Social Health Working Paper, A

Aleyah WilliamsSFU student number: 301369674Stuck in a Family Way: Inequitable access to abortion services in Northern British Columbia (Cariboo, North Coast, Nechako and Northeast districts) DescriptionWomen* seeking abortion in Northern B.C. face a number of obstacles to equitable abortion service. Most of these issues stem from the sub-optimal alignment between where women live and where services are available (Dhillon, 2018). In Northern B.C., there are nine hospitals providing abortion and no free-standing abortion clinics (B.C. Laws, 1996). The cost of travel to providers if none exist within one’s community and the lack of confidentiality in accessing abortion services may be infeasible and unsurmountable for some women (Sethna and Doull, 2013). Other extra-legal barriers to access are policies, or lack there of addressing: the inhibitive cost of work-time lost and childcare, treatment for uninsured women (ARCC, 2017), as well ultrasound, blood testing and pain relief medication for others depending on their type of health insurance coverage (Sex Sense Line, personal communication, September 27, 2018). In 2018, B.C. policymakers introduced no-cost coverage of medical abortion pill, Mifegymiso, for all with a Medical Services Plan (MSP) in order to increase access and ensure privacy for rural women, who can take the medication at home (B.C. Ministry of Health, 2018). However, acquiring Mifegymiso entails either self-referral to an abortion clinic in southern B.C. or a physician prescription within the pill’s allowable timeline (HealthLinkBC, 2018). The 9-week gestation period suitable for Mifegymiso is often surpassed before the pill is acquired, and necessary bloodwork and ultrasound are performed, forcing women to consider surgical abortion in hospital (HealthLinkBC, 2018). While Willow Women’s Clinic in Vancouver provides medical abortions at-a-distance, access is still restricted to those with ability to communicate with clinicians online, and who can have the precursory medical tests performed quickly (Willow Women’s Clinic, 2018). For First Nations, Métis and Inuit women, access to information regarding reproductive health choices including abortion, and abortion service, is even more onerous (Sethna, 2013). Historical factors Limited access to abortion in B.C.’s North is a by-product of the historical and patriarchal criminalization of abortion, and Canada’s physician-centric health legislation. Although legal today, policies stipulating where and by who abortions are performed ensure women do not have equitable access across the province (Khandaker, 2013). Narrowly defined abortion was decriminalized in 1969 (Stettner, 2016). To be legal, an abortion was performed by a licensed physician in an accredited hospital after a Therapeutic Abortion Committee deemed the procedure necessary to preserve the mother’s life or health (Stettner, 2016). In 1988, the Supreme Court of Canada found the narrow parameters of legal abortion unconstitutional, sanctioning abortion outside hospitals (Stettner, 2016). This led to the creation of private abortion clinics, which in B.C. are all located in the province’s southern half. (Opt, 2016). From 1988 to 2010, 58% fewer abortions were performed in rural B.C., and research indicates that as abortion services trend out of hospitals, people in the North are having to travel further to access services (ARCC, 2017). Canada’s fundamental health legislation, the Canada Health Act, prioritizes physicians and hospital services (Sethna and Doull, 2013). Two mechanisms work toward this end: 1) the per service billing system that incentivizes physicians to work in urban centres where they can see more patients (Tomlinson, 2017), and 2) the monopoly physicians have in performing certain healthcare services like abortion (Khandaker, 2013). Surgical abortion is only performed by physicians, and medical abortion by physicians and nurse practitioners. (Sex Sense, personal communication, October 1, 2018). Midwives cannot perform either. All this translates into rural areas firstly lacking physicians, and secondly, for abortion access to be dependent on providers’ pro-choice/pro-life politics (Paradise, 2017). Providers may refuse to provide abortion by exercising their right to conscientious objection; legally they must give referral to a pro-choice provider, but there is no guarantee this provider accepts new patients, or is within proximity to the community (Sex Sense Line, personal communication, September 27, 2018). Cultural factors Stigmatization of abortion affects the number of physicians willing to perform abortion, disadvantaging women in conservative communities (Dressler et al., 2012). This reality leads those who are willing to not advertise their services, either accepting patients through referral or not at all: the intention being to protect the privacy of both themselves and their clients (Sex Sense Line, personal communication, September 27, 2018). The lack of information about providers outside hospitals is exacerbated by anti-choice gate-keepers in these facilities who refer women to pro-life pregnancy crisis centres or withhold information entirely (ARCC, 2017). In other words, scheduling an abortion in a hospital or doctor’s office depends on the willingness of administrative staff to overcome stigma and logistical challenges (Khandaker, 2013). Structural factors Rural and remote Northern communities are disadvantaged by the spatial disparity of reproductive health care service. In 2010, 90% of B.C. abortions occurred in Vancouver, Victoria and Kelowna (Dhillon, 2018). Northerners without the resources to travel to these cities, instead negotiate limitations affecting hospital abortion, like operating room availability and triaging (ARCC, 2017). Colonialism and anti-Indigenous racism affect how Indigenous women, especially those on reserves, access abortion services. Firstly, reserves are typically located in rural, remote or Northern communities, many far from the North’s nine abortion-providing hospitals. A 2013 study showed the greater the distance women have to travel for abortion, the less likely they are to obtain one (Sethna and Doull, 2013). In this study, First Nations and Métis women were almost three times as likely to report travelling more than 100 kilometres to access abortion clinics, compared to other respondents (Sethna and Doull, 2013). Additionally, all respondents who lived more than 100 kilometres from a clinic indicated an earlier date for their abortion was preferred but not possible (Sethna and Doull, 2013). Another consideration for Indigenous women is the formal approval of funds system they must navigate to be reimbursed for off-reserve travel, otherwise pay out-of-pocket ( HYPERLINK “https://www-sciencedirect-com.proxy.lib.sfu.ca/science/article/pii/S0277539513000186” l “bb0195” Smith, 2010). Confidentiality is difficult to protect while navigating this slow system, though seeking abortion outside is financially more cumbersome (Smith, 2010). Critical factorsLeora Paradise suggests two policy options to increase access to abortion services in Northern B.C.: the expansion of ambulatory care capacity, and the allowance of midlevel providers to perform and administer abortion (2017). Increasing abortion outpatient services decreases healthcare spending by alleviating pressure on hospital operating rooms, and increases privacy for both providers and patients (UBC Faculty of Medicine, 2013). Already the 2018 introduction of no-cost coverage of Mifegymiso in B.C. is believed to be working to this effect by increasing access to abortion in communities without freestanding abortion clinics (Grant, 2017). There are two options for increasing access to ambulatory care presented by Paradise: 1) the creation of new women’s services clinics in hospitals, and 2) for hospitals without capacity for creation of clinics, the shared use of existent outpatient settings or the use of operating rooms as outpatient facilities (2017). Additionally, expanding the definition of allowable persons performing abortion in Canada would increase access for communities with few pro-choice physicians and nurse practitioners. Paradise proposes that midwives be allowed to prescribe medical abortion, and nurses be allowed to perform surgical abortion (2017). ReflectionThe biomedical model neglects the heart of the issue of access to abortion in Northern B.C.: its social and political context. The science exists to perform safe abortion, however, the experience of access differs greatly depending on geographic location, ethnicity, and level of stigma against abortion within home communities. In other words, to interpret abortion service from a biomedical standpoint is to assume women regardless of circumstance obtain abortions in equitable ways. Using the social model of analysis, we know there exist a number of legal and extra-legal obstacles specific to women in Northern B.C. that prevent them exercising this right. 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