Spatial disparities and travel to freestanding abortion clinics in Canada
Highlights
► Travel patterns accessing Canadian freestanding abortion clinics are illustrated. ► A spatial overview of access demonstrates inequitable travel burdens for some women. ► Policy makers need to address gaps in abortion services and the role of clinics.
Introduction
Abortion in Canada was legalized in 1969 but under very restrictive conditions. The Supreme Court struck down this law in 1988. Since then, Canada remains one of the few countries in the world without a federal law regulating abortion. Today, abortion is considered a “medically necessary” service. This phrase has various interpretations; it has not been defined federally but it generally means a service performed by a physician as defined by the Canada Health Act or a service a patient needs “in order to avoid a negative health consequence” (Charles, Lomas, & Giacomini, 1997: 365–94). In Canada, health care is administered by provincial or territorial governments but the federal government holds sway by allocating funds to provinces and territories for health care purposes. The federal government is also responsible for enforcing the Canada Health Act. This Act sets out five principles of public, universally funded Medicare. Health care must be accessible, portable, universal, comprehensive and publicly administered nationwide (Singh Bolaria & Dickinson, 2001). Although the overall intent of the Act is to create a system of equitable access to health care, Canadians have raised concerns about “timely access to existing services, particularly in rural and remote areas, limited progress in advancing primary health care reforms and growing wait lists, especially for diagnostic services” (Final Report of the Commission on the Future of Health Care in Canada, 2002). However, access to abortion services rarely figure in such national concerns despite the fact that it is uneven throughout the country and has been described as a “patchwork quilt with many holes”(Eggertson, 2001: 847).
The most recent data available suggest that Canadian women are obtaining fewer abortions than in previous years, and this decline is most apparent among young women under the age of 20 years (Statistics Canada, 2008a). It is speculated that the drop in abortion is due in part to decreased sexual activity among young people and increased contraceptive use (Rotermann, 2008, Santelli et al., 2007). However, abortion rates are also closely tied to the accessibility of the procedure (Jones & Kooistra, 2011). Data on abortion access in the United States have indicated the rise and fall of abortion rates among neighboring states when restrictive policies are introduced (Santelli et al., 2007) Studies show that the further a women has to travel to access abortion, the less likely she is to obtain one and the more likely she is to be young and underprivileged (Jewell and Brown, 2001, Lichter et al., 1998, Shelton et al., 1976). Legal or extra-legal obstacles can restrict access to abortion services. Extra-legal obstacles may include institutional policies regulating the delivery of abortion services, the costs of the procedure, the imposition of gestational limits, the lack of confidentiality, anti-choice harassment and violence, and the location of abortion services (Farid, 1997, Gober, 1994, Henshaw, 1991, Palley, 2006).
In Canada, these extra-legal obstacles have coincided with a steady drop in public sector hospitals performing abortions since 1977 (CARAL, 2003, Report of the Committee on the Operation of the Abortion Law, 1977, Shaw, 2006). Currently, only 15.9% of hospitals in Canada offer abortion services and the majority of these hospitals are located in urban centers (Shaw, 2006). Freestanding abortion clinics exist apart from hospitals, operate in the public, semi-private and/or private sectors and are based mainly in urban centers. Such clinics have become attractive options even though private health care services may disadvantage women because they are less likely able to pay for them (Rodgers, 2006) and private health care services have become contested ground in Canada for federal, provincial and territorial powers in an era of financial cutbacks, increased demand for public health care services, and proposals for the reform of Medicare (Browne, 2004, Pro-Choice Action Network, 2002, Taylor, 2006).
As a result, Canadian women attempt to find spatial solutions to an unwanted pregnancy, crossing provincial and territorial borders to garner access to abortion services in jurisdictions outside their home communities. Despite the importance of such travel to access abortion services, the topic has been largely ignored (Palmer, 2011, Sethna, 2011, Sethna and Doull, 2007), underlining the neglect of abortion as a medically necessary service for women in Canada (Fowler and Trouton, 2000, Norman, 2011). In this first-time study, we attempt to fill this knowledge gap by systematically tracking, mapping and analyzing the travel women undertake to access abortion services at freestanding clinics throughout Canada.
Section snippets
Methodology
Our national study was informed by a regional pilot study conducted on women's travels to the Toronto Morgentaler Clinic, a freestanding abortion clinic that operates in the public sector in Toronto, Ontario. The findings from the pilot study revealed that women were travelling considerable distances to access abortion services at this clinic. Moreover, women from lower income groups were more likely to have travelled further to access abortion services and younger women were more prone than
Analysis
Analysis was completed using SPPS (version 18.0). Simple counts and percentages were calculated for most variables. Where possible, odds ratios with 95% confidence intervals were calculated to quantify trends. Given the acknowledged importance of the “spatial turn” in the social sciences, the humanities and more recently in the health sciences (Dunae, 2008, Pickles, 1999), data emerging from the questionnaires were mapped to provide a graphic illustration of women's travel patterns to abortion
Results
A total of 1186 women participated in the national study. The average age of participants was 26.0 years (s.d., 6.4). The ages of the participants ranged from 12 to 48 years with 0.5% of the sample under 16 years old and 14.6% under 20 years old (Table 2). Over 60% of the participants reported that they made less than $30,000 per year (60.5%), 23.8% earned less than $10,000 per year and 9.7% were receiving social assistance. Most were Canadian born (76.7%) and self-identified as “white” (64.3%).
Discussion
Mapping the data on women's journeys to freestanding abortion clinics raises four important concerns about spatial disparities in abortion access in Canada: 1) the paucity of services outside urban centers; 2) the existence of substantial access gaps, particularly for women living in Atlantic, Northern and coastal communities; 3) the burdensome costs of travel and, in some cases, the costs of the abortion procedure itself, especially for younger women who travel the farthest; 4) the unique
Conclusion
This first-time national study on Canadian women's travel to freestanding abortion clinics is an illustrative example of spatial disparities in regard to abortion access. The maps provide convincing visual evidence that women living in Canada's rural, Northern and coastal communities are underserved. Therefore, freestanding abortion clinics can be attractive options for women even when women have to travel considerable distances to access them. Such clinics provide important lessons for policy
Acknowledgements
Funding for this study was provided by the Social Sciences and Humanities Research Council of Canada. We acknowledge Troy Hannah, who developed the first maps for this project, and the service of several dedicated research assistants at the University of Ottawa. Anthony N. Smith, University of British Columbia, produced all the maps in this publication. Francoise Moreau-Johnson, Centre for Academic Leadership, University of Ottawa, provided the space and time to facilitate the completion of
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