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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 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.

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)

The combined contraceptive vaginal ring releases 120 μg of etonogestrel and 15 μg of ethinylestradiol per day for at least a 3-week period. It is as effective as combined oral contraceptive pills with similar side effects but better cycle control. The ring is not associated with weight gain and may have many non-contraceptive benefits including a positive effect on sexual function, dysmenorrhea, premenstrual syndrome, and heavy menstrual bleeding. Contraindications are the same as for combined oral contraceptives, and serious complications are rare. The risk of venous thromboembolism with the ring is comparable with that of combined oral contraceptives. The rate of acceptability of the ring is high, and most women, including adolescents, can use the ring.

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)

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.

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).

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.

Background In the fall of 2007, the controversy about the contraceptive use of depot-medroxyprogesterone acetate (DMPA) and its potential impact on skeletal health reached the media in the province of Quebec, Canada, thereby becoming a matter of concern for the lay public and physicians. In order to discuss this subject openly, the National Institute of Public Health of Quebec (INSPQ) organized a scientific meeting on February 15, 2008, with targeted physicians delegated by their medical associations in the fields of general practice, obstetrics and gynaecology, rheumatology, orthopaedic surgery, physiatry and endocrinology. Study Design Participants reviewed the scientific literature using the study classification method according to the level of evidence, reviewed published guidelines of medical societies and organizations on the subject and reached a consensus position. This manuscript presents a review of the literature and describes the consensus position of the targeted medical associations. Results The consensus position adopted by all the targeted medical associations determined that DMPA was a cost-effective contraceptive option that must be considered in the light of the clinical situation and preference of each woman. Candidates for injectable contraception should be informed that the use of DMPA is associated with a slight decrease in bone mineral density (BMD), which is largely, if not completely, reversible. There should not be an absolute limit to the length of time that the DMPA contraceptive is used, regardless of the woman's age. Monitoring BMD is not recommended among users of DMPA for contraceptive purposes. Finally, the consensus statement declared that, although supplements of calcium and vitamin D are beneficial for skeletal health for women in general, such supplementation should not be recommended solely based on a woman's use of DMPA. Conclusion Given the scientific evidences, DMPA use remains a valid contraceptive option for women. Its potential impact on BMD must be balanced against the significant individual, familial and social consequences of unintended pregnancy.

Resume Objectif Offrir des conseils factuels aux femmes et a leurs fournisseurs de soins de sante quant a la prise en charge de l'oubli ou de la prise differee d'une ou de plusieurs doses de contraceptif hormonal, afin de prevenir les grossesses non souhaitees. Resultats Des recherches ont ete menees dans Medline, PubMed et la base de donnees Cochrane afin d'en tirer les articles, publies en anglais entre 1974 et 2007, qui portaient sur les modes de contraception hormonale disponibles au Canada et pouvant faire l'objet d'un oubli ou d'une prise differee. Les publications et les declarations de principe pertinentes issues d'organisations de planification familiale et de sante genesique competentes ont egalement ete analysees. La qualite des resultats est evaluee au moyen des criteres elabores par le Groupe d'etude canadien sur les soins de sante preventifs. Avantages, desavantages et couts La presente opinion de comite aidera les fournisseurs de soins de sante a offrir des renseignements clairs aux femmes n'ayant pas fait preuve d'observance quant au mode de contraception hormonale qu'elles utilisent, dans le but de prevenir les grossesses non souhaitees. Commanditaire : La Societe des obstetriciens et gynecologues du Canada. Declarations sommaires 1.Les consignes destinees aux femmes qui oublient de prendre une ou plusieurs doses de contraceptif hormonal se sont jusqu'ici averees complexes et ces femmes ne les comprennent pas correctement. (I) 2.Le risque d'ovulation le plus eleve se manifeste lorsque l'intervalle sans hormones se prolonge au-dela de sept jours, que cette prolongation soit attribuable au report de l'utilisation d'un nouvel emballage de contraceptifs hormonaux combines ou a l'oubli de doses d'hormones actives au cours de la premiere ou de la troisieme semaine du cycle d'utilisation de contraceptifs hormonaux combines. (II) Une ovulation survient rarement apres sept jours consecutifs d'utilisation de contraceptifs hormonaux combines. (II) Recommandations 1.Les fournisseurs de soins de sante devraient, dans le cadre du counseling sur la contraception, offrir des consignes claires et simples, tant de vive voix que sous forme ecrite, quant a la prise en charge de l'oubli de doses de contraceptif hormonal. (III-A) 2.Les fournisseurs de soins de sante devraient offrir aux femmes des ressources telephoniques / electroniques auxquelles elles peuvent se referer a la suite de l'oubli ou de la prise differee de doses de contraceptif hormonal. (III-A) 3.Afin d'eviter une hausse du risque de grossesse non souhaitee chez les utilisatrices de contraceptifs hormonaux combines, l'intervalle sans hormones ne devrait pas etre prolonge au-dela de sept jours. (II-A) 4.Une contraception d'appoint devrait etre mise en oeuvre a la suite de l'oubli d'une dose au cours de la premiere semaine du cycle de contraception hormonale, et ce, jusqu'a ce que sept jours consecutifs d'utilisation correcte du contraceptif hormonal en question se soient ecoules. Lorsque l'oubli de doses de contraceptif hormonal combine survient au cours de la deuxieme ou de la troisieme semaine du cycle de contraception hormonale, l'intervalle sans hormones devrait etre elimine en ce qui concerne le cycle en question. (III-A) 5.La mise en oeuvre d'une contraception d'urgence et d'une contraception d'appoint peut s'averer requise dans certains cas d'oubli de doses de contraceptif hormonal, particulierement lorsque l'intervalle sans hormones s'est prolonge au-dela de sept jours. (III-A) 6.Une contraception d'appoint devrait etre mise en oeuvre a la suite de l'oubli de trois doses / jours consecutifs de contraceptif hormonal combine ou plus au cours de la deuxieme et de la troisieme semaine du cycle de contraception, et ce, jusqu'a ce que sept jours consecutifs d'utilisation correcte du contraceptif hormonal en question se soient ecoules. Pour des raisons pratiques, l'intervalle sans hormones prevu devrait etre elimine dans de telles circonstances. (II-A) 7.La mise en oeuvre d'une contraception d'urgence est rarement indiquee a la suite de l'oubli de doses de contraceptif hormonal combine au cours de la deuxieme ou de la troisieme semaine du cycle, a moins que l'on ait affaire a des omissions repetees ou qu'aucune contraception d'appoint n'ait ete mise en oeuvre a la suite des oublis en question. En presence d'omissions repetees, la mise en oeuvre d'une contraception d'urgence peut s'averer requise et une contraception d'appoint devrait etre utilisee. Dans de telles circonstances, les professionnels de la sante devraient conseiller les femmes quant a l'adoption d'un mode de contraception moins exigeant sur le plan de l'observance. (III-A)

To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality.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.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.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). Chapter 1: Contraception in Canada Summary Statements 1. Canadian women spend a significant portion of their lives at risk of an unintended pregnancy. (II-2) 2. Effective contraceptive methods are underutilized in Canada, particularly among vulnerable populations. (II-2) 3. Long-acting reversible contraceptive methods, including contraceptive implants and intrauterine contraception (copper-releasing and levonorgestrel-releasing devices/systems), are the most effective reversible contraceptive methods and have the highest continuation rates. (II-1) 4. Canada currently does not collect reliable data to determine the use of contraceptive methods, abortion rates, and the prevalence of unintended pregnancy among reproductive-age women. (II-2) 5. A universal subsidy for contraceptive methods as provided by many of Canada's peer nations and a few Canadian provinces may produce health system cost-savings. (II-2) 6. Health Canada approval processes for contraceptives have been less efficient than those of other drug approval agencies and Health Canada processes for other classes of pharmaceuticals. (II-2) 7. It is feasible and safe for contraceptives and family planning services to be provided by appropriately trained allied health professionals such as midwives, registered nurses, nurse practitioners, and pharmacists. (II-2) Recommendations 1. Contraceptive counselling should include a discussion of typical use failure rates and the importance of using the contraceptive method consistently and correctly in order to avoid pregnancy. (II-2A) 2. Women seeking contraception should be counselled on the wide range of effective methods of contraception available, including long-acting reversible contraceptive methods (LARCs). LARCs are the most effective methods of reversible contraception, have high continuation rates, and should be considered when presenting contraceptive options to any woman of reproductive age. (II-2A) 3. Family planning counselling should include counselling on the decline of fertility associated with increasing female age. (III-A) 4. Health policy supporting a universal contraception subsidy and strategies to promote the uptake of highly effective methods as cost-saving measures that improve health and health equity should be considered by Canadian health decision makers. (III-B) 5. Canadian health jurisdictions should consider expanding the scope of practice of other trained professionals such as nurses, nurse practitioners, midwives, and pharmacists and promoting task-sharing in family planning. (II-2B) 6. The Canadian Community Health Survey should include adequate reproductive health indicators in order for health care providers and policy makers to make appropriate decisions regarding reproductive health policies and services in Canada. (III-B) 7. Health Canada processes and policies should be reviewed to ensure a wide range of modern contraceptive methods are available to Canadian women. (III-B) Chapter 2: Contraceptive Care and Access Summary Statements 8. Although there are many contraceptive options in Canada, only a narrow range of contraceptive methods are commonly used by those of reproductive age. (II-3) 9. Condom use decreases with longer relationship tenure and when the sexual partner is considered to be the main partner, likely due to a lower perceived risk of sexually transmitted infection in that relationship. Condom use may also decrease markedly as an unintended consequence when an effective non-barrier method, such as hormonal contraception or intrauterine contraception, is initiated. (II-3) 10. Family planning counselling provides a natural segue into screening for concerns about sexual function or intimate partner violence. (III) 11. Well-informed and well-motivated individuals who have developed skills to practise safer sex behaviours are more likely to use contraceptive and safer sex methods effectively and consistently. (II-2) Recommendations 8. Comprehensive family planning services, including abortion services, should be accessible to all Canadians regardless of geographic location. These services should be confidential, non-judgemental, and respectful of individuals' privacy and cultural contexts. (III-A) 9. A contraceptive visit should include history taking, screening for contraindications, dispensing or prescribing a method of contraception, and exploring contraceptive choice and adherence in the broader context of the individual's sexual behaviour, reproductive health risk, social circumstances, and relevant belief systems. (III-B) 10. Health care providers should provide practical information on the wide range of contraceptive options and their potential non-contraceptive benefits and assist women and their partners in determining the best user-method fit. (III-B) 11. Health care providers should assist women and men in developing the skills necessary to negotiate the use of contraception and the correct and consistent use of a chosen method. (III-B) 12. Contraceptive care should include discussion and management of the risk of sexually transmitted infection, including appropriate recommendations for condom use and dual protection, STI screening, post-exposure prophylaxis, and Hepatitis B and human papillomavirus vaccination. (III-B) 13. Health care providers should emphasize the use of condoms not only for protection against sexually transmitted infection, but also as a back-up method when adherence to a hormonal contraceptive may be suboptimal. (I-A) 14. Health care providers should be aware of current media controversies in reproductive health and acquire relevant evidence-based information that can be briefly and directly communicated to their patients. (III-B) 15. Referral resources for intimate partner violence, sexually transmitted infections, sexual dysfunction, induced abortion services, and child protection services should be available to help clinicians provide contraceptive care in the broader context of women's health. (III-B) Chapter 3: Emergency Contraception Summary Statements 12. The copper intrauterine device is the most effective method of emergency contraception. (II-2) 13. A copper intrauterine device can be used for emergency contraception up to 7 days after unprotected intercourse provided that pregnancy has been ruled out and there are no other contraindications to its insertion. (II-2) 14. Levonorgestrel emergency contraception is effective up to 5 days (120 hours) after intercourse; its effectiveness decreases as the time between unprotected intercourse and ingestion increases. (II-2) 15. Ulipristal acetate for emergency contraception is more effective than levonorgestrel emergency contraception up to 5 days after unprotected intercourse. This difference in effectiveness is more pronounced as the time from unprotected intercourse increases, especially after 72 hours. (I) 16. Hormonal emergency contraception (levonorgestrel emergency contraception and ulipristal acetate for emergency contraception) is not effective if taken on the day of ovulation or after ovulation. (II-2) 17. Levonorgestrel emergency contraception may be less effective in women with a body mass index25 kg/m2 and ulipristal acetate for emergency contraception may be less effective in women with a body mass index35 kg/m2. However, hormonal emergency contraception may still retain some effectiveness regardless of a woman's body weight or body mass index. (II-2) 18. Hormonal emergency contraception is associated with higher failure rates when women continue to have subsequent unprotected intercourse. (II-2) 19. Hormonal contraception can be initiated the day of or the day following the use of levonorgestrel emergency contraception, with back-up contraception used for the first 7 days. (III) 20. Hormonal contraception can be initiated 5 days following the use of ulipristal acetate for emergency contraception, with back-up contraception used for the first 14 days. (III) Recommendations 16. All emergency contraception should be initiated as soon as possible after unprotected intercourse. (II-2A) 17. Women should be informed that the copper intrauterine device (IUD) is the most effective method of emergency contraception and can be used by any woman with no contraindications to IUD use. (II-3A) 18.

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, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the availability of cited contraceptive methods in Canada. Evidence Medline and the Cochrane Database were searched for articles in English on subjects related to contraception, sexuality, and sexual health from January 1994 to December 2015 in order to update the Canadian Contraception Consensus published February-April 2004. Relevant Canadian government publications and position papers from appropriate health and family planning organizations were also reviewed. Values The quality of the evidence is rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice are ranked according to the method described in this report. Summary Statements 1.Although highly effective with perfect use, typical use failure rates for combined hormonal contraceptives, including the combined oral contraceptive pill, are as high as 9% (II-2). 2.The majority of qualified studies do not indicate decreased combined oral contraceptive pill efficacy in obese women; however, a small increase in contraceptive failure in women with a body mass index greater than 30 cannot be excluded (II-2). 3.Combined oral contraceptive pills are associated with a number of non-contraceptive benefits, including but not limited to decreased menstrual bleeding, decreased acne, fewer endometriosis-related symptoms, and a decreased risk of ovarian and endometrial cancers (II-2). 4.Combined oral contraceptive pills (COCs) are associated with an increased risk of venous thromboembolism (II-2). Potential differences in the risk of venous thromboembolism attributable to different progestin types and estrogen dosing in low-dose COCs do not currently justify preferential prescribing (III). 5.Low-dose combined oral contraceptive pills (containing less than 50 μg of ethinyl estradiol) are not associated with an increased risk of myocardial infarction or cerebrovascular accident in women with no additional risk factors (II-2). 6.Current epidemiological studies suggest that there is no increase in the risk of breast cancer or breast cancer mortality in women who have used combined oral contraceptive pills (COCs) compared with non-users (II-2). There may be a slight increase in breast cancer in current and/or recent COC users (II-2). The use of COCs in BRCA1/2 carriers is controversial but appears to be associated with a decreased risk of ovarian cancer and no increase in the risk of breast cancer (II-2). 7.Combined oral contraceptive pills (COCs) are associated with a decreased risk of ovarian, endometrial, and colorectal cancers (II-2). A possible association has been shown between COC use and risk of cervical cancer (II-2), but causation has not been demonstrated. 8.A blood pressure measurement is the only examination and/or investigation that is required prior to initiating combined hormonal contraception (CHC) in women who are otherwise healthy by history (II-2). Baseline weight and body mass index assessment might be helpful for monitoring changes in CHC users. Pelvic examination, Pap test, screening for sexually transmitted infections, and thrombophilia screening are not required prior to initiating CHC (III). 9.Combined oral contraceptive pills and other combined hormonal contraception (CHC) can be started at any time during the menstrual cycle provided that pregnancy or the possibility of pregnancy can be reasonably ruled out. Where there is uncertainty, the benefits of starting CHC likely outweigh any risks (III). 10.Starting combined hormonal contraception immediately (Quick Start) may improve short-term compliance and is not associated with an increase in unscheduled bleeding or other side effects (I). 11.The highest risk of ovulation occurs when the hormone-free interval is prolonged for more than 7 days, either by delaying the start of combined hormonal contraception (CHC) or by missing active hormone doses during the first or third weeks of CHC (I). Ovulation rarely occurs after 7 consecutive days of CHC use (II-2). 12.Emergency contraception (EC) and back-up contraception may be required in some instances of missed combined hormonal contraception (CHC), particularly when the hormone-free interval has exceeded 7 days. EC is rarely indicated for missed CHC in the second or third week of the cycle unless there are repeated omissions or failure to use back-up contraception after the missed doses (III). 13.Combined oral contraceptive pill exposure just prior to or during pregnancy is not associated with an increased risk of major birth defects (II-2). 14.The effectiveness of combined hormonal contraception (CHC), including combined oral contraceptive pills, may be affected by other medications, including but not limited to some anticonvulsants, some antiretrovirals, rifampicin, and griseofulvin. CHCs may affect the serum levels of other medications, including some anticonvulsants and antiretrovirals (II-2). 15.The contraceptive patch may be less effective in women with a body weight ≥90 kg (II-2). 16.Compared with the combined oral contraceptive pill, transdermal contraceptive patch use is associated with less breakthrough bleeding and spotting but more breast discomfort or pain, nausea and vomiting, and dysmenorrhea (I). 17.Pharmacokinetic studies indicate that serum hormone concentrations of ethinyl estradiol and norelgestromin are maintained at ovulation inhibitory levels throughout at least 9 days of continuous transdermal contraceptive patch wear (II-2). 18.The vaginal contraceptive ring is associated with less unscheduled bleeding than the combined oral contraceptive pill and the duration of menstrual bleeding is significantly shorter than that seen with the contraceptive patch (I). 19.Serum levels of ethinyl estradiol and etonorgestrel are maintained at ovulation inhibitory levels for at least 28 days after the vaginal contraceptive ring has been inserted (II-2). 20.Continuous and/or extended regimens of combined hormonal contraception (CHCs) have similar rates of adherence and effectiveness compared with 28-day cyclic CHC regimens (I). 21.Continuous and/or extended (C/E) regimens of combined hormonal contraception (CHC) are associated with significantly less menstruation-associated symptoms than are cyclic CHC (I). Bleeding and/or spotting with C/E CHC regimens decreases with each successive cycle and is similar to or less than that with cyclic CHC (I). Recommendations 1.Health care providers should give clear instructions for hormonal contraceptive use, including how to manage missed hormonal contraception, as part of contraceptive counselling. Women should be provided with resources to refer to in the event of missed and/or delayed hormonal contraceptives or if they develop any signs of a serious adverse event while using hormonal contraception (III-A). 2.Health care providers should consider advising women who are initiating contraception to start their combined hormonal contraception (CHC) immediately (Quick Start) provided that they are reasonably certain that the woman is not pregnant. Back-up contraception (barrier method) or abstinence should be used for the first 7 consecutive days of CHC use unless CHC was initiated on the first day of menses (I-A). 3.Health care providers should consider the possibility of irregular pill taking, concomitant medication use, malabsorption, uterine or cervical pathology, pregnancy, or chlamydial infection in women presenting with persistent unscheduled bleeding on the combined oral contraceptive pill (III-A). 4.If 1 combined oral contraceptive pill or other combined hormonal contraception (CHC) method is missed in the first week of use, back-up contraception or abstinence should be used until the CHC method has been used for 7 consecutive days. In the case of missed CHC in the second or third week of hormones, the hormone-free interval should be eliminated for that cycle (III-A). 5.Back-up contraception should be used when 3 or more consecutive doses/days of combined hormonal contraception (CHC) have been missed in the second or third week of hormone use until the CHC has been used for 7 consecutive days. For practical reasons, the scheduled hormone-free interval should be eliminated in these cycles (I-A). 6.Health care providers should be aware of other medications being used by combined hormonal contraception users and the possibility of drug interactions that could affect serum levels and effectiveness of either medication (II-2A). 7.Health care professionals should be aware of the option of using continuous and/or extended combined hormonal contraception regimens and consider offering them to women for contraception, medical reasons, and personal preferences (III-A). 8.Women using continuous and/or extended combined hormonal contraception regimens should be counselled about expected bleeding patterns and how to manage unscheduled bleeding or spotting (III-A). 9.When a specific product has been prescribed to a woman, she should be informed if a generic substitution is being considered and her health care provider should be advised if a substitution is made. The woman should have the option to agree or disagree to the substitution and be informed about any difference in cost for a specific product (III-B).

Objectif Mettre a la disposition des fournisseurs de soins des lignes directrices concernant le recours a des methodes contraceptives pour prevenir la grossesse et la promotion d'une sexualite saine. Issues Efficacite globale des methodes contraceptives citees : evaluation de l'innocuite, des effets indesirables et de la baisse du taux de grossesse; effet des methodes contraceptives citees sur la sante sexuelle et le bien-etre general; disponibilite des methodes contraceptives citees au Canada. ReSULTATS: Des recherches ont ete effectuees dans MEDLINE et la base de donnees Cochrane afin d'en tirer les articles en anglais publies entre janvier 1994 et decembre 2015 traitant de sujets lies a la contraception, a la sexualite et a la sante sexuelle, dans le but de mettre a jour le consensus canadien sur la contraception paru de fevrier a avril 2004. Nous avons egalement passe en revue les publications pertinentes du gouvernement canadien, ainsi que les declarations de principes issues d'organisations competentes vouees a la sante et a la planification familiale. Valeurs La qualite des resultats a ete evaluee au moyen des criteres decrits par le Groupe d'etude canadien sur les soins de sante preventifs. Les recommandations quant a la pratique sont classees en fonction de la methode decrite dans le rapport du Groupe. DeCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Objective To serve as a guideline for health care providers on the use of continuous and extended combined hormonal contraception regimens, to prevent pregnancy, and to delay menses that affect health-related quality of life. Options All combined hormonal contraceptive methods available in Canada that may be used in a continuous or extended regimen are reviewed, and the implications are discussed. Outcomes Efficacy of cited regimens and assessment of their side effects, patient safety, medical usage and non-contraceptive benefits, cost-effectiveness, and availability in Canada. Indications for patient counselling are also provided Evidence Medline, PubMed, and Cochrane Database were searched for articles published in English between 1977 and May 2007. Relevant publications and position papers from appropriate reproductive health and family planning organizations were also reviewed. Values The quality of evidence is rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table 1). Benefits, harms, and costs The guideline is intended to help reduce unintended pregnancies and improve health-related quality of life in women who find their menses problematic. Increased awareness and empowerment of women, their partners, and health care professionals will improve their ability to make appropriate choices between continuous or extended and cyclic usage of these regimens. Sponsors The development of this guideline has been supported by unrestricted grants from Bayer HealthCare Pharmaceuticals, Janssen Ortho, Organon Canada Ltd., Paladin Labs Inc., Pfizer Canada Inc., and Wyeth Pharmaceuticals.

Objective To review current knowledge about emergency contraception (EC), including available options, their modes of action, efficacy, safety, and the effective provision of EC within a practice setting. Options The combined estradiol-levonorgestrel (Yuzpe regimen) and the levonorgestrel-only regimen, as well as post-coital use of copper intrauterine devices, are reviewed. Outcomes Efficacy in terms of reduction in risk of pregnancy, safety, and side effects of methods for EC and the effect of the means of access to EC on its appropriate use and the use of consistent contraception. Evidence Studies published in English between January 1998 and March 2010 were retrieved though searches of Medline and the Cochrane Database, using appropriate key words (emergency contraception, post-coital contraception, emergency contraceptive pills, post-coital copper IUD). Clinical guidelines and position papers developed by health or family planning organizations were also reviewed. Values The studies reviewed were classified according to criteria described by the Canadian Task Force on Preventive Health Care, and the recommendations for practice were ranked according to this classification (Table 1). Benefits, Harms, and Costs These guidelines are intended to help reduce unintended pregnancies by increasing awareness and appropriate use of EC. Sponsor The Society of Obstetricians and Gynecologists of Canada.

To review current knowledge about emergency contraception (EC), including available options, their modes of action, efficacy, safety, and the effective provision of EC within a practice setting.The combined estradiol-levonorgestrel (Yuzpe regimen) and the levonorgestrel-only regimen, as well as post-coital use of copper intrauterine devices, are reviewed.Efficacy in terms of reduction in risk of pregnancy, safety, and side effects of methods for EC and the effect of the means of access to EC on its appropriate use and the use of consistent contraception.Studies published in English between January 1998 and March 2010 were retrieved though searches of Medline and the Cochrane Database, using appropriate key words (emergency contraception, post-coital contraception, emergency contraceptive pills, post-coital copper IUD). Clinical guidelines and position papers developed by health or family planning organizations were also reviewed.The studies reviewed were classified according to criteria described by the Canadian Task Force on Preventive Health Care, and the recommendations for practice were ranked according to this classification (Table 1).These guidelines are intended to help reduce unintended pregnancies by increasing awareness and appropriate use of EC.The Society of Obstetricians and Gynaecologists of Canada. Summary Statements 1. Hormonal emergency contraception may be effective if used up to 5 days after unprotected intercourse. (II-2) 2. The earlier hormonal emergency contraception is used, the more effective it is. (II-2) 3. A copper IUD can be effective emergency contraception if used within 7 days after intercourse. (II-2) 4. Levonorgestrel emergency contraception regimens are more effective and cause fewer side effects than the Yuzpe regimen. (I) 5. Levonorgestrel emergency contraception single dose (1.5 mg) and the 2-dose levonorgestrel regimen (0.75 mg 12 hours apart) have similar efficacy with no difference in side effects. (I) 6. Of the hormonal emergency contraception regimens available in Canada, levonorgestrel-only is the drug of choice. (I) 7. A pregnancy that results from failure of emergency contraception need not be terminated (I) Recommendations 1. Emergency contraception should be used as soon as possible after unprotected sexual intercourse. (II-2A) 2. Emergency contraception should be offered to women if unprotected intercourse has occurred within the time it is known to be effective (5 days for hormonal methods and up to 7 days for a copper IUD). (II-2B) 3. Women should be evaluated for pregnancy if menses have not begun within 21 days following emergency contraception treatment. (III-A) 4. During physician visits for periodic health examinations or reproductive health concerns, any woman in the reproductive age group who has not been sterilized may be counselled about emergency contraception in advance with detailed information about how and when to use it. (III-C).

To provide evidence-based guidance for women and their health care providers on the management of missed or delayed hormonal contraceptive doses in order to prevent unintended pregnancy.Medline, PubMed, and the Cochrane Database were searched for articles published in English, from 1974 to 2007, about hormonal contraceptive methods that are available in Canada and that may be missed or delayed. Relevant publications and position papers from appropriate reproductive health and family planning organizations were also reviewed. The quality of evidence is rated using the criteria developed by the Canadian Task Force on Preventive Health Care.This committee opinion will help health care providers offer clear information to women who have not been adherent in using hormonal contraception with the purpose of preventing unintended pregnancy.The Society of Obstetricians and Gynaecologists of Canada. SUMMARY STATEMENTS: 1. Instructions for what women should do when they miss hormonal contraception have been complex and women do not understand them correctly. (I) 2. The highest risk of ovulation occurs when the hormone-free interval is prolonged for more than seven days, either by delaying the start of combined hormonal contraceptives or by missing active hormone doses during the first or third weeks of combined oral contraceptives. (II) Ovulation rarely occurs after seven consecutive days of combined oral contraceptive use. (II) RECOMMENDATIONS: 1. Health care providers should give clear, simple instructions, both written and oral, on missed hormonal contraceptive pills as part of contraceptive counselling. (III-A) 2. Health care providers should provide women with telephone/electronic resources for reference in the event of missed or delayed hormonal contraceptives. (III-A) 3. In order to avoid an increased risk of unintended pregnancy, the hormone-free interval should not exceed seven days in combined hormonal contraceptive users. (II-A) 4. Back-up contraception should be used after one missed dose in the first week of hormones until seven consecutive days of correct hormone use are established. In the case of missed combined hormonal contraceptives in the second or third week of hormones, the hormone-free interval should be eliminated for that cycle. (III-A) 5. Emergency contraception and back-up contraception may be required in some instances of missed hormonal contraceptives, in particular when the hormone-free interval has been extended for more than seven days. (III-A) 6. Back-up contraception should be used when three or more consecutive doses/days of combined hormonal contraceptives are missed in the second and third week until seven consecutive days of correct hormone use are established. For practical reasons, the scheduled hormone-free interval should be eliminated in these cases. (II-A) 7. Emergency contraception is rarely indicated for missed combined hormonal contraceptives in the second or third week of the cycle unless there are repeated omissions or failure to institute back-up contraception after the missed doses. In cases of repeated omissions of combined hormonal contraceptives, emergency contraception may be required, and back-up contraception should be used. Health care professionals should counsel women in these situations on alternative methods of contraception that do not demand such stringent compliance. (III-A).

Many factors influence the effectiveness of contraceptive methods. Oral contraceptives are the second most popular contraceptive method after female sterilization in the US. A total of 25% of women do not use their oral contraceptives correctly; 30% of women do not use them consistently. Several new contraceptive methods with alternate routes of delivery and less frequent dosing are available. The combined etonogestrel/ethinyl estradiol contraceptive vaginal ring is marketed under the name of NuvaRing. This is the only contraceptive ring approved by the FDA. The administration of steroids by the vaginal route may offer many advantages. Because of less frequent dosing, self-administration, and possibly, an improved side effect profile, the ring has the potential to increase successful use.

Mifepristone and oral misoprostol are typically used for medical abortion in women up to 49 days of gestation, with a 36- to 48-hour interval between the medications. Alternative routes of misoprostol administration allow for use beyond 49 days of gestation. We designed this randomized, noninferiority trial to compare the efficacy, adverse effects, and acceptability of misoprostol 800 mcg vaginally administered simultaneously with, or 24 hours after, mifepristone 200 mg orally for abortion in women up to 63 days of gestation.The 1,128 participants swallowed mifepristone 200 mg and were then randomized to self-administer misoprostol intravaginally immediately in the office (group 1) or 24 hours later at home (group 2). Subjects returned for an evaluation, including transvaginal ultrasonography, 7+/-1 days after initiating treatment. Women who had not aborted were offered a second dose of misoprostol and returned for another evaluation in approximately 1 week. A phone contact was also attempted approximately 5 weeks after treatment. Treatment was considered a failure if a suction aspiration was performed for any indication.The complete abortion rate for group 1 (95.1%, 95% confidence interval [CI] 93.0-96.8%) was statistically noninferior to that for group 2 (96.9%, 95% CI 95.1-98.2%) (P=.003). The abortion rates between groups did not significantly differ by gestational age. Adverse effects were mostly similar, although nausea, diarrhea, and warmth or chills were significantly more common in group 1.Mifepristone 200 mg and misoprostol 800 mcg vaginally used simultaneously is as effective for abortion as compared with regimens using a 24-hour dosing interval.ClinicalTrials.gov, www.clinicaltrials.gov, NCT00269568I.

Introduction Late postpartum hemorrhage following a Caesarean section (CS) is uncommon. A partial or complete dehiscence of the lower segment CS incision is a rare but possible cause. Case A 33-year-old woman underwent a lower segment CS for chorioamnionitis and failure to progress in labour at 40 weeks and 5 days of gestation. On the 43rd postpartum day, she developed heavy vaginal bleeding. Emergency laparotomy revealed a complete dehiscence of the lower uterine segment incision. A subtotal hysterectomy was performed to control the bleeding, and the postoperative course was uneventful. Conclusion Dehiscence of a lower uterine segment incision is a rare but potentially dangerous cause of late postpartum hemorrhage.

To review current knowledge about emergency contraception (EC), including available options, their modes of action, efficacy, safety, and the effective provision of EC within a practice setting.The combined estradiol-levonorgestrel (Yuzpe regimen) and the levonorgestrel-only regimen, as well as post-coital copper intrauterine devices, are reviewed.Efficacy in terms of reduction in risk of pregnancy, safety, and side effects of methods for EC and the effect of the means of access to EC on its appropriate use and the use of consistent contraception.MEDLINE and the Cochrane Database were searched for English-language articles published from January 1998 through March 2003, to update the previous SOGC guidelines published in 2000. Clinical guidelines and position papers developed by health or family planning organizations were also reviewed. Key words used were: emergency contraception, post-coital contraception, emergency contraceptive pills, postcoital copper IUD.The studies reviewed were classified according to criteria described by the Canadian Task Force on the Periodic Health Exam and the recommendations for practice were ranked based on this classification.These guidelines are intended to help reduce unintended pregnancies by increasing awareness and appropriate use of EC.1. Women who have had unprotected intercourse and wish to prevent pregnancy should be offered hormonal EC up to 5 days after intercourse. (II-2A) 2. A copper IUD can be used up to 7 days after intercourse in women who have no contraindications. (III-B) 3. Women should be advised that the levonorgestrel EC regimen is more effective and causes fewer side effects than the Yuzpe regimen. (I-A) 4. Either 1 double dose of the levonorgestrel EC regimen (1.5 mg) or the regular 2-dose levonorgestrel regimen (0.75 mg each dose) may be used, as they have similar efficacy with no difference in side effects. (I-A) 5. Hormonal EC should be started as soon as possible after unprotected sexual intercourse. (II-2B)6. Women of reproductive age should be provided with a prescription for hormonal EC in advance of need. (I-A) 7. The woman should be evaluated for pregnancy if menses have not begun within 21 days following EC treatment. (III-A) 8. A pelvic examination is not indicated for the provision of hormonal EC. (III-A) Validation: These guidelines have been reviewed by the Clinical Practice Gynaecology and Social and Sexual Issues Committees of the Society of Obstetricians and Gynaecologists of Canada.The Society of Obstetricians and Gynaecologists of Canada.

The objective of this document is to serve as a guideline to the investigation and management of uterine leiomyomas.The areas of clinical practice considered in formulating this guideline are assessment, medical treatments, conservative treatments of myolysis, selective artery occlusion, and surgical alternatives including myomectomy and hysterectomy. The risk-to-benefit ratio must be examined individually by the woman and her health-care provider.Implementation of this guideline should optimize the decision-making process of women and their health-care providers in proceeding with further investigation or therapy for uterine leiomyomas, having considered the disease process and available treatment options, and reviewed the risks and anticipated benefits.English-language articles from MEDLINE, PubMed, and the Cochrane Database were reviewed from 1992 to 2002, using the key words "leiomyoma," "fibroid," "uterine artery embolization," "uterine artery occlusion," "uterine leiomyosarcoma," and "myomectomy." The level of evidence has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination.The majority of fibroids are asymptomatic and will not require intervention or further investigations. For the symptomatic fibroid, hysterectomy offers a definitive solution. However, it is not the preferred solution for women who wish to preserve their uterus. The predicted benefits of alternative therapies must be carefully weighed against the possible risks of these therapies. In the properly selected woman with symptomatic fibroids, the result from the selected treatment should be an improvement in the quality of life. The cost of the therapy to the health-care system and to women with fibroids must be interpreted in the context of the cost of untreated disease conditions and the cost of ongoing or repeat treatment modalities.1. Medical management should be tailored to the needs of the woman presenting with uterine fibroids and geared to alleviating the symptoms. Cost and side effects of medical therapies may limit their long-term use. (III-C) 2. In women who do not wish to preserve fertility and who have been counselled regarding the alternatives and risks, hysterectomy may be offered as the definitive treatment for symptomatic uterine fibroids and is associated with a high level of satisfaction. (II-A) 3. Myomectomy is an option for women who wish to preserve their uterus, but women should be counselled regarding the risk of requiring further intervention. (II-B) 4. Hysteroscopic myomectomy should be considered as first-line conservative surgical therapy for the management of symptomatic intracavitary fibroids. (I-B) 5. It is important to monitor ongoing fluid balance carefully during hysteroscopic removal of fibroids. (I-B) 6. Laparoscopic myolysis may present an alternative to myomectomy or hysterectomy for selected women with symptomatic intramural or subserous fibroids who wish to preserve their uterus but do not desire future fertility. (II-B) 7. Uterine artery occlusion may be offered as an alternative to selected women with symptomatic uterine fibroids who wish to preserve their uterus. (I-C) 8. Women choosing uterine artery occlusion for the treatment of fibroids should be counselled regarding possible risks, and that long-term data regarding efficacy, fecundity, pregnancy outcomes, and patient satisfaction are lacking. (III-C) 9. Removal of fibroids that distort the uterine cavity may be indicated in infertile women, where no other factors have been identified, and in women about to undergo in vitro fertilization treatment. (III-C) 10. Concern of possible complications related to fibroids in pregnancy is not an indication for myomectomy, except in women who have experienced a previous pregnancy with complications related to these fibroids. (III-C) 11. Women who have fibroids detected in pregnancy may require additional fetal surveillance when the placenta is implanted over or in close proximity to hen the placenta is implanted over or in close proximity to a fibroid. (III-C) 12. In women who present with acute hemorrhage related to uterine fibroids, conservative management consisting of estrogens, hysteroscopy, or dilatation and curettage may be considered, but hysterectomy may become necessary in some cases. (III-C) 13. Hormone replacement therapy may cause myoma growth in postmenopausal women, but it does not appear to cause clinical symptoms. Postmenopausal bleeding and pain in women with fibroids should be investigated in the same way as in women without fibroids. (II-B) 14. There is currently no evidence to substantiate performing a hysterectomy for an asymptomatic leiomyoma for the sole purpose of alleviating the concern that it may be malignant. (III-C) VALIDATION: This guideline was reviewed and accepted by the Clinical Practice Gynaecology Committee, and by Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.The Society for Obstetricians and Gynaecologists of Canada.

BACKGROUND: Nuchal cords are rarely associated with significant neonatal morbidity or mortality. CASE: A primigravida with a normal term pregnancy presented for diminished fetal movement. Several nuchal cord loops were found on the ultrasound imaging, with normal Doppler findings. Abnormal fetal heart rate pattern appeared after 6 hours of labor. A cesarean delivery was performed. A healthy baby was born with eight nuchal cord loops. CONCLUSION: The management of nuchal cord with a single loop, suspected before delivery, seems clear: it should not influence the clinical management. However, in this case, the previous knowledge of multiple nuchal loops may have influenced our decision to perform a cesarean delivery.