Global Women’s Health and Equity fellow partners with Access Alliance to improve reproductive care for refugees

International Women's Day is a day to celebrate the diverse achievements of women and girls around the world. Not only is it a day of celebration, it’s also a day of advocacy and action in recognizing the ongoing demand for gender equality in women’s health, education and beyond. This year, the Department of Obstetrics and Gynaecology honoured International Women's Day by showcasing the Department's global health and advocacy work in the community.

Dr. Jenny Yang, global women’s health and equity fellow, has partnered with Manavi Handa, associate professor in the midwifery education program at Ryerson University and midwifery clinical director at Access Alliance Community Health Centre, to provide reproductive care to newly arrived refugees and underserved populations in Toronto. As part of the global women’s health and equity fellowship rotation, Yang and Handa worked together to broaden the midwifery scope of care and provide urgently needed medical abortions and contraception to marginalized and immigrant communities.

Access Alliance, with one location in Toronto’s west end, provides services and addresses system inequities to improve health outcomes for the most vulnerable immigrants and refugees without health insurance, many without legal immigrant status. Among primary healthcare services and community programs, the community health centre offers a non-insured walk-in clinic (NIWIC) that provides confidential healthcare services to immigrants and refugees. For 10 years, Handa has been a midwifery leader in immigrant and refugee women’s health care, leading a midwifery program providing antenatal care as an integral part of the healthcare services offered to uninsured populations.

In 2016, Dr. Rachel Spitzer, associate professor and vice chair of global women's health and advocacy, established a partnership with Handa as part of the fellowship rotation program. Fellows participate in a three-month rotation, learning from Handa’s work and gaining firsthand exposure to a population often unseen by obstetrician-gynaecologists, while simultaneously expanding the midwifery scope of care by exercising clinical skills onsite.

“This program has been very successful. It allows obstetrical fellows to further understand the needs of marginalized populations while simultaneously supporting the expanded midwifery scope," said Handa. "The development of this program is a perfect example of how to optimize care for those most in need through interprofessional collaboration and education."

In response to the increasing number of refugees entering Canada, Access Alliance works alongside the Canadian government to offer a satellite clinic at the hotels where refugees are provided accommodation while awaiting housing. Upon the realization that many of the women entering Canada are pregnant and in need of urgent reproductive care, Handa extended her midwifery practice to the hotel clinic.

This past February 2021, Access Alliance was called upon to run a clinic for Afghan refugees at a hotel near Toronto Pearson Airport. Yang joined Handa in running an IUD insertion clinic onsite. The clinic serves as a first stop for refugees upon their arrival, reinforcing the importance of reproductive health as an area of care that is often neglected during tumultuous times.

“These women are very much in need of contraception, specifically long-lasting, reliable and effective contraception like the IUD that grants them reproductive autonomy,” said Yang. “Every single IUD we inserted that day was an accomplishment for these women and the subsequent potential for their future during their period of settlement and beyond.”

In December 2021, the two also spearheaded a Women’s Health Education Day for Afghan refugees at the hotel. The education day not only provided teaching about the Canadian healthcare system and the right to reproductive health, but it also fostered community among refugees built trust between immigrant women and the Canadian healthcare system.

“The education day focused on the Canadian healthcare system and how to navigate it, and allowed us to opportunistically discuss things like preventative measures that are routine in Canada but not in Afghanistan like Pap smears, breast exams and contraception,” said Yang.

In Ontario, midwives provide primary care to people with low-risk pregnancies continuing up to six weeks postpartum. In the last few years, midwifery regulation has allowed for midwives to partner with obstetrician-gynaecologists to offer more comprehensive care for both pregnant and non-pregnant clients.

“Even though the OB fellows are more advanced than I am in terms of what they can do clinically, they very rarely see the front end. They don’t see the people who can’t access the system; they only see them once they’ve gotten through all those barriers,” said Handa. “One of the most beneficial learning outcomes for the fellows is realizing, 'how would this person ever end up at my door?'"

Yang provides a first layer of support and mentorship to Handa while Spitzer provides a second layer of remote support by facilitating the rotation placements and stepping in to offer consultation in more complex cases. Together, Handa and Spitzer are working towards implementing medical directives that allow Handa to provide abortions and insert IUDs independently. Yang and Spitzer act as a safety net in providing medical oversight in the case that complications arise or urgent care is needed.

Beyond the services offered by Handa and Yang in-clinic, Handa leverages her hospital privileges and relationships with obstetrician-gynaecologists to set clients up for long-term success with referrals for ongoing care. In urgent cases, clients are referred to Spitzer’s clinic at Mount Sinai Hospital.

Handa, holding a master of health science (MHSc) in bioethics, aims to implement increased program offerings and continue to expand her scope of care with the support and oversight of Spitzer and future Global Health fellows. The partnership is an opportunity for bidirectional learning and teaching for Ob-Gyn fellows and Handa with the impact of reducing significant barriers in access to reproductive care.