Understanding health providers’ experiences with legal abortion in Mexico has helped overcome obstacles to implementing the new abortion legislation and expanding access to safe abortion.
In 2007, Mexico City became the only state in Mexico to permit elective first-trimester abortion. Abortion services became available free of charge for Mexico City residents and, for a small fee, for women from other states in Mexico and other countries in the region. However, decriminalization of elective abortion did not automatically mean that quality services were available when needed. Implementing the new law posed a significant challenge to the health care infrastructure, which was initially unprepared for the influx of thousands of women seeking safe, legal abortions in Mexico City’s public facilities.
Because abortion is legal in Mexico City only up to 12 weeks (with gestational age determined by ultrasound), it is essential that women can access services promptly. The Population Council examined health providers’ opinions of and experiences with providing legal abortion services to inform improvements and streamline service provision.
Shortly after implementation of the Mexico City law, Population Council researchers conducted in-depth interviews with 64 health care providers in 12 public hospitals and one health center where abortion is offered. Interviewees included ob/gyns who were participating in the program as well as conscientious objectors, nurses, social workers, hospital administrators, counselors, anesthesiologists, receptionists, and two key decisionmakers in the Mexico City Ministry of Health.
Half of the providers were in favor of the Mexico City law at the time of the interview. Others had mixed feelings about the new law, especially during the first months of implementation. Although they acknowledged the law would benefit women, some expressed concern about women seeking repeat abortions and using abortion as a contraceptive method. Similarly, while nearly one-third (30%) supported the law’s provision that abortion services for Mexico City residents should be free, some 38% felt a fee for services should be imposed, to offset the costs of the program and to create a deterrent against repeat abortions (33% did not respond).
For most participants, legislative approval of the new abortion law came unexpectedly, and they felt unprepared to meet the demand for services. Providers generally agreed with having the right to conscientious objection, but this also created problems as many hospitals had only one (or no) gynecologist willing to perform the procedure. The workload for providers participating in the program increased enormously, and some also noted a lack of appropriate space and supplies (such as misoprostol for medication abortions, instruments for manual vacuum aspiration, and anesthetic medication for dilation and curettage) for abortion provision in the first months after the law was passed.
Over time, a number of steps have relieved some of the pressure on health care providers and enabled more women to obtain safe, legal abortion services. In the first year following the law’s passage, the Mexico City Ministry of Health hired additional personnel, particularly non-objecting ob-gyns, and together with the Alliance for the Right to Decide provided training for hospital personnel on technical, legal, and ethical aspects of abortion provision.
Health care professionals who supported legal abortion services also began to form hospital-based teams, which helped them provide higher quality services and helped team members deal with societal and colleague-based prejudice as well as their own ambivalence toward abortion.
With input from several NGOs, the Ministry of Health defined a standardized regimen for use of misoprostol for women seeking abortion before nine weeks. Some providers felt that the expanded use of misoprostol reduced the number of conscientious objectors, because misoprostol is an indirect method and involves less intervention. More recently, the Ministry of Health adopted the buccal regimen of mifepristone plus misoprostol for medication abortion, and home administration is becoming more common among women attending MOH facilities.
In addition, while initially only obstetrician/gynecologists were permitted to perform abortions in Mexico City, with expanded availability of medication abortion general practitioners are now permitted to provide services. Results from a WHO-funded study the Council is conducting in partnership with the National Institute of Public Health will inform policy to allow task-sharing so that nurses can provide MA, thereby expanding access to abortion for women less than 12 weeks pregnant.