GRSJ224/BC abortions

Abortion Access in Rural British Columbia

Abortion accessibility in B.C. is questionable.

Canada is one of the few countries in the world which enshrined women’s right to safe abortions under the Canadian Health Act. This was achieved when the historic case R. v Morgentaler went to the Supreme Court which ruled that the provisions on abortions were in violation to a women’s right to life, liberty and security of the person that are guaranteed under section 7 of the Charter of Rights and Freedoms.

It’s been 30 years since this landmark victory for women’s right to safe abortion, however it is unfortunate that many women in Canada still face many barriers to access safe abortions. Many provinces still have logistical and structural barriers which prevent women from gaining access to one of their most fundamental rights. Furthermore, women in rural communities face even greater obstacles then their urban counterparts. As such, the focus of wiki is to outline how rural women in British Columbia are oppressed relative to urban women due to multiple intersecting dimensions which combine to create barriers that prevent rural women in B.C. from accessing abortion services.

“The BC Abortion Providers Survey”, conducted by Norma et al, outline the barriers women faced when accessing medical and surgical abortions. Using this papers, along with other articles, I will outline five distinct, yet interrelated barriers that intersect in order to hinder rural women’s access to safe abortion services within B.C, thus, resulting in their oppression.

Geographical Mismatch

In B.C. there is a mismatch between where abortion services are available and where women of reproductive age live. For example, in B.C. 90% of all abortions (medical and surgical) reported are offered in large urban areas (i.e. the lower mainland). However, only 57% of all reproductive age women live in these urban areas.  This means the other 43% of the women who do not live in urban areas (in other words, rural women) face geographical barriers while accessing abortion services. For example, women livings in rural areas are forced travel great distances to access abortion services. Leora Paradise states that “about a third of the women who visited Vancouver Island’s one abortion  clinic (in Victoria) traveled over 100km to do so. From the journeys depicted [see figure 1], with origins in BC, the average distance traveled was about 250km. The two longest distances traveled were 650km and 750km”. Additionally, indigenous women (i.e. Metis and First Nations) were three times more likely to travel more than 100km than non-indigenous women.

Thus, it is obvious that abortion services are more easily accessible to urban women than rural women causing them to become marginalized and discriminated against. In other words, despite living in the same province, and having the same rights and freedoms as urban women, rural women are discriminated and marginalized because of their geographical location.

Lack of Abortion Clinics in Rural Communities

In many rural communities, hospitals are the primary [and in some cases, the only] point of access for health care as opposed to urban cities where abortion clinics perform the majority of these services. The lack of abortion clinics rural communities poses a barrier for rural women because many rural hospitals do not even offer abortion services. For example, only 25% of all hospitals located outside of large urban areas were able to provide abortion services and 3/4th of rural communities do not even offer abortions beyond the first trimester.

Additionally, rural hospitals can pose confidentiality issues for women–especially hospitals that are in small communities. It has also been reported that the hospital staff in rural areas may harbour anti-abortion sentiments. In some places, there have been incidences where hospital staff provided misinformation to pregnant women as a covert way of preventing women from following through with the abortion. For example, in Leora Paradise's analysis, she writes, “there have been reports of physicians who misinform women about their eligibility for abortion or the timing of the procedure, in addition to using other stalling tactics, in order to prevent them from going through with an abortion”.

Furthermore, rural hospitals mainly (if not only) perform surgical abortions which are riskier, as opposed to medical abortions which pose less risk and can be performed easily in an abortion clinic or within the privacy of one’s home. Medical abortions are riskier because they are invasive procedures that not only require a referral from a general practitioner (GP) but also require various multiple appointments before having an abortion. For example, an ultrasound is usually required for surgical abortions to ensure no complications occur during the operation, however, many hospitals will indirectly favour non-abortion related ultrasound appointments consequently delaying abortion related appointments. To make matter worse, in rural areas, just getting an appointment with a GP has long wait time let alone other appointments. Consequently, increasing wait times lead to unfavourable situations since the longer a woman waits to terminate the pregnancy, the risker it becomes. Plus, surgical abortions must be performed using general anesthesia which must be performed by an anesthesiologist and require longer recovery times ---something many rural women do not have the luxury of. The lack of abortion clinics in rural areas means that women who want to terminate early pregnancies have no choice but to travel outside their communities to access these services.

Thus, we can conclude that the lack of abortion clinics in rural areas represents a logistical barrier [intersectional dimension] that results in the marginalization of rural women who want to terminate unwanted pregnancies. In other words, rural women are oppressed because lack of abortion clinics in rural area poses a logistical [planning] barrier and it is the responsibility of the B.C. government to ensure its entire population has equal access to facilities. It can then be inferred that the oppression of rural women is indirectly due to power relations between B.C. government and rural communities because the B.C. government has [chosen] to neglect the issue of inaccessibility of abortion clinics in rural communities.

Cost

Travel Patterns to Abortion Clinics

Due to the accessibility of abortion services, rural women often are forced to travel long distances in other to access abortion services. The costs incurred due to lack of accessibility further marginalizes women in rural communities who cannot afford to spend the time or money to receive safe abortions. Figure 1 provides visual representation of how far women from rural places in B.C. and Alberta have to travel to access urban abortion facilities. The costs associated with this travel are entirely paid by the women. In some cases, women in B.C. have to travel  8 to 10 hours just to reach an abortion clinic. Such long travel times means that many of these women will also have to pay for other accommodations such as hotel, car, gas, food, daycare or elderly care if they are leaving children or elders alone at home. Having to pay for these associated costs is something that is just not feasible from them because many rural women are financially/economically poorer relative to urban women. This further marginalizes rural women and indirectly forces them to utilize suboptimal procedures to terminate pregnancies (i.e using hospitals vs abortion clinics or worse, turning to self-induced abortions as a last resort). Indigenous women who live on reserves are particularly vulnerable because they often have the greatest cost associated to travel. Women on reserves are required to go through an application process to obtain formal approval of funds for off-reserve travel (unless they pay themselves) and this process can be very time consuming which no guarantees for approval.

Additionally, women who are not covered under government or third party  extended health benefits , such as those in minimum wage jobs, part time workers or those who are self-employed, have to pay at least $350 to buy Mifepristone (a.k.a abortion pill). Those who cannot afford to buy the abortion pill are forced to choose surgical abortions. Furthermore, even if women are covered by health benefits for the abortion itself, there are still supplementary costs which have to be paid by the patient (i.e. administrative fees). This is exemplified in Paradise’s paper, where she states, “about twenty-five percent of women who attended an abortion clinic in BC reported that they paid more than $300,”  [note: this amount does not include travel or other miscellaneous costs].

Thus, I contend that here, rural women experience oppression based on their economic status. Rural women, due to their lower economics status (i.e. poor) are often unable to enjoy the same privileges as their urban counterparts, in term of accessing abortion services. For example, urban women who have access to health coverage (most likely through an employer) can easily access an abortion pill  while rural women, who generally don’t have extended health coverage, cannot access an abortion pill and must opt for suboptimal options such as waiting to surgical abortions.

Stigma and Harassment

Although it has been over 30 years since the decriminalization of abortions, women trying to terminate pregnancies and the physicians who provide abortions still experience a lot of stigma and harassment from their communities—especially in small, rural communities.

As mentioned above, almost all of the surgical abortions performed by rural providers occur in hospital operating rooms (ORs) (due to the lack of availability of abortion clinics in rural areas). As such, hospitals must follow certain protocols when providing abortions, i.e. referral from GP, ultrasounds, and presence of anesthesiologists. Unfortunately, due to the controversial nature of abortions, many of these people (i.e. anesthesiologists) in rural hospitals, refrain from or refuse to partake in any abortion procedures. For example, the B.C Abortion Providers Survey outlined hat nearly half of the rural communities in BC reported that nurses and anthologists refused to accept/partake in abortion procedures. Here, it is important to note that it is the underlying systemic barriers that facilitate (albeit unintentionally) the ability for hospital staff/technicians to hinder abortion processes. This stigma of abortion creates a very unsupportive and in some places unsafe environment for women seeking abortion and the physicians that provide it. For example, one of the abortion physician/doctors, has said “I have suffered threats and have both (sic) anesthetists, ultrasound technologists and operating room nurses refuse to cooperate in treatment or have had patients [i.e. the women seeking abortions] suffer insults. Urban women on the contrary, are exposed to much less stigma and harassment because there are many support facilities available (i.e. pregnancy crisis centers, abortion clinics, counseling services) that create confidential, safe spaces for women to discuss options and/or have safe abortions. Thus, high levels of stigma and harassment together constitute another intersecting socio-cultural dimension through which rural women are oppressed relative to their urban counterparts.

Lack of Rural HealthCare Professionals

In the recent years, B.C has experienced a shortage in the number of healthcare professionals who are willing to provide abortion services in rural areas. According to a new study that surveyed family medicine residents in Canada, “the pool of willing providers appears to be shrinking” and that there is a lack of medical residents who are willing to be trained to become rural general practitioners who can provide abortion services.  In fact, 80% of the respondents in the study said that they received less than one hour of formal education on abortion during their residency.  There are two main factors which contribute to this worrisome trend.

First, in some part of B.C. women find themselves unable to seek abortion services because some of the physicians themselves do not want to partake in abortion procedures --i.e. due to personal beliefs. "Physicians, like anyone else, have a right to adhere to their own belief systems or philosophy," [...]"If they are anti-abortion or have strong feeling, they can't be compelled”, said Dr. Morris VanAndel. For example, Dr. Micheal Polay, one of the doctors at the Care Point Medical Centre on Commercial Drive in Vancouver, said, one of the doctors who works at this clinic, belongs to a “[ethnic] minority of B.C doctors who chooses not to [provide abortions] due to religious beliefs. These physicians are then, obligated to refer abortion seeking patients to doctors who are willing to do abortions. Unfortunately, for women living in rural communities, the lack of physicians willing to provide abortions or even provide information or referrals to those services, further adds to the inaccessibility of abortion services. .

Second, many of the existing rural healthcare professionals (i.e general practitioners) feel that they are lacking professional support in the from of easily accessible continuing professional education events and “camaraderie with other professionals providing abortion services” This lack of support often leads to abortion providers to feel isolated and incompetent in their abilities to guide their patients adequately thorough abortion procedures. As a result, there has been a growing trend in the decline of physicians offering abortion services, such as this one rural physician who, “discontinued her surgical practice, in part because she felt she was not providing women with an equivalent service to an urban clinic, and was unable to obtain updated training to reinforce her skills".

The unavailability of rural healthcare  professionals is a systematic failure on the government as there is nothing actively being done to reverse this declining trend. As such, I argue that rural women are being marginalized and oppressed as a result of this passive attitude towards a decline in availability of rural healthcare professionals. This again represents an imbalance in the power relations between rural communities (who are being increasing marginalized) and the provincial government of B.C.

Conclusion Summary

It has been about 30 years since the legalization of abortion practices yet many women in Canada still face and experience systematic barriers which prevent them from having access to safe abortions. In particular, women who live in rural areas of any province are more marginalized than their urban counterparts. The purpose of this wiki is to use an intersectional analysis in other to understand and outline the multiple intersecting dimensions which explain why rural women in British Columbia are more oppressed than urban women in terms of ability to access abortion services within B.C. I argue that there are 5 main barriers which prevent rural women from accessing their rights to safe abortions: i) there is a geographical mismatch between where services are available and where women who use these services live  ii) there is a huge lack of abortion clinics in rural communities iii) the cost associated with inadequate access to abortion further adds to the marginalization of rural women iv) rural communities stigmatize abortion and v) there is a huge decline in the availability of rural healthcare professionals who can perform abortion services. All these barriers manifest as a result of underlying intersection dimensions which combine to marginalize and oppress rural women from accessing safe abortion services. These underlying dimensions are, geographical location, economic status, dominant socio-cultural narratives, all of which intersect in the context of unequal power relations between the provincial government of B.C. and small rural communities. Simply put, rural women are oppressed because they live in rural areas where dominant socio-cultural narratives stigmatize abortion practices, they are not financially well off and they are on the losing side of the unequal power relationship with the provincial government.