Decriminalization of Abortion in Mexico City: The Effects on Womens Reproductive Rights

In April 2007, the Mexico

City, Mexico, legislature

passed landmark legisla-

tion decriminalizing elec-

tive abortion in the first 12

weeks of pregnancy.

In Mexico City, safe abor-

tion services are now avail-

able to women through the

Mexico City Ministry of

Healths free public sector

legal abortion program and

in the private sector, and

more than 89 000 legal abor-

tions 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 back-

lash against the legislation

in 16 states.

MexicoCitysabortionleg-

islation is an important first

step in improving reproduc-

tive rights, but unsafe abor-

tions will only be eliminated

if similar abortion legislation

is adopted across the entire

country.(AmJPublicHealth.

Published online ahead of

print February 14, 2013:

e1e4. doi:10.2105/AJPH.

2012.301202)

Davida Becker, PhD, and Claudia Daz Olavarrieta, PhD

IN APRIL 2007, THE MEXICO

City, Mexico, legislature passed landmark legislation decriminal- izing elective abortion in the first 12 weeks of pregnancy. The law included a provision that abortion services be available to women at Mexico City (Dis- trito Federal) Ministry of Health (MOH-DF) facilities in the city, free of charge for Mexico City residents and on a sliding fee scale for those outside Mexico City. In addition, the law strength- ened sexual education curricula in schools and called for wide- spread access to contraceptive methods. Shortly after being passed, the law was challenged in the Mexican Supreme Court by groups opposed to the legis- lation, but in August 2008, the Supreme Court voted to uphold the law.1,2

In Mexico, abortion laws are made at the state level, and be- fore this reform, across all of Mex- icos states and in the Federal District (or Mexico City, the cap- ital), abortion was permitted un- der very limited circumstances such as in cases of rape, fetal malformation, or when the sur- vival or health of a woman was in danger. Even when abortions were legally permitted, however, numerous barriers made access- ing a legal abortion extremely dif- ficult.3,4 Despite these barriers, abortion was commonly prac- ticed. One study estimated the induced abortion rate in Mexico in 2006 to be 33 abortions per 1000 women aged 15 to 44 years, a comparatively high rate by global standards.5 However,

because of the legal restrictions, the vast majority of abortions in Mexico took place clandestinely, often in unsafe circumstances, sometimes causing severe health consequences for women. From 1990 to 2008, 7.2% of all ma- ternal deaths in Mexico were abortion-related.6 Another study estimated that in 2006, 149 700 women were hospitalized from complications following induced abortions nationally.5

Inequity was an important di- mension of unsafe abortion in Mexico. A study that used data from the 2006 Mexican National Demographic Survey found the risk of having an unsafe abortion was highest for poor women, those with low levels of education, and those who belonged to indigenous groups.7 The abortion reform in Mexico City responded to the gravity of this public health prob- lem, delivering a major victory for womens reproductive rights by departing from the restrictive abortion laws in the rest of the country.

The Mexico City abortion law reform is significant not only for Mexico, but also for the entire Latin American and Caribbean region, which continues to have some of the most restrictive abor- tion laws globally. Virtually all abortions (95%) in the Latin American and Caribbean region are unsafe, and unsafe abortions cause an estimated 12% of all maternal deaths.8,9 Only a few countries and territories in this region have progressive abortion legislation, including Cuba, Guyana, Puerto Rico, and Uruguay, where

first-trimester abortion was decriminalized in 2012.10,11

We describe developments since this landmark reform was passed, both in Mexico City and in the states of Mexico. We highlight the development of the public sector legal abortion program by the MOH-DF, in- cluding important trends in this program. We also discuss the backlash that has occurred since abortion decriminalization.

DEVELOPMENTS IN MEXICO CITY SINCE DECRIMINALIZATION

Shortly following the abortion decriminalization decision, the MOH-DF established a public sector legal abortion program to provide abortion services. This program is operated by the MOH-DF at select facilities. Fed- eral MOH facilities and other state-funded health facilities in Mexico City are not legally obli- gated to offer abortion services, only the MOH-DF. Therefore, clients who regularly attend these facilities must attend MOH-DF facilities if they wish to obtain a public sector legal abortion.12

The MOH-DF legal abortion program began in 14 hospitals, and in its first year, more than 7000 women received legal abor- tion services.12 As of October 31, 2012, a total of 89 510 abortions have been performed.13 By con- trast, in the period before the legalization decision, between 2001 and 2007, just 62 legal abortions were carried out in Mexico City.14 Most women who

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have obtained the services are adults between the ages of 18 and 29 years; just 5.5% of the clients have been minors. Fifty percent are married or in civil unions, and two thirds already have one or more children. The majority of clients (82.6%) are Catholic.13

Over time, the program has evolved in several ways. One change has been toward the use of safer abortion methods for first-trimester procedures. In the first year of the program, a siz- able percentage of abortions were performed with the surgical abor- tion method, dilation and curet- tage (D&C), which is no longer recommended by the World Health Organization for first- trimester abortions because it has higher rates of medical com- plications than other methods. Gradually, the MOH-DF has vir- tually eliminated use of D&C for first-trimester abortions and now nearly all abortions are medical abortions or surgical abortions performed by using manual vac- uum aspiration. Between 2007 and 2011, the percentage of medical abortions increased from 24.7% to 74.2%.15 The high use of medical abortions has been an important factor enabling the program to increase client vol- ume and safety, which has been critical with the high demand for these services.12 With medical abortions, women self-administer the abortion pills in the privacy of their own home. Until recently, the regimen used for medical abortions was misoprostol alone, because the gold-standard drug, mifepristone, was not available in Mexico. In 2011, mifepristone was commercially registered in Mexico and the MOH-DF has since incorporated a mifepristone— misoprostol regimen for medical abortions into public sector services.

This regimen is more efficacious and causes fewer side effects.16

Another trend has been to- ward the delivery of services at the primary level, in specialized health centers.15 These special- ized health centers are dedicated to providing abortion as well as related reproductive health care. The centers are used exclusively for these services, and the clinical and support staff are hired spe- cifically because they support abortion services. At the start of the program, conscientious ob- jection of providers and support staff was an obstacle at many MOH-DF hospitals.17 This prob- lem was overcome after the MOH-DF clarified the guidelines on conscientious objection and hired additional nonobjecting providers to perform abortions. The decision to open specialized health centers with nonobjecting providers was also in response to this challenge.12 The first spe- cialized primary-level center was opened in 2008; two other centers have since opened. Over time, the MOH-DF has shifted the majority of its abortion ser- vices to these health centers, which are able to attend high client volumes at low costs and provide high-quality services in a sensitive environment. The centers are spacious with design features to help women feel com- fortable. At one of the centers, soft relaxing music is played in the waiting area, a television is placed in the recovery area, and tea and other drinks are made available to women postprocedure.12

As part of the 2007 law reform, the MOH-DF program provides women with free postabortion contraceptive services and coun- seling, in addition to clinical abortion services.18 The rate of acceptance of postabortion con- traception has been more than

80% in several studies,18,19 with high percentages of women accepting intrauterine devices (IUDs)between 42% and 63%, depending on the study.18,19 The high rate of acceptance of post- abortion IUDs is a positive find- ing as IUDs are among the most long-acting and effective methods for preventing unintended preg- nancy. This may be an underlying factor contributing to the low rate of repeat abortions. Data from October 31, 2012, indicate that the percentage of clients obtain- ing a repeat abortion was just 2.09%.13

Delivering high-quality, client- centered services is a central con- cern for any new program. Re- search has found high levels of client satisfaction with the MOH-DF services.1921 Studies have found high percentages of clients report- ing respectful treatment from the staff, adequate information provi- sion, sufficient pain control, and respect for privacy,19,21 all central elements of high-quality abortion services.22 Although there are areas for improvement, such as reducing the long waiting times, strengthening referrals between sites, and providing additional psychosocial support for those who desire this, the picture overall has been very positive.1921

The current evidence suggests that the MOH-DF legal abortion program is providing high-quality and acceptable services to clients, and that the majority of clients are receiving not only high-quality clinical care, but also postabortion contraceptive services and coun- seling to enable them to avoid future unintended pregnancies. Furthermore, the MOH-DF is undertaking steps to increase service availability. In 2012, the MOH-DF completed a random- ized controlled trial comparing the effectiveness of nurses to

physicians for administering medical abortions. It is hoped that evidence from this trial will help support modifications to the current norms and guidelines to allow midlevel providers to perform medical abortions. Cur- rently, only doctors are autho- rized to provide abortion services.

In addition to the MOH-DF public sector abortion program, abortion services in Mexico City are also available in the private sector. However, very limited in- formation exists on private sector abortion care, as the MOH-DF is not systematically monitoring abortions in private facilities.18 A study conducted in 2008 with 135 physicians working in private clinics found that on average just three abortions were conducted per facility each month, with many physicians only providing these services for their existing patients. Furthermore, 71% of providers performed first-trimester abortions with the surgical method of D&C, which is no longer rec- ommended clinical care. More- over, pain control methods were problematic, with a high percentage using general anesthesia, which is not recommended, or offering no pain management at all. Pro- cedure costs were also high.23

It is unclear how generalizable these results are to private sector abortion providers in Mexico City broadly, but the results suggest that the quality of care in the private sector may be of concern.

Public opinion research in Mexico City has revealed that support for the abortion legisla- tion has grown over time. In 2007, immediately before the reform was passed, only 38% of adults surveyed in Mexico City supported the proposed abortion legislation, but two years later, in 2009, public support for the

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abortion law had increased to 74%.24 The existence of a free public sector abortion service is important not only in creating access to safe abortion services for those with limited resources, but also in legitimizing and destig- matizing abortion. It is significant and meaningful to women and society for abortions to be pro- vided openly in public sector facil- ities. Although there are areas for improvement with respect to the availability of services, and a need for better training and monitoring of providers in the private sector, women have al- ready benefitted from the abor- tion reform in Mexico City.

Because the MOH-DF services are available to women from outside Mexico City on a sliding fee scale, some nonresident women have been able to access safe abortion services in Mexico City. Statistics for MOH-DF services indicate that 26.8% of all clients obtaining abortion services were nonresidents, with 23.5% of all clients from the neighboring state of Mexico, and just 3.3% from other states in Mexico or other countries.13 The Maria Abortion Fund for Social Justice is an ad- vocacy organization founded in 2009 to support women from the states of Mexico to travel to Mexico City to access legal abor- tions. To date, this fund has paid for food, lodging, or transportation for more than 1000 women who traveled to Mexico City for a legal abortion,12 but the vast majority of women in the states of Mexico remain without access to safe and legal abortion services.

STATE-LEVEL DEVELOPMENTS SINCE DECRIMINALIZATION

Womens and human rights advocates and other progressives

had hoped the Supreme Court ruling would lead to the passage of similar progressive abortion legislation in other states of Mex- ico, but this has not occurred and abortion continues to be highly restricted in every state through- out Mexico. Currently, the only circumstance for which abortion is legal across all 31 states is in cases of rape. Abortion is permit- ted when the life of a woman is at risk in 27 states, in cases of severe fetal malformation in 13 states, and when the health of a woman is at risk in 12 states, in addition to a few other minor legal clauses. In one state, Yuca- tan, abortion is also permitted for economic reasons.25

Furthermore, there has been a conservative backlash in 16 of Mexicos states (more than half of the states) where amendments have been passed to the states constitutions recognizing a right to life that begins at the moment of conception.25 These amend- ments were passed in rapid suc- cession following the abortion law reform in Mexico City.26

Research in 2008 in eight states where amendments had been recently passed or were under consideration found low public awareness about them; only 23% of surveyed adults were aware of their states reforms or initia- tives.27 The constitutionality of two of these state amendments was challenged before the Mexican Supreme Court, but the Supreme Court upheld both amendments in 2011.26 The amendments are intended to block future pro- gressive abortion legislation from being passed. They also jeopardize current legal excep- tions under which abortion is permitted, and possibly the IUD and in-vitro fertilization. In ad- dition, the amendments have created confusion among health

care providers and women re- garding the legal status of abor- tion, and resulted in increased prosecutions of women for illegal abortions.26

CONCLUSIONS

In Mexico City, the political will to address the problem of unsafe abortion has resulted in a strong implementation effort and a public sector program that has already had clear benefits for women. However, unsafe abor- tions are unlikely to be com- pletely eradicated in Mexico City in the near future. Factors such as persistent stigma, fear, and lack of knowledge about the services may lead some women to con- tinue to terminate pregnancies unsafely rather than use safe public or private services.28 Fur- thermore, because of the gesta- tional age limit of the law (up to 12 weeks), women who seek abortions in the second trimester of pregnancy are not eligible for a legal abortion except in a few limited circumstances,25

and may continue to use unsafe procedures with devastating consequences.29 Nevertheless, because of the strong implementa- tion effort and the high quality of services, we expect this program will lead to significant reductions in unsafe abortion in Mexico City. Unfortunately, data are not yet available to evaluate the health impacts of the reform.28

Although Mexico Citys abor- tion legislation is an important first step to improve womens repro- ductive health and rights in Mex- ico, the continued restrictive abortion legislation in the states of Mexico and the conservative backlash will likely result in the persistence of unsafe abortions in Mexicos states and the crimi- nalization of women who seek

abortions. To end unsafe abor- tions and ensure equal access to reproductive rights and health for all Mexican women, similar abortion legislation is needed across the entire country. j

About the Authors Davida Becker is with the Institute for Health Promotion and Disease Prevention Research, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles. At the time this study was conducted, Claudia Daz Olavarrieta was with the National Institute of Public Health, Tlalpan, Mexico. Correspondence should be sent to Davida

Becker, Postdoctoral Fellow, Institute for Health Promotion and Disease Prevention Research, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, 2001 N Soto St, Los Angeles, CA, 90032-3628 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the Reprints link.

This commentary was accepted December 21, 2012.

Contributors D. Becker wrote the first draft of the article. C. Daz Olavarrieta contributed to the review and editing of the article.

Acknowledgments We would like to thank James P. Thing for his insightful comments on an earlier draft of the article.

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