A collage with a gynecologist, a midwife and a box of emergency contraceptives

When It Comes To Abortion Rights, Canada Can’t Save You

As long as Americans are fighting, again, for their right to choose, they should fight for better than what we have in Canada. Trust me.

by Carla Ciccone
Originally Published: 

When Prime Minister Justin Trudeau suggested that Americans are welcome to use the Canadian health care system, and the abortions it provides, I scoffed.

Offering the Canadian health care system to American abortion seekers is a nice sentiment from someone whose country decriminalized abortion in 1988, but the reality is that much of Canadian health care is currently in shambles. As a Canadian woman who has covered the issue, and experienced it personally, I know that abortion care in this country is uneven at best.

While it’s true that anyone who finds themselves in Canada can technically go to the hospital if they need to, you can’t just roll up to any hospital and ask for an abortion. Many of them don’t even perform them, and some only do on certain days. Each of Canada’s provinces and territories has its own regulations around the specifics of abortion care, and especially outside of major city centers, access to abortion is limited. And while basic health care is covered by yearly taxes, pharma care is not always publicly funded, meaning many people have to pay the $300-450 it costs for a medication abortion.

As long as Americans are fighting, again, for their right to choose, they should fight for better than what Canada has. Trust me.

I’m sure that, like most of us, Trudeau’s outrage over the Supreme Court’s decision to overturn Roe v. Wade was sincere. I’m sure he meant well, but his misguided offer immediately struck me as shallow. After all, limitations of Canadian health care aside, are the types of American with a passport, time off of work, child care, and enough money to travel to a major Canadian city really the people who will need access to abortion the most?

Of course not. Trudeau is offering nothing more than an illusory utopian health care narrative, one that most Canadians have come to realize is a myth. If he’s sincere, he needs to put his federal money where his feminist mouth is and fix our reproductive health care system before offering it up as a viable option to Americans in need.

In 2014, I had a legal, surgical abortion in a Western Canadian hospital clinic. My guts fell into my feet when the doctor walked into the surgery room still chewing her lunch. She refused to look at me before I went under. What followed was weeks of trying to figure out why I was bleeding profusely, in constant pain, and passing large amounts of tissue. The hospital provided no follow-up care, and since I was not in my home province, I went to a walk-in clinic and was abortion shamed by the Catholic doctor on staff.

In a country where abortions are supposed to be a human right, I returned to that clinic three times, begging for the ultrasound that would eventually confirm my abortion was “incomplete.” A month-and-a-half after my first D&C, I had my second. The shame of the entire experience has not left me and might never. The sad truth is, even in a country that offers abortions, the experience of procuring them is often still shrouded in stigma, and sometimes even features medical neglect.

Not just me but all of us need and deserve better than this. We deserve access to compassionate, respectful reproductive care, regardless of geography, and we need basic respect from the health care providers tasked with such imitate work.

Midwives, who performed abortions long before the field of gynecology even existed, are qualified to provide this care, and if they hadn’t been shut out of their own profession many years ago by male doctors who wanted their patients, more of us would know about it.

It’s important, I think, to remember that while the stigma inherent in present-day abortion care is pervasive, it’s not a tale as old as time. It’s actually about 175 years old. That makes it as old as Salt Lake City, Utah, the book Wuthering Heights, Necco Wafers, and Alexander Graham Bell, the inventor of the telephone. The North American medical systems inherited the misogyny that came with the professionalization of medicine, and the deterioration of women’s reproductive health care followed. In other words, men did this, 175 years ago.

Not only were midwives the keepers of the technology of abortion before the Civil War, but midwives and the women who sought them were largely left alone when it came to the business of missed periods and the desire for them to return.

Like many things sullied by the involvement of men, getting abortions didn’t used to be a big deal. “In colonial times and before that, midwives were the keepers of the technology of abortion,” Suzanne Wertman, a midwife and a consultant in state government affairs for The American College of Nurse-Midwives (ACNM), reminds me.

Midwifery wasn’t necessarily a lucrative profession, but it was an always in-demand one. Not only were midwives the keepers of the technology of abortion before the Civil War, but midwives and the women who sought them were largely left alone when it came to the business of missed periods and the desire for them to return. The issue of abortion wasn’t a question of religion, egregious interpretations of the Bible, or political affiliation, and it was commonly understood that life didn’t begin until the pregnant person felt what was called “the quickening,” aka the first signs of fetal movement. Some pregnant people feel the quickening in the first couple of months, while others don’t sense it until five or more months along. This method wasn’t an exact science, but it was thought that up until the quickening, a woman doing what she needed to get her period back was fair game.

As Michele Goodwin stresses in her book Policing the Womb, and in a recent episode of NPR’s Throughline podcast, midwifery in the colonial era was not only full scope, but also interracial. Goodwin points out that fully half of those women providing reproductive health care were Black, while other midwives were Indigenous or white.

And then came the men.

While providers like the legendary Madame Restell were unremarkably performing medical and surgical abortions, aka “restoring the menses,” for her Fifth Avenue clients in the 1840s, male physicians were embarking on careers in the emerging field that would later become gynecology.

In an effort to thwart Restell and other midwives like her from cornering the market and hogging their potential clientele, these doctors used the creation of the American Medical Association (AMA) as a way to further their smear campaign against the midwifery profession. Early gynecologist Horatio Storer sent misleading letters on behalf of the AMA to the governors of every U.S. state outlining that life did not begin with the quickening, but at the exact moment of conception.

The Throughline podcast episode, called Before Roe: The Physicians’ Crusade, draws a direct line from the loss of women health care providers to the United States’s first curtailment of abortion rights. The movement to remove women from reproductive health care was the worst kind of triple threat: racist, sexist and capitalist.

Storer and his peers soon played into the race-based fears of the time. The abolition of slavery and influx of Catholic and Chinese immigrants to the United States, combined with declining birth rates among Protestant white women (thanks in part to their ability to procure abortions), was enough to cause a commotion among the white population, and to turn a formerly common, women-led, and uncontroversial procedure into an immoral, male-governed, and eventually illegal one.

Soon Storer and his ilk were lobbying congress to not only criminalize abortion but also regulate midwifery, and anyone who wanted to practice needed an expensive license. “I think the perception, even in history, is that abortion is this thing off to the side that has always been the purview of physicians,” Wertman says. “But the attempted extinction of our profession is directly tied to the professionalization of medicine.”

Midwifery didn’t die out overnight. According to Judith Walzer Leavitt’s Brought to Bed, by 1900, midwives and physicians were equally attending to births, but by 1930, the percentage of midwife-attended births was just 15, with 80% taking place in the South. Wertman has felt the impact of this throughout her 20-plus-year career. “In the 1920s, there were around 6,000 midwives registered with the state of North Carolina and now we have maybe just under 500,” she says.

The midwife model is at its core egalitarian. It is centered around providers building trusting relationships with their patients, treating them as whole people and considering different aspects of their experiences while caring for them. They provide the kind of compassionate care I didn’t know I deserved at the time of my own abortion. It’s the kind of care we all deserve.

“Midwives are incredibly well positioned to provide [abortion] care,” says Shezeen Suleman, a midwife at Midwifery and Toronto Community Health (MATCH), who routinely assists patients having medical abortions (aka the abortion pill). “We understand the physiology. We know how to counsel people. We are embedded in the health care system and connect people to urgent care and other forms of care, including contraceptive care. We know how to manage cramping and bleeding.”

Midwives provide the kind of compassionate care I didn’t know I deserved at the time of my own abortion. It’s the kind of care we all deserve.

Midwives in Canada don’t generally provide abortions, though. Which means Suleman’s clinic is one of a kind. MATCH is a pilot project, one where midwives work alongside doctors to provide normally underserved communities with full-spectrum reproductive health care. The safe, empathetic space Suleman and her colleagues have worked so hard to create sounds like an actual reproductive health care utopia, and that it exists at all gives me hope.

But midwives in Trudeau’s Canada are micro-regulated, with medical overseers in each province and territory mandating what they can do and can’t do. This ranges from which drugs they can prescribe to their scope of practice. These rules amount to hurdles that prevent midwifery from flourishing and potential patients from benefiting from their care.

If Canada was full of clinics like MATCH and providers like Suleman, it might be the abortion haven Trudeau would like us to think it is — the kind of place that people who can get pregnant, anywhere in the world, actually need.

The situation in the United States far predates the current U.S. Supreme Court. Like abortion access generally, American midwives’ scope of practice, or what they are allowed to do, varies from state to state, but they are often held back from providing full-scope reproductive care. For example, in Alabama, where there were zero accredited birthing centers in the entire state in 2015 and nurse-midwives are subject to “a collaborative agreement as a condition for practice,” only 1.67% of all births were nurse-midwives attended. But in Alaska, where there are 10 birth centers, 26.5% of all births were attended by midwives. Alaska is also an independent practice state, meaning midwives there have full authority to practice their profession and don’t need the same extra permissions to do their jobs that other states might require.

Medicaid coverage of midwifery also varies by state, as does the Medicaid reimbursement rate for the care that midwives can do. In many states, like California, Oregon, and Washington, midwives are reimbursed for their services at the same rate as physicians, but they’re only reimbursed at 85% of the physician rate in New York, and 80% in Florida.

Humans being able to choose what they want to do with their own bodies and getting treated with care and respect by their health care system should not be a daydream, but it has become one.

Wertman sees midwives providing abortion care as logical and necessary, and describes many present-day physicians as “the gatekeepers of midwifery.” “We already have the education and training to be able to manage miscarriage, and [abortion] is not much different from that,” she tells me. She adds that while there are specific skills to learn for surgical abortions, like using a manual vacuum aspirator, there are plenty of programs that offer comprehensive abortion care education to health care practitioners, like Teach, a nonprofit that developed the Abortion Training Curriculum, used nationally for resident and clinician training. Their abortion pill and surgical abortion trainings, as well as numerous reproductive health care resources, are available for free online. Imagine if the following were true: Abortion is a human right everyone has access to, getting one is straightforward, and midwives are empowered to provide comprehensive, compassionate abortion care alongside other health care practitioners.

Humans being able to choose what they want to do with their own bodies and getting treated with care and respect by their health care system should not be a daydream, but it has become one in the dystopian nightmare currently unfolding. We can only hope that people in need have access to on-the-ground networks to connect them with providers who will give them the kind of considerate, nonjudgmental care that midwives know how to do so well. And when pregnant people do not have access — for all the same financial and geographical reasons that American women will not be heading to Canada for their health care — they can access abortion medicine online.

As Wertman put it to me, and I found incredibly soothing, “Abortion has always happened and we’re trying to do our best to support our professionals’ ability to provide comprehensive care.” She struck me as seeming extraordinarily calm about this, considering the state of things. I asked Wertman how she managed it. “It’s a midwife trick,” she told me. “When everything is getting intense, stay calm and focused.”

It helps me to remember that the people who want to help the most are already doing so. Those people are not President Joe Biden and Trudeau, but people on the ground doing the work that needs to be done, like they have for all time, credentialed or not, because they actually care. These are the kind of people we want caring for us.

Photo Credit: Margaret Flatley/Romper, Getty/Shutterstock

Carla Ciccone is a writer and mom from Toronto. Her work has appeared in The New Yorker, The Cut, Catapult, and Bon Appétit.

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