Canada's daycare scheme is in disarray. Creative commons photo by Pink Sherbet Photography

Advocates have long argued that a publicly funded universal daycare system would support low-income families, single parents, and working mothers. Support for variants of universal child care was a hallmark of the Mulroney, Chrétien, and Martin election platforms—but none of them made it happen.

Instead, in 2006, the then new Harper government made the Universal Child Care Benefit (UCCB) its first major social policy initiative, paying families $100 per month for each child under six, money intended to support child-care costs. Arguing that they were giving parents more freedom in making child care decisions, the Conservatives’ UCCB was, and remains, a rejection of the very idea of universal daycare. Five years on, the problems with the new system are clear.

The UCCB is “ill conceived and inequitable,” says Ken Battle, President of the Caledon Institute of Social Policy. He raises several objections: despite the sound-bite friendly “hundred bucks a month” concept, the UCCB is actually “virtually incomprehensible” to the average citizen. That $100 is considered taxable income, so no family actually gets $1,200 a year. Furthermore, it’s actually harmed lower-income, single-parent families, who no longer receive the annual $249 young child supplement (which was quietly abolished to help pay for the UCCB). Given the complexities and perversity of the tax system, higher-income families actually receive the highest net benefit.

Battle also criticizes the social engineering implied in the UCCB, under which not all families are created equal. Two-parent families with two parents working actually pay more in taxes than two-parent families (with the same total income) with one parent staying home. This is because that extra $1,200 in yearly income is taxable in the hands of whichever parent earns less. In practice, this means the government privileges families with a stay at home parent—and because of weak pay equity regulation, that generally means mom stays home.

These are minor gripes, though, compared to the fact that the math just doesn’t work: with daycare costs often well in excess of $7,000 a year, $1,200 is simply not enough. Battle argues that in order for a system of cash payments to meaningfully reduce poverty and help families, the older Canada Child Tax Benefit would need to be boosted to $5,000 per child per year for low- and middle-income families. Food Banks Canada recommends the same figure as part of its larger argument that a well funded child care plan would be one of the most effective ways to fight hunger and child poverty.

It’s unlikely that the Conservatives will reverse direction, and the federal Liberals have now surrendered the issue, recently dropping their long-standing commitment to universal daycare. In October 2009, Liberal leader Michael Ignatieff called universal daycare a “legacy” item for his party: “I am not going to allow the deficit discussion to shut down discussion in this country about social justice,” Ignatieff told the Toronto Star in Februrary 2010. Last October, however, blaming the economic forecast and Conservative spending priorities, Ignatieff announced the Liberals would no longer push for a universal public child care program.

With the feds asleep at the switch, some advocates are hopeful that the provinces will step in. Organizations like the Ontario Coalition for Better Child Care point to Quebec’s high-profile $7-a-day daycare system as an example to follow. In the 10 years after its introduction in 1997, the province’s child-poverty rates declined by 50 percent. The program’s problem is that it’s too popular, with a shortage of available spaces and long waiting lists. Though the Conservatives say the UCCB is all about giving families more choice, it now obstructs universal publicly funded child care—the choice that most would like to be able to make.

Illustration by Sylvia Nickerson

The test kitchen of the Bayview Village Loblaws grocery store in North Toronto is packed. Around 30 women and men sit clustered in pairs in a horseshoe, framed by the cupboards and counters lining the room. They are almost all white, aged 30 to 60 years old. Some small houseplants sit on the counter, the floor is the colour of cream of carrot soup, and the cupboards are dark green; the aesthetic is vaguely gradeschool. Orchestral pop floats in from the grocery store, while outside the window, one floor below, shoppers select their salad greens. Some of the couples talk quietly amongst themselves. Others wait silently with an air of anticipation. No one is here for a cooking lesson.

A cheery woman in an argyle sweater takes up her position in the centre of the chairs and begins to speak. Welcome to “How to Adopt.” This seminar, hosted by the Adoption Council of Ontario, is Adoption 101 for prospective parents interested in the idea but unsure where to start. The class outlines the various types of adoption and introduces attendees to parents who have gone through with adoption and who can speak about their personal experiences.

There are three types of adoption in Ontario: public, private and international. ACO executive director Pat Convery stresses that each kind of adoption offers its own challenges and rewards, and the route a couple or individual chooses to pursue depends on their own personal situation. What she does not say, however, is that some personal situations affect the available options more than others.

Growing up in her home country of Iran, Shirin* never imagined she would find herself in this situation. For many years, Iran promoted the virtues of large families. Shirin herself has many siblings. But now the Iranian government is thwarting her maternal ambitions. Shirin now lives in Canada and wants to adopt an Iranian child, but her birth country has declared her unfit. She came to the ACO meeting to learn about her adoption options, but unlike the couples here tonight, Shirin faces an additional obstacle. According to many countries, including Iran, she’s an unacceptable candidate because she’s gay.

Shirin is just one of an increasing number of queer women to pursue the option of international adoption, only to find that most countries classify them as substandard parents. Single mothers and lesbian couples disproportionately face barriers to international adoption because, not being in a heterosexual marriage, they’re classified as single parents. Many countries explicitly state they will not allow single women, or gays and lesbians, to adopt children, favouring a family structure that includes a mother and father. While some countries do allow single women to adopt, no other country among those usually sourced for foreign adoption, with the exception of the United States, permits openly gay women to parent their children.

International adoption is popular in Canada, with Canadian citizens and permanent residents adopting around 2,000 foreign children each year. Canadians apply to private adoption agencies licensed by specific countries to place children with parents here. Of the three types of adoption, international adoptions are the most expensive, costing parents $25,000 to $50,000 per child. The $85 that couples pay to attend sessions like the Adoptions Council seminar is just the beginning. Every prospective parent must undergo a “homestudy”—a series of in-home evaluations by adoption practitioners to ensure the applicants will be prepared and competent parents—as well as complete the mandatory adoptive parents training course known as PRIDE (Parent Resources for Information, Development and Education). While the Children’s Aid Society does not charge for these services, many individuals opt to pay the thousands of dollars it costs to go through private agencies, because it cuts down on wait times.

For many Canadians, the expense is worth it. International adoptions are popular because younger children are more readily available; at the very least there is a perception that kids up for adoption through the Children’s Aid Society may be older, part of a sibling group, or have special needs. With private adoptions, there is the risk that a birth mother will change her mind and an adoptive parent’s money and effort will be spent in vain. International adoption provides prospective parents with a formulaic stability. There is lots of paperwork, months of waiting, and usually travel abroad, but the path to parenthood is clear and understandable. Parental age is another factor: women who delayed having families, whether to pursue careers or for any other reason, face barriers within the domestic adoption process that can often be avoided with international adoption. Women over 50 are unlikely to be given an infant domestically, for instance, but several countries, such as Bulgaria, have higher parental age limits for infant adoption. Some women, such as Shirin, have a connection to a certain country or region and would like to adopt a child from that part of the world. For all these reasons, international adoption is an important option—and for many, it is a last resort after the domestic adoption process fails. Yet a growing subset of potential parents are being excluded by the countries where Canadians adopt from most. Almost one quarter of all children within Canada adopted internationally in 2008 came from China—a country that only permits heterosexual couples to adopt.

Many lesbian, bisexual, and trans women dismiss international adoption, because of its near impossibility for them and also because they object to their sexual orientation being treated as a liability. Some queer women, however, view these discriminatory policies as just one more problem they have to solve in order to adopt. These women opt instead to conceal their sexual orientation and go through the rigorous application procedures closeted, and in many cases they successfully adopt children from countries that discriminate against LGBT individuals.

As for Shirin’s plan, she is unsure of her options. She is a tall, fit woman with rich brown eyes and a few smile lines around her mouth. She has a discernable accent when she speaks. Shirin looks younger than she is, but in her late thirties she knows her options for adoption are narrowing. “I never admitted it to my family,” she says, “but I want to have children.” She wants a baby, preferably a healthy one, and while a child from the Middle East is no longer a possibility, there are still other alternatives open to her. Shirin does have one advantage; she may be gay—but she is also single.

There are 83 contracting states to the 1993 Hague Convention on Protection of Children and Co-operation in Respect of Intercountry Adoptions. In the nearly two decades since the agreement was concluded, it has had a profound influence on international adoption for LBT women.

Designed to safeguard the interests of children and to combat child trafficking, the convention has changed how countries regulate adoption in several significant ways. Under the convention, keeping children within their own families or countries is prioritized. Foreign adoption is considered a last resort, to be taken only when all other domestic options have been exhausted.

“It’s taken away some of the worries that adopting families would have,” says Pat Convery, meaning that certain key questions are answered: “Was this child actually legally relinquished? Did the parent have every opportunity to parent the child? Did they really look to make sure there were no family members? Was there for sure no money that changed hands in those areas that would be illegal under Canadian law?”

But while the Hague Convention has been a positive measure for inter-country adoption in general, it has also made it more difficult for queer women to adopt. The U.S., as the only source country that permits openly queer parents to adopt, used to be a haven for many LGBT and non-LGBT would-be adoptive parents. Since signing onto the Hague Convention, however, more emphasis has been placed on securing domestic adoption for American children in need of homes.

More than the Hague Convention, however, it is countries’ own value systems that pose the largest obstacles to queer Canadians adopting abroad. Chris Veldhoven is the Queer Parenting Programs Coordinator at the 519 Church Street Community Centre in Toronto, and he teaches a seminar to would-be fathers entitled Daddies & Papas 2B that explores the topic of adoption among other parenting models and family creation practices.

“The screening tools for some countries are becoming more explicitly heterocentric,” says Veldhoven, “so it’s much more difficult for people to find a country that will officially welcome someone and not discriminate on sexual orientation or gender identity.”

Historically, Veldhoven says, lesbians led the queer community in adopting, but increasingly gay male couples are also looking to adopt. Despite domestic legal victories that prevent discrimination on the basis of sexual orientation, there remains a stigma surrounding single men (or “single” men) adopting kids. Within inter-county adoption, this stigma is magnified. Single women may find their international adoption choices limited, but their situation is still better than that of single men—few countries even consider male applicants.

Elizabeth’s house is on a quiet street in the east end of Toronto. It sits across from a park where kids are playing, despite the grey morning sky. Birds chirp from the trees. Inside, the living room is cozy with wooden floors and little purple coffee tables on which Elizabeth serves tea.

When Elizabeth adopted her daughter in the late ’90s, she knew many other lesbians who were exploring adoption. But none of her other gay friends were adopting from China; Elizabeth was able to do so because at that time the country had not yet banned single women from adopting. She began her homestudy process in late 1995 and had her daughter by the summer of 1997. Most of the girls up for adoption in China at the time were there as a result of the one-child policy and, unlike in many other countries, were from poor families rather than ones with drug and alcohol problems, which meant the babies were more likely to be healthy. The adoption process was well regulated; China seemed like the ideal country to adopt from.

“I felt like it would be a clean process,” she says, “and that I would be adopting a child who otherwise wouldn’t have had a family.” Elizabeth is in her 60s now and has been with her partner for over 20 years. In addition to her adopted daughter, they have a biological child together. She is a strong-framed woman with short hair that is a mixture of dark and lighter shades of grey. She sits with her legs crossed in jeans and a black cardigan, her purple shirt matching the frames of her glasses. Going to China without her partner to collect their daughter was difficult. “I really had to censor myself all the time,” Elizabeth says. She went with several heterosexual couples from the same agency and struggled with the urge to be honest about her sexuality as everyone bonded over the experience of meeting their children. The trip lasted two weeks.

“My deal with myself, when I actually went to China,” she says, “was, no matter what the circumstances, I would not reveal my real self and real situation.”

Elizabeth pulls out photo albums of pictures from her trip to collect her daughter. She reminisces about the time abroad and gushes about her daughter: “Isn’t she adorable?” she coos, and indeed, she is.

Elizabeth found her social worker through a referral from friends who were adopting as out lesbians domestically. She says she felt comfortable with the social worker that conducted her homestudy but won’t talk about the experience of closeting herself. She feels unable to confirm or deny whether she lied about her sexuality for the evaluation process. Regardless of her evaluation, Elizabeth was adopting from China during the best possible period for LBT women to adopt from that country: before China declared it would no longer permit single female applicants. In 2007, the country amended its requirements so that all single women were forced to sign an affidavit swearing they were not gay. “If you were a single woman you had to write a letter saying you weren’t a lesbian,” says Elizabeth, taking a sip of tea. “That would have been a huge crisis for me if that had been the case when I was in the process. I don’t know what I would have done.”

Paradoxically, as social equality for LGBT individuals has strengthened within Canada, international adoption has become more difficult for queer women. Adoption practioners who conducted the homestudies of lesbian or bisexual women 10 or 15 years ago might have been willing to take a “Don’t Ask, Don’t Tell” attitude; if they thought someone would make a good parent, they could opt to keep a parent’s sexual orientation out of their homestudy report. That’s significantly less likely to be the case today.

“If you’re going to be out and you have to have your homestudy done by a domestic social worker, they’re not as willing to censor anymore because of the ethics of it,” says Veldhoven. “In the face of decreased homophobia domestically, social workers are saying, ‘Now we have to be true about your family configuration because we don’t want to hide it, because you shouldn’t have to hide it.’ But for many countries internationally you do hide it.”

The process of the homestudy itself has also changed considerably over the last decade. Jackie Poplack is a social worker who has been working in the field for four decades and has been an adoption practitioner, which includes conducting homestudies, for the last 14 years. According to Poplack, homestudies have become much more standardized and involve a lot more verification than they used to. Poplack has worked with queer couples seeking children and says that for social workers, looking the other way is not an option. “I’m going to be 100 percent honest and if I have a question or concern I say it,” she says. But for prospective parents who are single, there’s a certain degree of plausible deniability. In her years as a practitioner, Poplack has had one or two clients who said they were heterosexual, and who might have believed that themselves, but who she thought could have been gay. When it comes to homestudies, she acknowledges that, regardless of sexuality, people will try and smooth over any aspects of their character that they think will diminish their chances of securing a child.

Lisa is one woman who hid it. In 2005, she adopted a baby girl from Haiti. She was closeted to her social worker, so the woman classified her as heterosexual on her homestudy report. Lisa was single, so while there were some fridge magnets to remove and books to hide, there was no life partner to implausibly pass off as a roommate. Today she is wearing blue jeans and an olive T-shirt with “garden hoe” written across it in black letters. As she sits sipping her mug of coffee, she smiles, talking about the process of adopting her daughter, who arrived in Canada at nine months old and who is now happily enrolled in grade school with no idea of the half-truths her mother told to secure her.

“My goal was to never lie,” says Lisa, picking her words carefully. “But not necessarily to say everything.”

The Sherbourne Health Centre sits at 333 Sherbourne Street in downtown Toronto, a massive structure of glass and concrete with wood accents elevated from the road.

Across the street is Allan Gardens. People sit on benches and soak up the sun by the greenhouse. Squirrels play in the bare branches of the trees and scurry up the wrought iron lampposts that dot the grounds. Rachel Epstein’s office is on the second floor of the centre. Epstein is coordinator of the LGBTQ Parenting Network at the centre. The parenting course she designed, Dykes Planning Tykes, has been running since 1997.

In Epstein’s years of experience working with queer parents she has seen women closet themselves and get children. But today she is more pessimistic about the possibilities for LBT women to adopt from abroad.

“Basically, queers do not see international adoption as an option,” she says. More countries are selective about who adopts and who doesn’t, and choose heterosexual married couples over single individuals. Epstein worries about the personal toll exacted by denying your sexuality. “In the past, either you are single or you closet yourself. You closet your relationship,” says Epstein. “I mean, even single people find it hard to go closeted for this process, and it can be not just the adoption process but for a while afterwards.”

For a potential LBT parent, finding a social worker to whom she can be open about her sexuality—and who is willing to omit her sexual orientation from the homestudy report—is rare. How open a woman will be with her social worker is a crucial decision that can set her adoption back months if the wrong choice is made. If a woman chooses to be honest and the social worker is unwilling to lie, then the woman must find another social worker and start the process again. “It’s more feasible if you’re single,” says Epstein. “You don’t get defined by your sexual orientation in the same way and it’s easier to not talk about that.”

Indeed, there are those within Canada’s tight-knight LGBT adoption community who feel that the less said about queers and international adoption the better. Many blame U.S. media coverage of queer adoptive parents as being instrumental in China’s decision to ban single women from adopting. As awareness of the issue grows in diplomatic circles, they say, more consulates close their doors, shutting off the few remaining channels available for women seeking this route to parenthood. One Canadian adoption advocate refused to be interviewed for this article and strongly discouraged publishing any story at all on the subject.

There are no easy answers to a problem of such emotional, legal, and cultural complexity. For Canadian social workers, having to lie about sexual orientation in a homestudy report is a serious dilemma. “That’s unethical; I would never do that,” says Poplack. “It’s tough sometimes, because some of the rules you think are really unfair. I think we have to respect other countries—but it’s really crappy for gays and lesbians.”

Lisa made the decision to out herself to her adoption practitioner after her adoption was finalized and, as a social worker herself, she has spent a long time thinking about the ethical implications of her decision. “How do you reconcile that you are going against our Charter of Rights and Freedoms? Okay, it is the other country’s rules—but they’re homophobic and they go against our codes. Social workers haven’t been able to work it out in a way that enables most of them to feel comfortable,” says Lisa. “So the people who are doing it are like the people who work as social workers for Catholic charities and then pass condoms out under the table; they’re basically doing it very quietly, very silently, afraid themselves to come out.”

The Loblaws seminar draws to a close. Everyone stands to put on their coats, wrapping scarves around their necks. The music drifting in from the grocery store has changed to the Beach Boys. Shirin thinks she may not adopt. “I can’t lie about this fact,” she says. “The homestudy is going to be really one-to-one, close work between me and the social worker or case worker, and that is going to be based on trust. The person should know about me, should know about my past, should know about my family, should know about everything. How is it going to be possible to not say such a big fact?” She’ll do some more research and talk to a friend who is also looking into inter-country adoption, but she’s still skeptical. Shirin did not come out as gay until later in her life, and after being closeted for so long she doesn’t want to be in that situation again. “I don’t approve of it; to lie about it,” she says. “You should be honest.”

Lisa, however, is contemplating adopting another child from Haiti. She will need to find a new social worker, one who doesn’t know she’s gay. Then she’ll undergo another homestudy, closeted again, but she’s willing to do it for another child. “I think I’m a seasoned pro now at it,” she says. “I’ve guided other people about how to do it; I can do it myself again and I’ve been through it once so it’s not as scary.” When she thinks back to the emotional toll of concealing her sexuality the first time, she reflects, “I never really lost connection to who I was as a person; I was just playing the game.”

It is a game that Shirin and countless other queer women may simply decide not to play.

Sally Rhoads. Illustration by Antony Hare.

Sally Rhoads is passionate about surrogacy. The 32-year-old mother of three (ages 12, seven and 10 months) lives near Stratford, Ontario. She has been a successful surrogate once and an unsuccessful one nine times. Although her commitment to surrogacy almost killed her, she remains an advocate for a practice that is highly restricted in Canada and banned in some U.S. states.

This: When did you first become interested in surrogacy?

Rhoads: After my first child in 1999. I had really enjoyed being pregnant and found it was easy for me. I was on the internet and came across some surrogacy boards. I realized there were a lot of couples that needed help having a baby. So I figured that’s one thing I know I can do.

This: At that time it wasn’t illegal in Canada to take money for surrogacy [it now is although “altruistic surrogacy” is permitted, except in Quebec where all surrogacy is banned]. Were you also motivated by money?

Rhoads: I just thought it was something you do, like organ donations. I wasn’t financially motivated whatsoever.

This: How did your husband feel about surrogacy?

Rhoads: He didn’t like the idea very much at the beginning because he didn’t understand it. When he learned it would be a gestational surrogacy, where I would be carrying an embryo created by the intended mother’s eggs and father’s sperm, their genetics, he decided it was OK.

This: How long after your child was born did you consider surrogacy?

Rhoads: Three months.

This: How did you choose a couple to help?

Rhoads: Through the internet. From March 1999 through September, I had more than 200 emails from couples, pretty well all from the U.S. I went with Heather and Sergey from Maryland. They said they would take care of all my expenses, including travel.

This: But you were eventually paid.

Rhoads: Much later, when we started talking about a contract; they brought it up. That’s what you do, especially in the U.S. You pay a monthly fee. Maybe $2,500 in the U.S. and $1,700 or $2,000 in Canada. For me it didn’t matter. They threw out $1,100, plus expenses. That was fine with us.

This: How was the pregnancy?

Rhoads: I had the embryo transfer in a clinic in New Jersey in April 2000. When I got pregnant, I got so sick my family doctor urged me to get an abortion. The morning sickness was so bad I ended up losing my job. I also got an infection from all the needles you have to inject yourself with. It felt as if I had the flu every day for months.

This: Did you start to wonder if you had made the right decision?

Rhoads: No. Never.

This: How did the rest of the pregnancy go?

Rhoads: We learned there were twins—actually, it had started out as triplets—so the sickness then made sense. They had to induce me at 37 weeks. So the birth was in Stratford, and Heather and Sergey weren’t there for it. They were both breech babies. And there was a prolapsed cord [where the umbilical cord emerges from the uterus before the fetus]. I ended up having a C-section. I had a boy and a girl, Peter and Victoria.

This: A question I’m sure you’re often asked is whether it was difficult to give up the babies.

Rhoads: Not at all. Heather had been with me through all the testing. The day they put the embryos in me she held my hand and cried the whole time. Right from that point, you see that those aren’t your children at all. So for me there was a huge detachment there.

This: How many more times did you act as a surrogate?

Rhoads: Nine.

This: Did any succeed?

Rhoads: No.

This: Do you know why?

Rhoads: Embryo problems…at the couple’s end.

This: Why did you keep trying?

Rhoads: I never really wanted to do another surrogacy. But the couples would have the worst stories imaginable. One couple had spent $150,000 on IVF. They had lost their home, everything, trying to have a baby. They would plead with me to help them, and I always relented. One, in 2005, almost killed me. I had just had a miscarriage from another surrogacy and I told myself I was through. But a couple came from China. They had lost three babies. They said “please put our last embryos in you.” How could I say no? They put three embryos in me and I got pregnant. A couple of weeks later I was bleeding and they said it looks as if you miscarried, and that was the end of it. A week later I was feeling awful. I went to the hospital and my blood pressure was almost not there. Lo and behold, I had twin babies in my left tube. They had gotten between the tube and the ovary, and I got a big clot and it had ruptured. I lost half my blood and needed emergency surgery. They said I would have died if I hadn’t come in.

This: So that was the last surrogacy?

Rhoads: No. I had three more transfers after that.

This: When was your last try?

Rhoads: January 2008. I’m retired now. I’m divorced and my new partner wants to have more children and is worried that surrogacy might prevent that. I’ve already lost a fallopian tube because of it.

This: Have your views of surrogacy changed at all over the years?

Rhoads: In some ways. Altruistic surrogacy is very idealistic. I don’t really agree with it anymore. I strongly believe compensation should be involved unless it’s like your sister or a relative you have a connection with. I’ve seen a lot of surrogates go through this with altruistic ideas and come out of it feeling very used and hurt at the end. Most couples don’t want any connection with you after the birth. When you’re pregnant and you have your own baby, you come home with a baby. When you’re a surrogate you come home to nothing, not so much as a picture.

This: Is that what happened with Heather and Sergey?

Rhoads: No. But they got divorced a couple of years later. And I wondered, God, what I went through for these people, and they didn’t even stick together. Heather and I became close and we still talk almost every week. The twins [who are 10] know all about me. They think it was neat they were born in Canada. They added me as friends on Facebook.

This: What did you get out of surrogacy?

Rhoads: I loved it. I was always so happy to find out I was pregnant for a couple. And I always felt so cheated if I couldn’t help them. I guess, for me, it was almost addictive.

Safe, affordable midwives are in demand, but a lack of education and funding forces healthy mothers into hospitals. Creative Commons Photo by Dave Haygarth.

It wasn’t until the early 1900s that it became “normal” to have a baby under the watch of an obstetrician in a hospital. But over the last few decades, childbirth has become an increasingly complicated, medicalized affair, with more inductions, surgeries, and drugs than ever before. The advancements have saved many otherwise dangerous deliveries, but it can also traumatize healthy mothers who would otherwise be fine on their own. Cesarean sections are increasingly common, for instance: Canada’s current C-section rate is 28 percent. The World Health Organization says it should be closer to 15.

Modern hospital-based childbirth, says Tonia Occhionero, Executive Director of the Canadian Association of Midwives, could result in a “cascade of interventions.” Sometimes there’s a temptation to use every tool available, even if that’s not always the best option. An unnecessary induction of labour, for example, can produce a snowball effect, with medical interventions accumulating, quickly complicating low-risk births into higher-risk ones.

According to the Canadian Association of Midwives, 70 to 80 percent of women could deliver on their own without complications and would therefore benefit from midwife supervised delivery at home, in a special birthing centre (only in Quebec) or even at a hospital. But health-care providers have been slow on the uptake.

“There are a lot of misconceptions about what a midwife is,” says Occhionero. “But how can we expect the general public to understand when midwifery still manages to be left out of Health Canada’s literature?”

But even without promotion of midwifery, more women are rejecting the assembly-line hospital birth—demand for midwives far outruns supply. There are only 850 midwives across Canada, 435 of whom are in Ontario, the first province where the profession was regulated in 1994. Ten percent of Ontario births are attended by midwife—but 40 percent of women who request a midwife cannot get one. With only six university programs offering certification, the shortage persists.

Occhionero says that situation will continue this way until schools add midwife training, which despite its earth-mother reputation is a highly professionalized four-year baccalaureate degree.

“It’s very regulated,” says Occhionero. “Not just anybody goes around catching babies.”

Illustration by Dave Donald.

It’s just another September day in Nova Scotia—sun shining, birds chirping, a late summer breeze playing in the treetops. Only one thing is different today for Shawna Young: she is pregnant. This one fact makes the sunshine seem a little brighter, the birds’ songs just for her. It’s like carrying around a secret, a secret that makes her smile at strangers and hold her head a little higher. Just yesterday, Shawna and

her husband, Benjie, put their one-bedroom house on the market, already full throttle into planning their lives for their little one. They’d dreamed of moving into a bigger, more family-friendly home when the time came; now, it was finally here. Today, Shawna is on her way to the doctor for her 13-week ultrasound. She knows exactly what to expect: the doctor will say she’s 12 weeks and six days pregnant, and she and Benjie will get to see the little hands and feet of their miracle baby.

But something feels wrong when she lies back in the chair, looking at the ultrasound image up on the screen. There is no movement. She tries to convince herself that everything is fine, even though a nagging feeling in the pit of her stomach suggests otherwise. The nurse’s words come like a blow to the head.

“Well, you’re not 12 weeks and six days.”

“Oh, is the baby measuring a bit small?” Shawna asks, looking helplessly at the blob on the screen.

“I’m sorry,” replies the nurse. “I have no good news for you today.”

When Shawna repeats the nurse’s words to me on the phone from her home in Halifax, I hear her voice crack, and I know it’s not the quality of the connection. For any woman who has miscarried, the emotional devastation is something that lingers long after the event has passed. But for a woman who has had fertility problems and struggled through years of tests, medications, alternative treatments, and thousands of dollars in debt, the devastation is that much harder to bear.

A few days after finding out she had miscarried, Shawna went in for her scheduled “D & C”—dilatation and curettage—which refers to the widening of the cervix so a doctor can scrape tissue from inside the uterus; in this case, excess tissue resulting from the miscarriage.

“I had the distinct feeling we were going to a funeral,” she says of the drive to the hospital. “After a morning of meeting with doctors, nurses, intake people, seemingly half the people who worked in the hospital, I was taken into the operating room. I walked in and climbed up on the table. I extended one arm out straight so they could put the IV in, but they couldn’t get it in, so they had to try the other arm. So I was lying there with my legs in stirrups and both arms extended out and very bright lights shining on me. The operating room itself and the procedure to that point reminded me very much of my egg retrieval for the in vitro fertilization, and as I lay there, the tears just started streaming down my face. I couldn’t wipe them away because both of my arms were extended and being worked on. I felt so alone and such complete and total sorrow. I didn’t fight the feeling, though; I just let myself feel what I felt and grieved for the baby I was about to lose. I was not only mourning the loss of our baby, but I was really grieving for my fertility.”

At 37, Shawna was on her second in vitro fertilization treatment after a year and a half of trying to conceive naturally. The decision put her and Benjie in debt more than $20,000. A single round of IVF can cost up to $10,000, which includes costs other than the procedure fee—women also pay for the drugs they need to inject themselves with in preparation for the procedure, and these can cost as much as $5,000. IVF is currently not covered by the provincial health-care system in Nova Scotia or most provinces in Canada. In Ontario, it is funded only for women with blocked fallopian tubes—no more than 20 percent of infertility cases. Last summer, Quebec became the first Canadian province to bring IVF under its provincial health plan when it passed Bill 26, which allows funding for up to three IVF treatments for women having difficulty conceiving. Outside Quebec, IVF remains a private medical cost in most cases.

IVF involves fertilizing an egg with sperm outside the uterus. It falls under the umbrella of Assisted Reproductive Technologies (ARTs), which emerged in the late 1970s, with the first Canadian fertility clinic opening in 1983. IVF is the most effective ART: with each cycle of treatment, it’s successful 38 percent of the time for women under 35; for women aged 35 to 39, it’s successful 28 percent of the time; starting at age 40, success rates drop to 11 percent. According to the Canadian Fertility and Andrology Society (CFAS), these rates have increased by 10 percent over the last decade.

The causes of infertility are numerous, and doctors usually look at lifestyle factors first—smoking, alcohol, and drug use all inhibit fertility. But the biggest cause of infertility in both men and women is unknown, and the most common type of infertility is unexplained—doctors simply find no reason why a woman cannot conceive naturally; everything seems to be medically normal, but it’s just not happening. In Ontario, infertility is known to occur in one in six couples, and in 2008, the CFAS reported a combined total of almost 10,000 IVF procedures performed in the 28 clinics across the country. However, although it is the most effective treatment, IVF is usually not the first procedure that couples attempt.

According to Dr. Keith Jarvi, director of the Murray Koffler Urologic Wellness Centre and head of urology at Mount Sinai Hospital in Toronto, doctors often try to increase ovulation in women and the number of eggs they produce during ovulation. This is done through stimulation medications that women take for a period of time prior to the procedure, so the sperm have more targets to aim for. If the process, known as Intrauterine Insemination, fails more than once or twice, the next step may be the use of IVF.

“We take the eggs out, take the sperm out, and incubate them together in a dish,” says Jarvi. Once the eggs are fertilized, the doctors take as many embryos as they feel are necessary for optimal chances of conceiving and return them back to the woman’s uterus. If IVF doesn’t work this way, doctors perform Intracytoplasmic Sperm Injection as part of the procedure. “[With ICSI], you can take the sperm and bring it closer to its targets,” Jarvi explains. To do this, doctors take a single sperm and inject it into a single egg, (after they have been extracted from the couple), and then place the fertilized embryo back into the woman’s uterus.

The costs of these procedures ranges anywhere from $5,000 to $8,000 each, not including the cost of the drugs women may need to take at the same time. “And you’re probably going to end up doing it two or three times,” says Jarvi. “You could easily spend a compact car’s worth of money on it. It’s not Lamborghini kind of money, but still, it’s a lot of money.” The huge expense adds a financial burden to the already high emotional cost of infertility, says Shawna. “It is really unfortunate that [the decision to do IVF] has to be a financial decision.”

Beyond the financial or emotional considerations, IVF also has implications for the health-care system. Such procedures result in a high number of multiple births, for one; because IVF costs so much, doctors transfer more than one embryo at a time to increase the chances of one coming to term. Multiple births suffer more complications, and it costs the health-care system a lot to care for them. Many doctors say these multiple births end up costing the government more than publicly funding IVF treatments mandating a single embryo transfer would.

As birth rates continue to drop, many advocates, patients, and doctors alike say that provincial governments need to recognize that these procedures inflict high costs on individuals—emotionally and financially—and additional economic costs on the public healthcare system. The solution, they say, is to make IVF a publicly funded treatment.

Most women spend a great deal of their lives trying to avoid pregnancy. We are taught to practise safer sex and use condoms and go on birth control. We do these things until we want to start a family, and it’s easy to assume that as soon as birth control stops, a pregnancy will occur. We’re conditioned to expect the process to happen naturally, like turning on a light switch. And when it doesn’t, we feel frustrated, angry, and confused.

“You feel at fault because you can’t do something that comes so naturally to everybody else,” says 39-year-old Charmaine Graham, of London, Ont., who has been through 11 IVF treatments. “You’re faced with people who are parenting children and they’re going through [general] parenting angst—they’re frustrated, they’re tired, they yell, they snap—and you just would do anything for that opportunity. I just wanted to go to the grocery store with a baby like everybody else.”

Graham says infertility can be an intensely isolating experience. Not only do women feel like outsiders for not being able to do something natural—and, arguably, what many women may feel is their unique duty—but they are further isolated by constant reminders of their failure.

“No matter where you go, every single person that you meet came from somebody’s womb. That is what we do as a human species—we procreate. And so there’s no way ever to escape that,” she says. “You have a lot of feelings that are paradoxical. You’re really happy for your sister when she gets pregnant, but you also want to smash her head up against the bathtub because you can’t. It’s very hard to live with those feelings all the time.” Of Graham’s IVF treatments four were fresh, and seven were frozen (frozen fertilized eggs are stored in case a fresh treatment fails, which is less expensive than starting again with another fresh treatment). While her husband, Jim, believes the experience ultimately brought them closer, Graham remembers how taxing the treatments were on their marriage at the time.

“You have to deal with the anger and frustration you might have with your partner as a result of them being infertile, or the guilt that you feel for being infertile. And then I have to make this man who loves me live with me when I’m fucking insane going through hormone treatments,” she says. “Women become so focused on just getting pregnant, it doesn’t even become about parenting anymore. Men don’t feel that they’re married to the woman they got married to. Something has hijacked their marriage entirely.”

This is one of the most compelling things about the struggle of infertility: it affects men and women very differently. Even if a man is the one with the issue, the procedure is still done on the woman because she is the child-bearer. “They’re the ones who have to do most of the drugs, they have to do most of the invasive technologies. They’re the ones being poked and prodded,” says Graham. “A man has to masturbate to get his sperm out. A woman has to have a probe put in her vagina, with a 22-gauge needle that goes through the side of her vagina into her ovaries to withdraw the eggs. I think it’s a very separating experience for most men and women.”

Other women agree with Graham that the reminders of what they can’t do never seem to cease. Some describe difficulty attending baby showers, seeing mothers with their children in the grocery store, and even walking by the Santa Claus display in malls around Christmas. And with all of these difficult feelings comes the worst part: paying out of pocket for a procedure that is not even guaranteed to work. No one knows that better than Kerri-Lyn Jessop, 37, of Caledon, Ont., whose three IVF treatments over two years have put her more than $30,000 in debt. “Unless you’re rich, that’s a lot of money to spend to find out an answer to one question,” she says. But it’s not enough to make her want to stop trying.

“Emotionally and physically, I’m not ready to give up, but there’s only so much money in the pot.”

Cheryl Dancey, 41, of London, Ont. agrees. She had 18 IUIs and four IVF treatments, none of which were successful. “As hard as everything else is, it’s not enough to stop you from doing it again. Money is the only thing that can make you not go on.” (Since our original interview, Dancey was able to give birth to a baby girl with the help of a donor embryo.)

Dancey says if IVF was publicly funded, half the burden of the experience would be gone. “It would take all that pressure completely away,” she says. “You wouldn’t have to worry, ‘Well, if I do it, we’re not going to have the house to put the kid in.’”

Many couples struggling with infertility turn to family and friends for financial help to pay for IVF treatments, which brings up the arduous task of explaining their situation to loved ones—something that can be very difficult to do.

“People don’t believe that it’s real,” Dancey says. “They say, ‘You’re not doing it right. All you have to do is relax. So-and-so’s brother’s cousin’s wife did this and she was fine.’ People just don’t get it. Everybody’s got some stupid story that somebody that they’ve known through the grapevine relaxed, or drank a certain tea, and that’s what will fix the problem.”

“The other thing that people also do all the time is that they stop talking to you,” says Graham. “I worked at the university and I was always very open about my situation. So, I’d go missing for a few weeks and I’d come back to work and people would say, ‘Where have you been?’ and I’d be like, ‘Making babies in a petri dish.’ And so everybody knew what I was going through. And then one of them would get pregnant and she wouldn’t come to my office for nine months.”

If IVF were publicly funded, couples could go ahead with treatments privately. They would also be spared having to deal with the naysayers who think seeking such treatment is selfish.

“By the time the government decides—if they ever decide—to fund this, it will be too late for us. My time will come and go by the time that it’s covered,” says Jessop. “We are speaking up for the next group of people that are coming into this. I don’t think I will ever benefit from [it], but I might be able to help somebody else benefit.”

The Ontario government established an expert panel in 2008 to take a closer look at ARTs, especially IVF, and whether it should be funded under the province’s health-care plan. It also examined adoption: its cost and its lengthy, complicated process. The panel released its recommendations this past August, which urged the government to institute a fertility education system, provide a funding strategy for IVF procedures, and make changes to the adoption process.

Dr. Jarvi provided expert advice to the panel, which also included Dr. Arthur Leader, a professor at the University of Ottawa and a partner at the Ottawa Fertility Centre. Both doctors agree that the most important public health reason to fund IVF is to limit the number of multiple births that result from multiple embryo transfers. Leader says that transferring multiple embryos is dangerous and more of a financial burden on the health-care system than IVF procedures would be.

“What the expert panel showed was that, by limiting the multiple birth rate in Ontario, you could save the taxpayer, over a 10-year period, half a billion dollars,” he said. “Twins are more likely to have medical or surgical needs in the first four months of life. The tremendous cost associated with having high rates of twins, never mind triplets, means that caring for them is actually costing the government more than it would have cost to fund IVF for single-embryo transfers.”

One of Leader’s patients became pregnant with twins through IVF. About halfway through the pregnancy, one of the twins died in utero as a result of a congenital heart defect. “It became a highrisk pregnancy,” says Leader’s patient, Kerri Stanford, who was 34 at the time. “We knew that one of the babies wasn’t doing well and was likely not going to make it. It just meant that the whole pregnancy was very complicated and it was watched in a high-risk unit.” Those high risks, of course, entailed high costs, exponentially more than a single healthy pregnancy would have. “Economically, there is a strong argument to be made to fund fertility services,” Leader says.

Leader has another reason he believes IVF should be added to provincial health-care plans: continuity of care for patients. “One of the paradoxes of infertility is that, in almost every province of the country, it’s medically necessary to do fertility testing in order to find out why people can’t get pregnant. In other words, the health plan pays for treatments to diagnose infertility. But once the diagnosis is made, the health plan abandons people, saying it’s not necessary to treat your problem. Then, once people get pregnant, the health plan says now it’s medically necessary to care for pregnant women. There’s a disconnect.”

Months after my first conversation with Shawna, I receive an email from her. “I should be 35 weeks pregnant now,” she writes, still lamenting her miscarriage. She goes on to tell me about one of the hardest parts of dealing with infertility: the public’s misconceptions about it.

“If I had a medical condition that prevented me from being able to walk,” she said, “and there was an effective medical treatment available, society wouldn’t question whether or not I should be able to access it. When someone is paralyzed, people think, ‘Oh my gosh, I could never imagine what that would be like.’ Nobody ever thinks, ‘What would my life be like if I didn’t have my fertility?’”

Advocates for IVF funding see it as positive that the Ontario government commissioned an expert panel to look at the issue, and Quebec’s new law is definitely a step forward. But it’s taking the rest of the country a while to catch up. Medical organizations have questioned Canada’s attitude toward funding, especially in comparison to other countries around the world, many of which do provide funding. Manitoba offers couples who have undergone treatment a tax credit for 40 percent of treatment costs. British Columbia now has the Hope Fertility Fund, which provides financial assistance to residents of the province who can’t afford treatment—commissioned by the UBC Centre for Reproductive Health, the Vancouver General Hospital, and the UBC Hospital Foundation, not by the government. The Nova Scotia government has previously deemed it not medically necessary to provide funding, and the rest of the country seems to agree.

Still, supporters remain hopeful. Beverly Hanck, executive director of the Infertility Awareness Association of Canada, believes all provinces will eventually cover treatment. “I suspect what’s going to happen, and this is my guess, is that they will put it on their platform for the next election,” says Hanck. “It’s a matter of time. But time is important for some of these couples.”

Time is indeed the enemy in the infertility battle. Women feel pressured by time because fertility decreases with age, and after an IVF treatment is performed, waiting to find out if they are pregnant can be excruciating. The burden of infertility is essentially a race against time. And so far, time is winning by a long shot.