Unintended Pregnancy And Induced Abortion In Mexico CAUses And ConseqUenCes Suggested citation: Juárez F et al., Unintended Pregnancy and Induced Abortion in Mexico: Causes and Consequences, New York: Guttmacher Institute, 2013. Guttmacher Institute 125 Maiden Lane New York, NY 10038 USA Telephone: 212‐248‐1111; Fax: 212‐248‐1951 E‐mail: [email protected] 1301 Connecticut Avenue NW, Suite 700 Washington, DC 20036 USA www.guttmacher.org El Colegio de México, A.C. Camino al Ajusco 20 Pedregal de Santa Teresa 10740 México, D.F. ©2013 Guttmacher Institute, a not-for-profit corporation that advances sexual and reproductive health and rights through an interrelated program of research, policy analysis and public education designed to generate new ideas, encourage enlightened public debate and promote sound policy and program development. English translation of Embarazo no planeado y aborto inducido en México: causas y consecuencias, ISBN: 978-1-934387-12-2. Cover design: © Emerson, Wajdowicz Studios/NYC/www.designEWS.com Cover photo: © Jean D’Avignon Acknowledgments This report was written by Fatima Juarez, El Colegio de México; Susheela Singh and Isaac Maddow-Zimet, both at the Guttmacher Institute; and Deirdre Wulf, independent consultant. Lisa Remez, independent consultant, edited the report. Kathleen Randall, Guttmacher Institute, supervised layout and production. The report was translated by Xavier González-Alonso. The authors express their gratitude to the following current and former Guttmacher staff members for assisting at various stages of the report: Akinrinola Bankole, Patricia Donovan, Axel Mundigo, Elena Prada and Gustavo Suárez. They also wish to especially thank the following individuals who helped finalize the report: José Luis Palma, Investigación en Salud y Demografía (INSAD); Rafaella Schiavon, Ipas–Mexico; Regina Tamés, Grupo de Información en Reproducción Elegida (GIRE); and Claudia Díaz Olavarrieta, Population Council–Mexico. In addition, the authors are grateful for the insightful comments of the following external reviewers: Prudencia Susana Cerón Mireles, Centro Nacional de Equidad de Género y Salud Reproductiva; Fernanda Díaz de León Ballesteros, GIRE; Vicente Díaz Sánchez, International Planned Parenthood Federation, Western Hemisphere Region; Sandra García, Population Council–Mexico; Silvia E. Giorguli Saucedo, El Colegio de México, Agnès Guillaume, Institut de Recherche pour le Développement, France; José Miguel Guzmán, United Nations Population Fund (UNFPA)–Central Office, New York; Edgar Kestler, Centro de Investigación Epidemiológica en Salud Reproductiva y Sexual, Guatemala; Andrzej Kulczycki, School of Public Health, University of Alabama, Birmingham; Diana Lara, Ibis Reproductive Health; Catherine Menkes, Centro Regional de Investigaciones Multidisciplinarias, Universidad Nacional Autónoma de México; Diego Palacios and Alfonso Sandoval, both at UNFPA–Mexico; José Luis Palma, INSAD; and Cristina Villarreal, Fundación Oriéntame, Colombia. 1 The authors are also grateful to Sandra García, Population Council–Mexico and Claudia Díaz Olavarrieta, Instituto Nacional de Salud Pública (affiliations at the time) for serving as co-researchers in the Health Professionals Survey (HPS) of 2007, which supplied essential data for the estimates presented here. In addition, the authors thank the 132 participating health professionals, medical and nonmedical, for their valuable knowledge of and opinions about induced abortion in the country. The authors are equally grateful to the 16 gynecologists with experience in postabortion care who shared their expertise on the impact of misoprostol on assigning CIE-10 diagnosis codes. Staff from the Dirección General de Información en Salud helped greatly, especially Luis Manuel Torres, who provided guidance on the quality and coding of hospital statistics, and Juan José González Vilchis, who supplied advice on managing the interactive feature of the Web site and answered questions about data quality. Finally, the authors would like to express their gratitude to El Colegio de México for their support of this project. This report was made possible by the contributions of several donors, among them the Population Council–Mexico. The Guttmacher Institute also gratefully acknowledges the general support it receives from individuals and foundations—including major grants from The William and Flora Hewlett Foundation, The David and Lucile Packard Foundation and the Ford Foundation—which undergirds all of its work. 2 Table of Contents Executive Summary 4 Chapter 1: The Uncomfortable Reality of Induced Abortion 8 Chapter 2: The Practice of Abortion in Mexico 21 Chapter 3: Consequences of Unsafe Abortion 31 Chapter 4: Unintended Pregnancy and Induced Abortion 42 Chapter 5: Factors Associated with the Risk of Unintended Pregnancy 59 Chapter 6: Implications and Recommendations 70 References 79 Appendix Tables 92 3 Executive Summary Examining the hidden and stigmatized practice of induced abortion is very hard to do. Throughout the Mexican Republic’s 31 states, induced abortion is highly restricted. (The exception is the capital, the Federal District, which decriminalized first-trimester abortions in 2007.) This report presents estimates of induced abortion for 2009, by the country’s 32 entidades federativas (or federative entities) and by the woman’s age. The report also examines what causes women to resort to abortion in the first place— unintended pregnancy. Progress has been made on many fronts  As of 2009, a high proportion of Mexican women in union (formal and consensual) practice contraception—67% use a modern method and another 5% rely on a less effective, traditional method.  Widespread use of contraceptives has been an essential factor underlying the country’s rapid decline in fertility: Average family size, which has been falling steadily over the past two decades, is now nearly at replacement level of two children per woman.  A breakthrough occurred in 2007 when the Federal District allowed legal interruptions of pregnancy (known by the Spanish acronym, ILE) in the first trimester. Thus, because of strict safety protocols instituted by the Ministry of Health of the Federal District, women who used the Federal District’s abortion services had almost no risk of complications in the year roughly corresponding to our estimates. Unintended pregnancy remains widespread  Behind almost every induced abortion is an unintended pregnancy. As of 2009, more than half—55%—of all pregnancies in Mexico are estimated to have been unintended.  Categorizing the country’s 32 federative entities into six regions by level of development shows that Mexico fits established patterns where levels of unintended pregnancy are highest in the most developed and urbanized areas: An estimated 70% of pregnancies are unintended in the most-developed region (Federal District; Region 1), compared with 45% in the least-developed region (Chiapas, Guerrero and Oaxaca; Region 6). 4  Each year, 71 unintended pregnancies occur per 1,000 women of reproductive age, a rate that is virtually the same as that estimated for all of Latin America and the Caribbean (72 per 1,000 women). Many unintended pregnancies end in induced abortion  Legally restricting abortion does not prevent it from happening. More than half (54%) of all unintended pregnancies in Mexico are estimated to end in an induced abortion, despite it being legally restricted in 31 of the 32 federative entities.  This translates to more than one million (1,026,000) induced abortions taking place each year, for a rate of 38 per 1,000 women aged 15–44. The abortion rate increases uniformly as the level of development rises, from 26 procedures per 1,000 women in Region 6 (the least-developed region) to 54 per 1,000 in Region 1 (the most-developed region).  As of 2009, Mexico’s rate of abortion had increased by more than half since 1990, when it was 25 per 1,000. This increase over time in the rate (which is not affected by population growth) suggests that women are having a harder time now avoiding unintended pregnancy and are also more motivated to avoid having unplanned births.  Abortion estimates by age (the first time such estimates have been made for Mexico) show an expected pattern whereby the rate peaks among women in their early 20s (at 55 per 1,000 20–24-year-olds), and then gradually declines with age. Unfortunately, adolescents aged 15–19 share the second-highest rate with women aged 25–29 (44 abortions per 1,000 women).  By federative entity, the Federal District, as the most developed part of the country, unsurprisingly has one of the highest abortion rates (54 per 1,000). The Northern state of Nuevo León, on the other hand, has the lowest (17 per 1,000), possibly reflecting both a very low unmet need for contraception and travel across the U.S. border for safe, legal procedures. Clandestine abortions endanger women’s health and use up scarce health resources  An induced abortion performed outside the law is often unsafe. Government hospital data clearly show the toll on women’s health and facilities: In 2009, some 159,000 women nationally were treated for complications of an induced abortion in public-sector hospitals alone. 5  More than one-third of all women having an induced abortion (36%) are estimated to develop complications that need medical treatment. The proportion of abortions accompanied by complications is highest—at 45%—among those obtained by poor rural women.  Unfortunately, one-quarter of all Mexican women experiencing abortion complications do not obtain the treatment they need, making them especially likely to suffer debilitating health consequences. The risk of complications is tied to how an abortion is performed and by whom  An estimated one in every three abortions is induced through the drug misoprostol. That some 39% of these procedures are thought to lead to complications requiring treatment likely reflects providers’ and women’s inadequate knowledge and use of misoprostol.  For abortions not involving misoprostol, the safest ones are the surgical procedures performed by doctors (accounting for 23% of all abortions); the least safe are those that are self-induced with a method other than misoprostol (16% of all abortions, but 24% of those among poor rural women). Action is needed to improve women’s health and lives The recent rise in the rate of abortion points to the need for concerted efforts to help Mexican women better prevent the unintended pregnancies that lead to abortions. Below are some suggestions to help alleviate unsafe abortion’s burden on women and the medical system. We also propose some recommendations for improving the provision of legal procedures and for reducing unintended pregnancy. Strengthen contraceptive services. Women need better information about correct and consistent use of contraception. To prevent unintended pregnancies and abortions, the 12% of women in union with an unmet need for contraception plus the 5% using traditional methods should start using a highly effective method that fits their personal preferences and situation. Tailored interventions are needed to help the group at highest risk for unwanted pregnancy—young women aged 15–24, in union and never married (both those with past sexual experience and currently sexually active). A high proportion 6 of these women are not using a contraceptive method despite not wanting to become pregnant soon, which signals the need for more information about effective contraception and better services. An improved understanding of temporary methods and better access to them would help these young women prevent unintended pregnancy and thus enable them to more precisely plan and time their births. Improve postabortion services. The coverage of postabortion services needs to be extended and their quality improved. Providers need more accurate information about caring for women who have used misoprostol; they also need training in treating complications with manual vacuum aspiration, a technique far less invasive and less resource-dependent than the widely used dilation and curettage. Contraceptive services, including counseling, need to be made a standard feature to prevent repeat abortion. Improve provision of legal abortions. Public education campaigns are essential to spread awareness of each federative entity’s conditions for legal abortion. Mechanisms to assure that women can actually get the legal abortions that they qualify for are also vital, along with the political will to put them into place. All 32 entity-level ministries of health, which are directly responsible for providing and funding care, should take the opportunity to use these newly available data to guide improvements in contraceptive and postabortion care in their respective jurisdictions. 7 Chapter 1: The uncomfortable reality of induced abortion Throughout the world, women cope with pregnancies that come too soon or are not wanted at all. In each country, the specific cultural, legal, economic and health-services context influences women’s ability to avoid unintended pregnancy and mediates their response if they experience one. Mexico is no exception. Despite induced abortion being highly legally restricted in all 31 states (but not in the Federal District), hundreds of thousands of Mexican women resolve unintended pregnancies through abortions each year. Because the Federal District is the sole area where pregnancy terminations are legal under broad criteria, almost all terminations occurring elsewhere in the country are practiced clandestinely, and many are carried out in unhygienic settings using unsafe methods. Unsafe abortion can have serious consequences for a woman’s health and a strong adverse impact on her household and community. Abortions that are performed with dangerous methods or by unskilled practitioners often lead to health complications, whose treatment uses up scarce hospital resources.1 Over the past 15 years, the growing use of a relatively inexpensive and accessible pill that causes abortion, misoprostol, has substantially changed the practice of induced abortion in Mexico. Misoprostol was originally developed to prevent gastric ulcers, but its off-label use for ending pregnancy is widely known to be effective.2–4 However, the pill’s efficacy at inducing abortion depends on it being used correctly—that is, that it be taken at the appropriate time in pregnancy, at the correct dosage and with accurate instructions. Unfortunately, such correct practices cannot be assured in Mexico, where misoprostol is usually taken clandestinely. 8