By Blair Darney and Lily Alexander
Women in Mexico City have had access to free and legal first-trimester abortion since 2007. During this time the Interrupcion Legal de Embarazo (ILE) program has provided abortion services to over 214,000 women.
However, Mexico City is an exception. In the other 31 states of Mexico, abortion is restricted. Exceptions exist, allowing access to legal abortion where there is a threat to life or health, and in cases of fetal anomaly, and vary by state. These are not implemented to the full extent of the law. The only instance in which abortion is legal at the federal level is in cases of rape.
The combination of stigma, criminalization, and fragmented health information systems in Mexico lead to a lack of data about abortion outside of Mexico City. The little that we do know about abortion in Mexico outside of Mexico City comes from small qualitative studies or indirect estimation techniques. Furthermore, there is no work that quantifies second-trimester abortion in health facilities at the national level in Mexico. Such information would help us understand the extent to which exceptions are used to provide access to second trimester abortion.
Second-trimester abortions occur between 13-24 weeks in a woman’s pregnancy. Our best estimates are that, at a global level, 10% of total abortions occur after 13 weeks. When you consider that there are 42 million abortions performed annually worldwide, 10% is not an insignificant amount. Also, despite being rarer than first-trimester, second-trimester abortions are responsible for the majority of morbidity and mortality, especially in settings where they are illegal and/or unsafe. Women seek second-trimester abortions for a myriad of reasons — late recognition of pregnancy, fear and stigma, diagnosis of fetal anomalies (which typically occurs in the second trimester of pregnancy), lack of sufficient funds, and medical conditions that may develop after the first trimester.
In our new study, published in BMJ Sexual and Reproductive Health, we explored the spatial and temporal landscape of second trimester abortion in health facilities across Mexico. We sought to describe utilization of services, not estimate incidence of second trimester abortion.
In this paper, we used available hospital discharge data for the public sector to examine trends and patterns in utilization of hospital services for second-trimester abortion from 2007 to 2015 throughout Mexico. This hospital discharge data included more than 700 public Ministry of Health hospitals that serve some of Mexico’s most vulnerable communities.
We used International Classification of Diagnosis Codes Version 10 (ICD-10) codes, O02 through O08 of the obstetric chapter, to identify cases of pregnancy that ended in an abortive outcome; we were unable to accurately identify spontaneous versus induced abortion and therefore include all abortive events. We calculated rates of second-trimester abortion, explored spatial variation across Mexico, and examined factors associated with having a second trimester abortion compared with a first trimester abortion. We did not separate induced and spontaneous abortion, as clinical management is the same and some women may begin the abortion process outside of a health facility and then seek care.
We found that second-trimester abortions are happening and make up about 13.5% of total utilization for abortion services over this period (n = 145,050). The annual nation-wide hospitalization rate for second-trimester abortion services remained stable, between 0.5 to 0.6 per 1,000 women of reproductive age (15-44) over the study period. We also observed a lot of heterogeneity throughout the country, with some of the highest rates of utilization of hospital-based, second-trimester abortion services in the Center-North of the country (Zacatecas and Durango), and some of the lowest rates in the Northeastern states of Coahuila, Nuevo León and Tamaulipas.
We hypothesized that states with exceptions for fetal anomalies or health of the woman would have higher rates of abortion, as these states theoretically provide more legal avenues for access. But we found this was not the case: the second trimester abortion rate was not higher in state with exceptions.
However, we did find that age and poverty mattered. Adolescents were more likely to have second-trimester abortions (versus first trimester) than older women. Women living in poorer areas (measured as an index of income and access to services) also had higher odds of presenting later for care.
We also documented an ongoing need for second trimester services in Mexico City. That is, need for second-trimester abortion remains even where first trimester abortion is legal.
Our research finds that there is need for safe, legal second-trimester abortion care in Mexico. Women are presenting to public-sector hospitals for induced, spontaneous, and post-abortion care. Hospitals must be equipped and have trained and willing personnel to care for these women. Lack of second trimester abortion services will exacerbate health disparities since more vulnerable women are more likely to present later for care.
Efforts to expand access to safe, legal abortion must also include full implementation of existing exceptions . Public hospitals in all of Mexico’s 32 states must have personnel and equipment to provide second-trimester abortion care in order to reduce morbidity and mortality from unsafe abortion and provide all women the means to realize their human rights.
Lily T Alexander, Evelyn Fuentes-Rivera, Biani Saavedra-Avendañom, Raffaela Schiavon, Noe Maldonado Rueda, Bernardo Hernández, Alison L Drake, Blair G Darney
Utilisation of second-trimester spontaneous and induced abortion services in public hospitals in Mexico, 2007–2015 was published in BMJ Sexual and Reproductive Health