Characteristics of private abortion services in Mexico City after legalization

Cost Analysis of Surgical and Medical Uterine Evacuation Methods for First-Trimester Abortion Used in Public Hospitals in Mexico

Background:

Data on abortion procedures costs are scarce in low- and middle-income countries. In Mexico, the only known study was conducted more than a decade ago, with data from years before the abortion legislation. This study estimated the costs, from the health system’s perspective, of surgical and medical abortion methods commonly used by women who undergo first-trimester abortion in Mexico.

Methods:

Data were collected on staff time, salaries, medications, consumables, equipment, imaging, and lab studies, at 5 public general hospitals. A bottom-up micro-costing approach was used.

Results:

Surgical abortion costs were US$201 for manual vacuum aspiration and US$298 for sharp curettage. The cost of medical abortion with misoprostol was US$85. The use of cervical ripening increases the costs by up to 18%. Staff comprised up to 72% of total costs in surgical abortions. Hospitalization was the area where most of the spending occurred, due to the staff and post-surgical surveillance required.

Conclusions:

Our estimates reflect the costs of “real-life” implementation and highlight the impact on costs of the overuse of resources not routinely recommended by clinical guidelines, such as cervical ripening for surgical abortion. This information will help decision-makers to generate policies that contribute to more efficient use of resources.

“Sigue siendo un sistema precario”. Barreras de acceso a abortos clínicos: la experiencia de acompañantes en tres regiones mexicanas

El objetivo de esta investigación fue la identificación de las barreras más recurrentes de acceso a abortos en contextos clínicos (clandestinos o legales), desde la perspectiva de acompañantes, activistas feministas que acompañan a mujeres que optaron por abortos autogestionados con medicamentos. Realizamos 14 entrevistas semiestructuradas con acompañantes en tres regiones mexicanas: Baja California y Chiapas, ambos contextos restrictivos, y la Ciudad de México, donde el aborto por voluntad es legal hasta las 12 semanas. Identificamos cuatro categorías en las cuales se entretejen las vulnerabilidades sociales de las mujeres que deciden abortar, la falta de información, persistencia de estigma, y la influencia del marco legal, los fallos en la atención del aborto, incluso en las clínicas de interrupción legal de embarazo (en la Ciudad de México), y mala calidad de los servicios prestados -maltrato, objeción de conciencia y denuncia de los proveedores de salud-, y, por último, los grupos anti-derechos y sus estrategias. En las tres regiones, el acceso a abortos clínicos sigue siendo un privilegio reservado para las mujeres que cuentan con los recursos económicos, logísticos y sociales indispensables para realizarlo en esos espacios. La existencia de un programa Interrupción Legal de Embarazo en solamente una entidad denota la existencia de una desigualdad jurídica y sanitaria. Los hallazgos de este estudio sobre mujeres acompañantes de abortos aportan elementos para que el Estado mexicano mejore el acceso a abortos seguros para todas las mujeres, sobre todo ahora que la Suprema Corte de la Justicia de la Nación decretó la despenalización, y la legalización inminente en todo el país.

Understanding women's provider choice for induced abortion in Turkey

In Turkey, women gained free access to induced abortion from public facilities through the legalization of abortion in 1983. However, due to unmet need and abortion stigma, women use predominantly private services. The political discourse on anti-abortion in the past decade has triggered a diminishing trend in public provision. This runs against both the 1983 Law and the healthcare reforms initiated in 2003, which aimed at universal access to health services. This study investigates the socioeconomic characteristics of women affecting the utilization of public services for induced abortion. Using "Turkey Demographic and Health Survey 2013", the results of Probit models indicate that women who were young, unmarried, wealthier and whose abortion decisions were made by themselves or their spouses were less likely to choose the public services for induced abortion. Regional differences in the utilization of public sector were also observed. Findings indicate a need to ensure and widen women's access to abortion nationwide; both at the hospital and outpatient level. Health education programs including family planning should give special emphasis to young, single and socioeconomically disadvantaged women who are more prone to apply for unsafe abortion when access to public and/or private sector is limited. A transparent referral system should be designed to timely direct women to abortion services.

Factors affecting the persistent use of sharp curettage for abortion in public hospitals in Mexico

Objectives:

Dilation and curettage is an outdated abortion procedure no longer recommended by the World Health Organization. However, use of dilation and curettage remains high in some countries, including Mexico. We aim to understand the factors that contribute to persistent use of dilation and curettage in Mexico.

Methods:

We conducted a mixed-methods study in two phases: (1) secondary quantitative data analysis from 40 Ipas-supported public hospitals in Mexico and (2) 28 in-depth interviews in 9 Ipas-affiliated hospitals with doctors, nurses, and hospital administrators.

Results:

Among our sample, 41% of abortions less than 13 weeks performed in 2019 were treated with dilation and curettage, while this increased to 67% of abortions at or above 13 weeks. Only 18% of induced abortions were performed with dilation and curettage compared to 44% of post-abortion care procedures. The main factor identified as determining use of dilation and curettage in in-depth interviews was availability of abortion supplies, both in terms of cleaning, storage, and maintenance of supplies and in the budgeting and procurement of supplies. Other factors included confidence in the efficacy of other methods, attitudes toward different methods, skill and training, and perceived benefits to patients.

Conclusion:

Ensuring supplies for recommended abortion methods are available is a key lever for any intervention aimed at reducing dilation and curettage use. However, as the doctor performing the abortion decides which method to use, individual factors such as lack of skill and mistrust in other procedures can become a particularly obstinate barrier to recommended method use. Localizing decision-making power in the hands of doctors is problematic in that it places the doctor’s preference above that of the person receiving the abortion. It is important to look deeply at the power structures that contribute to doctor-oriented models of abortion care.

The microeconomics of abortion: A scoping review and analysis of the economic consequences for abortion care-seekers

Background

The economic consequences of abortion care and abortion policies for individuals occur directly and indirectly. We lack synthesis of the economic costs, impacts, benefit or value of abortion care at the micro-level (i.e., individuals and households). This scoping review examines the microeconomic costs, benefits and consequences of abortion care and policies.

Methods and findings

Searches were conducted in eight electronic databases and applied inclusion/exclusion criteria using the PRISMA extension for Scoping Reviews. For inclusion, studies must have examined at least one of the following outcomes: costs, impacts, benefits, and value of abortion care or abortion policies. Quantitative and qualitative data were extracted for descriptive statistics and thematic analysis. Of the 230 included microeconomic studies, costs are the most frequently reported microeconomic outcome (n = 180), followed by impacts (n = 84), benefits (n = 39), and values (n = 26). Individual-level costs of abortion-related care have implications for the timing and type of care sought, globally. In contexts requiring multiple referrals or follow-up visits, these costs are multiplied. The ways in which people pay for abortion-related costs are diverse. The intersection between micro-level costs and delay(s) to abortion-related care is substantial. Individuals forego other costs and expenditures, or are pushed further into debt and/or poverty, in order to fund abortion-related care. The evidence base on the economic impacts of policy or law change is from high-income countries, dominated by studies from the United States.

Conclusions

Delays underpinned by economic factors can thwart care-seeking, affect the type of care sought, and impact the gestational age at which care is sought or reached. The evidence base includes little evidence on the micro-level costs for adolescents. Specific sub-groups of abortion care-seekers (transgendered and/or disabled people) are absent from the evidence and it is likely that they may experience higher direct and indirect costs because they may experience greater barriers to abortion care.

Abortion laws and women's health

We examine the impact of progressive and regressive abortion legislation on women's health in Mexico. Following a 2007 reform in the Federal District of Mexico which decriminalised and subsidised early-term elective abortion, multiple other Mexican states increased sanctions on illegal abortion. We observe that the original legalisation resulted in a sharp decline in maternal morbidity, particularly morbidity due to haemorrhage early in pregnancy. We observe small or null impacts on women's health from increasing sanctions on illegal abortion. These results quantify the considerable improvements in non-mortal health outcomes flowing from legal access to abortion.

Inequalities in access to and quality of abortion services in Mexico: Can task-sharing be an opportunity to increase legal and safe abortion care?

First-trimester abortion became legal in Mexico City in April 2007. Since then, 216 755 abortions have been provided, initially in hospitals, by specialized physicians using surgical techniques. With time and experience, services were provided increasingly in health centers, by general physicians using medical therapies. Meanwhile, abortion remains legally restricted in the remaining 31/32 Mexican states. Demand and need for abortion care have increased throughout the country, while overall abortion-specific mortality rates have declined. In an effort to ensure universal access to and improved quality of reproductive and maternal health services, including abortion, Mexico recently expanded its cadres of health professionals. While initial advances are evident in pregnancy and delivery care, many obstacles and barriers impair the task-sharing/shifting process in abortion care. Efforts to expand the provider base for legal abortion and postabortion care to include midlevel professionals should be pursued by authorities in the new Mexican administration to further reduce abortion mortality and complications.

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

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.

Misoprostol knowledge and distribution in Mexico City after the change in abortion law: a survey of pharmacy staff

OBJECTIVE

First-trimester abortion is widely available in Mexico City since legalisation in 2007, but few data exist surrounding pharmacy staff knowledge and sales practices. We describe misoprostol availability, whether a prescription is required, and knowledge of the legal status of abortion and uses for misoprostol among pharmacy staff in Mexico City.

METHODS

Data were collected from 174 pharmacies in Mexico City. One employee at each pharmacy was asked about availability, need for prescription, indications for misoprostol, and sociodemographic information. Our primary outcome was availability of misoprostol. We used descriptive and bivariate statistics to compare knowledge and practices by type of pharmacy and staff gender.

PATIENTS AND PUBLIC INVOLVEMENT

No patients were involved in this study.

RESULTS

Of the 174 pharmacies, 65 were chain and 109 small independent. Misoprostol was available at 61% of sites. Only 49% of independent pharmacies sold misoprostol, compared with 81.5% of chain pharmacies (p<0.05). Knowledge of indications for misoprostol use was similar. The majority (80%) of respondents knew that abortion was legal in Mexico City, and 44% reported requiring a prescription for sale of misoprostol, with no significant difference between male and female staff or by pharmacy type.

CONCLUSIONS

Availability, requirement of a prescription, and knowledge of indications for use of misoprostol varies among pharmacies, resulting in differential access to medical abortion. Pharmacies may be a good place to target education for pharmacy staff and women about safe and effective use of misoprostol for abortion.

Twelve years after abortion decriminalization in Mexico City: Can we still remain an island of liberties?

Latin America hosts the most restrictive abortion legislation globally. In 2007, Mexico, the second largest Catholic country in the world, decriminalized elective abortion within the first twelve weeks of pregnancy in the capital: Mexico City (also known as Federal District of Mexico). Following the reform, the Mexico City Ministry of Health (MX-MOH) implemented safe and legal services. Free services are provided to Mexico City residents and a sliding fee of up to $100 is applied to women from other Mexican states. Conscientious objection (CO) was addressed and included in service provision guidelines. Since 2007, 18 of 32 states amended their penal codes to restrict abortion. The road toward increasing access to abortion services at the MX-MOH included a shift from dilation and curettage (D&C) to medical abortion (MA), first with the misoprostol-alone regimen, followed by the combined mifepristone-misoprostol regimen. Manual vacuum aspiration is offered to out-of-state-women or to those beyond the gestational age where MA is less effective. Contraceptive uptake among abortion seekers is high (up to 95% of them prefer a free method of their choice). The Legal Interruption of Pregnancy program at the MX-MOH continues to provide effective, safe, reliable, and free services. However, women from indigenous groups residing in rural areas, those with low schooling, and adolescents with an unintended pregnancy who live in rural, urban, peri-urban districts, and at the state level are underserved despite being legally eligible to receive abortion services. Therefore, information and services for the disadvantaged groups need to be strengthened.

Abortion and conscientious objection: rethinking conflicting rights in the Mexican context

Since 2007, when Mexico City decriminalized abortion during the first trimester, a debate has been taking place regarding abortion and the right to conscientious objection (CO). Many people argue that, since the provision of abortions (or "legal terminations of pregnancy" as they are called under Mexico City's law) is now a statutory duty of healthcare personnel there can be no place for "conscientious objection." Others claim that, even if such an objection were to be allowed, it should not be seen as a right, since talk about a right to CO may lead to a slippery slope where we may end up recognizing a right to disobey the law. In this paper, I argue that there is a right to CO and that this may be justified through the notions of autonomy and integrity, which a liberal democracy should respect. However, it cannot be an absolute right, and in the case of abortion, it conflicts with women's reproductive rights. Therefore, CO should be carefully regulated so that it does not obstruct the exercise of women's reproductive rights. Regulation should address questions about who is entitled to object, how such objection should take place, and what can legitimately be objected to.

Nurse versus physician-provision of early medical abortion in Mexico: a randomized controlled non-inferiority trial

Objective

To examine the effectiveness, safety, and acceptability of nurse provision of early medical abortion compared to physicians at three facilities in Mexico City.

Methods

We conducted a randomized non-inferiority trial on the provision of medical abortion and contraceptive counselling by physicians or nurses. The participants were pregnant women seeking abortion at a gestational duration of 70 days or less. The medical abortion regimen was 200 mg of oral mifepristone taken on-site followed by 800 μg of misoprostol self–administered buccally at home 24 hours later. Women were instructed to return to the clinic for follow-up 7–15 days later. We did an intention-to-treat analysis for risk differences between physicians’ and nurses’ provision for completion and the need for surgical intervention.

Findings

Of 1017 eligible women, 884 women were included in the intention-to-treat analysis, 450 in the physician-provision arm and 434 in the nurse-provision arm. Women who completed medical abortion, without the need for surgical intervention, were 98.4% (443/450) for physicians’ provision and 97.9% (425/434) for nurses’ provision. The risk difference between the group was 0.5% (95% confidence interval, CI: −1.2% to 2.3%). There were no differences between providers for examined gestational duration or women’s contraceptive method uptake. Both types of providers were rated by the women as highly acceptable.

Conclusion

Nurses’ provision of medical abortion is as safe, acceptable and effective as provision by physicians in this setting. Authorizing nurses to provide medical abortion can help to meet the demand for safe abortion services.

Decriminalization of abortion in Mexico City: the effects on women's reproductive rights

In April 2007, the Mexico City, Mexico, legislature passed landmark legislation decriminalizing elective abortion in the first 12 weeks of pregnancy. In Mexico City, safe abortion services are now available to women through the Mexico City Ministry of Health's free public sector legal abortion program and in the private sector, and more than 89 000 legal abortions have been performed. By contrast, abortion has continued to be restricted across the Mexican states (each state makes its own abortion laws), and there has been an antichoice backlash against the legislation in 16 states. Mexico City's abortion legislation is an important first step in improving reproductive rights, but unsafe abortions will only be eliminated if similar abortion legislation is adopted across the entire country.

Clients' perceptions of the quality of care in Mexico city's public-sector legal abortion program

CONTEXT

In 2007, first-trimester abortion was legalized in Mexico City. Limited research has been conducted to understand clients' perceptions of the abortion services available in public-sector facilities.

METHODS

Perceptions of quality of care were measured among 402 women aged 18 or older who had obtained abortions at any of three public-sector sites in Mexico City in 2009. Six domains of quality of care (client-staff interaction, information provision, technical competence, postabortion contraceptive services, accessibility and the facility environment) were assessed, and ordinal logistic regression analysis was conducted to identify the domains that were important in women's overall evaluation of care.

RESULTS

Clients gave overall services a high rating, with a mean of 8.8 out of 10. In multivariate analysis, overall ratings were higher among women who said the doctor made them feel comfortable (odds ratio, 3.3), the receptionist was respectful (1.7), the staff was very careful to protect their privacy (2.5), they had received sufficient information on self-care at home following the abortion and on postabortion emotions (1.9 and 2.0, respectively) and they felt confident in the doctor's technical skill (2.5). Rating site hours as very convenient (2.4), waiting time as acceptable (2.8) and the facility as very clean (1.9) were all associated with higher overall scores. Compared with women who had given birth, those who had not rated the services lower overall (0.6).

CONCLUSION

Efforts to improve patient experiences with abortion services should focus on client-staff interaction, information provision, service accessibility, technical competence and the facility environment. The most highly significant factor appears to be whether a doctor makes a woman feel comfortable during her visit.

Abortion practice in Mexico: a survey of health care providers

BACKGROUND

Little is known about abortion practice in Mexico postlegalization of abortion in Mexico City in 2007.

STUDY DESIGN

In 2009, we anonymously surveyed 418 Mexican health care providers at the Colegio Mexicano de Especialistas en Ginecologia y Obstetricia meeting using audio computer-assisted self-interview technology.

RESULTS

The majority of respondents were obstetrician gynecologists (376, 90%), Catholic (341, 82%), 35-60 years old (332, 79%) and male (222, 53%) and worked with trainees (307, 74%). Prior to 2007, 11% (46) and 17% (71) provided medical and surgical abortions; now, 15% (62) and 21% (86) provide these services, respectively. Practitioners from Mexico City were more likely to provide services than those from other areas. Most medical abortion providers (50, 81%) used ineffective protocols. Surgical abortion providers mainly used either manual vacuum aspiration (39, 45%) or sharp curettage (27, 32%). Most abortion providers were trained in residency and wanted more training in medical (54, 87%) and surgical (59, 69%) abortion. Among nonproviders, 49% (175) and 27% (89) expressed interest in learning to perform medical and surgical abortion, respectively.

CONCLUSION

Given the interest in learning to provide safe abortion services and the prevalent use of ineffective medical abortion regimens and sharp curettage, abortion training in Mexico should be strengthened.