 It's my pleasure to introduce Minavi Honda, who has been a registered midwife in Toronto, Canada for the past two decades. She's an associate professor at Ryerson University in the Midwifery Education Program. Minavi has focused her midwifery practice on care for marginalized women, particularly newcomers, refugees, and those without legal immigration status. Minavi has been head midwife at two hospitals and has sat on numerous local and national committees. Her research interests include midwifery and bioethics, vaginal birth after cesarean and homebirth, midwives as abortion providers, and cannabis use in pregnancy. Minavi, I'm going to turn control over to you, and we're eager to hear your presentation. Thank you so much. It's such a pleasure and honor to be part of the Virtual International Day of the Midwives Conference. I spoke at the first conference many years ago, and so it's a pleasure to be a keynote speaker. I'm going to be talking today about my perspective on care for Syrian refugees when they came to Toronto. So, just to give you a bit of an overview of the presentation, it's an experiential presentation. It's not research-based, so it's very much about my experience. I'm going to give you an overview of the first two days of my work with Syrian refugees, because those first two days really represented all of the systemic issues that were present. I'm going to talk a little bit about the political context in Canada at the time, the health care response, what the setting was at the refugee receiving hotel where I provided care, midwifery involvement, and then I'll give you an overview of a few cases and the lessons learned from those cases. So, everything from systemic issues to population insights and midwifery lessons that were learned, and then I'll talk a little bit about future applications and the role for midwives. So, just a bit of a disclaimer, this presentation demonstrates multiple systemic issues that arose in Canada in the care for Syrian refugees. This is for future learning. It's not at all a criticism about taking in refugees. I have a very strong political position on Canada as humanitarian country, and in general of Western and higher resource countries taking in refugees. So, I don't want anyone to take away from this that I don't think we should take refugees in. We really did try our very best, but as you will see, we didn't do very well actually in caring for Syrian refugees. We did, but not as well as we could have. And really, I'm talking about the experience of myself as one midwife. I volunteered to provide care to all pregnant clients at Canada's largest Syrian refugee receiving hotel. So, just a little bit of a political context. This is a presentation about what happened at the end of 2015 in the beginning of 2016. The Syrian refugee crisis was seen as the largest humanitarian refugee crisis since World War II. So, Syrian refugees were a major Canadian election issue at the end of 2015. The previous government that we had in power before the end of 2015 was very politically conservative, very similar to the current American government. So, they were very reluctant to take refugees into Canada, and there was a lot of rhetoric about terrorism and screening for refugees. There was a new government established in October 2015 that was much more liberal, and they promised to take in 25,000 Syrian refugees by the end of 2015. So, in a very short period, within two months, they wanted to take 25,000 people into the country. There were two pretty seminal events that happened right before Syrian refugees were taken into Canada. And this might be new for some of you, or it might be a little bit of a review. So, at the end of 2015, there was the San Bernardino terrorism shootings in California. So, it was a mass shooting, 14 people were killed, 22 were seriously injured. The perpetrators were a married couple that met online. So, one legally immigrated to the U.S., and one was born and raised in the U.S. There was a lot of FBI rhetoric about homegrown violent extremists being inspired by foreign terrorists. And for those of you who might not remember this particular shooting, because, unfortunately, there are many mass shootings in the U.S., this was the shooting where the FBI petitioned the government to unlock, petitioned Apple to unlock the iPhone that they thought there was seminal information on. At the same time, within a couple of weeks, there was the case of Alan Curdie. So, you see these very tragic pictures on the right-hand side. These images became a global symbol of the Syrian refugee crisis. So, these are pictures of a three-year-old child's death while fleeing Syria at sea. And you can see this child being carried by his father, and the father was Alan Curdie. This family actually was previously refused refugee status in Canada. So, this family story really became representative of the refugee crisis in Syria overall, and also Canada's role. And for the first time in many decades, Canada was globally criticized for its lack of response in the refugee crisis by the U.N. and many other countries across the globe. So, the refugee crisis of Syria was really seen as a major issue with respect to Canadian identity and reputation as a humanitarian country. So, the Canadian government response, there were very mixed feelings at the time among Canadians about taking Syrian refugees. So, there was a large response of wanting to be humanitarian and continue with Canada's humanitarian reputation. And at the same time, there were a lot of fears about the rhetoric of terrorism, especially from Islamic countries. It was very important to the new government profile to take in asylum seekers. They really promised to renew Canada's commitment to asylum seekers. So, the compromise between this Canada wanting to be humanitarian but also wanting to be careful about quote-unquote terrorism, and I put that in quotes for many reasons. They decided to only take in two parent families with children. So, there's very heterosexual gender normativity implied in this decision, and this will be reflected in the language that I use in this presentation. The idea is that families with children, there was less concern about radicalization. So, this San Bernardino case, there were two single people who were quote-unquote radicalized and met online, so they didn't want to take single people, particularly men. And there was a big rush to fulfill the election promise of taking a large number of refugees within a short period of time. So, because of this, intake was not well planned at all. So, the healthcare response. As soon as the government said that they were going to take Syrian refugees in a considerable number, so 25,000 within about two months, there were a lot of discussions within the healthcare setting with settlement, within the settlement community and public health agencies. It was interesting because a lot of the focus, I'm just going to ask if people are not on mute to put their speakers on mute. I'm just getting a lot of background noise if that's okay. Anyway, so there was a lot of public health concern, there was a lot of discussion about vaccinations, post-traumatic stress syndrome and acute health issues. There were a lot of meetings at the national and provincial level in Canada as well as the local level, among primary care providers. And as a midwife who works a lot with refugee communities, I was involved in a lot of these discussion boards. A lot of them were on Facebook or through email and it was very interesting. There was virtually no midwifery presence even though we were talking about primary care providers. It was very much unknown where, when or how many refugees would arrive and there were rumors all over the place. So, there were rumors that refugees would be settled in military bases, which doesn't sound like the best place for refugees to be, who are leaving a war torn country to rural areas, to cities. There was really no one had an idea where people were going to be landing, but knew they were going to be coming very soon. So, this really shows systemic issues about the lack of communication between immigration agencies and healthcare agencies. And this question about what about the pregnant women? So, on these discussion boards, I kept asking, what about pregnant women? And nobody was talking about people who might be pregnant. They were talking about vaccinations, they were talking about public health concerns, but there was literally no conversation about pregnancy or reproductive care. So, the initial plan was that 10,000 refugees were planned to land in Toronto, which is Toronto's Canada's biggest city, and to be housed at local hotels. Within days of this government announcement, refugees started arriving at the largest receiving hotel. There was very little time for planning. So, community agencies, health networks, independent clinics in the city were all activated to develop a plan. There were 28 clinics in Toronto staffed and ready to take in families, which sounds great, but it didn't actually work out and I'll explain why. They were on site at the hotel. So, these people came literally from the airport and went straight to a hotel within 10 kilometres of the airport. There were multiple volunteers and agencies on site and nobody was really in charge. So, it was actually chaos. And the idea of doing a cute triage on site was very contentious. So, there were these 28 clinics that were activated and ready to take people, but they were not on site. And there was a lot of criticism about people who were on site undermining the work of those clinics that were waiting to receive refugees. So, just to give you an idea of what was happening at the hotel. So, it just so happens that I was very involved with the planning around refugees coming in and this hotel, which was the largest Syrian refugee receiving hotel, was within 2 kilometres of my midwifery practice. So, that was very fortunate. 500 people arrived within 2 to 3 days and healthcare providers were notified on the day of arrival. So, we didn't know when people landed at the airport. They were all in the hotel and we were notified people are here and they need healthcare. There were two community health staff on site. So, one was a nurse practitioner, one was a nurse. There was one volunteer pediatrician and I say volunteer because this pediatrician was volunteering her time, but she did have the ability to bill for services. Everybody who came in on arrival had full access to healthcare. And that's an important piece that this person was volunteering their time, but they actually were getting paid for their services. There were very large families that arrived. So, the average family size was 7, so 2 parents and 5 children. Again, remembering that we only decided as a country to take in people who were coupled with children. There were very low levels of literacy, zero English. I didn't mean anybody in the time that I was there who spoke English. The most common professions were farming and truck driving. So, these were really some of the last refugees to be able to leave Syria. We're very impoverished and very different from previous Syrian refugees that we had worked with that were generally pretty upper to middle class, very well educated, had good rates of literacy. So, again, what about the pregnant women? There was no discussion about care for pregnant women. And the kind of other care providers' insights or comments that I was told when I kept asking, what are we going to do with all the pregnant women, was how many pregnant women do you think there will be? Or they don't seem to be that many women whose health records indicate they're pregnant. And this was a big one. Pregnancy is not a medical emergency. And I kept saying, people who have gone through war and finally leave and are safe are concerned about the health of their children, including the children that might be in their belly. One of the issues I also talked about was termination. And the comment I got was we're dealing with religious Muslim women here. They're not going to be wanting termination. So, in terms of systemic overarching issues, there was really a lack of knowledge or understanding of women's reproductive issues. There was a lack of understanding of the importance of pregnancy care and the importance of the family unit and resettlement and what the effects of pregnancy could be on that process. Just a very brief note about setting the stage for midwifery involvement. So, for people who are trying to replicate similar services in other areas, I got in touch with our provincial bodies, so the Association of Ontario Midwives. They were really a hub of information. We were writing blogs and updating midwives about when refugees might be coming, what they might be able to do within their own communities. We involved risk management. So, midwifery in Canada is very, or midwifery in Ontario is very specific in terms of its scope. So, I knew I would be working within midwifery scope, but not necessarily providing our major tenants of care, including continuity of care. So, I knew I'd be caring for women in the hotel, but not necessarily in the interpartum period. So, we had to get the insurance company to agree to that and they were very amenable. And the College of Midwives of Ontario, which regulates our scope of practice, they were ready to put an alternate practice arrangement in place in case we needed to do things that were not within midwifery scope. So, while women physicals for people who are not pregnant is not within the scope in Ontario, neither are vaccinations for families. And so, they put some things in place in case that was what was needed at the hotel. And really in terms of communication, communication with the health centers and coalitions was really to keep midwives involved and to keep midwives involved in mind. So, I kept staying involved to remind people that midwives were able to provide care for pregnant women, even though nobody was interested in pregnant women at the time. So, the first day, I decided I would just come to the hotel and see what was needed. The community agency staff informed clients through translators that I was coming, so that a midwife was coming. Only one woman disclosed pregnancy and just to give you an idea of the setting, really it was a hotel that was not at all, I mean it was adequate, but it was not a nice fancy hotel by any means. I was given a storage closet with boxes all over and that was where I was able to run my clinic for the evening. So, that storage closet was transformed into a clinic room. There was no paper, no pens, no desk, no fax, no files, nothing. There wasn't even a bed. We ended up getting a massage table as a bed so I could at least palpate people's bellies not on the floor. And I thought I was very prepared. I came with my prenatal bag and realized I didn't have a pen, I didn't have anti-natal records. And just to understand the scene, the lobby really was like a town square. It was very, surprisingly it was very joyful. There were lots of people, like probably 500 people sitting in the lobby of the hotel and children everywhere. And I really was looking around at these women and would see families with a five-year-old, a four-year-old, a three-year-old, a two-year-old, a one-year-old. And then looking at these women and thinking there's a bigger chance there's a baby in your belly. And so I really believe in bonding with people through humor so I learned the word for pregnancy would just hamel and the word for midwife would just kabela. So I walked around with a translator to groups of women and I just pointed at them and said hamel, are you pregnant? And then pointed at myself and said kabela. And then the translator would say this is a midwife. You can see anyone who's pregnant and literally within half an hour, I had about six pregnant women disclose that they were pregnant and that I saw on the first day, which really speaks to the importance I think of personal relationships because the community agency had asked who was pregnant and only one person came forward. But when people could see my face and have a bit of a rapport, there was many who came forward. And I say many because I really I think I approached about 15 women and six of them were pregnant and so that was all I could deal with on the first day. So the pregnancy needs at the hotel overall, I thought I would be there for two weeks, but I was there for actually 16 weeks, not 12 weeks. I did about 60 to 80 visits in that time, 30 were with pregnant women. Many visits were for pregnancy tests, so people who thought they were pregnant, many clients for IUD placement. There was a very strange rumor and I don't know if it was true or not, but people really seem to think IUDs were a very common form of birth control and people seem to think that going through multiple airport X-ray machines had dislocated their IUDs. So many people were concerned that their IUDs were not in the right place and many people came for contraception. They were not accommodated and I'll talk to you a little bit about that in a minute. So now I'm going to go through a few case studies that really I think there's just four case studies that really show the overall are the overarching issues that happened with care at the hotel. So the case case one, this was the only client to initially come forward. So this was the one disclosed pregnancy to the community health center. This client was actually a previous health care provider. She was a labor and delivery nurse herself. She was the only one with health records. She had diagnosed dichlorionic-diamnionic twins and she was in the third trimester. She had had three previous caesarean sections and had no operative reports. So she was definitely not a good candidate for VBAC and she actually didn't want to VBAC. So she needed an OB referral and part of the issue was that we were unsure where permanent housing would be found. So I needed an OB who could see her in the community until she moved and then another OB who could see her in the community where she moved. The second case was a 28-year-old G5 P4. So again, remember the average family, there were five children. So this was not uncommon. It was early pregnancy. There was severe nausea and vomiting to the extent that the client was actually planning to go to the emergency room the same day for her nausea and vomiting. And she had had such severe nausea and vomiting in previous pregnancies that she actually was planning a termination with support from her partner. Not pressure, but really they were new to the country and decided this wasn't a good time to have a baby. Which goes back to that comment that one of the practitioners had said where I said we need termination services and they said but we're dealing with a Muslim religious population, they're not going to want termination. So that really speaks to kind of a lack of understanding about women's reproductive health needs. And also the importance of on-site care, which was really important to avoid expensive and unnecessary use of hospital emergency rooms. If I wasn't there she would have gone to an emergency room and really she just needed a prescription for anti-imetics, which I gave her and worked out quite well. So case number three, this was a 19-year-old G1 P0. She was 28 weeks pregnant and she had had previous care and was quite certain of her dates. One of the things that was very interesting about this population is everyone who was coming from a refugee camp had care in pregnancy. So almost all of people who knew they were pregnant had at least an ultrasound and blood work. None of them had their pregnancy records with them and this was very deliberate in getting to know the population and talking to women. There was a lot of fear that if it was disclosed they were pregnant they would not be able to get immigration. So people did not disclose their pregnancy and they did not bring their pregnancy records with them. So they had health records for the entire family. They did have pregnancy records and they deliberately chose to leave them behind. So this client had been trying to get pregnant for five years. So yes, she was trying to get pregnant since she got married at the age of 14 and the average age of marriage in this population at the hotel was 15 years old. Her fundal height was 21 and she palpated as having severe IUGR. She was also married to her first cousin. Consanguinuity was very high in this population. Many people were married to first or second cousins and she was referred to a tertiary care center. So case number four and we'll come back to this case because this is kind of my most favorite case. This is a G11 P10. There was a very limited time at this point and so I kind of had to group my questions about her obstetrical history. So I would say things like what was your longest labor? What was your shortest labor? What was your longest pregnancy? What was your earliest baby? This client had very low literacy even in Arabic. Her and her partner had no written literacy in Arabic. No formal education for either parent. I think she had gone to school until grade three and her partner, I don't think actually had any formal education. It was very difficult to discern a pregnancy history. She had anywhere from one to four preterm births. She was one of the people who was unsure of her due date. She was maybe 32 weeks and it was unclear whether she had a history of precipitous birth. So it became obvious when seeing this population that everybody I'm presenting to hospital essentially was augmented with oxytocin. So because hospital beds were so scarce as soon as people arrived, they were augmented so they would deliver and get out of the hospital bed quickly. So it was unclear when I asked her how long her longest or shortest labors were. She said her longest labor was an hour and I thought that was a miscommunication. So I said, no, not your shortest labor. I mean your longest and she said, no, I don't really feel anything. I just have a bit of bloody show and feel pressure and go to the hospital and have my baby. And this ends up being really important later on. So I'll revisit this case in a minute. So the wrap up and follow up to day one just to get an idea of what it was like. I had planned to be there for five hours. I left after nine hours and then I went to clinic for about two or three hours. I made labels. I sent off labs. I arranged ultrasounds for all of the patients. I arranged OB referrals. So for the IUGR patients, I arranged tertiary care for the client presenting with twins. I arranged care at a twin clinic. I sent off blood work for all of the patients. This ends up being quite humorous, but all of the patients are told when to return by me writing down in English on a piece of paper when they should come back to see me. I arranged for my practice to receive all of the lab results. And I thought I was being really smart. So I did a Google search on material about pregnancy in Arabic. And I printed out these 20 page booklets that I, it's quite humorous, but I thought I was being very smart. And it was information on preterm labor and preeclampsia, fetal movement, nutrition, all of the kind of regular stuff we would want pregnant people to know. So day one kind of lessons and issues. There was no communication at all between healthcare providers and the settlement agency. They were about five doors away from each other at the hotel. So I'm taking women's names and writing them down on the anti-natals. And I have pieces of paper saying Sarah Alhamoud has an ultrasound in three days at 10 o'clock in the morning. And I found out that all of the families by the settlement agency were written down by the name of the head of the family, which is the husband. And that Syrian married couples, certainly in this demographic, they do not have the same last name. So what would happen is they would write down the head of the family. So as an example, Ahmed Alhamoud plus wife age 19 plus six children age eight, six, five, four, three, one. So I had no way of finding all of these women that I had seen who I had just arranged all of these ultrasounds and follow-up visits for. So it just speaks to the importance of good communication and did not even dawn on me that I wouldn't be able to find these clients later. And the written information in Arabic was irrelevant. There were no except for that one client who was a health care provider. Nobody actually was literate in Arabic enough to read any of the booklets that I thought I was so smart in producing. So just to revisit case four from day one. So the second day I arrived and there are many families waiting for the midwife, which was great. I felt like it was a great success. And like at least people knew there was a midwife there. They wanted to come see the midwife. And this translator said to me, this woman is bleeding. So this is the G11 P10 woman from the previous time I was there. She was now almost 34 weeks gestation. So I had her come in quickly first and she had some bloody show on her underwear and said to me, I'm not having contractions. And again, she might have had a history of preterm labor or might have had a history of precipitous birth. So she said to me, I said, are you having contractions? And she said, no, but I'm having my baby today. So I did a vaginal exam. She was about eight centimeters dilated, great grand multiboss. I could stretch her to anything. And this really speaks to the importance of continuity and knowing the client history. So I knew that she had a history of precipitous birth and maybe silent birth and maybe preterm labor. And that was really useful. So I got her in an ambulance right away, got her to go see. I called the midwife at my practice and have them meet her at the hospital and called the obstetrician. So she had appropriate follow up care. So the outcome of that case, she delivered within five hours of arrival. The baby was fine at delivery. And as preemies often do, she had a 34 week baby that destabilized on day three and ended up being sent to a tertiary care center for sepsis. It was very interesting to me, there was a lot of media attention about this case. There was news all over and it was a real feel good story, which was great. It was a feel good story. But on day five, we realized that this client had been pumping for days and that her premature child in a high resource country like Canada was not had not received any of her breast milk yet. And that again really speaks to the importance of ongoing midwifery care. The midwives who were involved, basically their role was to take these parents to the downtown tertiary care center so that they could see their child and actually deliver breast milk to the baby. And it also shows the importance of involvement with other agencies. So the settlement agency, the healthcare agency, the tertiary care center, nobody was in communication with each other. And transportation was a huge issue. It was organized by the settlement agency, not the healthcare provider. So they were expecting this client to go two hours across town in a bus at three days postpartum, which just didn't make any sense. So this is just a little clip from the newspaper about how this story was taken up. So it was a feel good story and people were really happy that this was the first baby of this group of Syrian refugees delivered in Canada. So people were very happy about that. Minavi? Yeah. Oh, it looks like you're coming to the end because you have about four minutes and that would give us five minutes for questions. Yeah, that's perfect. Great, thanks. So the lessons were learned really there were systemic issues so contraception access was a big issue. There were many women who were presenting to clinic that were looking for contraception and contraception is not within the scope of midwives of Ontario. So there was a big issue around transportation and coordination issues and I'm really sad to say that none of these clients that I saw were adequately able to access contraception. And nobody really recognized that as a settlement issue like how many unplanned pregnancies resulted from this and what are the implications of that during settlement and the initial stages of a family being integrated into a new country. They were systemic issues so really women's reproductive health was not prioritized or seen as important. There was a really big missed opportunity for contraception and family planning education. Not one of the women I saw had previously had a pap test or breast exam. So I did do well women physicals but no pap tests. There were two women with breast lumps that were detected and sent for follow up. But research really shows that immigrant communities, especially from the Middle East and South Asia don't often have breast or cervical cancer screening and I feel like this was a big missed opportunity. There were a lot of interagency issues so a lot of importance of talking to the media and giving political reassurance about how well things were running but really on the ground they were not running well at all. There was a lot of issues around transportation so clients were given tokens for the bus but not explained how to take the bus. Again remember this is a very low literacy population. This speaks to the systemic issue that there really needed to be a systems coordinator. Metson Saint Frontier always has a systems coordinator and that would have been really important that there was no understanding of the population in terms of just the cold weather. It was January in Toronto it was freezing. There was no literacy. This is a population that did not know how to deal with the cold. They did not have any knowledge of the community and there was no rationale. Sorry there was no teaching around how to move around the community with the rationale that these people were going to be housed permanently somewhere different. I think there was a lot of victim blaming. They are in a new country they need to learn how to be here and make their way around without the appropriate education. I think that really spoke to provider exhaustion and just how difficult it was to actually get people from one appointment to another. I am just going to move forward and talk a little bit about midwifery lessons. It is really important in these cases to make midwifery visible and relevant when it is not on the national health care agenda. To be prepared as midwives to get involved, OB consultants must be available and in place. It was very useful that I was within my own community because I was able to set up ultrasounds and know the population. I was able to set up lab appointments quite easily and obstetric community health care provider appointments. I really believe care needed to be on site because these were people who did not have the ability for transportation and also had large families without childcare. And just some bottom lines, reproductive health care needs of women including contraception must be seen as critical during settlement. There needs to be immediate care and ongoing care. We need to look at reproductive health care as a settlement issue. And midwifery must be seen as integral to the care of refugees. And that's it. Thank you so much Manavi. Those are lessons that will be with us sometime as we all learn how to share the planet. Are there questions for Manavi? You can type them in the chat box. We have just about four minutes left. So Manavi, here's a question. Has there been any policy change from above since then? So that's a really good question. There has not and I think one of the most important policy changes would be for midwives to have a mechanism to be paid. When they step in during emergency public health issues. And I would never change it. I love the work I did there, but I worked for 16 weeks for free because I thought care to this community was really important. And unfortunately, I don't think there have been any policy changes. Although there have been a number of papers written nationally that did actually admit how much we kind of failed this population. So I hope that that means there will be policy change in the future. You know, for many years I worked in the state of Florida, which was regularly devastated by hurricanes. And Florida has emergency health provision laws so that when there are emergencies, health care providers can work out of network, be paid, write prescriptions, work to the fullest extent of their scope of practice. And that's exactly what we should have had. We don't have emergency care provision and midwives must be included in that. Yeah. Thank you so much Manavi. Thank you.