Date Published: February 7, 2018
Publisher: Public Library of Science
Author(s): Biani Saavedra-Avendano, Raffaela Schiavon, Patricio Sanhueza, Ranulfo Rios-Polanco, Laura Garcia-Martinez, Blair G. Darney, Cassandra Nichole Spracklen.
To identify socio-demographic factors associated with presenting for abortion services past the gestational age (GA) limit (12 weeks), and thus not receiving services, in Mexico City’s public sector first trimester abortion program.
We used clinical data from four high volume sites in the Interrupción Legal de Embarazo (ILE) program, 2007–2015. We used descriptive statistics to quantify the proportion of women who did not receive an abortion due to presenting past the gestational age limit. We used multivariable logistic regression to identify associations between women’s characteristics and presenting past the GA limit and calculated predicted probabilities of late presentation for key characteristics.
Our sample included 52,391 women, 8.10% (n = 4,246) of whom did not receive abortion services due to presenting past the GA limit. Adolescents (12–17) made up 8.69% of the total sample and 13.40% of those presenting past the GA limit (p< 0.05). In multivariable analyses, all age groups of adult women had significantly lower odds than adolescents of presenting past the limit (aOR = 0.77, aOR = 0.63, aOR = 0.58 and aOR = 0.37 for 19–24, 25–29, 30–39, and > = 40 years’ old respectively). Women living in Mexico City and with higher levels of education had lower odds of presenting past the GA limit, and there was an educational gradient across all age groups. In the multivariable predicted probability models, adolescents at every level of education have significantly higher probabilities of not receiving an abortion due to presenting past the gestational age limit compared with adults (among women with a primary education: 11.75% adolescents vs. 9.02–4.26% across adult age groups).
Our results suggest that continued efforts are needed to educate women, especially younger and less educated women, about early pregnancy recognition. In addition, all women need information about the availability of first trimester legal abortion to ensure timely access to abortion services.
Access to legal and safe abortion services is crucial to reducing abortion-related morbidity and mortality and expanding human rights . In Mexico, abortion law is determined at the state level; first trimester abortion was decriminalized in Mexico City, one of Mexico’s 32 states, in 2007. First trimester abortion remains highly restricted in Mexico’s other 31 states. In Mexico City, legal abortion services are available in public and private sectors. The public sector abortion program, called “Interrupcion Legal de Embarazo” (ILE) , has provided services for over 188,000 women since program inception in 2007 . In order to receive abortion services women must present official identification, and adolescents (under 18 years old) must be accompanied by a parent or guardian. Women who present for care past 12 weeks’ gestational age (GA) are not eligible to receive services in the ILE program, and second trimester abortion is available only under narrow exceptions requiring documentation (rape, danger to the woman’s life and congenital malformations) .
We conducted a retrospective cohort study using clinical data from four public facilities in the Mexico City ILE program: two primary care clinics and two hospital-based clinics. We generated a database pooling information from two sources: a) an existing electronic database containing information from paper medical records of women who requested abortion services from 2008 to 2012 in two ILE clinics (n = 43,139); and b) a database created by our research team with information extracted from paper medical records between 2007 and 2015 in two hospitals with high ILE volume (n = 11,938). Hospital chart abstractors were trained by the study team how and where to identify relevant information within the chart. The study team developed a web-based platform to capture the data and data were downloaded daily. We performed a 5.00% random re-abstraction of charts and data quality validation exercise to assess the quality of the data abstracted from paper charts, which included all records from the hospital- based clinics (n = 11,938). Overall inter-rater reliability was high, with an average concordance of 95.51% and an average kappa value of 0.93 (S1 Table).
Our final analytical sample included 52,391 women. Overall, 8.10% (n = 4,246) did not receive abortion services due to presenting past the gestational age limit. Of the 91.90% women who received the abortion they sought, 77.70% had a medication and 22.30% an aspiration abortion. Adolescents (12–17) made up 8.69% of the overall sample. Just over 41.87% of women were never married, 29.02% resided outside of Mexico City (23.90% in state of Mexico and 5.12% were from other states), and 36.86% had not experienced a pregnancy previous to the one they were seeking to terminate (Table 1).
We report important disparities in who presents past the gestational age limit, and is thus not able to receive services, in the public legal abortion program in Mexico City (ILE). These disparities in late presentation translate directly into disparities in obtaining wanted abortion services. Adolescent age, lower educational level, and residing outside of Mexico City were associated with presenting for ILE services past 12 weeks’ GA. Local evidence from low and middle income countries about which women seek care past the GA limit can be used for education and advocacy to develop target interventions to both ensure that all women of reproductive age are aware of the availability of legal first trimester abortion and the GA limit, and facilitate early entry into care, especially for adolescent women.