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Raising Expectations Executive Summary

 
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Executive Summary

Families are the heart and soul of our society. They help give children – the next generation – the best start and provide support as they move through life. Strong families help build strong communities, a prosperous economy and a more secure future.

Ontarians build their families in different ways. Many – including heterosexual couples, same-sex couples, and single people – use adoption and assisted reproduction services. but barriers like cost, lack of information, system weaknesses, location, work constraints and stigma, prevent many Ontarians from accessing these services and keep many children waiting to be adopted.

The Numbers Tell the Story

  • 1,600 Approximate number of children adopted into Ontario families each year through the province’s three adoption services – public, private domestic and intercountry.
  • 9,400 Approximate number of Crown wards in 2007-08.
  • 822 Crown wards adopted in 2007-08.
  • 1 in 6 Ontario couples who struggle with infertility in their lifetime.
  • 1,500 Babies born in Ontario in 2006 through in vitro fertilization.

For Ontarians who are successful in building their families through adoption or assisted reproduction services, the journey is not simple. It can take years, and the experience can be emotionally devastating and financially draining.

Everyone in Ontario knows someone who has struggled to build their family. Ontario’s adoption and assisted reproduction services are not working as well as they could – and should – for children and families.

In 2008, the Government of Ontario established the Expert Panel on Infertility and Adoption to provide advice on how to improve Ontario’s adoption system and improve access to fertility monitoring and assisted reproduction services.

The Best Jurisdiction to Build a Family

In our view, Ontario has the opportunity to become a leader in adoption and assisted reproduction in Canada and the world. The Province can join a select group of countries that are setting the standard for family building.

Our Vision 

Ontario should aim to be the best jurisdiction in the world to build a family. 

Our Goals 

  1. To help more children find permanent homes and more Ontarians build families through adoption.
  2. To help more Ontarians build families through high quality and safe fertility education, monitoring and assisted reproduction services.
  3. To provide information and raise awareness about adoption, fertility and assisted reproduction services and make it easier for Ontarians to access these services.

That said, we have a long way to go.

The Problem is the System, Not the People

During our deliberations, we talked to many professionals who work in adoption and assisted reproduction services. We talked to agencies, consumer organizations and individuals. We heard from service providers and Ontarians who used adoption and assisted reproduction services, adults who had been adopted or donor-conceived, foster parents and current and former Crown wards.

We know that there are many dedicated, committed people working in both adoption and assisted reproduction services who want to do the best for children and families. We know that there are courageous adoptive parents and children who succeed in building strong families. The problem that prevents many more Ontarians from building their families is not the people, it’s the system: the structures, policies, laws, regulations and costs.

When it comes to adoption services:

When it comes to fertility monitoring and assisted reproduction services:

The Solution? Empower Ontarians, Intervene Early and Improve Access

Instead of maintaining the existing barriers to adoption, we see a province where:

Instead of maintaining the existing barriers to assisted reproduction, we see a province where:

To make Ontario the best jurisdiction in the world to build a family, the Province must pursue three key strategies:

Chart Key Strategies
  1. Empower Ontarians
    • Develop a multi-tiered public awareness campaign which supports people in making informed choices about family building.
  2. Intervene Early
    • Support concurrent permanency planning for Crown wards and re-position the system so that contact with birth families is not a barrier to adoption.
    • Actively recruit adoptive families.
    • Provide fertility education, monitoring and preservation services.
  3. Improve Access to Family Building Options
    • Create a provincial adoption agency – with a local presence – that offers services from system entry to post-adoption and that manages public adoption.
    • Set consistent policy, standards and oversight for all adoption services.
    • Overhaul Ontario’s adoption legislation to address gaps and barriers in the public, private domestic and intercountry adoption systems.
    • Provide funding to support permanency planning and for adoption subsidies and supports for former Crown wards with special needs.
    • Publicly fund safe, evidence-based IVF.
    • Reduce social and legal barriers to assisted reproduction.
    • Require all IVF clinics and fertility centres in Ontario to be accredited and set targets for best practices, including decreasing multiple births.
    • better educate service providers so that Ontarians receive world-class adoption and assisted reproduction services.
    • Collect data to improve services and outcomes.

Our report sets out a series of recommendations designed to empower Ontarians, encourage early intervention and improve access to services.

Ontario Cannot Afford to NOT Fix the Adoption System

The problems and barriers in adoption services are costing Ontario in lost opportunities for waiting children and families and in high social costs.

It costs at least $32,000 a year to keep a Crown ward in care. It costs significantly less to provide supports and subsidies to help adoptive families parent children.

The stated cost of keeping a child in care does not include the long-term cost to society of a child who grows up without a stable family. Former Crown wards are less likely to finish high school, and more likely to rely on social assistance and live in homeless shelters.

For the sake of the more than 9,000 Crown wards in the province – many of whom could be adopted – children in other jurisdictions waiting to be adopted, and the families anxious to adopt, the Province must act now. It must create an integrated, responsive adoption system that works for children and families.

Ontario Cannot Afford to NOT Fund Assisted Reproduction Services

Because of the high cost of assisted reproduction services, many Ontarians are making choices that are not good for their health, their children’s health or the sustainability of the health care system. For example, the high cost makes it difficult for Ontarians to choose to transfer fewer embryos, which is a best practice in in vitro fertilization. As a result, the rate of multiple births from assisted reproduction in Ontario was 27.5% in 2006 compared to rates below 10% in other jurisdictions with controls on the number of embryos transferred.

Multiples are 17 times more likely to be born pre-term, to require a caesarian delivery and to need expensive care at birth and throughout their lives. As a result of its decision to not pay for comprehensive assisted reproduction services, Ontario is now spending hundreds of thousands of dollars a year dealing with the consequences.

It costs more to care for multiple births than it does to prevent them. Given the growing number of people using assisted reproduction services – people struggling with infertility, single people and same-sex couples – Ontario cannot afford to NOT fund assisted reproduction services.

A Question of Fairness and Equity

Ontario is committed to making a difference for Ontario families.

To become the best jurisdiction in the world to build a family, Ontario must ensure that all Ontarians – regardless of income, race, culture, sexual orientation, marital status or geography – have access to adoption and assisted reproduction services. Right now, many family building options are only available to people with higher incomes, people who live in major centers and people who are able to advocate for themselves.

We must move to actively support Ontarians in making informed decisions for family building options that are right for them, and to create responsive services that work for children and families.

Families are our future. Strong families build strong communities and a prosperous Ontario.

By acting now – by implementing the recommendations in our report – Ontario can become a world leader in family building and we will all reap the social and economic rewards.

Adoption Recommendations

1. Create a Provincial Adoption Agency

1.1 The Government of Ontario should create a provincial adoption agency with a local service presence to:

For Families

For Children

Post-Adoption

Centre of Excellence

1.2 The government should set service delivery timelines for public parental training (PRIDE), homestudies (SAFE) and child welfare and criminal record checks, as required by the SAFE process. Specifically, guarantees should be established that parental training will commence within 60 days of initial contact with the provincial adoption agency, that homestudies will begin within 30 days after the completion of parental training and that child welfare and criminal record checks will take no longer than 30 days upon receiving the request.

Children’s Aid Societies

1.3 The government should standardize permanency planning practices for all children in care.

1.4 As part of their responsibility for child welfare services, children’s aid societies should collaborate closely with the provincial adoption agency and provide transparent concurrent permanency planning, including planning for adoption from the point of early contact with a child in care.

Obligations of the Provincial Adoption Agency

The provincial adoption agency should:

1.5 Operate in the best interests of the child.

1.6 Recognize prospective adoptive families as a valuable resource and support them to enter the adoption system, where appropriate.

1.7 Closely collaborate with government, children’s aid societies, private practitioners, licensees, community-based service providers and other adoption stakeholders so that the adoption of children from the public system can occur in the best interests of the child.

1.8 Work with the Ontario Association of Children’s Aid Societies to develop a more flexible delivery model for PRIDE (e.g., develop some components that could be offered online).

1.9 Develop a focused program to find families for older Crown wards and Crown wards with special needs.

1.10 become formally responsible for adoption planning for Crown wards at the time of application for Crown wardship.

1.11 Provide adoptive families and birth families with support to negotiate openness and ongoing support to maintain openness.

1.12 Work with local community agencies to help increase the availability of post-adoption supports in communities across Ontario.

1.13 Advocate for the creation of provincial programs and strategies that support adoptive families (e.g., advocate for a provincial Fetal Alcohol Spectrum Disorder strategy).

1.14 Work with provincial bodies and other organizations to raise awareness about the needs of all adoptive families in community and provincial service planning, specifically, work collaboratively to influence education and training of courts, educators and other professionals.

2. Develop Tools to Manage the Adoption System

Openness and Court-ordered Access

2.1 The Government of Ontario should remove barriers resulting from court-ordered access to birth families while addressing the importance of contact or communication with birth families:


2.2 The government should create overarching policy and processes to support adoption with openness:

Policy and Legislation

2.3 The government should immediately review all current adoption policies and move forward to develop a policy framework that will underpin public, private domestic and intercountry adoption.

2.4 The government should ensure that the policy development process is informed by the knowledge and experience of a cross-section of external stakeholders including, but not limited to, child welfare and adoption service providers, licensees and private practitioners, prospective and successful adoptive families, adopted youth and adults, birth parents, foster parents, current and former Crown wards.

2.5 The government should review the framework every five years to ensure the policies remain evidence-based, current and consistent.

2.6 The government should create consistency within and between the three adoption services and articulate provincial policy that:

2.7 The government should develop clear policy that demonstrates support for relative adoption including for relatives adopting intercountry.

Gaps and barriers

2.8 The government should review intercountry adoption policy and overhaul legislation with the purpose of safeguarding children and families, addressing barriers and legislative gaps, as well as creating harmony between the Child and Family Services Act, Intercountry Adoption Act, with the Hague Convention and additionally, with the realities of non-Hague countries.

2.9 The government should enact policy and/or legislative amendments to:

Advocacy

2.10 The government should advocate that the Government of Canada amend federal employment insurance rules to provide the same treatment for birth parents and adoptive parents.

2.11 To better support more timely intercountry adoption processes, the government should play an advocacy role:

Oversight and Monitoring

2.12 The government should provide clear oversight and monitoring of Ontario’s adoption system.

2.13 The government should set a provincial target to double the number of Crown wards adopted within five years and, within five years, review and establish new and ambitious targets.

2.14 The government should set service standards and ensure that they are re-evaluated and reviewed before the end of the five-year period.

2.15 The government should introduce a graded licensing process for intercountry adoption.

Data Collection and Reporting

2.16 The government should identify the data required to evaluate Ontario’s adoption services and establish clear reporting processes.

2.17 The government should contract with a trusted independent third party to collect and analyze longitudinal, anonymized data on outcomes for children who are adopted.

2.18 This third party should collect information about Crown wards who are not adopted, including outcomes for children who are placed in kinship care and legal custody arrangements.

2.19 The government should make accurate information about all adoption services available to all Ontarians, including reporting on average costs, wait times, placement success and service standards.

Complaint Processes

2.20 The government should review and enhance formalized complaint mechanisms to be sure that all parties involved in adoption processes – adoptive and birth families, as well as children and youth – who are dissatisfied with the service they received, are heard.

3. Provide Adequate Funding that Supports the Realities Of Adoption

3.1 The Government of Ontario should fund permanency planning to reward children’s aid societies and the provincial adoption agency when children are placed for adoption.

3.2 The government should provide adequate funding to support the provincial adoption agency to perform all identified duties, including establishing a central and local presence.

3.3 The government should fund special initiatives, including:

3.4 The government should provide funding for standardized and regular adoption subsidies for the adoption of Crown wards aged two and older, as well as Crown wards under two with special needs. We recommend the use of needs-based criteria for subsidies ranging from 50% to 80% of the current foster care rate, and further recommend that the government set aside an additional funding pot for additional supports and future needs.

3.5 The government should increase the ceiling of allowable adoption-related expenses for income tax purposes to $30,000.

Assisted Reproduction Recommendations

1. All Ontarians Should Know How To Protect Their Fertility

Education

1. 1 The Government of Ontario should ensure that all primary care practitioners are educated about fertility and related issues, including: the impact of age on fertility, male and female infertility and the important risk factors that affect fertility; the reproductive needs of non-traditional families; and the complementary services available to enhance fertility or treat infertility.

1.2 All primary care practitioners – including naturopathic doctors and doctors of traditional Chinese medicine – should make fertility education/counselling a routine part of care for all patients, beginning in their 20s. This includes males and females, those in a relationship or single (including those who are not trying to start a family), regardless of sexual orientation.

1.3 The government should ensure that printed and web-based educational materials are developed and made available to primary care practitioners to share with their patients.

Counselling

1.4 The government should adjust the Ontario Health Insurance Plan fee schedule to allow physicians to identify counselling services that are provided specifically for infertility, so that practitioners can make the time for this in their busy practices, and the government can understand how many Ontarians are receiving this information.

Fertility Testing/Monitoring

1.5 All primary care providers, obstetrician/gynecologists or fertility specialists should offer fertility testing/monitoring to:

Anyone who, based on fertility monitoring, appears to have a fertility problem should receive a timely referral to a fertility specialist (e.g., women under 30 should be referred after 12 months of trying to conceive naturally without success and women aged 30 and older should be referred after six months).

1.6 Clinical practice guidelines for fertility education and monitoring should be developed that include:

1.7 The government should continue to fund existing tests (i.e., Follicle Stimulating Hormone, Antral Follicle Count, Semen Analysis tests), and introduce newer tests (i.e., Anti-Mullerian Hormone) that are more accurate and easier to use as they become available and are approved.

2. Assisted Reproduction Services Should Be Safe And Meet the Highest, Evidence-Based Standards

Accreditation

2.1 The Government of Ontario should identify a provincial body to provide a mandatory accreditation program for clinics and fertility centres in Ontario.

2.2 All clinics and fertility centres should be required to be accredited within five years in order to provide assisted reproduction services in Ontario. The cost of accreditation should be paid for by the Province.

Multiple births

2.3 To maintain their accreditation, fertility clinics and centres must reduce their annual multiple birth rate to less than 15% within five years and to less than 10% within 10 years.

2.4 To help clinics meet this target, clinical practice guidelines should be developed that set out:

2.5 Providers should be given information to inform them of the negative impacts of multiple births and the benefits of transferring fewer embryos for children, mothers and families.

2.6 To control for multiple births and protect the safety of the children and women using assisted reproduction, clinical practice guidelines should be developed on the safe prescribing of all fertility medications.

2.7 As a condition of accreditation, clinics should be required to collect and report on:

Safety

2.8 To support physicians in providing the best possible care, Ontario should collect aggregate and anonymized data on the outcomes of:

2.9 To reduce the risks for children, intracytoplasmic sperm injection should be provided only for individuals where:

2.10 Clinical practice guidelines should be developed by a panel of andrologists and reproductive endocrinologists that clearly defines “severe male factor infertility.”

2.11 Clinical practice guidelines should be developed to identify:

Timeliness

2.12 Ontario should examine the state of assisted reproduction technologies every five years and update policies and practices to reflect current capabilities.

Centre of Excellence

2.13 An academic centre of excellence for assisted reproduction should be created to work with the medical and research communities and service providers to:

3. Ontario Cannot Afford Not To Fund Assisted Reproduction

Funding

3.1 The Government of Ontario should fund up to three cycles of in vitro fertilization for women ages 41 years + 12 months and younger. The following ancillary services should be funded when provided for a funded cycle of in vitro fertilization:

3.2 A patient must undergo frozen embryo transfer using good quality embryos before another publicly funded fresh in vitro fertilization cycle is provided.

3.3 Up to four cycles of intrauterine insemination should be funded for women ages 41 years

+ 12 months and younger. Sperm washing should be funded for intrauterine insemination procedures.

3.4 Clinical practice guidelines should be developed:

Fertility Medications

3.5 The government should develop an awareness campaign that:

3.6 The government should consider different options to help control the cost of fertility medications.

3.7 The government should introduce a 50% refundable tax credit with a ceiling of $20,000 for Ontarians to help offset the costs of fertility medications.

Counselling

3.8 All Ontarians undergoing assisted reproduction services should be offered one funded counselling session.

3.9 The government should fund any mandatory counselling required by the federal government under the Assisted Human Reproduction Act. In the absence of federal legislation, all Ontarians undergoing third party reproduction should be required to participate in counselling as part of the informed consent process, and the government should cover the cost of this counselling.

3.10 All health care providers – including primary care practitioners – should be knowledgeable about where to refer patients who would need counselling services relating to fertility, infertility and using assisted reproduction services.

3.11 Educational materials on counselling – for fertility, infertility and assisted reproduction for all types of families – should be developed and made available to all professionals who may provide these types of services.

4. Ontarians Who Could Benefit Should Have Access To Assisted Reproduction Services

Work Life

4.1 In a public awareness campaign, employers should be made aware of their responsibilities under the Human Rights Code to accommodate employees’ special needs during the pre- and post-natal periods.

4.2 The definition of personal emergency leave in the Employment Standards Act should be interpreted to include assisted reproduction services.

Geographic Access

4.3 The Government of Ontario should extend the Ontario Telemedicine Network to all fertility clinics.

4.4 The government should ensure that the monitoring tests required for intrauterine insemination and in vitro fertilization (e.g., sonography, lab technician services) are available as needed in designated medical centres outside Southern Ontario.

4.5 The government should extend eligibility for the Northern Health Travel Grant to all people in Northern Ontario who have to travel for assisted reproduction services.

Legal barriers

4.6 When the overdue review of the Assisted Human Reproduction Act is undertaken by the federal government, Ontario should participate actively in this review.

4.7 The Province should join or support any Charter challenge pertaining to the Assisted Human Reproduction Act.

4.8 A provincial regulatory framework for clinics and assisted reproduction services, including third party reproduction, should be developed under the equivalency provisions of the Assisted Human Reproduction Act.

4.9 An altruistic, province-wide donor sperm, egg and embryo bank and surrogate database should be established, operated at the clinic level, and regulated by and accountable to the government.

4.10 Ontario should ensure that the guidelines on the safe insemination of women using known and anonymous donor sperm protect the safety of women and children.

4.11 The government should review the process for establishing parentage to accommodate assisted reproduction services wherever possible, and to ensure that no intended parents are discriminated against on the basis of sexual orientation or reproductive needs.

4.12 Once they are finalized, the government should review and implement the Uniform Law Conference of Canada’s recommendations on declaration of parentage.

Social barriers

4.13 The government should ensure that social barriers to assisted reproduction are removed and legal barriers minimized for services to members of the Lesbian, Gay, bisexual, Transgendered and Queer communities.

4.14 The government should ensure that barriers to assisted reproduction are removed from services for single Ontarians.

4.15 A public awareness campaign on infertility and assisted reproduction should focus on reducing the shame and stigma attached to infertility.

Fertility Preservation

4.16 All specialists caring for people with a medical condition or providing treatment for a medical condition that can affect fertility should be aware of the availability of services to help preserve fertility and make timely referrals to these services.

4.17 The government should fund the freezing and storage of eggs, sperm and embryos for fertility preservation.

4.18 Clinical practice guidelines should be developed on how long sperm, eggs and embryos can be stored at public cost.

HIV Discordant Couples

4.19 The government should develop a comprehensive approach to reducing barriers to assisted reproduction services for HIV-infected people.

4.20 Development of resources (including education programs) should be supported to allow safe access to these services in Ontario.

1. Raising Awareness about Family Building Options in Ontario

1.1 The Government of Ontario should develop a coordinated public education and social awareness campaign on family building to educate Ontarians about fertility, infertility, assisted reproduction and adoption, and about the resources and options for building or expanding their families.

1.2 The campaign should use a multi-tiered approach that is based on a provincial framework and implemented locally.

1.3 The multi-media campaign should utilize partnerships with organizations outside of government.

1.4 The government should develop evaluation tools to measure the success of the campaign and to shape the subsequent phases.

1 This figure does not include CASs’ infrastructure spending that supports adoption services.


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