Economic Costs of Travel for Birth - Reclaiming Indigenous Birth

The Economics of Obstetric Evacuation

This study is the first to attempt to systematically identify the costs of obstetric evacuation across Canada, as documented in academic literature.

In our search for articles, we were unable to find any specific to costs for travel for birth. We also found that the experience of urban health care was vastly different from that of rural and remote regions.

For these reasons, we refined the research question from:

What is the evidence about the costs of travel for birth for First Nation, Métis, Inuit and/or Indigenous birthing persons in Canada and globally?

to:

For First Nations people and Inuit in rural and remote regions within Canada, what are the economic costs associated with medical evacuation and transportation to receive medical care?

Using this criteria, 19 studies were included in the review. Here is what it told us about costs for medical transportation.
Direct costs reported varied, likely due to travel distance. The lowest reported cost in Canada of medical evacuation was $7,714 with the figure reaching a high of $31,794. This is higher than previously estimated.

The costs identified were not comprehensive.

Two other types of costs were mentioned in the literature; indirect and intangible. Indirect costs can be assigned a monetary value, but the articles we reviewed had not done so. Intangible costs cannot be given a monetary value and are routinely excluded from cost analysis. We documented examples of each type of cost.

The literature reviewed also indicated that funding of travel for medical care was shared among different types of payers, including —but not limited to —federal, provincial, and territorial governments as well as individuals paying for costs out of pocket. Who should pay is often contested.

A summary of our findings from the systematic review is presented below.

The Findings

Presented as a cost analysis framework

There is a lack of evidence in existing academic literature about costs of travel for birth. As a result, we presented the findings of the systematic review as a cost analysis framework with examples of costs categorized into direct, indirect, and intangible costs.

We chose this framework to report costs in a way recognizable to health economists, although it may not reflect Indigenous ways of knowing and being.

Indirect costs

Indirect costs represent an important cost category, as they account for costs associated with land-based resources and community-based care networks. The most common indirect cost cited was lost income due to travel. Other examples of indirect costs include cost of childcare, cost of eldercare, lost land-based resources or income, and learning loss from children missing school when taking on childcare responsibilities. These indirect costs can have long-term impacts, with accumulating economic costs that have not been explored previously.

Intangible costs

We grouped intangible costs documented in the literature into the following themes:

fear, anxiety, depression, stress, isolation/loneliness,
loss of connection to family and community,
lack of respect for cultural practices,
lack of support, compromised care, and
lack of choice, control, and power.

Intangible costs cannot be given a monetary value.

Costs not included in the literature

Several costs were not quantified, including costs incurred while waiting for reimbursement, cost of time spent navigating the payment, cost of time spent arranging travel for care, and the costs associated with avoidance of care due to complicated processes.

Future research needed

There is a continued need for researchers to inspect costs and provide accurate measures, ensuring the nuances of community, geography, and policy are taken into account. Our systematic review did not include identifying the costs of providing care in urban centres, however, this could be relevant to review in the future.

Keywords: Indigenous · First Nations · Inuit · Midwifery · Obstetric evacuation · Cost

Cost Analysis Framework for medical evacuation

Several frameworks exist for describing and categorizing the cost of health services. We opted to categorize costs using a framework based on the cost of illness (CoI) methodology, proposed by Rice et al. (1985). This commonly used framework divides costs into direct, indirect, and intangible costs. The table below lists examples of each type of cost found in the literature we reviewed. We chose this framework to report costs in a way recognizable to health economists, however, this may not reflect Indigenous ways of knowing and being.

Direct Costs

The direct costs of medical evacuation include:

Medical evacuation flights
Commercial air transportation
Accommodation
Meals
Escorts
Ground transportation

Direct costs reported varied, likely due to travel distance. The lowest reported cost in Canada of medical evacuation was $7,714 with the figure reaching a high of $31,794. This is higher than previously estimated. These figures do not include the costs of providing health care.

Indirect Costs

The most common indirect cost cited was lost income due to travel. Other costs include:

Cost of childcare,
Cost of eldercare,
lost land-based resources or income, and
learning loss from children missing school when taking on childcare responsibilities.

These indirect costs can have long-term impacts, with accumulating economic costs that have not been explored.

Intangible Costs

We grouped intangible costs documented in the literature into the following themes:

fear, anxiety, depression, stress, isolation, and loneliness,
loss of connection to family and community,
lack of respect for cultural practices,
lack of support, compromised care, and
lack of choice, control, and power.

Intangible costs cannot be given a monetary value.