Ostrach’s 2017 Health Policy in a Time of Crisis

In Catalunya and beyond, abortion is never just a medical or even a moral issue. It is an explosive nexus of intense social conflict over power, ‘rights,’ bodily autonomy, access to health care and the equal distribution of resources in society” (Ostrach 2017: 69).

Health Policy in a Time of Crisis stems from ten months of institution-based participatory research in a healthcare clinic—Public Clinic—providing state-funded abortion services in Barcelona. Using a mixed-method approach, Ostrach surveyed 350 women who sought abortion care at the Public Clinic, interviewed 11 women on their experiences with the public health system in seeking abortion as well as 11 providers on their perspectives of the experiences of the hundreds of women for whom they provided abortion care.

This methodologically grounded and theoretically innovative ethnography is informed by the author’s long-standing engagement with the topic of abortion rights and access in the United States. In a context of global restrictions on women’s reproductive rights and the fight of activists worldwide for legal access to abortion, the author vividly demonstrates how legal abortion does not necessarily equate with abortion access. Health Policy in a Time of Crisis takes abortion as a window to analyze the everyday impact of austerity measures (national and European) and shifting status for immigrants on abortion access. The shadow of La Crisis, the widespread recession that struck most of Europe from 2007 on, and the consequent austerity measures, forms the background of women’s decisions to get abortion care, health personnel’s struggle to provide it, and the Public Clinic’s ability to maintain full access to all women seeking its services. Austerity cuts during the author’s fieldwork translated in a drastic reduction of the number of publicly funded abortions, illustrated by women who had come for a procedure in previous years’ saying, “better a crowded clinic than no clinic!”

Contrary to much of Latin America, where some countries have the strictest abortion laws of the planet, there is little stigma associated with abortion in Barcelona, and even women who personally oppose abortion strongly contest legislative attempts to put restrictions on women’s bodies. Ostrach builds on feminist critique to analyze the notion of “bodily autonomy,” which is central to Catalan activists’ demand for abortion access for all. The emphasis on bodily autonomy challenges mainstream discourses on reproductive rights. Catalan activists’ grassroots demands for access to reproductive care and bodily autonomy rather than the right to abortion echoes many demands of activists and indigenous peoples across Latin America, who frame access as rights in practice, rather than theoretical human rights.

In Catalunya, demands for bodily autonomy are interwoven with protests for regional autonomy, and a strong commitment to healthcare access for all, no matter their residency status. In this peculiar context, one might think that barriers to access are reduced. However, Ostrach’s research showed that 51 percent of the 350 women surveyed were not aware that their abortion would be fully state-funded, even as they had interacted with at least one health system representative. Building on Harvey’s civilized oppression framework, Ostrach vibrantly reveals how the power imbalance between women seeking information about abortion services, with some healthcare workers abusing their authority, shape women’s access to health services. In particular, immigrant women were most likely to report being misinformed on the gestational limit for abortion, encountering delays in seeking abortion services, and being provided with the incorrect referral voucher, for example. In some cases, structurally marginalized women faced ongoing stereotypes and had to convince providers that they were worthy of public funds.

Structurally marginalized women faced ongoing stereotypes and had to convince providers that they were worthy of public funds.
Health Policy in a Time of Crisis is an empathic ethnography on women’s frustrations, as they face a wide-range of obstacles such as terminating a wanted pregnancy because of La Crisis, the lack of access to transportation to the only publicly-funded clinic in the region, or finding a companion to wait for them after the procedure, as required by the clinic protocol. The women Ostrach interviewed were particularly insightful on the multiple challenges they had to face in addition to seeking abortion care—as single mothers, sex workers, and students. The author eloquently describes these efforts in the “Superwoman complex”: the strategies deployed by women to balance fewer economic resources and less perceived support for their abortions. Ostrach’s vivid descriptions of women’s journeys, and the long quotes of women themselves bring las dones (the women) to life, as they share their frustrations with the health system and these personal and structural obstacles.

Immigrant women in particular (from South America, other parts of Spain, and other European countries) encountered more delays in accessing abortion and arrived on average two weeks later than Catalans at the clinic. Factors accounting for this delay included women’s lack of awareness that the procedure would be covered upfront, and the shifting status of immigrants, which led to misinformation about their health coverage. Ostrach eloquently describes how providers’ attitudes can shape women’s access, and how some stereotypes shape the staff interactions with certain groups of patients like Roma or Muslim women, but the impact it might have on women’s experiences and their willingness to access the service is left unanswered. The author acknowledges the limitation of her study on immigrant women’s experiences, as she focused on those women who accessed the clinic, and raises important questions for future research, such as, what happens to immigrant women who are completely unaware of the public healthcare coverage for pregnant women? And, what are the stories of those who encountered too many delays and were unable to get the procedure?

To conclude, this exceptionally well-written and engaging ethnography is a constant reminder that “abortion is nothing without access,” at a period of revival of conservative movements in Europe—making the news in France and Poland recently—and increased restriction on abortion access in the United States. Health Policy in a Time of Crisis provides a unique example of engagement in medical anthropology. Ostrach shared the results of her investigation on the concrete impacts of funding cuts for the public clinic with representatives of the public health system. Even though the meeting did not result in a change in policy, such engagement symbolizes important calls for action. This promising first book will speak to a wide audience, offering insights for discussions in research methods and ethics classes from all disciplines, and the fields of medical and applied anthropology, women and gender studies, and public health and migration studies, to name a few.

Book Reviewed: Ostrach, Bayla. 2017. Health Policy in a Time of Crisis: Abortion, Austerity and Access. New York and London: Routledge.

Mounia El Kotni is a French-Moroccan cultural and medical anthropologist. Her research analyzes the multifaceted impacts of global maternal health policies on indigenous midwives’ practices and women’s reproductive care access in Chiapas, Mexico. As part of her ongoing commitment to reproductive justice, she is part of the recently founded Observatory of Obstetric Violence in France. She can be contacted at melkotni@albany.edu

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