A hotel by the airport might not be a typical setting for a prenatal checkup, but thanks to Manavi Handa, care often comes to those who need it, wherever that is. Since November 2021, the Toronto-based midwife has been providing full physical exams; routine visits; pre-, peri- and postnatal care; and more at a GTA hotel that acts as temporary housing for recently arrived Afghan refugees. Now, she’s preparing to provide similar services to Ukrainian refugees as they arrive in Canada.
Handa, who is also an associate professor in Ryerson University’s midwifery program, isn’t new to this setup. She launched clinics to provide care out of hotels when the first group of Syrian refugees arrived in Canada in 2015. The first baby born to a Syrian refugee in Canada was delivered by a midwife from her Toronto practice, West End Midwives, which provides perinatal care to expectant parents who are newcomers, refugees or without Ontario health insurance. “It shows how important it is to have us in the community,” she says.
Her work exemplifies the midwifery model, which is centred around trust and relationship building. This is reflected in the pre- and postnatal hotel visits Handa does in between teaching and working from West End Midwives, and the always-on-call hours of delivering babies. Handa has well-earned insight into the lives of the people she cares for—and many tell her about their gynecological needs outside of pregnancy.
She knows, for instance, that most people fleeing danger don’t have access to routine health checks or contraception. “I quickly realized many of the women want IUDs, so I trained on how to insert them,” she says. But she can’t always provide this care: “There’s a clause that says I can’t take care of people unless they’re within eight weeks postpartum without a medical directive from a physician.” Handa is used to providing gynecological care under medical directives from doctors she works with, but sometimes, like when the physician she normally collaborates with goes on maternity leave, attaining them can be a challenge. “IUD insertion is still one of the biggest reasons people come to see me,” she says, adding that she’s in the process of ensuring the directive she gets is ongoing.
Handa’s experience positions her to provide all of these procedures at any time. But like midwives in most places across Canada, there are hard limits on what she can do.
A profession almost exclusively staffed by women and regulated in Canada for nearly 30 years, midwifery has been left out of many policy decisions when it comes to reproductive health care. Allowing midwives to insert IUDs, provide medical abortions (including those used for miscarriages), offer stillbirth care and work outside of pre-natal clinics could transform reproductive health care in Canada. Instead, midwives such as Handa are left looking for workarounds to provide the care their communities need, often with little support.
In 1994, Ontario and Alberta became the first provinces to regulate midwifery as a health care profession. Today, midwives are a popular, government-funded perinatal-care choice among pregnant Canadians who have the time, knowledge and health care system know-how to access their often wait-listed services—in other words, educated, middle- to upper-class, and largely white people. But their popularity is no surprise: Midwives offer longer perinatal visits; more hands-on, personalized care; and a postnatal follow-up routine that includes home visits. And all of this goes a long way toward establishing good patient relationships.
These relationships, as well as their training—which includes a four-year degree and a clinical placement—equip midwives to provide a wider range of care than they’re currently allowed to deliver. According to a 2018 report from the University of British Columbia’s Contraception and Abortion Research Team, midwives’ training makes them experts in sexual-health planning, education and care delivery, and they could (and should) provide abortion care, but their scope of practice has been limited in Canada. In many countries, including the U.K., Sweden and France, midwives or nurse-midwives are already responsible for many of these types of care.
Cecilia Benoit, professor emeritus of sociology at the University of Victoria, has studied midwifery for more than 30 years. She points to Sweden, where midwives provide birth control and sex education, as exemplary. “Midwives should be seen as crucial primary care workers who are linked in at the community level, and they should be responsible for the reproductive-care cycle, including medical abortions,” she says. Benoit also thinks they should be able to work outside midwife clinics, as staff in hospitals or general-practice clinics. Last February, the Canadian Association of Midwives voiced its support of midwives providing more comprehensive reproductive health care, including safe and legal abortion and post-abortion care. “We need more abortion providers in Canada,” says association vice-president Elizabeth Brandeis. “The midwifery model of care is so well set up, not just for accessibility reasons but also to provide trauma-informed care that helps people through these experiences in life that sometimes feel like they exist in the shadows.”
Allowing midwives to provide abortion care could improve access to and the quality of a procedure that up to a third of Canadians with uteruses will need in their lifetime. It certainly would have helped me.
I had an abortion in Alberta in 2013, but the experience felt like a trip to a time before abortion was legal. It started with a Google search. The first links led to anti-abortion counselling organizations, which outnumber abortion clinics in Alberta nearly four to one. The two Calgary clinics that provided surgical abortions charged for out-of-province access to their services. At least I had options: In Alberta, Saskatchewan, Manitoba and Ontario, where up to 40 percent of the population live in rural areas, abortion providers only exist in urban centres.
When I experienced severe bleeding and cramps a week after the surgery, the clinic provided no help. It took three visits to a walk-in clinic, where the residing doctor told me she was Catholic and uncomfortable providing abortion-related care, to get a referral for an ultrasound to find out what happened: an incomplete abortion that did not properly remove the fetus and required a second procedure. This difficulty in accessing care is, sadly, not unique. Conscientious objection—the ability to refuse to perform certain medical procedures based on religious beliefs—is a documented roadblock to abortion access in Canada.
Not once during this process did anyone hold my hand, ask about my pain or follow up with me. I needed a care provider who understood what my body and mind were going through. I needed a midwife.
Expanding midwifery’s scope to include abortion would help make the experience more humane. Joyce Arthur, executive director of the Abortion Rights Coalition of Canada, says that including abortion care in the scope of midwifery practice would help it become an accepted, normalized part of health care—and could greatly reduce the impact that conscientious objection rights have on those seeking abortion. “That’s a big problem here, especially in rural areas,” says Arthur, “so midwives who are willing to help with abortion is a way around that.” Plus, midwives typically travel, so they can assist those in need wherever they are, eliminating the access barrier that many in remote locations face.
The midwifery approach could also reimagine the experience of wanted-pregnancy loss, which affects 15 to 25 percent of pregnancies in Canada. “What we’re watching for and what we’re counselling for with abortion is the same [as] for someone having a miscarriage,” says Handa. “In fact, those medications can actually help people who are having a miscarriage if it’s not happening on its own.”
The community midwife-care centres Benoit envisions do exist in Canada but are usually grant-funded pilot projects. One of them is Midwifery and Toronto Community Health (MATCH), a program run by Shezeen Suleman and her team out of the South Riverdale Community Health Centre. Since 2018, four full-time midwives have provided a full range of reproductive services—from birth control to perinatal care to medical abortion—through the clinic, focusing on patients facing significant barriers to accessing health care, including racialized folks, drug users, single parents and underhoused people.
“When we first got funded, we unabashedly took training at the National Abortion Federation on providing medicinal abortion, knowing there was no way that we could actually provide the care because the drug is not on our drug list right now,” says Suleman. But with the doctors and nurse practitioners at her clinic on board, they began to offer abortions collaboratively: Physicians write prescriptions for mifepristone and misoprostol, while midwives provide most of the care, including speaking with patients by phone to support them after they take the second pill, which causes labour-like contractions. They also give patients a care package that includes medicines they’ll need, pads, a thermometer and a cellphone if they don’t have one.
Suleman doesn’t see the work as unique; her great aunt was a midwife in Kenya, where she provided reproductive health care to her community, including abortions. “In white-dominant spaces in North America, there is a very particular lens of what midwifery care can and should look like,” she says, “when in many parts of the world, midwives have long been providing full-spectrum perinatal care.”
The midwife abortion model has been successful at MATCH, but in order to address limited access in rural communities, midwives who don’t work alongside doctors need to be able to prescribe mifepristone and misoprostol themselves. Currently, regulations in every province and territory in Canada vary, and some provincial parameters are much stricter than others. In Nova Scotia, for example, midwives can prescribe hormonal contraceptives, but Ontario midwives cannot, although the College of Midwives of Ontario is pushing for this to change. “One of the biggest barriers is that we’re still microregulated,” says Handa. “The college is trying to change that, but the Ontario Medical Association [OMA] has a lot of power.”
A 2020 report from BMC Health Services found that Ontario’s different payment models for physicians and midwives have limited midwives’ ability to work outside of strictly defined parameters. “In the medical model, payment mechanisms privilege physician-provided and hospital-based services,” the authors noted. (While doctors bill for individual services, midwives bill by course of care—which usually means billing once for all services provided during the course of a pregnancy.)
The care midwives are—and are not—permitted to provide can seem confounding. In 2009, when Ontario passed legislation that allowed midwives to collect specimens to test for two STIs, it didn’t include the ability to prescribe the antibiotics needed to remedy them. “It’s the same with prescribing hormones,” says Handa. “With contraception, the [OMA] saw it as us creeping into the family-medicine area, as opposed to looking at reproductive health care in a more holistic way.”
In response, the OMA noted in a statement that “the regulations that health professionals are allowed to operate under are created by the Ontario government and not the OMA.” They expressed support for the contribution midwives bring to health care, but the organization’s stance on prescriptions remains: “Midwives are not trained in pharmacology to the level of a family doctor or obstetrician. Prescribing substances and drugs is a complex and, at times, high-risk activity that must be done in the context of the whole patient.”
Despite the barriers, many physicians and ob-gyns would welcome a midwifery-integrated model of gynecological care. Dr. Rachel F. Spitzer, associate professor at the University of Toronto and ob-gyn at Mount Sinai Hospital, is in awe of the work midwives have done to foster relationships in marginalized communities, and she understands their appeal. “With midwives, you have somebody who’s going to come to your home to visit you and check in on you for six weeks without having to pay them extra to do it,” she says. By contrast, Spitzer does one visit with patients at six weeks postpartum in her office. “For people who don’t have built-in support at home, we have a good opportunity to make that kind of care a standard offering with midwives.”
Spitzer adds that the ideal model of care would involve allowing everybody the space and energy to do what they do best. “We need each other,” she says. “Sometimes they might feel over their depth in the complexity of a case and need colleagues to reach out to. It works best when we work together.”