When the U.S. Supreme Court overturned the Roe v. Wade abortion rights earlier this year, Canadians speculated that this country would become a destination, if not a safe haven, for Americans who could no longer get care in their home states.
As it stands, though, the system in Canada is struggling to provide for its own patients.
Experts on abortion access highlight a rural-urban divide: in remote parts of the country, surgical abortion providers can be few or non-existent. As a result, patients resort to a domestic kind of medical tourism, travelling hundreds of kilometres at a considerable cost to a city where access is presumably more reliable.
But in reality, the divide is more of a blur.
“People discuss abortion access issues in Canada as a rural versus urban problem,” said Dr. Geneviève Bois, a Quebec abortion provider and activist. “This dichotomy, this notion that access is resolved in urban settings – that is not correct.”
To test that argument, Global News used the Greater Toronto Area as the measure. Canada’s most populous region, the GTA is home to most of Ontario’s independent surgical abortion centres.
A months-long investigation revealed a system at risk. Facing financial neglect, some facilities are fighting every day to stay open. At the same time, the stakes are high: one in six Canadian women say they have had a surgical abortion.
“When we’re talking about abortion, it means it’s under threat,” said Daphne Gilbert, a University of Ottawa law professor focused on researching reproductive justice in health.
Ontario fully funds only half of its eight freestanding surgical abortion clinics, meaning the province pays for rent, salaries and equipment. The four unfunded facilities, however, rely on the province to reimburse them for each procedure covered by the Ontario Health Insurance Plan (OHIP). But that’s not always enough to stay in business, especially during the COVID-19 pandemic. Some centres without funding say they have no choice but to ask the public for donations. One of them even started a charity last year.
“Trying to get money out of the government is not easy, so this seemed like an easier way to get money to help these patients,” said the clinic’s owner.
The funded surgical centres are mostly clustered in Toronto. Another is in Ottawa. The unfunded businesses are also in the Toronto region.
Sources say this split in financial treatment for these clinics stems from the early-to-mid 1990s, when Ontario fully funded its abortion facilities. But the province later cut its health-care spending across the board – and the newer private surgical abortion centres never received overhead money, experts say.
Staff at the non-funded clinics say they are stretched to their budgetary limits. While they say they will always try to treat every patient and will accommodate same-day requests, they also try to fit in as many people to keep revenue flowing and their doors open. Some of these centres will overbook, so even if people do get appointments, they may have to wait for hours.
One unfunded facility Global News spoke with said it can only afford to deliver surgical services a few days a week, so people who call will have to wait until the next available day or try another place. In some extreme circumstances, waiting may mean not getting an abortion at all.
Then comes the tricky issue of fees: who picks up the bill for the procedure? On paper, this service is fully covered by OHIP, but unfunded clinics end up asking patients for money. Payment is optional, and many people can’t afford it anyway.
While Ontario insures abortion care, fees charged at clinics go toward maintaining uninsured services, including dispensing medication and running a 24-hour hotline for patients. Without charging fees, some businesses say they would close.
The manager of one of these centres has asked the province for financial help twice, but he says it has never given him firm answers.
“Especially in places like Toronto, if we’re not getting that kind of funding, we are definitely threatening access and the existence of clinics,” said Omar, who asked to conceal his last name and where he works. “If we were forced to shut down, I cannot imagine where all those patients would go.”
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As a matter of personal safety, Omar and many other staff members at abortion clinics asked to keep their facilities’ names – and at least part of their identities – out of this story. Many of these sources spoke to the media for the first time. Global News has agreed to safeguard these sources’ names and has given some of them pseudonyms.
The need for anonymity fits a larger trend of stigmatization and controversy, which are added burdens for people working in this field. Even though a recent poll shows that more than half of Canadians support abortion access whenever it’s wanted, the country has a history of violent attacks against providers. To name just a few examples, the former Toronto Morgentaler Clinic was destroyed by arson in 1992, and two years later, Vancouver gynecologist Dr. Garson Romalis was shot through the window of his home. He was also stabbed in 2000.
Two decades later, many current staffers say they feel unsafe at work, although Ontario has had legislation since 2018 that’s meant to protect abortion providers from potential threats.
A partner of one of Omar’s patients called in this year and threatened his main doctor, he says. A clinician at his facility told him that for more than a year, she was so scared that she wore a bulletproof vest during her commute.
Safety needs set their jobs apart, employees say. But while unfunded clinics Global News spoke with say they can’t afford to pay for a security guard, a funded centre says it can.
Omar’s facility put in a $3,000 security camera and lock system.
“These are the precautions that we have to take,” he said.
Experts say that stigma concerns may prohibit some hospitals from providing abortion services, which is why some freestanding centres opened. They absorb the overflow.
The Canadian Institute for Health Information (CIHI) says almost three out of four Ontario abortions in 2020 were reported from non-hospital settings, including clinics. The actual statistic may be even higher, the institute says, because some abortions are not included in its reporting.
Ontario’s abortion centres provide either medication abortions, surgical abortions or both. But experts say clinics delivering surgical care play an especially critical role: most abortion doctors recommend this procedure for people who want to terminate a pregnancy above 10 weeks. The province is one of the few places in Canada offering abortions for pregnancies that go to or extend beyond 24 weeks.
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“There is no replacement for surgical abortions,” Omar said. “This is the most efficient and foolproof way of making sure the procedure is done properly.”
Abortion clinics in the Toronto area face immense pressure to stay open. The GTA’s population accounts for nearly half of the province’s and is expected to grow by three million people in the next 25 years.
The investigation raises this question: if reliable abortion care is not guaranteed in a place as big as the Greater Toronto Area, where is it?
How Ontario got its two-tiered system of abortion clinics
Back in the early 1980s, advocate Carolyn Egan campaigned with Dr. Henry Morgentaler, the late leader of the Canadian abortion-rights movement, to help overturn Canada’s 1969 federal abortion law, she says. They were taking aim at a ruling that permitted abortion under two conditions: if a committee of doctors decided that continuing the pregnancy may endanger the person’s health or life and that it be performed in a hospital.
Egan was in the courtroom alongside Dr. Morgentaler in 1988 when the Supreme Court struck down the legislation as unconstitutional. This decriminalized abortion care.
“You win a victory, but it’s not a victory for everyone,” she says. “I don’t think there’s any doubt that there’s better access now than there was then. And the fact that there’s no law regulating it is hugely important. But does it mean that everyone has the access they need? It does not mean that.”
She says she has been fighting to make this service accessible to everyone in Canada, and with the spotlight on abortion care right now, “this is the moment to make a change.”
Soon after the 1988 Canadian Supreme Court ruling, Ontario lawmaker Gilbert Sharpe said that while eating pizza, he wrote scribblings on a napkin that would later become the backbone of a law called the Independent Health Facilities Act, or IHFA. The director of legal services for the province’s ministry of health from 1980 to 2000, Sharpe said he wrote this because the private abortion clinics were charging patients fees to help cover the centres’ overhead. He said he wanted to create legislation that would instead require the province to fund these expenses.
“The IHFA was an abortion bill,” said Sharpe, who now teaches law and medicine at the University of Toronto. “The idea certainly was that women do not pay.”
After the act was proclaimed in 1990, Premier Bob Rae’s NDP government rolled out the IHFA. Under this legislation, the province fully funded the five freestanding surgical abortion clinics that existed around that time: four in Toronto and another in Ottawa.
Four other private surgical abortion centres, all in the GTA, have opened since Ontario financed the first handful. But when the Progressive Conservative government of Mike Harris came into power in 1995, it made sweeping cuts to health care, which Egan says included limiting new IHF licences.
She says she thinks this was a deliberate, ideological decision to curb funding for abortion care.
Harris was unavailable to respond to Global News’ questions.
Only half of Ontario’s freestanding surgical abortion clinics now receive provincial overhead money under the IHFA: those licensed in the 1990s except for Toronto’s Scott Clinic, which has since closed after its main doctor fell ill, Egan says.
Sharpe said he didn’t know about the disparity. “That is disgusting.”
When asked why only some facilities are funded, a media relations coordinator with the Ontario Ministry of Health did not offer a direct response.
What’s similar, and different, about funded and unfunded clinics
Of the four clinics that provided patient volumes to Global News, three reported similar numbers: the weekly averages range from 55 to 64 abortions. This is regardless of whether they receive overhead money or not.
But one unfunded centre says it delivers around 125 abortions a week. This is the only way it can stay profitable. Its owner, Kelly, a pseudonym to protect their identity, says they wanted to hide their business name, too. They say their numbers will probably go up because of the high demand for the service.
Although Omar said his facility is operating fine as is, his head doctor said, “You have to work like a dog.” The doctor did not want to reveal their name.
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Omar says his clinic’s yearly overhead costs are $978,000, his highest number yet. The COVID-19 pandemic saw people worldwide scramble for medical equipment, which inflated prices for everyday materials: tubing, for example, used to cost $5, but now it’s $10.
“There isn’t a lot of money left over,” Omar says.
For funded centres, on the other hand, Ontario sets patient targets and gives them budgets in line with those numbers, staffers say. Choice in Health Clinic, an IHF, says it has an operating budget of $1.6 million to provide abortions to more than 2,000 insured patients a year.
When subsidized abortion centres fall short of making their expected client numbers, they say they face possible budget clawbacks from the province – not the prospect of completely shutting down.
A source connected to Toronto’s Cabbagetown Women’s Clinic, who asked to remain anonymous, says it was having trouble making its patient targets three years ago. And then came COVID-19 lockdowns and isolation requirements, which kept numbers down. It was seeing about 70 per cent of its usual volumes.
By fall of 2021, Ontario started withholding some of Cabbagetown’s money. The source says this felt appropriate given how low its numbers became, and this did not hamper services or staffing. As soon as the centre started seeing an influx of patients in January of 2022, the province stopped the clawback, the source says.
Lee, whose name has been changed to a pseudonym, works at a funded Ontario abortion clinic. They also wanted to keep the facility’s name out of the story to protect the safety of their staff. They did not give details about their overhead, but they said it’s so big that their clinic “wouldn’t exist without government funding.”
Burden of paying for abortion care is “falling on the public”
At unfunded clinics like Omar’s, they bill the province for insured services only – so, the abortion care itself. But there are other expenses his facility needs to cover that the government does not subsidize. Omar says this is why he asks patients to pay a fee of about $60.
“If we don’t charge, we cannot survive,” his main doctor said.
Omar says he considers this to be “more of a donation,” adding his team is explicit with patients that this fee is optional.
But he says, “With the demographic that we deal with, a lot of them are not able to pay.”
“We give … the same level of care for every single patient, whether they pay or they don’t pay.”
In contrast, Lee says their facility is so well funded through the province that there are no uninsured services – and there’s no need for fees.
“Clinics should not be put in a position to charge anything,” said Jill Doctoroff, the executive director of the National Abortion Federation Canada. “It’s not the clinics. It’s the system that does not adequately fund them to give the care needed.”
As with Omar’s clinic, Kelly also charges patients an optional fee for services that Ontario doesn’t cover. As a business that’s close to breaking even, they said they would have otherwise gone into debt last year.
But they believe health care should be free, so they say they have started a charity to help collect money to cover their expenses. Their hope is that they can take in sufficient donations to stop charging people these fees – a goal that’s proving to be difficult. So far, they’ve raised around $4,000, but to completely get rid of the extra charges, they said they would need to raise a few hundred thousand dollars a year.
Read more: Drop in virtual care fees could lead to ‘unintended consequences,’ Ontario doctors warn
Frédérique Chabot, the director of health promotion at Action Canada for Sexual Health and Rights, says because the province neglects to properly finance these clinics, the burden of funding abortion care is “falling on the public.”
When Global News asked the Ontario Ministry of Health to respond through email to Chabot’s claim, a media relations coordinator did not directly answer the question.
Not enough to go around
Many reproductive-rights advocates and clinic staff are now pushing for the ministry to fully finance all of its freestanding surgical abortion centres.
“We have access,” said Gilbert of the University of Ottawa. “We just need to fund it. We just need to make sure it’s equal.”
But this demand comes at a time when Ontario’s wider health-care supports are crumbling. The ministry of health says the system is “extraordinarily strained.” Many hospitals are grappling with upticks in COVID-19, influenza and respiratory virus cases, all while operating at critically low staffing levels. A recently leaked report shows hospital wait times are worsening, and most pediatric centres will be scaling back planned surgeries to try to safeguard critical care beds.
“Everyone is saying they need funding right now, but whose voice is going to be the loudest?” said Abi Sriharan, a health-crisis leadership expert at Toronto’s Dalla Lana School of Public Health. “Who is going to get attention at the end of the day?”
The pediatric problems have to be Ontario’s priority right now, Sriharan adds. “That said, abortion issues are huge issues and women’s health is involved.”
Abortion care falls prey to “all the problems within the health-care system right now – and worse because it can be stigmatized and dangerous,” Gilbert says.
If the unfunded abortion centres in Ontario had to close, Omar said, “I don’t know where the overflow would go. With only four publicly funded clinics, how could you possibly see all the patients?”
Funded or not, all facilities said they share the same goal: to provide a safe, reliable space for people to receive controversial medical care.
“It speaks to the commitment of those who are providing the service … because they’re meeting a need,” Egan said. “They’re doing it even though they’re being financially stretched to provide it, and that’s just unacceptable in today’s world.”
“They give me hugs,” Omar’s lead clinician says tearfully about their patients. “I don’t do this for the money. I’m an old-fashioned doctor. I love them so much. They need me.”
Omar says he’s unsure how long his clinic’s head doctor will be working in the field. Once that physician leaves, he fears that finding an equally passionate replacement will be tough, as many surgical providers are aging into retirement. He says if he can’t find a replacement, his centre will have to shut down permanently.
“That’s the bleak future we’re looking at unless we receive public funding.”