, mifepristone and misoprostol, became available in Canada. Strong evidence highlights the safety, efficacy, and acceptability to clients of care of mifepristone in combination with misoprostol for first trimester abortion [3]. Prior to this, according to a 2012 national survey of abortion providers in Canada, less than 4% of all abortions were medication abortions which were carried out with a less effective off-label use of a methotrexate and misoprostol regimen [4]. The majority were procedural abortions conducted at high-volume abortion clinics in urban areas. Mifepristone availability offers the potential to expand abortion access, if the regulations around the medication could support its dispersal via primary care. While no laws govern abortion care in Canada, drug regulator Health Canada initially specified mifepristone restrictions such as: mandatory training and registration for prescribers and pharmacists, as well as physician-only direct dispensing [3]. Evidence indicated that regulations such as these would impede safety, access, and provision of medication abortion in primary care in Canada [5]. Between 2017 and 2020, Health Canada removed these restrictive regulations making it available through normal prescribing and pharmacist dispensing pathways and expanding medication abortion prescribing authority to include nurse practitioners. Evidence highlights that mifepristone has enabled a rise in provision of medication abortion in primary care, and the opportunity for rural residents to access abortion care closer to home [6– 8]. The COVID-19 pandemic further catalyzed changes to medication abortion access in Canada starting in 2020, with the introduction of practice guidelines for low- to no-touch telemedicine abortion [9, 10]. Analysis of surveillance data suggests that new abortion providers in Canada include primary care providers who offer abortion as a part of their overall practice, with a large proportion practicing in rural communities [11]. Since the outset of the COVID-19 pandemic, the Society of Obstetricians and Gynaecologists of Canada has recommended use of a low- or no-test medication abortion protocol through telemedicine, where the patient obtains the prescription by mail or at a local pharmacy [10]. While prior research has described the abortion workforce, there is limited evidence regarding the factors that influence or motivate primary care providers to initiate abortion care. Although thousands of primary care providers in Canada have mifepristone prescribing authority, workforce survey data indicates that barriers to implementing abortion practice can include fears of interprofessional or community stigma, perceptions of limited patient (...truncated)