Health Policy in a Time of Crisis

Abortion, Austerity, and Access

Bayla Ostrach

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9781629583648
• eBook ISBN:
  9781315308654
• Topic: Medicine
• Subtopic: Anthropology

Health Policy in a Time of Crisis is a vivid ethnographic account of women and providers navigating the Catalan health system to obtain and provide publicly funded abortion care.

Grounded in critical medical anthropology, the book situates access to publicly funded abortion care in the context of austerity and ongoing threats to recently liberalized laws, examining the actual levels of access in the region. In so doing, it examines the disparities experienced by immigrant and other women, documenting the diverse approaches adopted to overcome obstacles to care. Using accounts from both providers and women seeking care, Ostrach's richly grounded analysis illuminates a healthcare system during a period of economic crisis and disagreement over reproductive governance. Researched against a backdrop of growing movements against austerity and for Catalan independence, the result is at once a study of true access to public health care in times of crisis and a compelling account of some women's determination to go to any length to get the health care they need.

Engagingly written, it will make interesting reading for scholars and students of anthropology and public health, as well as policymakers and the general reader concerned with the politics of abortion and public health.

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1

PEOPLE, POLICY, AND PRACTICE

“Duran”¹ and I sit at her kitchen table in a small town in northeastern Catalunya, about an hour’s ride on commuter rail from Barcelona. Her toddler son crashes around at our feet, as a teenage neighbor/sometime-babysitter plays on her cellphone nearby. Duran is reticent at first, her manner muted. She seems uninterested in her own story, even though she was more than willing to reschedule the interview when a migraine forced me to cancel the first time. In her mid-30s, Duran sits with the back of her chair angled into the wall just below a narrow shelf displaying pictures of her two sons, the older one now at school. Next to the family pictures is a box of birth control pills—when my eyes land on them, Duran hastens to tell me she just got them from the health system midwife at her recent abortion follow-up appointment. When she eventually begins to open up in response to my usual initial question, “Tell me what happened from the time you found out you were pregnant until you got to the clinic…” Duran describes the emotional turmoil over her most recent pregnancy. She tells me she really wanted another child, but her partner’s job is uncertain in the current economic crisis, and they realized they could not afford another baby. Like many participants in this doctoral research study, Duran did not know (and apparently wasn’t told) the Catalan public health system would cover her procedure. Initially referred by local health system staff to a town only a short train trip away, for an early medication-induced abortion, Duran was too far along in her pregnancy for that option when she arrived. After borrowing money from her in-laws to pay cash for a surgical abortion procedure only available in Barcelona or another town even further away, Duran arranged childcare for a day when her husband could miss work and accompany her on the longer journey. By the time staff members at her local health center completed the necessary paperwork for Duran to have a surgical abortion in Barcelona, paid for by the health system, she had already taken time to raise money from her husband’s family because local health system staff did not tell her the abortion would be paid for, at her initial appointments. By the time she reached the clinic in Barcelona, she was near the end of the first trimester. Duran tells me softly, not making eye contact, “one week further and I would not have gone through with it.”

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(Fieldnotes, interview conducted February 2013 in Rubí, Catalunya)

In July of 2010, women in the contested region of Catalunya,² as well as in Spain, gained legal access to publicly funded abortion care for any reason in the first trimester of a pregnancy, and under a set of qualifying circumstances in later trimesters. Since that time, abortion services are offered within existing public health systems throughout Spain, and in Catalunya, free of charge—if woman are able to obtain a necessary referral voucher from their local health system office. This ostensibly ideal access to legal, publicly funded abortion makes the region a rare departure from the troubling majority of countries throughout the world where abortion is illegal, heavily restricted, difficult to obtain, stigmatized, or simply subject to an individual’s ability to pay (e.g., Ostrach, 2016; Finer and Fine, 2013; Barot, 2011a; Amado et al., 2010; Lara et al., 2005). Even in the limited places where abortion is legal and publicly funded under certain circumstances,³ people seeking care face any or all of the following obstacles: delays in getting health care coverage, gestational limits, waiting periods, mandatory counseling, and/or ultrasound requirements; and the need to travel (sometimes considerable distances) to reach a provider (Alan Guttmacher Institute, 2016; Ostrach and Cheyney, 2014; Jones and Weitz, 2009; Jones et al., 2008; Canadian Abortion Rights Action League, 2003; Helström et al., 2003).

A wide range of socio-cultural and political-economic factors shape access to legal and safe abortion. These include legal restrictions, health system coverage for care (or the lack thereof), logistical issues, and even the degree of local abortion-related stigmas, each with significant known health and economic implications for those denied care (Ostrach, 2013; Barot, 2011a; World Health Organization, 2011a; Jones and Weitz, 2009; Kumar et al., 2009; Boonstra, 2007; Grimes et al., 2006). Coverage under national or public health systems is a particularly important feature of abortion access for many, especially immigrant women and women in poverty who may not otherwise have any health coverage (Ostrach, 2013). Even in countries where immigrant or other marginalized women are eligible for public health coverage, these populations still encounter significant barriers when seeking abortion (Ostrach, 2013). Where legal and health system restrictions or delays produce obstacles to access and increase risks for complications related to unsafe abortion, the economic, political, social, and cultural contexts that limit access are directly responsible for poor health outcomes in the form of increased reproductive morbidity and mortality (Barot, 2011a; Kumar et al., 2009). The ability to access abortion in a timely manner, and before gestational limits in a given setting, is increasingly recognized as important to health and well-being after the receipt or denial of a wanted abortion (Greene Foster et al., 2015; Greene Foster and Biggs, 2014; Greene Foster et al., 2008; Harries et al., 2007). Despite the notable global public health burden resulting from abortion being illegal and/or often unsafe in many places, people worldwide seek abortion in a diverse range of settings, obstacles or number. The particular combination of political-economic, legal, and sociocultural circumstances in which a woman seeks care has a significant impact on her ability to obtain an abortion, and on the likelihood of it being provided in a safe setting. Women have better access to safe and timely abortion where the procedure is:

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1. subject to fewer legal restrictions;

2. less stigmatized, and;

3. where it is covered by a public health system that offers at least some level of health care to all or most residents of a region, without charging for services.

(Ostrach, 2016)

Abortion legality is therefore a good predictor of both safety and accessibility (Ostrach, 2016; Sedgh et al., 2012; Grimes et al., 2006). Nevertheless, many women in Catalunya who ostensibly live in a setting of ideal abortion access also experience delays, bureaucratic obstacles, and logistical hassles when they navigate the public health system to obtain care. Some face difficulties related to a lack of social support, as women seeking abortion elsewhere also report (Ostrach and Cheyney, 2014; Kumar et al., 2009; Jones et al., 2008).

If women in Catalunya, who on paper have the best possible access to abortion, still encounter obstacles to care, what does this say about the effect and efficacy of abortion law reforms? What can we learn about the implementation and enforcement of reformist policies in public health systems? Why is even legal abortion subject to substantial bureaucratic delays, not treated as an equal part of a full spectrum of reproductive health care? The case of Catalunya was an important microcosm in which to ethnographically examine larger global issues of concern to public health and reproductive justice (Ross, 2011):⁴ legal reforms and health policy changes in recent years increased provision of legal, publicly funded abortion, which nevertheless became constrained in the context of an economic crisis. In this book I present these dynamic shifts against a backdrop of the social movements advocating for an end to austerity and for full independence from Spain, which unmistakably informed the context of the research, and infiltrated participants’ narratives.

La Crisis, the local name for the widespread recession and associated economic crash that struck Spain and Catalunya (along with much of Europe) from 2007, plunged many people into poverty or worsened already difficult economic realities (Murcía López, 2013). It continues to reverberate through the economies, governments, and daily lives of the region. While I was in the field, La Crisis prompted European Union (EU) officials to impose Euro-zone austerity measures on Spain via the national government in Madrid, which in turn sought to extend these to all Spanish states and autonomous nations, including Catalunya (Raventós and Wark, 2012; Saurí, 2012).

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As anthropologists elsewhere in Europe highlight (Firat, 2014), periods of economic crisis offer important opportunities to examine exactly these moments of policy formation and people’s responses. To this observation, Joanna Mishtal adds an exhortation for anthropologists to monitor the progression of reproductive policy in Europe, particularly in the early stages, as this:

offer[s] a useful site of analysis for deeper understandings of the mechanisms used for particular political agendas and rationalities that seek to advance, or stall, as the case may be, policymaking in new Europe.

(Mishtal, 2014: 73)

Catalunya, soon after the liberalization of abortion, and in the context of austerity cuts, is an example of one early stage of shifting reproductive policy worthy of monitoring. Moreover, Firat argues, “policymakers, workers and recipients are in relationships with each other . . . especially at times of crisis” (Firat, 2014: 14). Based on my ethnographic fieldwork in the region, I would add to Firat’s list community organizers and activists, and specifically define “workers,” in my sample, as both abortion and sexual and reproductive health (SRH) providers contracted with the health system, and public health system representatives including nurse-midwives, obstetrician-gynecologists (Ob/Gyns), and primary care providers. The “recipients,” in this case, were women seeking publicly funded abortion, but could really be any resident of Catalunya who attempts to use a public health system deeply affected by austerity, in the context of economic crisis. The relationships between these actors in the context of health policy and abortion access, against a backdrop of austerity, were brought into sharp focus in the ethnographic data here.

Although the ultra-conservative Partido Popular (PP) government elected in Spain in 2011 soon claimed that the recession was over, and that its future budgets would be free of austerity cuts, most participants seemed skeptical that the economic situation in Catalunya would improve quickly. Several key informants in fact tended to see full independence from Spain, and a distancing from its transferred Euro-zone austerity measures, as Catalunya’s best chance for an economic recovery (Minder, 2013). With Spanish Prime Minister Mariano Rajoy making contradictory statements such as, “Spain is out of the recession but not out of the crisis” (Russia Times, 2013a), the PP’s claim that things were improving even as unemployment rates and evictions grew (Homs, 2013), did little to convince some of my Catalan participants that down-stream austerity would not continue to impact them. Meanwhile, the Catalan government’s own decisions about how to implement forced austerity cuts in their public health system, and the health system’s resulting internal restructuring of abortion provision quotas protocols, had immediate implications for the actual availability and accessibility of abortion threatening the viability of the few clinics offering second-trimester care in the region.

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This multi-layered combination of political-economic and health policy factors produced the precise situation I explored through extensive ethnographic research, that I present in this book. In the wake of multiple policy changes at national and local levels, women in Catalunya, including immigrants, ostensibly gained unprecedented access to legal, publicly funded abortion care. However, to obtain and provide publicly funded services, women and providers were forced to navigate a bureaucratic health system deeply affected by austerity —confronting logistical and social challenges in the process. What obstacles women and those who provided their care perceived, which they regarded as most challenging, and how they perceived women to be able to overcome them within larger political-economic and cultural contexts, are the specific questions I address here.

The contribution of this book, then, is to offer my answer to Firat’s call “Why [should] anthropologists care about crisis and policymaking in Europe?” (Firat, 2014). Based on the lessons taught to me by participants, I am convinced that examining what people deeply affected by health policy and access in the wake of policy changes, within a landscape of economic crisis and austerity, say about their experiences of seeking legal, publicly funded abortion and how they overcome obstacles to care, offers valuable lessons. From participants’ accounts and my observations in the clinic, at non-governmental organizational (NGO) offices and events, and from social movements meetings and rallies, there is much to learn about what barriers to abortion are most persistent; the limits of policy change without accountability and enforcement; the threat of austerity to undo valuable health policy reforms, and the indefatigable determination of marginalized sectors of a population and those who serve them to find ways over and around obstacles. They do so either by mobilizing social support that represents a challenge to power inequality or by finding a way to summon inner strength and manage on their own. A further message of this ethnography is that the local context of abortion access and health policy changes matters. What economic crisis and austerity meant for people seeking and providing abortion was likely far different in Catalunya than it might be in a region without a similar history of providing full health care access to immigrants. These issues intersected meaningfully with local popular responses to political threats to the newly gained abortion reforms, and with growing sentiments about Spain and the movement for full Catalan independence.

Some of the important power relationships that foregrounded my research began with grassroots feminist organizing and popular support that led to the expansion of access to abortion in Spain and in Catalunya, through legal reforms in 2010 (Associació de Planificació Familiar de Catalunya i Balears, 2014; Associació de Planificació Familiar de Catalunya i Balears, 2010; Hughes, 2011). Abortion law reforms enacted across Spain by the Socialists then in power in 2010, under pressure from grassroots feminist coalitions, resulted in the full inclusion of legal abortion care in Spanish public health systems (Boletín Oficial del Estado, 2010), which were therefore applied to the intersecting Catalan legal and health systems (Catalan Institute of Health, n.d.). In Catalunya, the reforms introduced the option of requesting a public health system referral to a contracted abortion clinic, where women can then obtain publicly funded abortion services (Boletín Oficial del Estado, 2010). The organizing relationships that led to these health policy changes, in a landscape of shifting power, were overlaid by other looming political and potential economic shifts similarly shaped by historical relationships, in turn influenced by economic policies in Spain and Catalunya.

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Catalunya is a historically and officially autonomous region in both a cultural and political sense, recognized as such by the 1978 Spanish constitution (Bel, 2013; Crow, 1985). Many Catalans identify their country as being, in most ways, independent of Spain, as does the formal Catalan government, yet Catalunya wrestles with ongoing economic and political ties to the Spanish national government in Madrid (Bel, 2013; Tremlett, 2008; Crow, 1985).

More broadly, in this book I document the impact of an economic crisis—an ever more common event in late capitalism—and resulting shifts in cultural and political identities, on health policy, health care access, and women’s and providers’ perceptions of access to public health services, specifically, in this example, on abortion care. In a historical period when threats to legal and publicly funded abortion are apparent in a myriad of state-level campaigns in the Unites States and elsewhere, when the links between legality and safety are the focus of political and public health efforts to expand abortion reforms in several Latin American and European countries, and when health care debates in the United States (U.S.) and elsewhere focus on what reproductive health services should be covered or excluded, this examination of women’s and providers’ experiences with publicly funded abortion in Catalunya offers a lens through which to view the many layers of economic, political, social, cultural, and interpersonal dynamics that can and do affect access to health care in the modern world—particularly so for abortion. The findings I present and discuss here have been and will be of use to reproductive health and justice advocates who work to maintain and expand abortion access and legality, including where it is covered by public health systems, and to providers who hope to understand what recipients experience before they arrive in the exam room. This book thus offers opportunities:

1. to consider how an economic crisis may shape a woman’s thinking about continuing a pregnancy or not;

2. to provide a glimpse of how cuts to public health care (both actual and threatened) affect access to care and inform reactions to political movements that resist such cuts, and, most importantly;

3. to recognize how marginalized people and those who provide ...

Table of contents

• Cover Page
• Health Policy in a Time of Crisis
• Advances in Critical Medical Anthropology
• Title
• Copyright
• Praise
• Contents
• List of Illustrations
• Acknowledgments
• 1 People, Policy, and Practice
• 2 Catalunya, Crisis, and Cuts
• 3 Uneasy Collaboration
• 4 Uneasy Collaboration
• 5 Confronting Obstacles
• Appendix I Mixed-methods Data Analysis
• Appendix II Response from the Campanya pel Dret a l’Avortament Lliure i Gratuit, to the Announcement that the Abortion Laws Would Be Overturned. December 21, 2013
• References
• Index