Dataset Information

Con la ley y sin la ley/With and without the law: Utilization of abortion services and case fatality in Mexico, 2000-2016.

ABSTRACT: OBJECTIVE:To describe utilization of health services for, and case fatality from, abortion in Mexico. METHOD:A historical cohort study using a census of state-level aggregate hospital discharge and primary care clinic data across Mexico's 32 states from January 2000 to December 2016. Abortive events and changes over time in utilization per 1000 women aged 15-44 years, and case fatality per 100 000 abortion-related events were described by year, health sector, and state. Associations of location (Mexico City vs 31 other states) and time (Mexico City implemented legal abortion services in 2007) with outcomes were tested by linear regression, controlling for secular trends. RESULTS:The national abortion utilization rate was 6.7 per 1000 women in 2000, peaked at 7.9 in 2011, and plateaued to 7.0 in 2016. In Mexico City, utilization peaked at 16.7 in 2014 and then plateaued. Nationwide, the case-fatality rate declined over time from 53.7 deaths per 100 000 events in 2000 to 33.0 in 2016. Case fatality declined more rapidly in Mexico City than in the other 31 states to 12.3 in 2015. CONCLUSION:Case fatality from abortive events has decreased across Mexico. Where abortion became legal, utilization increased sharply but plateaued afterward.

SUBMITTER: Darney BG

PROVIDER: S-EPMC7027437 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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Con la ley y sin la ley/With and without the law: Utilization of abortion services and case fatality in Mexico, 2000-2016.

Darney Blair G BG Fuentes-Rivera Evelyn E Polo Gerardo G Saavedra-Avendaño Biani B Alexander Lily T LT Schiavon Raffaela R

International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 20191227 3

<h4>Objective</h4>To describe utilization of health services for, and case fatality from, abortion in Mexico.<h4>Method</h4>A historical cohort study using a census of state-level aggregate hospital discharge and primary care clinic data across Mexico's 32 states from January 2000 to December 2016. Abortive events and changes over time in utilization per 1000 women aged 15-44 years, and case fatality per 100 000 abortion-related events were described by year, health sector, and state. Associatio ...[more]

PMID: 31821537

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Project description:Abortion is regulated in Mexico at the state level, and it is permitted under certain criteria in all 32 states, except in Mexico City where first-trimester abortion is decriminalized. Yet, more than a million abortions occur in Mexico each year. But most terminations occurring outside of Mexico City are clandestine and unsafe due to profound stigma against the procedure, lack of trained providers, lack of knowledge of where to find a safe abortion and poor knowledge of the laws. While this situation is moderated by the increasing use of misoprostol, a relatively safe method of abortion, the safety of the procedure cannot be assured in restrictive legal contexts. The purpose of this study is to explore women's experiences with induced abortion in three federal entities with different legal contexts, and whether abortion seeking behavior and experiences differ across these settings. The study was carried out in three states, representing three different degrees of restrictiveness of abortion legislation. Queretaro with the "most restrictive" law, Tabasco with a "moderately restrictive" law, and Mexico state with the "least restrictive" law. We hypothesize that women living in more restrictive states will resort to the use of more unsafe and risky methods and providers for their abortion than their counterparts in less restrictive states. Women who recently obtained abortions were selected through snowball sampling and qualitative data were collected from them using semi-structured indepth interviews. Data collection took place between mid-2014 and mid-2015, with a final sample size N = 60 (20 from each state). Various themes involved in the process of abortion seeking behavior were developed from the IDIs and examined here: women's knowledge of the abortion law in their state, reasons for having an abortion; the methods and providers used and women's positive and negative experiences with abortion methods and providers used. Our results indicate that abortion safety is not associated with the restrictiveness of abortion legislation. Findings show that there is a new pattern of abortion service provision in Mexico, with misoprostol, a relatively safe and easy to use method, playing an important role. Nevertheless, while access to misoprostol tends to increase the safety of abortion, the improvement is moderated by women and their informants (relatives, friends and partners) not having accurate information on how to safely self-induce an abortion with misoprostol. On the other hand, some women manage to have safe abortion in illegal setting by going to Mexico City or with the support of NGOs knowlegeable on abortion. Findings demonstrate the importance of decriminalization of abortion, but meanwhile, harm reduction strategies, including promotion of accurate information about self-use of misoprostol where abortion is legally restricted will result in safe abortion.

Project description:ObjectiveTo assess whether indicators of limited access to services explained changes in rates of second-trimester abortion after implementation of a restrictive abortion law in Texas.MethodsWe used cross-sectional vital statistics data on abortions performed in Texas before (November 1, 2011-October 31, 2012) and after (November 1, 2013-October 31, 2014) implementation of Texas' abortion law. We conducted monthly mystery client calls for information about abortion facility closures and appointment wait times to calculate distance from women's county of residence to the nearest open Texas facility, the number of open abortion facilities in women's region of residence (facility network size), and days until the next consultation visit. We estimated mixed-effects logistic regression models to assess the association between obtaining abortion care after the law's implementation and having a second-trimester abortion (12 weeks of gestation or more), after adjustment for distance, network size, and wait times.ResultsOverall, 64,902 Texas-resident abortions occurred in the period before the law was introduced and 53,174 occurred after its implementation. After implementation, 14.5% of abortions were performed at 12 weeks of gestation or more, compared with 10.5% before the law (P<.001; unadjusted odds ratio [OR] 1.45; 95% CI 1.40-1.50). Adjusting for distance to the nearest facility and facility network size reduced the odds of having a second-trimester abortion after implementation (OR 1.17; 95% CI 1.10-1.25). Women living 50-99 miles from the nearest facility (vs less than 10 miles) had higher odds of second-trimester abortion (OR 1.24; 95% CI 1.11-1.39), as did women in regions with less than one facility per 250,000 reproductive-aged women compared with women in areas that had 1.5 or more facilities (OR 1.57; 95% CI 1.41-1.75). After implementation, women waited 1 to 14 days for a consultation visit; longer waits were associated with higher odds of second-trimester abortion.ConclusionIncreases in second-trimester abortion after the law's implementation were due to women having more limited access to abortion services.

Project description:BackgroundZimbabwe has the highest contraceptive prevalence rate in sub-Saharan Africa, but also one of the highest maternal mortality ratios in the world. Little is known, however, about the incidence of abortion and post-abortion care (PAC) in Zimbabwe. Access to legal abortion is rare, and limited to circumstances of rape, incest, fetal impairment, or to save the woman's life.ObjectivesThis paper estimates a) the national provision of PAC, b) the first-ever national incidence of induced abortion in Zimbabwe, and c) the proportion of pregnancies that are unintended.MethodsWe use the Abortion Incidence Complications Method (AICM), which indirectly estimates the incidence of induced abortion by obtaining a national estimate of PAC cases, and then estimates what proportion of all induced abortions in the country would result in women receiving PAC. Three national surveys were conducted in 2016: a census of health facilities with PAC capacity (n = 227), a prospective survey of women seeking abortion-related care in a nationally-representative sample of those facilities (n = 127 facilities), and a purposive sample of experts knowledgeable about abortion in Zimbabwe (n = 118). The estimate of induced abortion, along with census and Demographic Health Survey data was used to estimate unintended pregnancy.ResultsThere were an estimated 25,245 PAC patients treated in Zimbabwe in 2016, but there were critical gaps in their care, including stock-outs of essential PAC medicines at half of facilities. Approximately 66,847 induced abortions (uncertainty interval (UI): 54,000-86,171) occurred in Zimbabwe in 2016, which translates to a national rate of 17.8 (UI: 14.4-22.9) abortions per 1,000 women 15-49. Overall, 40% of pregnancies were unintended in 2016, and one-quarter of all unintended pregnancies ended in abortion.ConclusionZimbabwe has one of the lowest abortion rates in sub-Saharan Africa, likely due to high rates of contraceptive use. There are gaps in the health care system affecting the provision of quality PAC, potentially due to the prolonged economic crisis. These findings can inform and improve policies and programs addressing unsafe abortion and PAC in Zimbabwe.

Project description:Background In 2005, Ethiopia took a bold step in reforming its abortion law as part of the overhaul of its Penal Code. Unsafe abortion is one of the three leading causes of maternal mortality in low-income countries; however, few countries have liberalized their laws to permit safer, legal abortion. Methods This retrospective case study describes the actors and processes involved in Ethiopia’s reform and assesses the applicability of theories of agenda setting focused on internal versus external explanations. It draws on 54 interviews conducted in 2007 and 2012 with informants from civil society organizations, health professionals, government, international nongovernmental organizations and donors, and others familiar with the reproductive health policy context in Ethiopia as well as on government data, national policies, and media reports. The analytic methodology is within-case analysis through process tracing: using causal process observations (pieces of data that provide information about context, process, or mechanism and can contribute to causal inference) and careful description and sequencing of factors in order to describe a novel political phenomenon and evaluate potential explanatory hypotheses. Results The analysis of key actors and policy processes indicates that the ruling party and its receptiveness to reform, the energy of civil society actors, the “open windows” offered by the vehicle of the Penal Code reform, and the momentum of reforms to improve women’s status, all facilitated liberalization of law on abortion. Results suggest that agenda setting theories focusing on national actors—rather than external causes—better explain the Ethiopian case. In addition, the stronger role for government across areas of policy work (policy specification and politics, mobilization for enactment and for implementation), and the collaborative civil society and government policy relationships working toward implementation are largely internal, unlike those predicted by theories focusing on external forces behind policy adoption. Conclusions Ethiopia’s policymaking process can inform policy reform efforts related to abortion in other sub-Saharan Africa settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-021-01255-z. Plain language summary Globally, deaths of women due to unsafe abortion remain high. However, few countries have changed their laws to allow safer, legal abortion. In 2005, Ethiopia reformed its law to permit women to obtain an abortion for a significantly greater number of reasons, and this reform has resulted in a real expansion of women’s access to services. This retrospective case study uses information from interviews with 54 people involved in Ethiopia’s reform and from government and research documents to see whether explanations of the reform that focus on the roles of national actors versus on the roles of external actors and influences better explain how Ethiopia’s reform took place. This study finds that national actors and processes were most central to Ethiopia’s reform. In particular, a ruling party open to reform, the work of the women’s movement and of reproductive health nongovernmental organizations, the ability to take advantage of political events, and the collaborative relationship between government and nongovernmental organizations all supported reform. At the time, many major external actors were either against the reform (the U.S. government) or stayed neutral. Findings can help those seeking to understand or plan policy reform efforts in other sub-Saharan Africa countries. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-021-01255-z.

Dataset Information

Con la ley y sin la ley/With and without the law: Utilization of abortion services and case fatality in Mexico, 2000-2016.

Publications

Con la ley y sin la ley/With and without the law: Utilization of abortion services and case fatality in Mexico, 2000-2016.

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