But Is It Good for Non-Urban Women's Health? Regionalizing Maternity Care Services in British Columbia *
Benoit, Cecilia, Carroll, Dena, Millar, Alison, The Canadian Review of Sociology and Anthropology
THE 1984 CANADA HEALTH ACT states that "[t] he primary objective of Canadian health care policy is to protect, promote and restore the physical and mental well being of residents of Canada, and facilitate reasonable access to health services without financial or other barriers" (Mhatre and Derber, 1992). Yet while this principle--accessibility--promotes universal health care coverage, and specifically prohibits extra-billing and user fees, equitable access to health services is not always the case in practice (Morton and Loos, 1995). The real test of equity of access involves determining whether there are systematic differences in use and outcomes among various groups in society and whether these differences result from financial or other barriers to care (Millman, 1993). Some recent developments are disturbing in this regard. Changes in the mid-1970s resulted from the enactment of the Canada Health and Social Transfer Act (Bill C-76), which included reduced proportional funding for health, education and soci al welfare from the federal to provincial governments and territories under a single "block payment." The provinces and territories have been left scrambling to meet public demands for services on substantially reduced provincial budgets. As a result health ministries in some regions have cut back on expenses by deeming certain hitherto publicly funded services "non-essential." More recently, private clinics have opened in a few jurisdictions to provide so-called non-essential services to fee-paying patients. At the same time, provincial governments have taken steps to regionalize health care service planning and delivery. Many health activists and researchers are concerned about whether these and other developments will threaten the principle of accessibility, arguing that they inevitably weaken health services to women and other vulnerable members of our society (Armstrong et al., 2002). This paper focusses on regionalization per se and seeks to determine whether it has positively or negatively affected acc ess to maternity care services for women living in non-urban communities of British Columbia.
Following the enactment of Medicare, the specialized fields of obstetrics, gynecology, family medicine and public health nursing all provided health care services to pregnant women free of charge. In the following two decades, labour coaches/dulas and midwives worked unregulated in the private health sector, offering alternative services to birthing women dissatisfied with the mainstream system. Initially these substitute services were offered for free or for exchange of services in kind. Eventually, out-of-pocket monetary payments were applied, in some cases on a sliding scale depending on the birthing women's ability to pay (Barrington, 1985; Burtch, 1994; Shroff, 1997). During the same period, many hospitals revamped their maternity wards to promote family-centred care, which included revising outdated policies to allow fathers to witness the birth and for infants to room-in with their mothers. In the 1990s, birthing women in Canada were given even greater "choice" when six provinces (Ontario, B.C., Quebec , Manitoba, Saskatchewan and Alberta) legalized midwifery as a health profession, affording them the same rights and obligations as family physicians. Further to this, four of these six provinces to date have provided public funding to cover midwifery services rendered in homes, at birthing centres or hospitals, thereby removing economic barriers to accessing midwives for less-advantaged birthing women (Bourgeault et al., forthcoming).
However, despite significant changes over the past couple of decades, systematic barriers still hinder access to appropriate maternity care services. Overuse of medical treatments (e.g., epidurals and Caesarean sections), lengthy stays in hospitals after normal childbirth, and high use of pharmaceuticals result in inappropriate care or the "medicalization" of women's health care (Martin, 1987; Van Teijlingen et al. …