Abortion utilization and safety when mifepristone is available without regulations restricting practice? A population-based study using linked health administrative data from Ontario

Objectives Canadian policy allowing mifepristone medication abortion without regulations limiting practice is globally unique. The objective of this study was to examine the impact of Canadian deregulated medication abortion policy on abortion utilization and complications. Methods We used linked administrative data (billing, hospital, ambulatory care, and prescription records) from Ontario to examine the 306,750 surgical and medication abortions from January 2012 to December 2019. We examined medication abortion utilization, second trimester abortion, abortion-related complications (infection, hemorrhage, embolism, shock, damage to pelvic organs, other venous complications), surgical follow-up (laparotomy, laparoscopy, hysterectomy), aspiration/re-aspiration, and ongoing pregnancy within 6 weeks of the abortion. We compared incidences before and after mifepristone deregulation (2012-2016 vs. 2018-2019). Results Medication abortion utilization increased substantially from 2.4% of all abortions from 2012-2016 to 30.9% in 2018-2019. Second trimester abortion decreased from 6.0% [95% CI 5.7-6.2] before to 5.3% [5.2-5.5] after mifepristone deregulation. Among the 289,013 first trimester abortions, complications were similar before and after deregulation: abortion-related complication incidence was 0.65% [0.62-0.69] before and 0.60% [0.55-0.66] after. Surgical follow-up was similar in both periods, occurring in 0.05% [0.04-0.06] before and 0.05% [0.04-0.07] after deregulation. Aspiration/re-aspiration increased modestly from 0.05% [0.04-0.06] to 0.12% [0.09-0.14], as did ectopic pregnancy diagnosed after the abortion, from 0.15% [0.13-0.17] to 0.22% [0.19-0.26]. Ongoing intrauterine pregnancy continuing to delivery increased from 0.07% [0.06-0.09] to 0.30% [0.27-0.35], while ongoing pregnancy continuing to subsequent abortion increased from 0.94% [0.90-0.99] to 1.49% [1.40-1.58]. Conclusions Canada's globally unique deregulation of mifepristone medication abortion substantially increased medication abortion utilization and was not associated with a clinically significant increase in abortion complications or ongoing pregnancy.