Critical medical anthropology as a roadmap

Understanding access to abortion in the Catalan health system

Bayla Ostrach

Global day of abortion rights, Barcelona, 28 September 2012Global day of abortion rights, Barcelona, 28 September 2012

Structural factors in the Catalan health system make obtaining a legal, publicly funded abortion difficult for many women, despite policy changes that ostensibly improved access. I had originally planned, in 2009, to conduct research on women’s experiences obtaining then-illegal (but widely available) abortion care in Spain. But as political and policy landscapes shifted in Catalunya,[note 1]Catalunya is the local, preferred spelling of the name of the nation, sometimes written in English as ‘Catalonia’. Catalans prefer their spelling, and my ready acceptance of this emic view (and of Catalan national identity overall) helped me establish rapport and be trusted by Catalans, including a key informant who enabled the clinic-based component of my research. My progress at understanding, and using, the Catalan language (which is distinct from Castilian, also called Spanish) further helped in establishing rapport and being embraced as part of the local reproductive health care settings where I did much of my fieldwork.
 my research focus, and ultimately, data analysis, shifted along with them.

While doing participant observation in an abortion clinic contracted by the health system to provide such care in 2012 and 2013, I discovered I had to keep pace with the changing economic and health policies affecting my participants. As a result, I experienced the ethnographer’s privilege of being swept along in the tide of popular responses and resistance to La Crisis, austerity cuts, and threats to the legal status of abortion. Attending anti-austerity and abortion rights rallies and marches, and befriending local feminist, left-wing, and Catalan independence activists, helped me to contextualize my clinic-based formal data with local emic understandings of the political climate. I was surrounded by visible and vocal markers of the movement for full independence, which colored the discourses of many of my participants far more than I anticipated, and thus became a larger part of my dissertation than I ever expected. 

As I adjusted to the changing terrain of my field site, the seminal article that first motivated my thinking about abortion access in terms of how women work within systems to get the care they need, but also challenge power inequalities inherent in bureaucratic health systems, continued to inspire me. Reading Merrill Singer’s ‘Beyond the Ivory Tower: Critical Praxis in Medical Anthropology’ (1995) as a new graduate student in 2008, I was struck by his description of ‘systems-challenging’ and ‘systems-correcting praxis’ as potent ways for scholars to use medical anthropology research as a means for social action and/or reform.  

I saw the utility of applying Singer’s model to evaluate how marginalized populations in need of health services may pragmatically respond to structural oppression to get their needs met, adopting a ‘reformist approach’, while also challenging the system’s power inequalities by demonstrating agency in the process of demanding the care they need. The possibility of using ethnographic data to understand people’s responses to structural oppression, and, ideally, to effect change, provoked me to examine what women and abortion providers say about how women themselves navigate a health system that reproduces inequality.

Going to Catalunya, I knew from my earlier research with women who struggled with state-level Medicaid systems in the United States to get coverage for abortion that simply being eligible for publicly funded health care does not guarantee access to abortion services covered by such systems. I knew, too, that women worldwide employ a variety of strategies to overcome logistical, financial, and social support-related obstacles to successfully obtain abortion care, combining reformist and more overt authority-challenging approaches. I knew it was likely that women in Catalunya would take both systems-correcting and systems-challenging approaches to exercising their newly acquired ‘right’ to publicly funded, legal abortion care. What I did not know, until I heard their stories, evaluated relationships between concepts emerging in my data, and learned about the larger contexts, was precisely how women in Catalunya do it.

Spain’s national abortion reforms were implemented within a Catalan health system that guaranteed care regardless of immigration status. This was an important factor in my research design because it is well documented that immigrant women encounter more barriers to reproductive health care, including abortion (Ostrach 2012). Catalunya’s health system was at that time the most accessible to immigrants, and the region has long been home to comparatively more immigrants (who seek abortion at a higher rate) than other regions. Catalunya was thus an ideal setting to explore what obstacles women encounter while navigating the health system to obtain publicly funded, legal abortion. And encounter obstacles, they did.

Nearly half of women who participated in my study were not aware that the voucher they had already been required to obtain at one of the health system’s neighborhood centers would fully cover their abortion care. Practical access to coverage in the Catalan health system deteriorated for immigrant women, even as policy changes increased all women’s legal rights to seek such care. As I spent day after day in the clinic documenting the wide array of ways that the health system caused unnecessary delays for women seeking care, I was frustrated to see that even in an optimal setting, with legal abortion and public funding of health care, the bureaucracy of health policy (Singer and Castro 2004) nevertheless perpetuated inequality and marginalization.

I struggled to make sense of how legal reforms that initially resulted from systems-challenging praxis, in the form of grassroots community mobilization demanding an expansion of legal abortion, trickled down through the health system in a way that proved to require continual systems-correcting praxis on the part of the individual women and providers who had to wait out delays, jump through additional hoops, and demand that health system representatives be accountable to comply with the improved policies. All of this was a stark lesson for me that, when health policies change, even as a result of systems-challenging praxis, the result is not the endpoint, but the beginning of an ongoing struggle to exercise and affirm newly won rights or access. As with research on abortion and Medicaid in the United States (Ostrach and Cheyney 2014; Kiley et al. 2010; Salganicoff and Delbanco 1998), policies guaranteeing coverage do not always translate into access.

As I analyzed accounts of the myriad ways that women respond to and overcome obstacles to abortion care, applying concepts from critical medical anthropology allowed me to consider how women themselves, through their persistence, were answering medical anthropology’s call to challenge power inequalities within health systems. This framework further allowed me to argue that women’s responses to bureaucratic delays represented a blend of both systems-correcting and systems-challenging praxis. I had arrived in the field planning to analyze health care disparities and evidence of structural violence, but found a catch-22 of new, different obstacles to abortion – ones that emerged from the very process of adding coverage for abortion in an existing health system.

About the author

Bayla Ostrach, MA, PhD, is a member of the faculty and Internship Director in the master’s program in Medical Anthropology & Cross-Cultural Practice in the Division of Graduate Medical Sciences, Boston University School of Medicine, where she has a pending appointment as an Assistant Professor in the Department of Family Medicine. Dr. Ostrach is a Junior Fellow of the Society of Family Planning, and an affiliated Research Scientist with the University of Connecticut Department of Anthropology.She has worked directly in the field of reproductive health and abortion care since 1999.

References

Kiley, Jessica W., Lynn M. Yee, Cassandra M. Niemi, Joseph M. Feinglass, and Melissa A. Simon. 2010. ‘Delays in Request for Pregnancy Termination: Comparison of Patients in the First and Second Trimesters’. Contraception 81(5): 446–51. 
Ostrach, Bayla, and Melissa Cheyney. 2014. ‘Navigating Social and Institutional Obstacles: Low-Income Women Seeking Abortion’. Qualitative Health Research 24(7): 1006–17.
Ostrach, Bayla. 2012. ‘“Yo No Sabía”: Immigrant Women’s Use of National Health Systems for Reproductive and Abortion Care’. Journal of Immigrant and Minority Health 15(2): 262–72.
Salganicoff, Alina, and Suzanne F. Delbanco. 1998. ‘Medicaid and Managed Care: Meeting the Reproductive Health Needs of Low-income Women’. Journal of Public Health Management and Practice 4(6): 13–22.
Singer, Merrill, and Arachu Castro. 2004.‘Policy: A Critical Perspective’. In Unhealthy Health Policy: A Critical Anthropological Examination, xi–3. Lanham, MD: Altamira Press.
Singer, Merrill. 1995. ‘Beyond the Ivory Tower: Critical Praxis in Medical Anthropology.’ Medical Anthropology Quarterly 9(1): 80–106.