Analysis of maternal and abortion-related mortality in Mexico over the last two decades, 1990-2008

Relationship Between Abortion at First Pregnancy and Live Births by Young Adulthood: A Population-Based Study Among Mexican Women

STUDY OBJECTIVE

To identify factors associated with having an abortion (spontaneous or induced) at the time of first pregnancy, and to test the association between abortion in the first pregnancy and the number of live births among young women 20-24 years of age.

DESIGN

Cross-sectional study.

SETTING

We used a nationally representative survey of Mexican women 20-24 years of age with data at time of survey and retrospective measures of exposures in adolescence. We include 1913 women who reported ever having a pregnancy.

MAIN OUTCOMES

Our outcomes were history of abortion (spontaneous or induced) and number of live births by 20-24 years of age. We used multivariable logistic regression models to estimate the association between sociodemographic factors at the time of pregnancy and abortion history, and between abortion history and number of live births.

RESULTS

Among women 20-24 years of age who ever had a pregnancy, 15.5% reported an abortion in the first pregnancy, and 84.4% never had an abortion. Among women who had an abortion in the first pregnancy, 62.3% did not report any live birth by age 20-24 years. Young women living with their parents (adjusted odds ratio [AOR] = 1.87; confidence interval [CI] = 1.16-3.02) or with a partner with a higher educational level (AOR = 4.64; CI = 1.05-20.44) had greater odds of having an abortion in the first pregnancy. Compared with women who never had an abortion, women who reported an abortion in the first pregnancy had lower odds (AOR = 0.02; CI = 0.01-0.03) of having 1 or more children by the age of 20-24 years.

CONCLUSION

Young women who reported abortion in the first pregnancy had fewer live births at ages 20-24 years compared to women with no history of abortion.

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.

Abortion exile: navigating Mexico's fractured abortion landscape

This paper develops the concept of 'abortion exile' to understand the situation of women who are forced to travel for abortion services because the procedure is outlawed, stigmatized, unaffordable or otherwise inaccessible in their place of residence. A number of legislative, economic, and moral mechanisms conspire to deny women abortion rights at home such that they must journey within and across national borders in pursuit of needed abortion care. While anthropologists have examined the movement of women and men in search of fertility care that is unavailable at home, attention to the situation of women forced to relocate to terminate an untenable pregnancy is surprisingly scarce. Taking Mexico's fractured abortion landscape as an ethnographic starting place, this paper examines the experiences of women made to venture to the capital for legal abortion services because the procedure is criminalised and difficult to access elsewhere in the country. The concept of 'abortion exile' can helpfully explain the forced movement, political status and subjective experiences of women in different world regions where abortion rights are limited, absent, or under threat, and for whom reproductive citizenship remains elusive.

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.

The prevalence and the reasons of issuing permission for therapeutic abortion in department of forensic medicine, Kermanshah, Iran, during 2005 to 2010

Objective

The present study aimed to investigate the prevalence and the reasons of issuing permission for therapeutic abortion in department of forensic medicine, Kermanshah-Iran.

Results

There were a total number of 428 applications for issuing permits. The most common reasons of issuing permit for therapeutic abortion were fetal and maternal problems, specifically cerebral abnormalities (70.8%), and anencephaly (30.3%). Furthermore, 354 (82/7%) out of 428 applications were able to get the legal permit and 17.3% of the applications did not receive permission, which was mainly due to “the lack of maternal indication”. Increased knowledge of physicians and clinical personnel on indications of therapeutic abortions and related regulations would lead to the implementation of strategies which prevent void referrals to the department of forensic medicine and a better execution of therapeutic abortion law. By improving the health condition of pregnant women who seek pregnancy termination, informing them about indications of therapeutic abortions, and developing proper strategies to make pregnant women more acquainted with legal cases of abortion, we can take a significant step towards helping pregnant women and promoting their health.

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 Legalization and Childbearing in Mexico

In 2007 abortion was legalized in the Federal District of Mexico, making it the largest jurisdiction in Latin America, outside of Cuba, to allow women to have abortions on request during the first trimester of pregnancy. While the implications of the law for women's health and maternal mortality have been investigated, its potential association with fertility behavior has yet to be assessed. We examine metropolitan-area differences in overall and parity-specific childbearing, as well as the age pattern of childbearing between 2000 and 2010 to identify the contribution of abortion legalization to fertility in Mexico. Our statistical specification applies difference-in-difference regression methods that control for concomitant changes in other socioeconomic predictors of fertility to assess the differential influence of the law across age groups. In addition, we account for prior fertility levels and change to better separate the effect of the law from preceding trends. Overall, the evidence suggests a systematic association between abortion legalization and fertility. The law appears to have contributed to lower fertility in Mexico City compared to other metropolitan areas and prior trends. The influence is mostly visible among women aged 20-34 in connection with the transition to first and second child, with limited impact on teenage fertility. There is some evidence that its effect might be diffusing to the Greater Mexico City Metropolitan area.

Measuring progress in maternal and newborn health care in Mexico: validating indicators of health system contact and quality of care

BACKGROUND

The majority of births in Mexico take place in a health facility and are attended by a skilled birth attendant, yet maternal mortality has not declined to anticipated levels. Coverage estimates of skilled attendance and other maternal and newborn interventions often rely on women's self-report through a population-based survey, the accuracy of which is not well established.

METHODS

We used a facility-based design to validate women's report of skilled birth attendance, as well as other key elements of maternal, newborn intrapartum, and immediate postnatal care. Women's reports of labor and delivery care were collected by exit interview prior to hospital discharge and were compared against direct observation by a trained third party in a Mexican public hospital (n = 597). For each indicator, validity was assessed at the individual level using the area under the receiver operating curve (AUC) and at the population level using the inflation factor (IF).

RESULTS

Five of 47 indicators met both validation criteria (AUC > 0.60 and 0.75 < IF < 1.25): urine sample screen, injection or IV medication received during labor, before the birth of the baby (i.e., uterotonic for either induction or augmentation of labor), episiotomy, excessive bleeding, and receipt of blood products. An additional 9 indicators met criteria for the AUC and 18 met criteria for the IF. A skilled attendant indicator had high sensitivity (90.1 %: 95 % CI: 87.1-92.5 %), low specificity (14.0 %: 95 % CI: 5.8-26.7 %) and was suitable for population-level estimation only.

CONCLUSION

Women are able to give valid reports on some aspects of the content of care, although questions regarding the indication for interventions are less likely to be known. Questions that include technical terms or refer to specific time periods tended to have lower response levels. A key aspect of efforts to improve maternal and newborn health requires valid measurement of women's access to maternal and newborn health interventions and the quality of such services. Additional work on improving measurement of population coverage indicators is warranted.

Ideal citizens: the birthing of state truths and fictions in Quintana Roo

Reducing the maternal mortality rate (MMR) is an important part of Mexico's commitment to the Millennium Development Goals, and the country has made great strides towards achieving this goal. However, researchers have questioned to what extent the focus on improved MMR and other indices of maternal health has contributed to an emphasis on improved statistics rather than quality care, and the effect this has had on the quality of reporting. While public health officials and hospital administrators alike agree that improved obstetric reporting is necessary, there is little discussion regarding the accuracy of the data that are submitted and the institutional pressures that may contribute to the production of inaccurate data. Using ethnographic research collected in Tulum, Quintana Roo, this paper explores how biomedical childbirth functions as a source of legitimization for the state while simultaneously providing the means for the presentation of an ideal subjecthood, one that situates birthing women and healthcare personnel as properly attenuated to the norms and needs of the modern Mexican state. By highlighting the point of disjuncture between women's experiences and the formal 'reality' created through hospital texts, this paper explores the place of biomedical birth as a producer of and legitimization for Mexican public health policy.

Abortion legislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: a natural experiment in 32 Mexican states

OBJECTIVE

To test whether there is an association between abortion legislation and maternal mortality outcomes after controlling for other factors thought to influence maternal health.

DESIGN

Population-based natural experiment.

SETTING AND DATA SOURCES

Official maternal mortality data from 32 federal states of Mexico between 2002 and 2011.

MAIN OUTCOMES

Maternal mortality ratio (MMR), MMR with any abortive outcome (MMRAO) and induced abortion mortality ratio (iAMR).

INDEPENDENT VARIABLES

Abortion legislation grouped as less (n=18) or more permissive (n=14); constitutional amendment protecting the unborn (n=17); skilled attendance at birth; all-abortion hospitalisation ratio; low birth weight rate; contraceptive use; total fertility rates (TFR); clean water; sanitation; female literacy rate and intimate-partner violence.

MAIN RESULTS

Over the 10-year period, states with less permissive abortion legislation exhibited lower MMR (38.3 vs 49.6; p<0.001), MMRAO (2.7 vs 3.7; p<0.001) and iAMR (0.9 vs 1.7; p<0.001) than more permissive states. Multivariate regression models estimating effect sizes (β-coefficients) for mortality outcomes showed independent associations (p values between 0.001 and 0.055) with female literacy (β=-0.061 to -1.100), skilled attendance at birth (β=-0.032 to -0.427), low birth weight (β=0.149 to 2.166), all-abortion hospitalisation ratio (β=-0.566 to -0.962), clean water (β=-0.048 to -0.730), sanitation (β=-0.052 to -0.758) and intimate-partner violence (β=0.085 to 0.755). TFR showed an inverse association with MMR (β=-14.329) and MMRAO (β=-1.750) and a direct association with iAMR (β=1.383). Altogether, these factors accounted for (R(2)) 51-88% of the variance among states in overall mortality rates. No statistically independent effect was observed for abortion legislation, constitutional amendment or other covariates.

CONCLUSIONS

Although less permissive states exhibited consistently lower maternal mortality rates, this finding was not explained by abortion legislation itself. Rather, these differences were explained by other independent factors, which appeared to have a more favourable distribution in these states.

Second trimester abortion as a cause of maternal death: a case report

Each year, an estimated 529 000 maternal deaths occur worldwide. In literature, it is known that maternal mortality can occur during pregnancy, peripartum and also in postpartum period. Although very rare, maternal deaths may occur after spontaneous abortion. In present case, 37 year old G5P4 (Caesarean Section) women was admitted to Adnan Menderes University, Obstetrics and Gynecology clinic with diagnosis of missed abortion at 18 weeks' gestation. She had been hospitalized in the public maternity hospital for five days due to abortus incipience and prolapse of amnion membranes but had no contractions. Fetal heart beats ceased at the second day of hospitalization. Medically induced abortion was recommended but not accepted by the patient. At the fifth day of hospitalization, she was referred to our clinic due to deterioration of general health condition, low blood pressure and tachycardia. In emergency department, it was determined that she was not oriented, had confusion, had blood pressure of 49/25 mmHg and tachycardia. In ultrasonographic examination, 18 week in utero ex fetus was determined and there was free fluid in abdominopelvic cavity. The free fluid was suspected to be amniotic fluid due to rupture of uterus. Laparotomy was performed, no uterine rupture, hematoma or atony was observed. However during laparotomy, a very bad smelling odor, might be due to septicemia, was felt in the operation room. Cardiac arrest occurred during that operation. In autopsy report, it was concluded that maternal death was because of remaining of inutero ex fetus for a long time. In conclusion, although very rare, maternal deaths after spontaneous abortion may occur. Because spontaneous abortion is a common outcome of pregnancy, continued careful, strict monitoring and immediate treatment of especially second trimester spontaneous abortion is recommended to prevent related, disappointing, unexpected maternal deaths.

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.

Fundamental discrepancies in abortion estimates and abortion-related mortality: A reevaluation of recent studies in Mexico with special reference to the International Classification of Diseases

In countries where induced abortion is legally restricted, as in most of Latin America, evaluation of statistics related to induced abortions and abortion-related mortality is challenging. The present article reexamines recent reports estimating the number of induced abortions and abortion-related mortality in Mexico, with special reference to the International Classification of Diseases (ICD). We found significant overestimations of abortion figures in the Federal District of Mexico (up to 10-fold), where elective abortion has been legal since 2007. Significant overestimation of maternal and abortion-related mortality during the last 20 years in the entire Mexican country (up to 35%) was also found. Such overestimations are most likely due to the use of incomplete in-hospital records as well as subjective opinion surveys regarding induced abortion figures, and due to the consideration of causes of death that are unrelated to induced abortion, including flawed denominators of live births. Contrary to previous publications, we found important progress in maternal health, reflected by the decrease in overall maternal mortality (30.6%) from 1990 to 2010. The use of specific ICD codes revealed that the mortality ratio associated with induced abortion decreased 22.9% between 2002 and 2008 (from 1.48 to 1.14 deaths per 100,000 live births). Currently, approximately 98% of maternal deaths in Mexico are related to causes other than induced abortion, such as hemorrhage, hypertension and eclampsia, indirect causes, and other pathological conditions. Therefore, only marginal or null effects would be expected from changes in the legal status of abortion on overall maternal mortality rates. Rather, maternal health in Mexico would greatly benefit from increasing access to emergency and specialized obstetric care. Finally, more reliable methodologies to assess abortion-related deaths are clearly required.