*Names have been changed to protect privacy
After the condom broke, Amanda’s* boyfriend hurried to the drugstore to get the morning-after pill. Anxiety eddied as Amanda waited for him to return. The teenage couple had experienced pregnancy scares before but had never resorted to emergency contraception. A baby couldn’t be in the picture yet, Amanda knew.
In 2018, Amanda was 19 years old. The teen from Chatham-Kent, a rural municipality in southwestern Ontario, had dropped out of high school in Grade 11. They struggled with mental health and lived with their parents. They were unemployed. Their boyfriend, the same age, hit them.
If the morning-after pill didn’t work and they became pregnant, who could help? Not their parents, who were unaware they were sexually active — and not their family doctor. Two years earlier, he’d rejected their request to be put on the pill to control heavy and painful periods. “It felt like he was telling me that my pain was exaggerated,” Amanda, now 25, says.
Abortion clinics in London, Sarnia and Windsor, only about an hour’s drive away, might as well have been on the other side of the moon because Amanda lacked a car and didn’t dare ask their parents for a lift.
When their boyfriend returned with the emergency contraceptive, Amanda read the instructions on the box and realized they were above the weight limit for the recommended dosage. “I was extremely nervous about taking it,” they recall. They began to panic. What to do next?
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Amanda is one of many people in southwestern Ontario who has experienced contraceptive or pregnancy insecurity — a struggle to obtain the information, services and products needed to prevent or eliminate an unwanted pregnancy. Whether these people live in rural communities or in urban centres, they describe not knowing where to find pregnancy information, negative interactions with medical professionals, and products too expensive to afford. Many say the hurdles generate suffering, stress and a deep-seated fear that the community health-care system will fail just when it’s needed the most. “We’re not getting the things we need to protect ourselves,” Amanda says.
These challenges come at a time when this system has never appeared to be more accessible. Many Ontarians under 25 with a uterus can get birth control pills or the morning-after pill for free if they have a prescription. Ontario also makes Mifegymiso, a medication that safely induces abortion, free to those of reproductive age with a provincial health card and a prescription. People in southwestern Ontario can self-refer for surgical abortions at hospitals in Windsor, Sarnia and London or access the non-profit SHORE Centre in Kitchener, which specializes in sexual health.
And yet problems accessing contraception and abortion persist. Professional caregivers and researchers say the influence of right-to-life groups, particularly in resource-poor rural areas, exacerbates the stigma surrounding sexual health and leads to systemic issues. “If we want folks to thrive in communities, to have the safety and wellness that they need, they have to have access,” says TK Pritchard, executive director of the SHORE Centre. “There is no path to bodily autonomy or gender equity without strong reproductive health care in all communities.” Pritchard adds, “It’s not reasonable that you have to leave [your community] to access such basic care.”
With small urban centres nestled among corn, soybean and wheat fields, Chatham-Kent typifies much of southwestern Ontario. Here, far-right Christian conservative and evangelical outlooks ripple through the aging population. Nearly a third of the municipality’s population of just over 100,000 is Catholic, and nearly 7,000 identify as Anabaptist, Baptist, Reformed or Pentecostal. An anti-abortion billboard near Dresden, Ont., recently featured a picture of a newborn with the caption, “Kill her now, it’s murder. Kill her a week ago, it’s abortion.”
“It is a very, very older, conservative riding,” says Christine Button, a member of Trinity United Church in Wallaceburg, Ont. Often when going to church on Sunday, she has seen “people protesting in a park for freedom, and yet they’re the same people that want to take my freedom away as a woman to choose.”
Button worries that local pro-life sentiment has gathered momentum in the wake of the Roe v. Wade reversal in the United States. Since the U.S. Supreme Court overturned the decision last year, abortions have been banned in 14 states.
Through her work as an office manager at a physiotherapy clinic, Button is hearing more and more complaints about the lack of access to reproductive health services. “I’m just really starting to get concerned that [reproductive rights are] just slowly disappearing,” she says.
In Ontario, family doctors, nurse practitioners, public health units, pharmacies, hospitals, non-profit clinics such as SHORE and even local school boards all contribute to the reproductive health system. Some educate and advise. Others prescribe or dispense medication. Yet despite this seeming abundance of care, users of this system describe barriers at every point of access.
In 2022, when Brianna* was 14, she went the public health route to obtain birth control pills. “I wasn’t planning on being sexually active, but it’s better to be prepared,” she says.
Brianna worried that if she approached her family doctor for a prescription, her mother would find out and get upset. The teen had learned through her health class at school that she could get the pills for free through a public health nurse.
Instead, the nurse at Chatham-Kent Public Health told her via a text message that she would have to shell out $10 per monthly pack of the medication. The cost astonished Brianna. She didn’t have the money and was too embarrassed to text back.
“It took a lot of courage to reach out,” Brianna, now 15, says. She remembers locking herself in her closet to make sure no one could hear her first call to the health unit.
Marnie Van Vlymen, Chatham-Kent Public Health’s chief nursing officer, says public health nurses typically outline options to a client in a face-to-face appointment. Clients under 25 may qualify for free contraception under the OHIP-plus program, but not everyone is eligible, and some who are, like Brianna, may be reluctant to obtain a doctor’s prescription due to privacy concerns.
If clients can’t afford to pay the health unit fee, Van Vlymen says, “We would look at that as a barrier and look at covering that cost.” She adds that since 2015, the health unit’s policy has been to charge a nominal or pay-what-you-can fee for birth control medications. The health unit also charges a nominal fee for most other forms of contraception it provides, including day-after emergency contraceptives.
Spokespeople for three other public health units in the region — Middlesex-London, Southwestern Public Health and Huron Perth — say they follow the same policies.
“We don’t receive funding for birth control,” Van Vlymen explains. “It’s not something that is specifically mandated for health units [by the province].” Instead, the local health unit works the cost of birth control into its general program.
“That is the reality,” confirms Sheila Dunn, an associate professor at the University of Toronto department of family and community medicine and a former medical director of a sexual health clinic at Women’s College Hospital in Toronto. “I can almost guarantee that they’re not getting those pills in their local units for free.”
Carolyn Martin, a former public health nurse with Chatham-Kent Public Health, thinks all public health units should waive the fee for birth control pills for clients under 25 until they can safely obtain a prescription, as is done at nearby Lambton Public Health. “You can’t be charging kids money for that.”
Last year, Martin spoke out about the health unit’s practice of charging youth for birth control, which she claims it started to do in 2020. But that’s not her only concern about her former employer. She worries an anti-abortion bias might be affecting the delivery of its services.
Martin bases these concerns on the close relationship between the Chatham-Kent health unit and Refuge, a centre for pregnancy crisis. While the Refuge website says it offers “comprehensive pregnancy & postpartum support to women and families,” it is an arm of Right to Life Kent Inc., a federally registered anti-abortion charity that’s funded by community and church donations. Right to Life describes itself as an “organization of caring people united to protect the precious gift of human life from conception to natural death.”
Before the pandemic, the Chatham-Kent unit routinely held breastfeeding clinics at Refuge. Until late last year, it also listed Refuge on its website as a resource for people experiencing a pregnancy crisis. “When I saw that, my blood ran cold,” Martin says. “This agenda is being pushed by the [health unit] management.”
Many crisis pregnancy centres are steeped in anti-abortion bias, researchers and pro-choice activists warn. Like Refuge, these centres are non-profit organizations “that present themselves as unbiased medical clinics or counselling centres for pregnant people,” according to a March study by the Abortion Rights Coalition of Canada and the British Columbia Humanist Association. Most “are religiously affiliated anti-abortion agencies whose primary objective is to dissuade pregnant people from choosing to terminate their pregnancy,” the study says. The researchers analyzed the websites of 143 crisis pregnancy centres and found 74 percent of centres “showed evidence of a religious outlook or agenda” — most openly, but a subset “were not transparent and upfront about their religious motivations or affiliations.”
In rural areas that lack hospital abortion clinics and family doctors, and where health unit clinics can be difficult to access, pregnancy crisis centres are often the only option. These centres claim to fill the gap but “are typically not truthful about the services they provide” and spread abortion misinformation, says Pritchard of the SHORE Centre. “We’ve seen people in our clinic after they have been to a crisis pregnancy centre, and they’ve been told, ‘[Abortion] increases your risk of breast cancer; you’ll never be able to get pregnant again if you want to,’ and those things are just not true.”
More on Broadview:
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Martin says the relationship between the health unit and Refuge aligns the health unit with pro-life interests in a way that might intimidate some clients and deter them from seeking help. It is “almost like common knowledge,” she says, that when people come in for pregnancy counselling, Refuge will ensure they hear a recording of a fetus’s heartbeat. Refuge did not respond to multiple requests for an interview.
Martin filed a formal complaint internally about the relationship in 2018. She supplied Broadview with copies of two 2022 letters from Chatham-Kent officials that reference her grievances as well as a settlement. One, from Dec. 8, 2022, states that the settlement resolved that “the Employer had the right to continue to offer programs out of Refuge.”
The health unit fired Martin on Dec. 16, 2022. Van Vlymen declined to discuss Martin’s firing, citing privacy concerns.
Van Vlymen says the health unit hasn’t hosted breastfeeding clinics at Refuge since early fall 2019. Late last year, the health unit also removed references to Refuge from its website. B.J. Kivell, Refuge’s director, told the CBC last December that regardless of her pro-life views she provides pregnant women with unbiased information about their options. And in January, April Rietdyk, Chatham-Kent’s general manager of health and family services, stated to CBC that relationships would continue with Refuge “and other organizations that may have views on certain subjects such as abortion.” Rietdyk said the health unit doesn’t “take sides on any political agenda.”
Van Vlymen notes the health unit’s breastfeeding clinics that took place at Refuge supported women who had given birth, not those who were pregnant. She describes the Refuge facility as “a nice, comfortable setting that was congruent with what we needed” to host group sessions, something that could not be done at the health unit’s location. “Refuge,” she adds, “provides a very important service and access to supplies and things that moms need in those last few weeks of pregnancy for the hospital or for their baby coming.”
The March report on pregnancy crisis centres across Canada revealed that 92 percent of those studied offered programs such as prenatal or parenting classes, and 17 percent made access to items such as baby clothes conditional on participation in their programs.
MOST HEALTH-CARE PROVIDERS will acknowledge the potential of personal beliefs getting in the way of care delivery. But they say the risk is countered by licensing colleges’ codes of ethics and specialized policies, such as ones requiring moral objectors of a particular service or procedure to refer patients to another practitioner.
Joyce Arthur, executive director of the Abortion Rights Coalition of Canada, says referral policies are only effective if professional colleges are prepared to back these with some form of enforcement — and most don’t. Referral policies also can “lead to a potentially endless chain of referrals” to professionals who might have similar moral objections, “since no-one is required to make an effective referral,” she writes in a 2022 report.
Moreover, most colleges’ investigative and disciplinary procedures are motived by complaints. Chances are slim, Arthur says, of someone complaining about a practitioner not following a referral policy. Most people don’t know that such policies exist, and even if they did, “almost all people seeking abortions will prioritize their privacy and confidentiality, especially given the stigma of abortion,” she writes.
On the ground, even a hint of a judgmental attitude can produce emotional distress that lingers long after the experience.
Just ask Chloe,* a London post-secondary student, who in 2020, at age 19, went to her family doctor suspecting she was pregnant. His test proved her right.
When Chloe said she wanted an abortion, the doctor gave her a London Health Sciences abortion clinic pamphlet and then told her to come back if she wanted to continue the pregnancy. “He kept saying that over and over again,” says Chloe. “Once the patient has decided what they want to do and is adamant … you shouldn’t keep repeating something that you know they’re not going to want.”
Those who use reproductive services and supports say the main challenge by far is accessing information that can help them act or protect themselves. For instance, Brianna, the Chatham-Kent teen who didn’t have $10 a month for birth control pills, says no one at the health unit told her they provide condoms for free. (Condoms are funded under a provincial sexually transmitted disease prevention program.)
Rebecca,* a post-secondary student in London, says that when she obtained a birth control prescription from the local health unit, she was only told to come back in six months. “I take a bit of other medications as well, so wasn’t sure how I was going to react,” she says. “I felt really anxious about going on it.”
Soon after she began the medication, she began to experience “very intense negative emotions” along with weight gain and acne. She wanted to stop but continued, partly because she had no idea what to do if she became pregnant and needed an abortion. “What I know about it is it’s only if and when you need it that you get the information,” she says. “That’s difficult.”
The Middlesex-London health unit website provides extensive information about medicated abortion but lacks information about arranging a surgical abortion. Middlesex-London and Huron Perth are the only two of seven health units in the region that supply any abortion information on their websites.
The lack of such information on public health websites “just speaks to abortion stigma,” says Frédérique Chabot, director of health promotion with Action Canada for Sexual Health and Rights. “There are so many decisions or absences or policies that don’t make sense if you don’t factor in abortion stigma.”
However, Chabot is encouraged by the Ontario Ministry of Health’s decision earlier this year to add abortion information on its Sexual Health Ontario website. “I think this is an important development,” Chabot says. “As we see the rise in disinformation about abortion and other stigmatized health care like gender-affirming care happening in the U.S. and Canada as well, it is their responsibility to step up.”
On its own, each piece of missing information or barrier to access might seem minor, but the effects can be cumulative. Dunn, the associate professor in family and community medicine at the University of Toronto, says people face huge challenges in finding reproductive care in their communities. “It is so dependent around having access to health-care providers,” she says. As many as 2.2 million Ontario residents, or 15 percent of the population, do not have a family doctor. The Ontario Medical Association notes the shortage is “especially acute in northern and rural areas.”
Nevertheless, Dunn predicts access to support will improve. Mifegymiso is revolutionizing access to medical abortion, and Dunn is among several Canadian researchers who have been studying the medication’s adoption by primary care providers since it was first made available for prescription across the country in 2017. In Ontario, abortion medication providers tripled to nearly 1,000 between 2017 and 2020. Most of these increases were in cities, but in rural areas, abortion medication providers jumped to more than 100 from fewer than 10.
“It only takes a small number of people in rural areas to pick up this type of service for that to really improve things in a rural area,” Dunn says.
Access to reproductive care information and resources may also see improvement as yet more health-care providers, such as midwives and pharmacists, take on more responsibility for their delivery.
Last year, Quebec approved midwives to administer Mifegymiso. Liz Darling, assistant dean of midwifery at McMaster University in Hamilton, is researching how midwives can help improve access to sexual and reproductive supports across Canada. She says midwives are a natural for the role. “We have the clinical expertise, but I think also the way in which midwives in Canada work and the philosophy that we have supports the provision of abortion care.”
Many of the more than 1,000 midwives across Ontario already serve rural areas. Midwives also work in groups to facilitate 24-hour care, which could prove helpful to those undergoing medication abortion. Moreover, midwives can offer follow-up care to support psychological health.
Approving midwives outside Quebec to take on an expanded role won’t be easy, however. “Midwifery is regulated differently in every single province,” Darling explains, and provincial laws would have to change to allow midwives to deliver and bill for these services.
Similarly, Jen Belcher, a spokesperson for the Ontario Pharmacists Association, envisions an expanded role for pharmacists. She points to the Ontario health ministry’s recent decision to allow pharmacists to prescribe medication for 19 minor ailments. Adding oral contraceptives to the list is “well within our skills and abilities,” she says. Four provinces — Alberta, Saskatchewan, Quebec and Nova Scotia — allow pharmacists to prescribe oral contraceptives.
Belcher says oral contraceptives had been on the initial list of drugs recommended to the province of Ontario but were excluded from the final regulations. Belcher says she is confident a case can be made for their in- clusion in the future. The Ontario Ministry of Health did not respond to Broadview’s in- terview request.
IN THE END, a phone call to Carolyn Martin, then a public health nurse, was what eased Amanda’s worries about the correct dosage for the day-after pill. Today, the Chatham-Kent resident has rebuilt their life. College is nearly completed. Job prospects look good. Accidental pregnancy is no longer a concern: they have left their abusive boyfriend and are now in a queer relationship.
Amanda believes that making contraception free in Ontario, as British Columbia did earlier this year, could go a long way toward solving the hurdles they have faced.
In March, NDP MPP Jennie Stevens tabled a motion asking for the Ontario government to make contraception free. At the time, Sylvia Jones, the Progressive Conservative Ontario health minister, agreed to talks; neither Stevens nor Jones could be reached to confirm whether talks have taken place.
Amanda — and thousands like them — needs political leaders to keep pushing for access to reproductive health care. Because without it, “we get put in the situation of, you either have to have a baby or you have to abort it,” Amanda says. “And then they don’t give you the resources to abort it if you need to.”
Mary Baxter is a journalist in London, Ont.
This article first appeared in Broadview’s September 2023 issue with the title “The Illusion of Choice.”
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