Ile book eng 2apr14 by rafael gamboa

Presented by: The Mexico City Ministry of Health In collaboration with: Marieke van Dijk and the National Pro-Choice Alliance

* A quotation from a presentation by Leticia Bonifaz, General Counsel for Mexico City, titled â&#x20AC;&#x153;The Legal Abortion Program as a guarantor for the reproductive rights of womenâ&#x20AC;? given at the Research Meeting: Contributions to research after four years of implementing legal abortion services, held in Mexico City on March 17, 2011.

Establishing the Legal Abortion Program in Mexico City: “An Island of Liberties”*

Images by Paola Roblesgil-Renovales ÂŠ Book Cover: Mexico City - Rick Mendoza ÂŠ All Rights Reserved. First Edition. Any part of this publication, including the cover design, may not be reproduced, stored or transmitted in any form or by any means without prior permission of the authors. Printed in Mexico.

Table of contents

List of Abbreviations Introduction Acknowledgements

7 11 15

1. The problem of unsafe abortion

2. The decriminalization of first-trimester abortion in Mexico City History of abortion leading up to the decriminalization Political opportunity in 2007 April 24th, 2007, a new abortion law in Mexico City Unconstitutionality claims and the SCJNâ&#x20AC;&#x2122;s decision

25 25 28 30 31

3. Challenges and opportunities during the first year of the LA program Mexico City MOH preparations prior to the reform A challenging start Clarification of the right to conscientious objection Issuing the procedural guidelines and manual Standardization of the medical abortion regimen Multidisciplinary trainings Human and materia resources The official registry for legal abortion Information on legal abortion services for women and men Facilitating access for women from other states Managing the anti-choice groups The private sector services

35 36 38 40 41 41 44 46 47 47 49 50 51

4. Towards a new model of LA service provision The opening of health centers offering comprehensive sexual and reproductive health services The introduction of mifepristone The legal abortion service model Characteristics of the women accessing the services Sexual and reproductive health campaign Building evidence and sharing the experience

57 57

5. Looking forward: the future of the LA program

6. The effect of the law reform and the implementation of the LA program Improved health Improved access Improved contraceptive use Lower costs

Positive effect on public opinion Conclusions

60 60 70 76 76

89 89 91 92 93 93 97

List of Abbreviations ALDF Federal District Legislative Assembly (Asamblea Legislativa del Distrito Federal) Alternativa Social Democratic Party (Partido Alternativa Socialdemócrata) Andar National Pro-Choice Allliance (Alianza Nacional por el Derecho a Decidir) BVA Beatriz Velasco de Aleman Health Center CAM Center for Support of Latin American Women (Centro de Apoyo a la Mujer Latinoamericana) CDD Catholics for Choice (Católicas por el Derecho a Decidir) CDHDF The Human Rights Commission of Mexico City (Comisión de Derechos Humanos del Distrito Federal) CIPA Center for Couples’ Integral Care (Centro de Atención Integral a la Pareja) CLACAI Latin America Consortium Against Unsafe Abortion (Consorcio Latinoamericano Contra el Aborto Inseguro) CNDH The Mexican National Human Rights Commission (Comisión Nacional de los Derechos Humanos de México) COFEPRIS Mexican Federal Regulatory Drug Agency (Comisión Federal para la Protección contra Riesgos Sanitarios) Colmex The College of Mexico (Colegio de México) D&C Dilation & Curettage Ddeser Network for Sexual and Reproductive Rights in Mexico (Red por los Derechos Sexuales y Reproductivos en México) Equidad Gender Equality: Citizenship, Work and Family (Equidad de Género: Ciudadanía, Trabajo y Familia) ESAR Foundation Education for Reproductive Health Foundation (Fundación Educación para la Salud Reproductiva) EVA Electrical Vacuum Aspiration FIGO International Federation of Gynecology and Obstetrics (Federación Internacional de Ginecología y Obstetricia) FLASOG Latin America Federation of Obstetrics & Gynecological Societies (Federación Latinoamericana de Sociedades de Obstetricia y Ginecología) GBV Gender-Based Violence GIRE Information Group on Reproductive Choice (Grupo de Información en Reproducción Elegida)

HIV Human Immunodeficiency Virus HPV Human Papilloma Virus ICD International Classification of Diseases ICMA International Consortium for Medical Abortion IFE Mexican Federal Electoral Institute (Instituto Federal Electoral) ILE Legal Termination of Pregnancy (Interrupción Legal del Embarazo) IMSS Mexican Social Security Institute (Instituto Mexicano del Seguro Social) INSAD Research on Health and Demographics (Investigación en Salud y Demografía) INSP National Institute of Public Health of Mexico (Instituto Nacional de Salud Pública) IPPF International Planned Parenthood Federation ISSSTE Institute for Social Security and Services for State Workers (Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado) IUD Intrauterine Device IUSSP International Union for the Scientific Study of Population LA Legal Abortion KAP Knowledge, Attitudes, and Practices LAC Latin America and the Caribbean MDG Millennium Development Goals Mexfam Mexican Foundation for Family Planning (Fundación Mexicana para la Planeación Familiar) MOH Mexico City Ministry of Health (Secretaría de Salud del Gobierno del Distrito Federal) MSI Marie Stopes International MVA Manual Vacuum Aspiration NAF National Abortion Federation NGO Nongovernmental Organization PAC Post-Abortion Care PAN National Action Party (Partido Acción Nacional) PATH Program for Appropriate Technology in Health PEMEX State-Owned Mexican Oil Company (Petróleos Mexicanos) PPFA Planned Parenthood Federation of America PRD Party of the Democratic Revolution (Partido de la Revolución Democrática) PRI Institutional Revolutionary Party (Partido Revolucionario Institucional)

PVEM Ecological Green Party of Mexico (Partido Verde Ecologista de México) RNCJDD Catholic National Youth Network for the Right to Decide Red Nacional Católica de Jóvenes por el Derecho a Decidir) SCJN National Supreme Court of Justice (Suprema Corte de Justicia de la Nación) SEDENA Mexican Ministry of National Defense (Secretaría de la Defensa Nacional) SINAIS National System of Information on Health (Sistema Nacional de Información en Salud) STI Sexually Transmitted Infections ToT Training of Trainers UNAM National Autonomous University of Mexico (Universidad Nacional Autónoma de México) WHO World Health Organization

â&#x20AC;&#x153;Justice has been done for health and gender equity. It is a victory for Mexico and principally for women.â&#x20AC;? Dr. Manuel Mondragon y Kalb, former Mexico City Minister of Health.

Introduction

On April 24 2007, a landmark legal reform decriminalized termination of pregnancy in the first trimester of gestation in Mexico City. The Mexico City Ministry of Health (MOH) quickly responded by initiating the Legal Abortion (LA) program or the ILE program, as it is known in Spanish. In the past seven years, close to 117,000 women have received safe legal abortion services, using the best available evidence-based technologies and including comprehensive post-abortion care and contraceptive counseling.1 LA services are available free of charge to any woman residing in Mexico City, and to women from other states at a low cost, in the nine hospitals and three LA health centers selected for the LA Program by the MOHâ&#x20AC;&#x201D;all of which are certified by the National Abortion Federation (NAF) in the United States. The law reform and the subsequent implementation of the LA program constitute a significant step forward in the advancement of the sexual and reproductive rights of Mexican women. In a region where the abortion debate is increasingly polarized, Mexico City now has one of the most progressive abortion laws in Latin America and the Caribbean (LAC)2; only Cuba, Guyana, and Puerto Rico have more liberal abortion legislation, which allows women to legally terminate their pregnancy at any gestational age.3

An island of liberties

Despite this momentous advancement, the Mexico City reform precipitated an unexpected backlash. Since 2007, 16 of 31 Mexican states have amended their constitutions to define life from the moment of conception.4 While abortion is still permitted in the case of rape and under other limited legal indications in most states, these 16 reforms intended to impede the decriminalization of abortion at the state level, as well as to reduce womenâ&#x20AC;&#x2122;s access to legal abortion.5 However, with the success of the Mexico City LA program being disseminated across the country, some state governments have shown interest in learning more about this model of care. The aim of this document is to share the details of the process of transforming the abortion law reform in Mexico City into accessible, high-quality LA services. In the first section, we describe why access to safe and legal abortion procedures is imperative for the well-being of women. The second section describes the unique political context that preceded and facilitated the law reform. While the Mexico City MOH was not involved in the political discussions leading up to the decriminalization of abortion, the history of how the law change came about is important to properly understand the challenges that the Mexico City MOH faced once it was presented with implementing the law. In the third section, the challenges as well as the opportunities that presented themselves during the first year of LA service provision are addressed. The Mexico City LA program is described in detail in Section four, including a detailed description of the service model offered in the selected LA health centers. The fifth section focuses on current MOH strategies to continue to improve the quality and accessibility of LA services in the future. In Section six, we describe the benefits of seven years of safe and legal abortion services on the sexual and reproductive health and rights of women. Finally, we conclude with arguments as to why the LA program in Mexico City achieved such success.

References 1. 2. 3. 4.

Grupo de Información en Reproducción Elegida (GIRE). Cifras. Available at: http://gire.org.mx/nuestros-temas/aborto/cifras. Accessed March 26, 2014. Repogle J. Abortion debate heats up in Latin America. Lancet. 2007;370(9584):305-306. Singh S, Wulf D, Hussain R, Bankole A, Sedgh G. Abortion Worldwide: A Decade of Uneven Progress. New York: Guttmacher Institute; 2009. Grupo de Información en Reproducción Elegida (GIRE). Reformas aprobadas a las constituciones estatales que protegen la vida desde la concepción/ fecundación, 2008-2011. Available at: http://www.gire.org.mx/publica2/ ReformasAbortoConstitucion_Marzo14_2011.pdf. Accessed April 28, 2012. Grupo de Información en Reproducción Elegida (GIRE). Legislación Estatal. Available at: http://www.gire.org.mx/index.php?option=com_content&view=ar ticle&id=409&Itemid=1154&lang=es. Accessed April 28, 2012.

Acknowledgements

The Mexico City Ministry of Health would like to express gratitude to Mexico City’s former Mayor, Marcelo Ebrard; former Minister of Health for Mexico City, Dr. Manuel Mondragón y Kalb; current Minister of Health for Mexico City Dr. Armando Ahued Ortega; Martha Lucía Micher Camarena from the National Institute for Women, Mexico City; and the General Counsel for the Mexico City Government, Leticia Bonifaz, for their outstanding commitment to women’s sexual and reproductive health and rights. We would also like to thank all the health professionals providing LA services, as part of the LA program, for their unwavering commitment to this work, and to all the women who have accessed the LA program for their faith in our services. The development of the LA program is not solely the Mexico City MOH’s accomplishment; the Mexico City MOH worked closely with several nongovernmental organizations (NGOs) which have provided invaluable support for the range of activities needed to initiate and sustain the program, while providing the constructive feedback needed to improve the quality and accessibility of services.

An island of liberties

We would expressly like to mention the National Pro-Choice Alliance (Alianza Nacional por el Derecho a Decidir, andar) in Mexico, a consortium of five organizations: Catholics for Choice (Católicas por el Derecho a Decidir, CDD), Gender Equality: Citizenship, Work, and Family (Equidad de Género: Ciudadanía, Trabajo, y Familia, Equidad), Information Group on Reproductive Choice (Grupo de Información en Reproducción Elegida, GIRE), Ipas Mexico, and the Population Council’s Mexico Office. These organizations, each according to their own expertise, have worked closely with the MOH throughout the implementation process. We would also like to acknowledge three organizations for their contribution to the successful implementation of the LA program: the ESAR and Oriéntame Foundations from Colombia, and Gynuity Health Projects from the United States. In addition, many other national and international NGOs, governmental agencies, donors, academic institutions, and individuals have contributed in several ways to make the LA program a success. These are (in alphabetical order): • • • • • • • • • • • • • • •

ALDF Anonymous donors Balance – Promotion for Development and Youth CDHDF CIPA CLACAI Colmex ddeser Emilio Álvarez Icaza (former Ombudsman for Mexico City) FIGO FLASOG Guttmacher Institute Ibis Reproductive Health ILETEL (LA information hotline) INSAD

Acknowledgments

• • • • • • • • • • • • •

INSP IPPF John D. and Catherine T. MacArthur Foundation MARIA Fund – Abortion Fund for Social Justice Marta Lamas (Debate Feminista Organization) Mexfam MSI NAF PPFA RNCJDD UNAM University of California, Los Angeles WHO

The Mexico City MOH is grateful to all the people who have joined our efforts to uphold the reproductive health and rights of Mexican women.

A 35-year-old woman and mother of two children, aged 9 and 13, was found by her son in bed at home unconscious and covered in blood. By the time a family member took her to a hospital, she had already died. The physical examination suggested she had had an induced abortion. Nobody knew she was pregnant. (Summary from a maternal mortality patient record, reported in van Dijk et al., 2005.1)

1. The problem of unsafe abortion

Unsafe abortion is a persistent, but preventable cause of maternal morbidity and mortality.2 It has a direct relationship, not only with the attainment of Millennium Development Goal (MDG) Five (reducing maternal mortality by three quarters by 2015), but also with the MDGs related to other aspects of development, including poverty reduction, gender equality and womenâ&#x20AC;&#x2122;s empowerment.3 The World Health Organization (WHO) defines unsafe abortion as a procedure to terminate an unintended pregnancy, performed by an individual lacking adequate skills, or occurring in conditions that do not meet basic medical standards, or both.4 Approximately 47,000 women worldwide lose their lives each year as a result of complications from unsafe abortion: incomplete abortion, post-abortion sepsis, hemorrhage, and genital trauma. At least 220,000 children lose their mothers.5 Many more women cope with long-term complications, including reproductive tract infections leading to infertility, chronic infections, and an increased risk of ectopic pregnancy, premature delivery, and spontaneous abortion in subsequent pregnancies.6 These consequences do not only affect families and communities, but they also burden national public health systems.2,6

An island of liberties

Box 1. The cost-effectiveness of safe abortion: Mexico City before the legal reform. In 2005, PATH, Ibis Reproductive Health, and the Population Council Mexico calculated the direct and indirect cost of abortion in the Mexico City public health services.7 •

•

The safest procedure, using the manual vacuum aspiration technique (MVA), is cheaper ($111 USD in public hospitals and $53 USD in private clinics per woman) than the more invasive and risky dilation and curettage (D&C) ($143 USD). The least expensive procedure is the medical abortion, using only misoprostol ($79 USD). The cost of treatment, for critical complications from abortion, in the public hospitals ranges between $601 USD and $2,100 USD*

Despite having some of the most restrictive abortion laws in the world, the LAC region has the highest rate of abortion—31 per 1,000 women aged 15–44.8 Mexico has a slightly higher rate of 33 induced abortions per 1,000 women; an increase of 33 percent since 1990.9 The estimated total number of induced abortions in the country was 875,000 in 2006. Approximately 150,000 of these cases resulted in treatment for induced abortion complications in public-sector hospitals.9 Between 1990 and 2008, 24,805 maternal deaths occurred in Mexico. According to the International Classification of Diseases (ICD, 10th revision), 7.2 percent or 1,786 of these maternal deaths, were abortion-related.10 Unsafe abortion is the fifth leading cause of maternal mortality in Mexico, with a maternal mortality rate of 48 deaths per 100,000 hospitalizations.10,11 While the current classification does not allow for a distinction between deaths from a spontaneous or an induced abortion, it is expected that this number is largely composed of unsafe induced abortions.11 On the other hand, an abortion performed under safe and legal conditions, particularly during the first trimester, is a very safe procedure, with a reported global mortality rate of about 0.6 deaths per 100,000 procedures.12,13

*Using the exchange rate from 2005, the amounts are equivalent to 1,221, 583, 1,573, 6,611 and 23,100 Mexican pesos. 20

The problem of unsafe abortion

Evidently, having restrictive abortion laws does not prevent women from having abortions. Many countries do not have national family planning programs extensive enough to be able to cope with the population’s demand. Furthermore, countries such as Mexico that have transitioned quite rapidly from high to low fertility, are often unable to meet the growing demand for fertility regulation, which includes providing sufficient contraceptive services. In 2009, 72.5 percent of married Mexican women used a contraceptive method, however in the group of married sexually active young people between the age of 15–19 years, contraceptive use was only about 44.7 percent.9,14 This marked gap explains, in part, the number of unplanned pregnancies; some of which end in an induced abortion.5 Furthermore, no short-term contraceptive method is 100 percent effective, even with consistent and correct use, and there will always be some unintended pregnancies.2,5 Women with economic resources, a high level of education, and good access to information can readily afford and obtain access to abortion services, provided by well-trained professionals, even in contexts where abortion remains illegal. On the contrary, women living in poverty are generally those who end up using unsafe abortion procedures, either offered by untrained abortion providers or by self-induced unsafe methods (see Box 2).15 Even though post-abortion care (PAC) —provided to women suffering complications —from an induced abortion – is legal worldwide, women experiencing abortion complications may avoid seeking medical care because they fear stigmatization, abuse, ill-treatment, or legal reprisals.5 Evidence suggests that the decriminalization of abortion does not increase the abortion rate. In 1999, the abortion rate was below 10 per 1,000 women in countries with liberal abortion laws, such as the Netherlands, Belgium, Tunisia, and Switzerland. Countries with restrictive abortion laws (such as Chile and Peru) sustain abortion rates of over 50 per 1,000 women.11 Decriminalization of abortion, accompanied by broad access to safe abortion services, sexual and reproductive health education, and effective family planning programs, may contribute to reduce the number of unwanted pregnancies, and, in turn, the number of abortions.16

An island of liberties

Box 2. Socioeconomic determinants and the probability of having an unsafe abortion Data from the 2006 Mexican National Demographic Survey showed that lowincome, indigenous women who have less than five years of formal education are nine times more likely to induce an abortion, compared to women from a non-indigenous background with a higher level of education and income.17

References 1.

van Dijk, M.G., Ahued Ortega, A., Contreras, X., García, S.G. (2012) Stories behind the statistics: a review of abortion-related deaths from 2005-2007 in Mexico City. International Journal of Obstetrics and Gynecology, 118(Suppl 2): S87–S91. 2. Grimes, D.A., Benson, J., Singh, S., Romero, M., Ganatra, B., Okonofua, F.E., Shah, I.H.. (2006) Unsafe abortion: the preventable pandemic. Lancet, 368(9550): 1908–1919. 3. Sousa, A., Lozano, R., Gakidou, E. (2009) Exploring the determinants of unsafe abortion: Improving the evidence base in Mexico. Health Policy and Planning, 1–11. 4. World Health Organization (WHO). (1992) The Prevention and Management of Unsafe Abortion: Report of a Technical Working Group. Geneva: WHO. 5. World Health Organization (WHO). (2010) Unsafe abortion. Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2008. Geneva: WHO. 6. Singh, S. (2010) Global consequences of unsafe abortion. Women’s Health, 6(5): 849–860. 7. Levín, C., Grossman, D., Berdichevsky, K., Díaz, C., Aracena, B., García, S.G., Goodyear, L. (2009) Exploring the costs and economic consequences of unsafe abortion in Mexico City before legislation. Reproductive Health Matters, 17(33): 120–132. 8. Shah, I., Ahman, E. (2010) Unsafe abortion in 2008: Global and regional levels and trends. Reproductive Health Matters, 18(36): 90–101. 9. Juárez, F., Singh, S., García, S., Díaz-Olavarrieta, C. (2008) Estimates of abortion incidence in Mexico: What’s changed between 1990 and 2006? International Family Planning Perspectives. 34(4): 2–12. 10. Schiavon, R., Troncoso, E., Polo, G. (2012) Analysis of maternal and abortionrelated mortality in Mexico over the last two decades, 1990-2008. International Journal of Gynecology and Obstetrics, 118S: S14–S22.

11. Consejo Nacional de Población (CONAPO). (2009) Principales Indicadores de Salud Reproductiva. ENADID. Retrieved from: http://www.conapo.gob. mx/work/models/CONAPO/Resource/216/1/images/4Anticoncepcionen.pdf. Accessed September 10, 2012. 12. Bartlett, L.A., Berg, C.J., Shulman, H.B., Zane, S.B., Green, C.A., Whitehead, S., Atrash, H.K. (2004) Risk factors for legal induced abortion-related mortality in the United States. Obstetrics and Gynecology, April 103(4): 729–737. 13. Raymond, E.G., Grime, D.A. (2012) The comparative safety of legal induced abortion and childbirth in the United States. Obstetrics and Gynecology 119: 215–219. 14. Juárez, F., Palma, J.L., Singh, S., Bankole, A. (2010) Las Necesidades de Salud Sexual y Reproductiva de las Adolescentes en México: Retos y Oportunidades. New York: Guttmacher Institute. 15. Sedgh, G., Henshaw, S., Singh, S., Ahman, E., Shah, I.H. (2007) Induced abortion: estimated rates and trends worldwide. Lancet, 370: 1338–1345. 16. Grupo de Información en Reproducción Elegida (GIRE). Aborto/Justicia social. Retrieved from: http://www.gire.org.mx/index.php?option=com_content&view =article&id=410&Itemid=1157&lang=es. Accessed April 23, 2012. 17. Sousa, A., Lozano, R., Gakidou, E. (2009) Exploring the determinants of unsafe abortion: improving the evidence base in Mexico. Health Policy and Planning, 1–11.

"That day the planets aligned.â&#x20AC;? Leticia Bonifaz, General Counsel for the Mexico City government.

2. The decriminalization of first-trimester abortion in Mexico City

Several pro-choice groups have explored how Mexico City’s unprecedented decriminalization of first trimester abortion came to be in 2007.1 Two decisive factors facilitated the approval of the law: a long history of abortion debate and the gradual liberalization of the law in a positive environment of political momentum. History of abortion leading up to the decriminalization The women’s movement in Mexico had worked for 35 years to bring to the public forefront the deleterious consequences that restrictive abortion laws have on women’s health. However, in the 1990s the abortion debate intensified, particularly in Mexico City, where academics, journalists, lawyers, opinion-leaders, legislators, physicians, and public authorities joined the discussion.1 During this period, Mexico City’s abortion legislation was even more restrictive than in other Mexican states—it only allowed for legal abortion in cases of rape and when the woman’s life was at risk.2 In 1997, one of Mexico’s main left-wing parties, the Democratic Revolution Party (PRD, in Spanish) came into power in Mexico City, and included the decriminalization of abortion and “voluntary motherhood” as a part of their manifesto. However, when women’s groups proposed

An island of liberties

adding legal indications for abortion to the Penal Code, during a 1999 review, the government chose to ignore the controversial bill, rather than take a political risk just before the 2000 Presidential elections. Even so, the PRD lost the 2000 elections to the conservative National Action Party (PAN), but maintained a majority in Mexico City.1 In 2000, the tragic story of Paulina Ramirez Jacinto became national news. Paulina, a 13-year-old girl from Mexicali, Baja California, became pregnant after being raped by a gang of thieves in her family’s house. Although Paulina received permission to obtain a legal abortion, the hospital authorities pressured her mother by using misleading information to deny her the abortion.2,3 The Paulina case garnered significant national and international media attention. At the same time, conservative legislators in the state of Guanajuato proposed removing an article from the Penal Code allowing for abortion in cases of rape. This proposal was made despite the fact that public opinion polls in Guanajuato showed that 60 percent of the population disapproved of this legislative reform.4 The public opinion evidence left the Mayor of Guanajuato with no choice but to veto the proposed change to the penal code.1 Both events generated increased favorable public opinion about abortion.1 The Mexico City Interim Mayor Rosario Robles, from the PRD, used this opportunity to introduce a bill in the Federal District Legislative Assembly (ALDF) allowing for abortion in cases of fetal impairment, risk to the woman’s health, and artificial insemination without the woman’s consent. The law was passed and became known as the “Robles Law,”1,2 The PAN and the Ecological Green Party of Mexico (PVEM) claimed, before the National Supreme Court of Justice (SCJN), that these amendments were unconstitutional. In 2002, the SCJN concluded, that even though life is protected under Mexican jurisprudence, there may be certain circumstances where women should not be sanctioned.1 The SCJN decision paved the way

The decriminalization of first-trimester abortion in mexico city

for subsequent improvement of access to legal abortion in Mexico City. Subsequently, the MOH, under the leadership of Dr. Asa Cristina Laurell, issued general guidelines on the organization and operation of legal abortion services as well as a protocol for abortion procedures. These guidelines were distributed to health care professionals in MOH public hospitals. At the same time, the public prosecutor’s office established guidelines to guarantee the authorization of abortions resulting from rape or “forced artificial insemination.”1,5,6 These measures were an important breakthrough. Several studies had shown that in Mexico City access to legal abortion in the case of rape was limited. Unfortunately, women often obtained their authorization for a legal abortion after the first trimester and by then the majority of physicians would refuse to perform an abortion.6 In 2003, a delegate from the centrist Institutional Revolutionary Party (PRI) presented an initiative to decriminalize first-trimester abortion, though the proposal included components that were considered a step backward by some women’s groups.1 As it was uncertain whether the initiative would gain the majority of ALDF votes, a PRD assembly member presented a new plan, suggesting more conservative reforms to the Penal Code and the Mexico City Health Law. The plan, which included new legal indications for abortion, was passed by the ALDF and supported by the PAN party. The new plan included: 1) an increased penalty for forcing a woman to abort, 2) the requirement of public medical facilities to provide free, high-quality abortion services to women legally entitled to an abortion within five days of them soliciting the service, 3) permission for individual physicians to conscientiously object to providing services for personal convictions (with the exception of cases of women in need of urgent life-saving treatment), however the hospitals had to guarantee access to services even though some of the physicians were objectors, and finally 4) the elimination of the classification of abortion as a crime.1Even with these advances, however, from 2001 until the law reform in 2007, only 62 women received legal abortion services, primarily under the already existing rape and health indications.7

An island of liberties

Political opportunity in 2007 Prior to the 2006 presidential elections, a small left-wing party, the Social Democratic Party (Alternativa), explicitly raised the issue of the decriminalization of abortion, forcing the other parties to publicly voice their position on the controversial topic.1 The PRD unenthusiastically characterized abortion as a public health problem and promised to review the legislation. The PAN insisted that life begins at the moment of conception and rejected legal abortion. Finally, the PRI remained neutral and did not express support for any changes to the existing abortion law. After controversial presidential elections where the defeated PRD candidate claimed fraud and the PAN candidate was declared the winnerâ&#x20AC;&#x201D;albeit by a very narrow marginâ&#x20AC;&#x201D;Mexican society was left divided and polarized.8 Despite this defeat, the PRD maintained its majority in the Mexico City government, and Marcelo Ebrard Casaubon became the cityâ&#x20AC;&#x2122;s new mayor. A few months after the election, a PRI delegate unexpectedly introduced a bill to decriminalize abortion in Mexico City, building upon the previous 2003 initiative. Alternativa followed up with a second bill to further advance the abortion law.1 The ALDF, comprised of a PRD majority, allowed the legislators to publicly debate the bill for four months. Legislators in favor of reform used this time to build support within their parties. Those opposing the change in law emphasized the importance of the availability of contraceptive methods and sexual education at schools to avoid unwanted pregnancies. This openness on topics that were not historically part of the right-wing discourse, was an unprecedented occurrence in Mexican history.1 The public debate on abortion and reproductive rights was followed closely for weeks by the national and international press. Pro-choice and antichoice movements organized a range of activities including marches, demonstrations, media events, and printed material to raise awareness among the public about the position of each movement on the issue of reproductive health rights.9

The decriminalization of first-trimester abortion in mexico city

At the same time, the Mexican Catholic Church condemned the apparently imminent decriminalization of abortion, threatening to excommunicate the legislators who were to vote in favor of the bill. The Vatican intervened, clarifying that only physicians carrying out abortions and women undergoing abortions could be excommunicated. The moral authority of the Mexican Catholic Church was already weakened as a result of public scandals surrounding child sex abuse among Catholic priests. Thus, the interference of the Church in the abortion debate initiated a parallel debate about the secularity of the Mexican State.1 During the discussions leading up to the ALDF vote, the Mexico City mayor, Marcelo Ebrard, expressed his support for the law. He declared on several occasions that should the law be approved, he and his government would support its implementation. Legal Counsel to the Mexico City government, Leticia Bonifaz, participated in the ALDF discussion on the final contents of the new law; which also ensured an alignment between the ALDF decision and the Mexico City governmentâ&#x20AC;&#x2122;s position.1

An island of liberties

Box 3. Public opinion about legal abortion A few weeks before the vote on the bill, the Population Council conducted a public opinion poll with Mexico City residents, and repeated similar polls one and two years later.10 The findings show that: • • • •

•

Favorable opinion for the Mexico City abortion law increased, from 38 percent in 2007 to 74 percent in 2009. Public knowledge of the law increased from 73 percent in 2007 to 86 percent in 2009. Support for expanding the law to the rest of Mexico increased from 51 percent in 2007 to 83 percent in 2009. Support for allowing women from other states to come to Mexico City for a legal abortion increased from 45 percent in 2007 to 83 percent in 2009. The proportion of respondents expressing support for extending access to legal abortion to women under the age of 18 increased from 47 percent in 2007 to 61 percent in 2009. A vast majority agreed that the woman alone or the woman and her partner should have the final decision about having an abortion: 76 percent in 2007 to 91 percent in 2009. A vast majority believed that legal abortion would especially benefit poor women, and showed an increase from 77 percent in 2008 to 84 percent in 2009 (question not asked in 2007)

April 24, 2007, a new abortion law in Mexico City On April 24, 2007, the bill was approved by 46 of the 66 ALDF members and included the following reforms:1 •

•

Abortion was redefined in the Penal Code as the termination of pregnancy after the twelfth week of gestation. As a consequence, elective abortion, or legal termination of pregnancy (ILE, in Spanish) before the twelfth week of gestation was no longer considered a crime; The sentence for women undergoing an abortion after 12 weeks (which remained illegal) was reduced;

The decriminalization of first-trimester abortion in mexico city

• •

Pregnancy was defined as beginning with the implantation of the fertilized egg in the uterus; and The concept of forced abortion (without the woman’s consent) was included as a punishable act.

The new law indicated that the Mexico City MOH would provide LA services to women, irrespective of their level of health insurance. As the services would form part of the Mexico City MOH health system, they would be offered free of charge to Mexico City residents, or for a moderate fee to women living outside of Mexico City (as are any other services offered by the MOH health system, in line with Mexico City’s Free-of-Charge Law). Women under the age of 18 may access these services with written permission from a parent or guardian, as is the case for other medical procedures for minors. The existing guidelines for the legal termination of pregnancy were maintained. The law also emphasized that the LA services should be accompanied by objective, nonjudgmental counseling on the procedure and its risks, as well as the provision of information on alternative options, to enable women to make a free, informed, and responsible decision. The bill also stipulated that the Mexico City government would prioritize contraceptive services (including greater availability of contraceptive methods and adequate counseling about their use), sexual education, and campaigns on reproductive and sexual rights, especially aimed at adolescents. The law specified that the MOH would need to publish new procedural service guidelines within 60 days of its approval.1,11 Unconstitutionality claims and the SCJN’s decision Immediately after the reform, the National Human Rights Commission (CNDH) and the Federal Attorney General’s office filed unconstitutionality claims against the law in the Supreme Court, arguing that the ALDF did not have the authority to reform a health law, and that the law infringed upon the rights of the fetus.1 Again, months of public debate and media

An island of liberties

coverage followed. Pro-choice and anti-choice groups were both given the opportunity to provide arguments to assist the 11 Supreme Court Justices in making their decision. Both groups presented their informed opinions in documents called “amici curiae,” had private appointments with Justices, and provided arguments during the six subsequent public hearings. On August 28, 2008, eight of the 11 Justices voted in favor of the constitutionality of the Mexico City law. This majority gave the law a higher level of jurisprudence, meaning that other states would not have to face similar anti-constitutionality claims if, and when, their abortion laws were reformed. Among the Court’s ruling the most important considerations were that: 1) local legislatures are competent to decriminalize abortion; 2) the right to life in gestation is not recognized expressly in the text of the Constitution and, therefore, does not constitute an absolute right; 3) the decriminalization of abortion is an appropriate measure to guarantee various women’s human rights, such as: the right to life, health, bodily integrity, autonomy, privacy, nondiscrimination, and a life free from violence; and 4) the decision to interrupt a pregnancy is a right of the woman alone because of the unequal implications that bearing a child has for a woman. This decision marked another victory for Mexican women’s reproductive rights.9

References Grupo de Información en Reproducción Elegida (GIRE). (2008) El proceso de despenalización del aborto en la ciudad de México. Ciudad de México: GIRE. 2. Lamas, M., Bissell, S. (2000) Abortion and politics in Mexico: Context is all. Reproductive Health Matters. 8(16): 10–23. 3. Taracena, R. (2002) Social actors and discourse on abortion in the Mexican press: The Paulina case. Reproductive Health Matters, 10: 103–110. 4. The Population Council. (2000) Encuesta de Aborto en Guanajuato. México: Population Council. 5. Billings, D.L., Moreno, C., Ramos, C., Gonzalez de Leon, D., Ramírez, R., Villaseñor Martínez, L., Rivera Díaz, M. (2002) Constructing access to legal abortion services in Mexico City. Reproductive Health Matters, 10(19): 86–94. 6. Lara, D., García, S.G., Ortiz, O., Yam, E.A. (2006) Challenges accessing legal abortion after rape in Mexico City. Gaceta Médica de México. 142 (S2): 85–89. 7. Dirección General de Servicios Médicos y de Urgencias. (2008) Registro de los casos de aborto legal en el Distrito Federal 2001-2007. Ciudad de México: Gobierno del Distrito Federal. 8. Grupo de Información en Reproducción Elegida (GIRE). Aborto/Justicia social. Retrieved from: http://www.gire.org.mx/index.php?option=com_content&view =article&id=410&Itemid=1157&lang=es. Accessed April 23, 2012. 9. Alianza Nacional por el Derecho a Decidir (andar). (2007–2011) Building a Pro-Choice Alliance in Mexico. Project reports 2007–2011. Ciudad de México: andar. 10. Wilson, K., Garcia, S., Díaz-Olavarrieta, C., Villalobos-Hernández, A., Valencia Rodríguez, J., Sanhueza Smith, P., Burks, C. (2011) Public opinion on abortion in Mexico City after the landmark reform. Studies in Family Planning, 42(3): 175–182. 11. Gobierno del Distrito Federal. (2007) Gaceta Oficial del Distrito Federal. April 26(17): 70. 1.

3. Challenges and opportunities during the first year of the LA program

The Mexico City MOH was interested in finding out which hospital the first women would present themselves to soliciting legal abortion services. The first woman to show up for a legal abortion procedure arrived at the Hospital Materno Infantil Cuautepec on April 26, only two days after the passing of the law. She would be the first of thousands of women accessing the services. After three months, more than 1,000 women had accessed the services.1 After a year this number had increased to over 7,000 women. The women were not only from Mexico City; many arrived from the neighboring State of Mexico, and others came from states with restrictive abortion legislation. Some even arrived from other countries (see Section 4 for detailed characteristics of women accessing the LA program). The overwhelming demand for services was perhaps the most important challenge for the program. Immediately after the passing of the law, the MOH mobilized efforts to initiate legal abortion service delivery. The first months were full of challenges, but it was also a period of positive developments and important opportunities for growth. In retrospect, the lessons learned in those first few months formed the basis for the success of the LA program in place today.

An island of liberties

Mexico City MOH preparations prior to the reform During the uncertain months prior to the passing of the law, the MOH, under the leadership of Dr. Manuel Mondrag贸n y Kalb, the Minister of Health at the time, started to prepare MOH hospitals for a possible increase in demand for legal abortion procedures should the bill be approved by the ALDF. The MOH authorities held regular meetings with an existing group of committed, pro-choice obstetrician/gynecologists (ob/gyns) who were acquainted with state-of-the-art evidence-based abortion practices. This group comprised the future leaders of the LA program. During these meetings they designed preliminary plans for setting up the services. Furthermore, the MOH authorities explored who among the ob/ gyn personnel would be willing to provide such services. Based on the availability of non-objecting ob/gyn staff, the MOH selected 14 of its 20 general and maternal hospitals to offer LA services. In these hospitals, with the support of Ipas Mexico, the MOH trained ob/gyns in manual vacuum aspiration (MVA) procedures. Ipas Mexico had a long history of working alongside the MOH, through trainings of health care personnel in the provision of integral PAC, as well as legal abortion procedures in the case of rape. The MOH defined the delivery of LA services as a part of the existing package of reproductive health services offered at MOH public hospitals. Once the bill was approved, the law permitted any qualified physician (ob/gyn or general surgeon) to offer LA services within the boundaries of Mexico City. In the public system, however, only the selected Mexico City MOH facilities were obligated to offer the services. The federal MOH hospitals and the Mexican Institute for Social Security (IMSS) hospitals located in Mexico City (see Box 4), as federal institutions, were not required to implement the law.

Challenges and opportunities during the first year of the la program

Box 4. The Mexican health system Mexico has different, parallel systems of health care at both federal level and state levels: • • •

•

State-level Ministry of Health facilities: People with Seguro Popular insurance or no insurance coverage have access to subsidized health care facilities run by the state-level Ministry of Health. Federal Ministry of Health facilities: Some states, but especially Mexico City, have specialized, mostly tertiary-care hospitals that are administered by the federal MOH. Social security facilities: The employed population and their dependents are provided care through several social security institutions, regulated by the federal MOH. The largest social security organization is the Mexican Institute for Social Security (IMSS). However, the IMSS does not provide services to employees of the public sector. Health care needs of government employees are serviced by the Institute for Social Security and Services for State Workers (ISSSTE). The other social security institutions include hospitals from the state-owned Mexican Oil Company (PEMEX) and from the Ministry of National Defense (SEDENA). Private sector: The private sector is diverse, including general physicians offering basic health services in luxurious high-quality private clinics and hospitals. Services are mainly paid out of pocket, though some Mexicans may have private health insurance.

An island of liberties

A challenging start As soon as the bill was approved, the Mexico City MOH informed the Directors and the heads of the ob/gyn departments working at the 14 selected hospitals that they had to start offering the LA services. It also issued the official government publication Gaceta Oficial del Distrito Federal2, which described the law and the requirements that women must meet to receive the services. Senior staff in the hospitals were in charge of informing hospital personnel although many of them had also heard about the approval of the law through the media.3 Despite these efforts, the approval of the new abortion law came as a surprise for many health care professionals, and caused confusion and anxiety due to the speed with which the law was passed and implemented.3 While a group of ob/gyns immediately started to offer the services and agreed about the public health importance of the LA program, several health care professionals had conflicting feelings. These physicians acknowledged that the law would benefit women but also felt that more emphasis should be placed on contraceptive use. They expressed concern about the young age of some women seeking services and about the possibility that women would undergo repeat terminations.3 Some also feared legal repercussions, and therefore sometimes required women to provide additional paperwork to obtain services: for example one or two witnesses (even if the woman were an adult), a birth certificate, or a handwritten letter explaining their motivation for requesting a legal abortion.3,4 Close media attention to LA services caused additional pressure, as any mistake would likely become national news.

Challenges and opportunities during the first year of the la program

Box 5. Health care professional’s opinions on abortion in 2002 A study by Population Council in 2002, on knowledge, attitudes and practices (KAP), with a national sample of 1,206 Mexican physicians, showed the indications for which physicians would be in favor of legal abortion: • • • •

Pregnancy as a result of rape: 86% The pregnancy is a risk for the woman’s life: 93% The pregnancy is a risk for the woman’s health: 87% In case of severe congenital malformations: 82%

84% physicians believed that all public health facilities should offer legal abortions, whereas only 11% had performed an abortion procedure themselves.33

Another issue that caused confusion was the right to conscientious objection. This right was originally established in the 2003 amendment to the abortion law and sustained after the 2007 reform.6 However, after the law was passed, it was unclear which providers had the right to refuse to offer LA based on conscientious objection.3 When women began accessing the services, diverse groups of hospital health care personnel began to refuse to provide any type of service to women seeking LA, including anesthesiologists, radiologists, nurses, admissions staff, patient transportation staff, and even hospital security staff. As a consequence, some hospitals had very little personnel willing to provide and support the services. This not only caused delay in service provision, but also created an atmosphere of hostility toward women seeking legal abortion procedures and towards the health professionals providing them. The combination of emotional stress and a demanding workload led some ob/gyns to resign from their positions, causing an even further shortage of non-objecting staff.5 As a result, some of the selected hospitals had to discontinue their legal abortion services.3

An island of liberties

Some hospitals lacked the necessary infrastructure to provide legal abortion services. The health care personnel needed private rooms to provide counseling, surgery rooms to streamline the patient flow, and separate recovery rooms for postpartum and post-abortion women.3 Some hospitals had a shortage of equipment, such as ultrasound machines used for defining gestational age, as well as cannulae and syringes for MVAs.3 The MOH response to this was to undertake a series of important measures to address these challenges. First, it issued procedural guidelines and a manual as well as clarifying the right to conscientious objection. Further, the MOH provided multidisciplinary trainings, developed a protocol for the provision of medical abortion, and made the important decision to decentralize the services in to dedicated LA health centers. Clarification of the right to conscientious objection In response to the confusion about which providers had the right to object to offering services, the Minister of Health Manuel Mondragón y Kalb clarified that only physicians responsible for conducting the abortion procedure—ob/gyns and general surgeons—had the right to refrain from providing abortion services if they were conscientious objectors. The institution, nevertheless, had an obligation to offer the services.7 This definition was important for several reasons, explained below. The definition respected the wishes of the physicians who objected to the procedure for religious or other personal reasons—an ob/gyn or general surgeon who did not want to participate in the program could abstain from doing so without further requirements or bureaucratic procedures. Nonetheless, the definition ensured that any woman would be able to access legal abortion services within the selected institutions. Finally, the definition also specified that health care professionals other than ob/ gyns or general surgeons, did not have the right to refrain from providing services. This marked the beginning of a process of acceptance among the health care personnel who initially disapproved of the program.

Challenges and opportunities during the first year of the la program

They started to offer services corresponding to their position and, after having participated in legal abortion trainings, the majority resolved their ambivalence toward the program. The discrimination toward women seeking LA procedures, as well as the tensions between hospital staff, diminished over time and eventually disappeared. Issuing the procedural guidelines and manual On May 4, 2007 the MOH published technical guidelines for LA procedures—two weeks after the law reform (prior to the 60 days required by the law). These guidelines highlighted the gestational age limit of 12 weeks and added that only adequately trained health personnel such as ob/gyns and general surgeons were permitted to carry out the procedure. Physicians from health centers and hospitals that were not a part of the LA program were instructed to refer women seeking legal abortion services to the appropriate facilities. The health centers were required to provide the services within 10 days of the first consultation with a woman soliciting a legal abortion.8 Furthermore, the MOH issued a standardized procedure manual based on international best practices. The manual describes detailed step-by-step instructions to be followed for women accessing a legal abortion procedure as well as second trimester interruptions of pregnancy for other legal indications. The manual also includes the definition of conscientious objection, as previously outlined by the Health Law and enforced by Dr. Mondragón.7 Standardization of the medical abortion regimen In June 2007, the MOH Coordinator of the Mexico City Reproductive Health program attended a seminar on medical abortion organized by the NGO Gynuity Health Projects and was impressed by the simplicity and the excellent results of the latest evidence-based medical abortion technology. In November 2007, the Mexico City MOH, Gynuity Health Projects, and the Population Council jointly organized a seminar in Mexico for MOH physicians, officials, and experts to review the available

An island of liberties

evidence on medical abortion regimens—specifically the misoprostolalone regimen (see Box 6). Mifepristone, the drug that in combination with misoprostol is the gold-standard regimen for termination of pregnancy procedures, was not yet registered or available for use in Mexico at that time.

Box 6. Misoprostol characteristics8,9 • • • • • • • • •

Misoprostol is a synthetic prostaglandin analogue. It is marketed in Mexico for treatment and prevention of gastric ulcers, among others, It has been available over-the-counter in Mexican pharmacies since 1985, The tablets are stable in tropical climates, easy to transport, and simple to administer, Misoprostol is appropriate to use for pregnancy termination, Several administration routes have been studied (oral, sublingual, buccal, vaginal) with several doses and intervals between the doses, Effective regimens, their course, and success and complication rates depend on the length of gestation, It is safe for use in pregnancies of up to 9 completed weeks (63 days), The success rate for pregnancies of 9 completed weeks is 85–90 percent.

Following the seminar, the MOH standardized the dosage and route of administration of misoprostol, and ordered that this regimen be used across sites for all women seeking to interrupt a pregnancy of less than nine weeks gestation. The agreed regimen was: self-administration of 800 mcg of buccal misoprostol (four tablets of 200 mcg) (between the cheek and the gum, two tablets on either side of the mouth), followed by an interval of four hours, and another self-administration of a second dose of 800 mcg of buccal misoprostol. In cases of incomplete abortion, confirmed during the follow-up visit after two weeks, the women would take a third dose of 800 mcg of buccal misoprostol. Women with an ongoing pregnancy, confirmed at the follow-up visit, would be provided a surgical procedure through vacuum aspiration.

Challenges and opportunities during the first year of the la program

Procedures per Month* By type of technology used

Total: 89,562

1,800 1,600 1,400

Medicine

1,200 1,000 800

MVA 600 400 200

D&C Apr 07 Jun 07 Aug 07 Oct 07 Dec 07 Feb 08 Apr 08 Jun 08 Aug 08 Oct 08 Dec 08 Feb 09 Apr 09 Jun 09 Aug 09 Oct 09 Dec 09 Feb 10 Apr 10 Jun 10 Aug 10 Oct 10 Dec 10 Feb 11 Apr 11 Jun 11 Aug 11 Oct 11 Dec 11 Feb 12 Apr 12 Jun 12 Aug 12 Oct 12

*Information retrieved from the daily MOH report on legal abortion procedures performed.

An island of liberties

Offering medical abortion as an option for pregnancy termination has played a huge role in expanding access to women. This standardized medical abortion regimen was well received, and easily integrated into the MOH facilities. As a result of standardizing the medical abortion regimen and building capacity among health care providers, the uptake of medical abortion and vacuum aspiration (either MVA or Electric Vacuum Aspiration, EVA) at the Mexico City MOH has increased dramatically to almost 70 percent while less safe and more invasive dilation and curettage (D&C) procedures have been virtually eliminated as an LA procedure. As hospitalization is unnecessary for both vacuum aspiration and medical abortion, the legal abortion services became entirely outpatient. In addition, medical abortion has several advantages for women. It is more private than an invasive procedure as the women can complete the process in their home, many feel it is a more “natural” process and less invasive, and they feel more in control. In addition, some health care professionals feel that the availability of medical abortions has contributed to a decrease in conscientious objectors, as misoprostol is an indirect method and involves less “active involvement” in the procedure.3 Multidisciplinary trainings Once the law was passed the MOH offered a two-week on-the-job training course on the provision of reproductive health services, designed for ob/gyns, nurses, social workers, and other health care providers (anesthesiologists, general physicians, psychologists, medical students, administrative personnel). The purpose of the course was to “guarantee high-quality services for the legal termination of pregnancy using modern procedures and techniques based on the best available scientific evidence.” It included modules on the medical aspects of the procedure (medical abortion and MVA techniques), abortion counseling and contraceptive use, post-procedure pain management and follow-up.10

Challenges and opportunities during the first year of the la program

The hospitals that were incorporated into the program, and in turn the personnel dedicated to providing LA services, increased rapidly, and with them, the demand for training increased. To meet the demand, the joint training plan with Ipas Mexico was strengthened, adapted and expanded to meet specific needs and professional profiles. The trainings included workshops on value clarification, orientation and counseling, training of trainers (ToT) courses, and training on the proper use of the pelvic ultrasound, and on how to cope with the burn-out syndrome. In October 2007, the MOH offered these training courses, recognized and certified by the MOH Education Department, to ob/gyns, general physicians, nurses, social workers and psychologists in all the selected LA health centers. From May 2007 to August 2012, a total of 174 courses and workshops were implemented through this joint collaboration. The total number of trained health professionals in this period was 5,539; 216 of these trained health professionals were directly involved in the provision of legal abortion procedures. GIRE, an NGO specializing in the legal aspects of reproductive rights, contributed to these trainings by providing workshops on the legal issues within the LA program. Catholics for Choice (CDD) contributed with workshops on ethics and legal abortion, with the help of their close ally, a Dominican priest who addressed any religious concerns regarding LA provision. The MOH called in specific expertise from other NGOs for more specialized trainings on specific aspects of LA services. For example, Helena Acosta, from the Colombian NGO â&#x20AC;&#x153;OriĂŠntame,â&#x20AC;? affiliated to the ESAR Foundation, was invited to present her pre- and post-abortion counseling model to 200 health care professionals providing LA services (physicians, social workers, psychologists). Gynuity Health Projects offered workshops on medical abortion to the staff of all selected hospitals and, later, health centers. The workshops consisted of a thorough review of the standardized medical abortion regimen, its side effects, warning signs and follow-up. Ibis Reproductive Health, an NGO based in the

An island of liberties

United States, provided training to ob/gyns in all the selected LA health centers on the use of the electric vacuum aspirator instead of the manual aspiration. To ensure that all would women receive adequate attention when dealing with an incomplete abortion, it was necessary to train all health care personnel, including personnel from institutions outside the LA program. Therefore, Gynuity Health Projects and Ipas Mexico organized workshops on strategies for post-abortion care (PAC), cutting-edge technology in medical abortion, and MVA techniques. A key component in the training process, was the participation of legal abortion service providers and MOH officials (including the Minister of Health) in international seminars and conferences on abortion, as well as visits to abortion clinics, in countries such as Cuba, Colombia, Spain, South Africa, the United Kingdom, and the United States, facilitating the exchange of knowledge and best practices and the replication of some aspects of successful models within the Mexico City context. Human and material resources In the first months of the LA program, the MOH hired new personnel, particularly non-objecting ob/gyns, which helped to reduce the overall workload and reduce waiting times. In some hospitals, ob/gyns, nurses, and social workers in favor of the program began forming teams to attend to the women accessing LA services which helped to streamline service provision. Also, the MOH reorganized the space within the hospitals, in line with perceived needs; arranging separate spaces for counseling, procedures, and recovery. The MOH purchased or received donated ultrasound machines from the Foundation RĂo Arronte, ensuring an expedited flow of supplies and equipment.3 With regard to human and material resources, the MOHâ&#x20AC;&#x2122;s key decision was to adapt existing primary-level health centers to provide LA and other reproductive health services in order to improve service access and efficiency. These health centers operated parallel to the existing hospital sites. The service model offered in these health centers is described in Section 4. 46

Challenges and opportunities during the first year of the la program

The official registry for legal abortion Typically, hospitals used the general hospital intake forms for women accessing legal abortion services. However, it soon became clear that essential data, such as post-procedure contraceptive uptake or data on the completeness of the abortion procedure, could not be recorded using the existing system. The MOH, in collaboration with other organizations— the Population Council, Ipas Mexico, Gynuity Health Projects, NAF, the National Institute of Public Health (INSP), Investigation in Health and Demography (INSAD), and the College of Mexico (Colmex) — developed a specially designed data form for women accessing the LA program. This form has been improved over the years and is now a succinct four-page tool used to capture key information for each woman, such as her sociodemographic, pregnancy, health, and LA background. The Population Council has trained the medical personnel to correctly complete the intake form and provided invaluable support during data processing. The MOH and the Population Council have jointly created an electronic database for LA services over the past seven years. This information helps to improve service delivery and enables an assessment of individual patient characteristics, in order to respond to service needs and to carry out investigations (see Section 4). Information for women and men on legal abortion services Media coverage had been significant leading up to and during the time the reform was passed, therefore, 73 percent of the general population knew that the termination of pregnancy up to 12 weeks had been decriminalized.11 However, women and men actually seeking the services were in need of specific information on how and where to access them. In May 2007, the MOH opened a free hotline, ILETEL, which with time would be included in a broader and more ambitious “distance medicine” project. This project aimed to strengthen the link between Mexico City residents, and the programs and medical services offered by the Mexico City MOH.12 47

An island of liberties

ILETEL started with two psychologists, but as a result of the demand for its services it grew to a team of three physicians and seven psychologists, including the additional support of psychology students in their final year of study (Rafael Rodríguez Patricio, personal communication, April 2012). Today, the hotline is manned 24 hours a day throughout the year. The trained ILETEL team provides information about how to access LA services, the addresses and opening hours of the hospitals and health centers offering them, information about post-procedure contraceptive method use, in addition to psychological counseling and any other questions related to the services. For women who have already started their legal abortion procedure, ILETEL provides information on warning signs or on side effects of the procedure. In addition, the MOH uses the existing Mexico City government telephone line “Locatel” to provide contact information on how, where and when people can access legal abortion services.12 The Mexico City MOH has also printed several brochures for distribution in its health centers and hospitals, describing the procedures, warning symptoms, and contact information for anyone with doubts or questions regarding the legal abortion procedure.

Challenges and opportunities during the first year of the la program

Through the use of informational materials and a website, the Mexico City Women’s Institute, Inmujeres DF, also provides information about LA services.13 Each year on September 28, the Day for the Decriminalization of Abortion in Latin America and the Caribbean, Inmujeres DF, the MOH, and the Alliance organize an event to commemorate the law reform and the LA program, with wide media coverage. The Alliance organizations offered key support in informing the public about accessing legal abortion services in Mexico City public hospitals by launching a campaign entitled: “Pregnant? You Now Have 12 Weeks to Decide.” This campaign included announcements in the subway system as well as the distribution of printed flyers during public events. The Alliance has also organized outreach and awareness-raising activities to inform Mexico City residents of the LA program; e.g., festivals on the main Zócalo square in the city center, workshops with youth and other groups, fairs, conferences, cultural events such as concerts and cinema debates, mobile information stands, radio spots, and television interviews. The Alliance also created a website called andar providing information on legal abortion services, and opened an email account where people can request information on the services offered in Mexico City.14 Three of the Alliance NGOs have telephone hotlines where women and men from Mexico City and other states can receive legal, medical, spiritual, and psychosocial support from trained staff. If requested, Alliance staff can accompany women to the hospital for their legal abortion procedure and stay with them throughout treatment.15 Facilitating access for women from other states Many of the women arriving from other states with restrictive legislations, and who seek legal abortion services in Mexico City, belong to vulnerable population groups. Therefore, when the Mexico City MOH opened its first selected health center, it made the important decision to allow all Mexico City residents to access legal abortion services free of charge,

An island of liberties

and to only charge a symbolic fee for the women from other states accessing the services. This change meant a significant improvement in the accessibility of the services for all women needing them. In May 2009, in response to the legal changes at the state level (16 states passed law reforms protecting life from the moment of conception), young pro-choice activists launched the “MARIA Abortion Fund for Social Justice.” This fund, created by donations from pro-choice NGOs, offers financial or in-kind support to women traveling to Mexico City from other states to access a legal abortion procedure at one of the MOH health centers. The MARIA Fund also offers to accompany women from other states to the Mexico City health centers and to stay with them during the procedure, at the women’s request. To date the MARIA Fund has paid for food and/or lodging for 863 women; it has provided financial support for lodging, food and transportation to 366 women; and it has accompanied 296 women through the legal abortion procedure in Mexico City (Oriana López Uribe, personal communication, May, 2012). Managing the anti-choice groups Only weeks after the selected hospitals began providing legal abortion services, anti-choice groups set up mobile stands near the entrances, presenting themselves as the Center for Support of Latin American Women (CAMand displaying signs suggesting that they were providing information on “pregnancy interruption.”3,16 Staff from the NGO Equidad have monitored the activities of these stands, and observed that the people manning the CAM stands approach women entering the hospital and distribute misleading and exaggerated information on the physical and psychological risks of abortion. They also try to convince women seeking a legal abortion to keep the pregnancy by showing them plastic fetal models or photos of fetuses. They offer to provide food, housing and medical care for the duration of the pregnancy, and to handle the procedure for adoption, if the women

Challenges and opportunities during the first year of the la program

choose this option.15 At some hospitals, the anti-choice groups offer free ultrasounds to women, either in mobile mini-clinics set up in trailers in front of the hospitals, or persuade women to accompany them in a taxi to the pro-life headquarters, where they are shown the anti-choice video “The Silent Scream.” The individuals operating the stands are also abusive toward the health care staff entering the hospitals or health centers, calling them “assassins” or “baby killers,” or by mentioning them by name in prayers recited over megaphones.3,17 The MOH has chosen not to confront the anti-choice groups; instead, it has posted signs outside hospitals and health centers and included information in its brochures to strengthen the message that official information regarding the procedure can only be obtained inside the hospitals. Equidad has supported these efforts, denounced the stands to the district authorities, and succeeded in removing some of them. Private-sector services Following legal reform, the private sector also began to provide elective legal abortion services, including high-quality clinics operated by organizations such as Marie Stopes International (MSI). Some clinics, such as the Mexican affiliate of International Planned Parenthood Federation (IPPF), as well as Mexfam, and the Center for Couples’ Integral Care (CIPA) broadened their services to include legal abortion services after the reform. The Mexico City MOH has worked with these organizations, particularly with regard to exchanging models of service delivery and sharing experiences. There are, however several other private practitioners and clinics providing legal abortion services (see Box 7), and not all are adequately trained in evidence-based abortion techniques. The MOH closely monitors the provision of private sector services, and offers regular training in legal abortion service delivery to private physicians.

An island of liberties

Box 7. Private sector services In 2008, Ipas Mexico carried out a study to obtain information on the effect of the law on private sector abortion services.17 The study team interviewed 135 physicians working in private clinics located through an exhaustive search for contacts (internet, telephone directory, yellow pages, and magazines). The results highlighted the need for private abortion providers to be trained in recommended abortion methods and the quality of private abortion care provision improved. Among their findings were: • •

• •

A large majority of the clinics offered a range of reproductive health services, including abortions. Although no exact figure exists for the number of women who have undergone LA procedures in private sector facilities, the study however estimated that the private sector contributed with approximately 21,600 induced abortions in 2008. Over 70% of the private sector clinics still used dilatation and curettage (D&C); less than a third offered vacuum aspiration or medical abortion. The average number of abortions per facility was only three per month; few reported more than 10 abortions monthly. More than 90% said that they had been offering abortion services for at least 20 months.

References 1. 2. 3.

4. 5.

6. 7.

Secretaría de Salud del Distrito Federal (SSDF). (2007) Reporte Diario de Actividades, Programa de Interrupción Legal del Embarazo. August 7. Gobierno del Distrito Federal. (2007) Gaceta Oficial del Distrito Federal. April 26 (17): 70. Contreras, X., van Dijk, M.G., Sánchez, T., Sanhueza Smith, P. (2011) Experiences and opinions of health-care professionals regarding legal abortion in Mexico City: A qualitative study. Studies in Family Planning, 42(3): 183–190. Red por los Derechos Sexuales y Reproductivos en México (ddeser). (2009) Fiscalización Grupo Anti-Derechos. Mexico City: ddeser. García, S.G., Lara, D., Goldman, L. (2003) Conocimientos, actitudes y prácticas de los médicos mexicanos sobre el aborto: Resultados de una encuesta nacional. Gaceta Médica de México, 139(S1): S91–S102. Grupo de Información en Reproducción Elegida (GIRE). (2008) El Proceso de Despenalización del Aborto en la Ciudad de México. Mexico City: GIRE. Secretaría de Salud del Distrito Federal (SSDF). (2008) Manual de Procedimientos para la Interrupción Legal del Embarazo en las Unidades Médicas. Mexico City: SSDF\.

8. 9.

10. 11.

12.

13.

14. 15.

16.

17.

Gobierno del Distrito Federal. (2007) Gaceta Oficial del Distrito Federal. May 4(17: 75. Gynuity Health Projects. Instructions for Use. Abortion Induction with Misoprostol in Pregnancies up to 9 Weeks LMP. Retrieved from: http://gynuity. org/resources/read/misoprostol-for-early-abortion-en/. Accessed April 23, 2012. Pérez Martínez, M. (2007) Curso de Capacitación y Adiestramiento en Servicio de Salud Reproductiva. PowerPoint presentation, Mexico City: SSDF-Ipas. Wilson, K., García, S., Díaz-Olavarrieta, C., Villalobos-Hernandez, A., Valencia Rodríguez, J., Sanhueza Smith, P., Burks, C. (2011) Public opinion on abortion in Mexico City after the landmark reform. Studies in Family Planning, 42(3): 175–182. Secretaría de Salud del Distrito Federal (SSDF). Dirección de medicina a distancia. (2011) Apoyo por Teléfono a Usuarias en Situación de Embarazo. Mexico City: SSDF. Inmujeres DF. (n.d.) Interrupción Legal del Embarazo. Retrieved from: http:// www.inmujer.df.gob.mx/wb/inmujeres/interrupcion_legal_del_embarazo. Accessed April 23, 2012. Alianza Nacional por el Derecho a Decidir (andar). (2007–2011) Building a ProChoice Alliance in Mexico. Project reports 2007–2011. Mexico City: ANDAR. Fondo MARÍA. (n.d.) ¿Quieres interrumpir legalmente tu embarazo y necesitas ayuda? MARÍA te apoya y te acompaña. Retreived from: http://www. redbalance.org/maria/inicio_maria.html. Accessed May 3, 2012. Romero Contreras, M.E. (2011) Fiscalización de Módulos Anti-Derechos 2007–2010. PowerPoint presentation. Mexico City: Equidad de Género, Trabajo, y Familia. Schiavon, R., Collado, M.E., Troncoso, E., Soto Sánchez, J.E., Otero Zorrilla, G., Palermo, T. (2010) Characteristics of private abortion services in Mexico City after legalization. Reproductive Health Matters, 18(36): 127–135.

“By allowing access to legal abortion services, and quality medical care, we are respecting and guaranteeing the women’s right to choose.” Dr. Armando Ahued Ortega, Minister of Health of Mexico City In July 2008, Dr. Mondragón*, the Minister of Health in the first phase of the LA program, was called away for other duties, and was replaced by the Deputy Minister of Health, Dr. Armando Ahued Ortega. Dr. Ahued shared his predecessor’s mission to deliver a successful LA program, and under his leadership, the LA program matured to the regional success story it is today.

*Dr. Mondragón became Minister of Public Security of Mexico City .

4. Toward a new model of LA service provision

The opening of health centers offering comprehensive sexual and reproductive health services The growing demand for legal abortion services, and the limitations to adapting the hospital-based services to allow for meeting this demand, led to an important change in legal abortion service delivery. While the hospitals would remain open for women seeking the services, the MOH decided to establish primary care health centers dedicated to providing comprehensive sexual and reproductive health services, including LA. This decision became a real possibility when the medical abortion procedure proved to be effective in women at up to nine weeks gestation, and was well received by the women. The services offered in these health centers are free of charge to all women. The first health center, Beatriz Velasco de Aleman (BVA), opened in May 2008, one year after the legal reform, in the northern part of the city right on the border with the State of Mexico. Apart from legal abortions, the center also offers general sexual and reproductive health services to the general population. These include family planning services, prevention of and screening for sexually transmitted infections (STIs) and HIV, screening for cervical and breast cancer, as well as screening for cases

An island of liberties

of gender-based violence (GBV). Moreover, the center offers treatment for human papilloma virus (HPV) infection and early phases of cervical cancer for women who have screened positive. For the provision of abortion services, the MOH selected and hired a motivated pro-choice staff of four ob/gyns, eight nurses, four social workers, and an anesthesiologist. Also the support personnel, such as receptionists, cleaning personnel, and security guards, were chosen based on their pro-choice stance to ensure a warm, nonjudgmental environment for the women attending for the legal abortion services. The facility’s interior was modeled after international examples of abortion services. It includes a waiting area, three examination rooms (two with modern ultrasound machines), two surgery rooms (both with modern ultrasound machines and one with an electric vacuum aspirator), a recovery area, and some smaller areas for storage of equipment and medicine. Since the opening of the BVA health center, an ever-growing proportion of women seeking legal abortion services have been accessing its services (today 39 percent of all legal abortion services are carried out at the BVA health center). The MOH Reproductive Health Program Coordinator and his staff, in collaboration with the team working at the BVA health center and NGOs such as Ipas Mexico, Gynuity Health Projects, and ESAR developed a model for high-quality abortion service provision and counseling. In March 2009, the BVA health center obtained the prestigious certification of “quality care for legal abortion services” by NAF in the United States. This means that women who access the LA program in Mexico City are receiving certified high-quality evidence-based care and best practices. The health center was dedicated to the late Charlotte Ellertson, a leader in the struggle for sexual and reproductive rights in Mexico, and former Director of the Population Council’s Reproductive Health Program in LAC.1

Toward a new model of la service provision

Because of the immense demand for services from the BVA health center, the MOH mobilized resources to remodel a second health center in Iztapalapa. The Santa Catarina health center is located in one of the poorest and most populated parts of the city. Following the example of the BVA, Santa Catarina is operated by specialized and trained personnel. Furthermore, in comparison to BVA, the Santa Catarina health center is more spacious, and includes special design features to ensure that women feel comfortable during their stay: areas with natural light and plants and flowers, soft relaxing music in the waiting area, the use of recovery chairs instead of stretchers, a television in the recovery room, the availability of drinks and tea for women post-procedure, as well as the use of colorful saris during recovery, instead of hospital gowns. The MOH dedicated the clinic to Dr. Beverly Winikoff, Director of Gynuity Health Projects, in recognition of her instrumental role in promoting standardized medical abortion services in the Mexico City MOH. The Santa Catarina health center began providing legal abortion services in July 2010. In addition to legal abortion services it also provides general sexual and reproductive health care, including family planning services.2 The opening of a third health center followed in February 2012. The health center México España was dedicated to leading Mexican feminist, Marta Lamas, whose role in the process leading up to the decriminalization of abortion in Mexico City, and her ongoing support for Mexican women’s right to decide, have been fundamental to the program.3 The Mexico España health center is situated in the west of Mexico City, and is the largest of the three selected health centers. In addition to legal abortion services, and general sexual and reproductive health services, the center specializes in the provision of modern contraceptive methods (such as the hormonal intrauterine device and the subdermic implant), and breast cancer screening, offers mammograms, and evaluates mammograms from all other Mexico City MOH sites.

An island of liberties

The introduction of mifepristone Another critical breakthrough in the implementation of the LA program was the registration of mifepristone with the Ministry of Health in August 2011. Mifepristone in combination with misoprostol is more effective compared to the misoprostol-only regimen (around 95 percent) as well as producing fewer side effects.3 The Mexico City MOH collaborated with Gynuity Health Projects in a clinical study, testing the efficacy and acceptability of mifepristone-misoprostol medical abortion in Mexico, with positive results. The Mexican Federal Regulatory Drug Agency (COFEPRIS) registered one commercial mifepristone brand, and the registration of another is still in process. The Minister of Health for Mexico City has added mifepristone to its official list of essential medicines and has negotiated preferential prices for the public sector with the manufacturer. These measures assure that all the selected health facilities within the LA program have a guaranteed supply of mifepristone. The shift from the misoprostol-only regimen to the gold standard combined misoprostolmifepristone regimen has been completed throughout all facilities offering legal abortion. Gynuity Health Projects supported the MOH by training all health care providers in the use of this highly effective medical abortion regimen. The legal abortion service model The Mexico City MOH has developed a legal abortion service model that is client-friendly, high-quality, effective, and free from discrimination. The procedure consists of a series of components; each of them is described below.4 Although the hospitals have a slightly different organization, the steps are comparable.

Toward a new model of la service provision

Figure 1. Flowchart for the legal abortion procedure Registration Screening Ultrasound Clinical history Informative group session of the medical abortion procedure

Individual counseling and informative session regarding the MVA procedure

Individual counseling session for the medical abortion procedure

Vacuum aspiration procedure

Informative group session for the accompanying persons

Two week follow-up appointment

â&#x20AC;˘

Registration

Typically, the women arrive at the health center early in the morning and are attended to on a first-come, first-served basis. Their first contact at the health center is with the receptionist. The receptionist receives all the identification documents required: a photocopy of her Federal Electoral Institute (IFE) identity card and a photocopy of an official document with her address. If the woman accessing the services is below the age of 18, she must be accompanied by a parent or legal guardian, who must also present an IFE identity card and a document including their address, as well as a photocopy of the birth certificate of the minor. With this information, the receptionist opens a patient record and asks the woman for some general sociodemographic questions to enter into the intake form. Afterward, the woman is invited to take a seat in the waiting area. People accompanying the women are invited to wait in an area available outside the facility. 61

An island of liberties

•

Screening

The woman is then invited to the screening area, where a nurse takes vital sign measurements: blood pressure, pulse, temperature, height, and weight. A laboratory assistant takes a blood sample (for analysis of hemoglobin/hematocrit and blood-group typing). The nurse provides a short explanation to the woman about the steps of the procedure and responds to any general questions that the woman might have. •

Ultrasound

The woman then sees a radiologist who performs an ultrasound to determine the gestational age of her pregnancy. The radiologist explains the results of the ultrasound, and the procedure she will receive based on the following criteria: • •

•

The woman is a candidate for a medical abortion if the ultrasound shows a pregnancy of less than 10.0 weeks of gestation. The woman is a candidate for vacuum aspiration (either manual or electric) if the ultrasound shows a pregnancy between 10.1 to 12 complete weeks of gestation. Women from states outside of Mexico City can access a vacuum aspiration procedure, even if they have a pregnancy of less than 10.0 weeks of gestation.

While, in principle, the type of procedure depends on the gestational age of the pregnancy, women under nine weeks of gestation with a strong preference for a surgical procedure may request to have a vacuum aspiration. The woman cannot access a legal abortion procedure if the ultrasound shows a gestational age of more than 12 weeks. She is then offered counseling by a social worker and referred to a general health center near her home for prenatal care.

Toward a new model of la service provision

If the ultrasound does not show a gestational sac, indicating a pregnancy, additional tests are performed (determination of Î˛HCG, transvaginal ultrasound) to rule out an ectopic pregnancy. In the case of an ectopic pregnancy, the woman is referred to an MOH hospital for appropriate treatment. If she is not pregnant, she is then offered contraceptive counseling and a contraceptive method. â&#x20AC;˘

Medical history

Eligible women (or the parent or guardian in cases of minors) are then seen by an ob/gyn, or a general practitioner. The provider asks the woman questions about her medical history and conducts a physical examination. The ob/gyn explains the medical and vacuum aspiration procedures, the risks and the complications that may occur in extremely rare cases, and responds to any questions the women may have. â&#x20AC;˘

Information and counseling

The counseling session is probably the most important aspect of the legal abortion procedure. All health care personnel providing counseling have been trained in evidence-based counseling techniques for sensitive health issues. Their approach is warm and respectful, and they communicate using language that is easy to understand. For women using medical abortion (approximately 70 percent of the cases), the counseling is divided into an informative group session, followed by an individual counseling session; both are led by experienced social workers who have special training in abortion counseling. Women eligible for vacuum aspiration receive individual information and counseling provided by the ob/gyn. The group session for women who have chosen a medical abortion takes about 20 to 30 minutes and is designed to be interactive; women are encouraged to ask questions. The social worker introduces herself and invites the women participating in the session to do the same, mentioning that they may use a pseudonym to ensure confidentiality.

An island of liberties

Women who want to may share the reason they decided to have an abortion. The social worker first discusses the possibility of alternative options, such as carrying the pregnancy to term or adoption. Then the social worker explains the step by step instructions for a medical abortion procedure. The social worker describes the normal side effects of the procedure, provides advice for alleviating these effects, and discusses the warning signs of potential complications (see Box 8). The social worker emphasizes that if they experience such signs, the women should go to a Mexico City MOH hospital or call ILETEL. She also explains that while the procedure is highly efficient, some women are resistant to the medication and may still have to undergo a vacuum aspiration. Finally, the social worker underlines the importance of attending the scheduled follow-up appointment two weeks later to verify whether the medical procedure had been successful.

Box 8. Information provided to women for a medical abortion procedure Mifepristone and misoprostol regimen: • •

The woman takes the dose of mifepristone (200 mg) at the health center. After 24 to 48 hours, at her home she takes a dose of buccal misoprostol, placing four misoprostol tablets (800 mcg) between the cheek and the gum (two at each side of the mouth) and leaving them there to dissolve. After 30 minutes, she drinks a glass of water to swallow the remainder of the tablets.

Normal side effects: • Vaginal bleeding with clots generally starts after taking the misoprostol and diminishes after two hours following the expulsion of all the clots. The clots tend to be the size of a lime or larger, and can be one or more. Bleeding can be heavy, and it can take two weeks or more before it has disappeared entirely. • Abdominal pain and cramps are more intense than normal menstrual bleeding, and present within 24 hours of taking of the second dose. Painkillers such as ibuprofen, paracetamol, or ketorolac can be taken to control pain (one tablet every six hours for a maximum of three days).

Toward a new model of la service provision

• •

Nausea, vomiting, and diarrhea can occur after the second dose and generally disappear the same day. Mild fever or chills for less than 24 hours generally present after the second dose.

Potential complications: • Allergic reaction • Hemorrhage • Infection • Ectopic pregnancy Warning signs: • Intense bleeding after two hours following the expulsion of clots (soaking through more than two sanitary napkins in one hour during two consecutive hours). • Severe abdominal pain • Dizziness for over 24 hours • Persistent fever (over 38 C°) or chills (over 24 hours) • Unpleasant-smelling vaginal discharge Other instructions: • Eat light meals, drink two liters of water a day, and avoid heavy physical activity. • Abstain from sexual intercourse for 30 to 40 days following the procedure. • Contact the health center if the bleeding has not started within a week of having begun the treatment.

An island of liberties

The counseling session then turns to the importance of using a contraceptive method to prevent future unplanned pregnancies. The social worker explains that the procedure will not affect the women’s fertility for future pregnancies and that they will be fertile again in approximately three weeks. The social worker then describes the wide range of existing methods and indicates those that are available for free at the MOH facility. (See Box 9)

Box 9. Contraceptive methods available in the MOH hospitals or health centers • • • • • • • • • •

Male condoms Oral contraceptives Injectables Hormonal patch Subdermal implant Contraceptive vaginal ring Intrauterine device (IUD) (both copper-releasing and hormone-releasing IUDs), can be inserted after a vacuum aspiration Vasectomy (in hospitals) Female sterilization (in hospitals) Emergency contraception

During the group session, women are also offered information about other sexual and reproductive health issues. Social workers emphasize the importance of using condoms to prevent sexually transmitted infections as well as yearly screenings for cervical cancer (Pap smear). Women with risk factors (mother or sister with breast cancer before age 40) are advised to screen for breast cancer (mammography). All women are provided with a short list of questions screening for GBV, and those who ask for more information receive specialized counseling. All women leave with written information about the abortion procedure,

Toward a new model of la service provision

contraceptive methods, the ILETEL phone number, and addresses of hospitals where they can seek help in case they experience warning signs and symptoms. After the group session, women are offered counseling in a private space. The sessions are held individually, in small groups (of maximum three persons), or with the woman and her partner or accompanying person. The aim of this session is to enable women to make a free and informed decision about the termination of their pregnancy. The social worker and the women have a structured conversation about her specific situation, her feelings, her thoughts and her options regarding the pregnancy and contraception. The women are encouraged to ask questions and express any fears and the social worker offers counseling and emotional support. The social worker also makes sure the women have understood the information provided during the group session. If they decide to continue with the abortion procedure, the women (or the parent or guardian in cases of minors) are asked to sign the informed consent form. Women who express the need for more in-depth psychological support are referred to a psychologist. An ob/gyn or general practitioner explains vacuum aspiration to qomen undergoing the procedure (see Box 10). (S)he also provides counseling similar to that provided to women undergoing a medical abortion. If women decide to continue with the procedure, they sign informed consent, and women opting for an IUD sign a consent form for its insertion post-procedure. Women are scheduled for the aspiration (normally within two days), while women from other states can access the procedure on the same day.

An island of liberties

Box 10. Information provided to women having a vacuum aspiration Normal post-procedure side effects: • Light bleeding for a few days and spotting for a few weeks. • Light abdominal pain • Potential, extremely rare complications: • Hemorrhage • Infection Warning signs: • Fever (over 38 C°) or chills • Very heavy bleeding (soaking through more than two maxi pads in one hour, during two consecutive hours). • Intense abdominal pain • Unpleasant smelling vaginal discharge Other instructions: • Eat light meals, drink two liters of water a day, and avoid heavy physical activity for a few days. • Abstain from sexual intercourse, tampon use, and swimming pool visits for 30 to 40 days • Have a daily bath. • Take the antibiotic medication as instructed.

•

Information session for accompanying persons

In order to reduce the anxiety among people accompanying women for an abortion procedure (usually partners, mothers, sisters, and friends), social workers provide an informative session for them twice a day while they wait. They provide information on the abortion procedure, contraceptive options, and other sexual and reproductive health issues. •

The procedure and follow-up

After the counseling session, women who are eligible to continue with the medical abortion procedure are instructed to take the mifepristone tablet in the health center. They are provided with a dose of misoprostol 68

Toward a new model of la service provision

to take one to two days later in the comfort of their homes, and are then scheduled for a follow-up appointment two weeks later. During the follow-up visit, the radiologist performs an ultrasound to confirm a complete abortion. Women with an incomplete abortion receive a third dose of misoprostol and schedule another follow-up appointment for a week later. Women with an ongoing pregnancy are referred for a vacuum aspiration.

Box 11. Two studies on the client´s perspective A study carried out by Becker and colleagues measured perceptions of quality of care among 402 women who had obtained abortions at any of three publicsector sites in Mexico City in 2009.5 The findings showed that clients gave overall services a high rating, with a mean rating of 8.8 out of 10. The factors that proved important for clients were whether: • • • • • • • •

the physician made them feel comfortable; the receptionist was respectful to them; the staff was careful to protect their privacy; they had received sufficient information on self-care at home following the procedure, and on post-abortion emotions; they felt confident in the physician’s technical skill; the site hours were perceived to be convenient; the waiting time was perceived as acceptable; and the facility was rated as clean.

Focusing on these aspects can further improve clients’ satisfaction with the services. In a study by van Dijk and colleagues, 15 women who had attended the BVA health center for an abortion procedure, in 2008 were interviewed.6 Participants were highly satisfied with the abortion services provided. None of the women expressed doubts about their decision to have an abortion and they all felt they were treated with respect. The women were pleased with the counseling they received, and most accepted a post-procedure contraceptive method. In particular, women indicated that the Mexico City MOH, through its development of a specialized facility, is providing high-quality services, despite remaining challenges such as long waiting times and difficulties finding a facility to provide the services.

An island of liberties

Women attending for a vacuum aspiration procedure are accompanied individually by a nurse throughout the procedure for emotional support. The woman first undergoes a physical examination and is administered a dose of misoprostol (400mcg) sublingually to prime the cervix. After two hours, she is admitted to the surgery room and the procedure is carried out by an ob/gyn using MVA or EVA, under local anesthesia, and with ultrasound monitoring. After completion of the procedure, the woman rests in the recovery area for two to three hours. When she feels well enough to leave, she undergoes a final physical examination and is discharged. All women are offered free condoms and a package of emergency contraception pills.

Box 12. Trends in patient characteristics Trends of the womenâ&#x20AC;&#x2122;s characteristics in the years 2007 to 2010 have been published in the special section of the journal Studies in Family Planning.7

Characteristics of the women accessing the services The electronic database, based on the abortion intake forms, allows access to up-to-date information about the program at any time. The MOH and the Population Council regularly assess the characteristics of the women accessing the legal abortion services to monitor their provision. The graphics, displayed below, include the data available as of September 2012 from the two highest performing health centers which carry out 58 percent of the legal abortion procedures in the MOH network.8

Toward a new model of la service provision

Age groups*

50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0%

<18 years

18-24

25-29

30-34

35-39

40-44

45 and above

S/D= no data available

*Information retrieved from BVA and Santa Catarina health center's records, 2007 to September 2012.

An island of liberties

Relationship status* 60%

50%

40%

30%

20%

10%

Single

Co-habiting

Married

Separated

Information Unavailable

Divorced

Widowed

No answer

Primary School

Middle School

High School

University

Post Graduate

No Answer

No Information Available

Education* 45% 40% 35% 30% 25% 20% 15% 10% 5% 0%

None

*Information retrieved from BVA and Santa Catarina health center's records, 2007 to September 2012.

Toward a new model of la service provision

Occupation* 35%

30%

25%

20%

15%

10%

Employed

A Homemaker

Student

Unemployed

Self-employed

No Information Available

Other

Place of residence* Residence

2007

2008

2009

2010

2011

2012

Mexico City (Federal District)

100%

66%

70%

69%

68%

66%

State of Mexico

26%

24%

27%

28%

Other state or country

Number of children*

None

37%

1-2

40%

3-5

23%

5 or more

*Information retrieved from BVA and Santa Catarina health center's records, 2007 to September 2012.

An island of liberties

Derechohabiencia a programas de cobertura en salud* 70%

60%

50%

40%

30%

20% 10% 0%

Without affiliation

Mexican Social Security Institute

Institute of Security and Social Services for State Workers

Seguro Popular

Private Health Care

No information available/ No answer

Weeks of gestation* Weeks of gestation

Until 9 10 11

81% 9% 6% 2% 2%

12 N/A Tipo de procedimiento* No information 1%

Aspiration (manual or electric) 21%

Medical abortion 78%

*Information retrieved from BVA and Santa Catarina health center's records, 2007 to September 2012.

Toward a new model of la service provision

Repeat abortions at a MOH Health Center* #

O 1 2 or more

96% 4% 0%

Complications* Complication

Numner of cases

Infection Hemorrhage Uterine perforation

13 14 5 1 33

Ectopic pregnancy Total

Type of post-abortion contraception* Method

2007

2008

2009

2010

2011

2012

IUD/IUS Injectables Pills Condom Emergency contraceptive pill Contraceptive patch

100%

25% 8% 18% 8%

19% 12% 12% 17%

25% 8% 20% 11%

19% 22% 23% 20%

28% 21% 14% 8%

12%

10%

Tubal ligation Sub-dermic implant

Adopted at least one method

2007

2008

2009

2010

2011

2012

100%

59%

58%

65%

89%

79%

*Information retrieved from BVA and Santa Catarina health center's records, 2007 to September 2012.

An island of liberties

Sexual and reproductive health campaign Since the beginning of Mayor Marcelo Ebrardâ&#x20AC;&#x2122;s administration in Mexico City in 2006, information and education campaigns on sexual and reproductive health for young people have been a priority9,10 as evidence suggests that this group has a high rate of unmet need for contraception.11 The 2007 legal reform reinforced this commitment toward adolescents by requiring the Mexico City Government to offer contraceptive services and sex education and campaigns on reproductive and sexual rights to this age group.12 Hand in hand with the provision of legal abortion services, the MOH has improved the provision of family planning services in its health centers. In addition, in 2011, the MOH developed a citywide campaign to raise public awareness and knowledge about important aspects of sexual and reproductive health, including family planning (as well as other themes such as pregnancy, breast, cervical and prostate cancer; GBV; STIs; HIV; and menopause). A subset of the campaign focuses on adolescents and young people, and was expanded into a large media campaign, including an interactive website and a short film to promote condom use which was screened in movie theatres in Mexico City.13 Building evidence and sharing the experience The LA program provided an opportunity for the development of new research studies; many of which we have highlighted throughout this document. While the MOH has (co-)authored several studies, national and international NGOs, academic institutions, and individual researchers have also carried out independent studies on several aspects of the implementation of the LA program.

Toward a new model of la service provision

In March 2011, the MOH and the Population Council organized a meeting titled “Four Years of Research on the Implementation of Legal Abortion Services.” During this meeting, 150 public officials, health care professionals, researchers, and advocates from civil society presented findings of research studies and reviewed the progress of the LA program. The majority of these studies have been published in scientific journals. The peer-reviewed academic journal Studies in Family Planning published a special section focused entirely on the results of studies based on the LA Program in Mexico City. This publication was translated into Spanish and contributes to sharing the success of the LA program with interested parties worldwide. Furthermore, the MOH has been eager to share its own experience, since the beginning of the LA program, and learn from the experiences of abortion services in other countries. MOH representatives have presented information about the LA program in many national and international forums and conferences. At the 2008 NAF meeting, the Mexico City experience was the topic of the opening plenary session; Dr. Mondragón was the keynote speaker. In the following year’s meeting, NAF dedicated an international luncheon session to the decriminalization of abortion in Mexico City. The MOH LA program was also a prominent topic at both the Third (2008) and the Fourth (2011) “Research Meeting on Unwanted Pregnancy and Unsafe Abortion: Public Health Challenges in Latin America and the Caribbean,” organized by the Population Council. These regional conferences were an excellent platform for presenting the MOH LA program as they bring together activists, academics, and policy- and decisionmakers from across the region to showcase the latest research, form new connections, and shape a regional policy platform to promote safe and legal abortion.

An island of liberties

The MOH has presented its LA program at conferences convened by the American Public Health Association (APHA), CLACAI, Colmex, FIGO, FLASOG, Gynuity Health Projects, ICMA, IUSSP, INSP, IPPF, Maternal Health Task Force, and Women Deliver. In 2012, the Mexico City MOH, as an emerging international leader in the field, hosted the annual NAF meeting on Risk Management targeted to medical staff. References 1.

8. 9.

Ibis Reproductive Health. (n.d.) About Charlotte Ellertson. Retrieved from: http://www.ibisreproductivehealth.org/about/charlotte.cfm. Accessed May 29, 2012. Gynuity Health Projects. (n.d.) About Beverly Winikoff. Retrieved from: http://gynuity.org/about/staff/winikoff/. Accessed May 29, 2012. Gender Across Borders. (n.d.) Global Feminist Profiles: Marta Lamas of Mexico. Retrieved from: http://www.genderacrossborders.com/2009/04/20/globalfeminist-profiles-marta-lamas-of-mexico/. Accessed May 29, 2012. Secretaría de Salud del Distrito Federal (SSDF). (2012) La Consejería en el Programa de Interrupción Legal del Embarazo de la Secretaría de Salud del Gobierno del Distrito Federal. Mexico City: SSDF. Becker, D., Díaz-Olavarrieta, C., Juárez, C., García, S.G., Sanhueza, P., Harper, C.C. (2011)Clients’ perceptions of the quality of care in Mexico city’s publicsector legal abortion program. International Perspectives on Sexual and Reproductive Health, 37(4): 191–201. van Dijk, M.G., Arrellano, L.J., Aranguré, A.G., Toriz Prado, A.A., Krumholz, A., Yam, E.A. (2011) Women’s experiences with legal abortion in Mexico City: A qualitative study. Studies in Family Planning, 42(3): 167-174. Mondragón y Kalb, M., Ahued Ortega, A., Morales Velázquez, J., Díaz Olavarrieta, C., Valencia Rodríguez, J., Becker, D., García, S.G. (2011) Patient characteristics and service trends following abortion legalization in Mexico City, 2007–10. Studies in Family Planning, 42(3): 159–166. Secretaría de Salud del Distrito Federal (SSDF). Reporte Diario de Actividades, Programa de Interrupción Legal del Embarazo. December 2011 to November 2012. Secretaría de Salud del Distrito Federal (SSDF). (2006) Programa de Salud Sexual y Reproductiva 2006-2012. PowerPoint presentation. Mexico City: SSDF. Secretaría de Salud del Distrito Federal (SSDF). Dirección de Promoción de la Salud. Coordinación de Promoción de la Salud y Cultura del Envejecimiento. (2011) Informe de Resultados de la Encuesta sobre la Campaña de Salud Sexual y Reproductiva: “¡No te Embarques! Planea tu Bida!,” Mexico City: SSDF.

10. Juárez, F., Palma, J.L., Singh, S., Bankole, A. (2010) Las Necesidades de Salud Sexual y Reproductiva de las Adolescentes en México: Retos y Oportunidades. New York: Guttmacher Institute. 11. Gobierno del Distrito Federal. (2007) Gaceta Oficial del Distrito Federal. April 4(17): 70. 12. Secretaría de Salud del Distrito Federal (SSDF). Salud Sexual y Reproductiva. Retrived from: http://www.salud.df.gob.mx/ssdf/index.php?option=com_conte nt&task=view&id=5583&Itemid=334. Accessed April 15, 2012.

5. Looking forward: The future of the LA program

At the selected Mexico City health centers, the legal abortion service model has proven its effectiveness, and women who have attended the program report high levels of satisfaction with the experience. However, the MOH continues to work to improve the quality and accessibility of its services and is planning to apply innovative service-delivery strategies in the near future. For example, the MOH is paving the way for opening an additional health center to further expand service sites. Also, it intends to open two or three smaller health centers for pregnancy up until nine weeks of gestation, where only medical abortion procedures will be carried out, in addition to other reproductive health services. In June 2012, the MOH in collaboration with Ipas Mexico included important changes to update the General Guidelines for legal abortion. The updates were published in the Official Gazette of the Federal District. Some updates are: •

•

The inclusion of the phrase “12 completed weeks” in the updated guidelines; clarifying that women are legally entitled to receive abortions up until the thirteenth week of pregnancy. The guidelines also now clearly state that legal abortion procedures are free for women from the Federal District in health facilities.

An island of liberties

•

• •

All health facilities, including primary health centers, are now allowed to provide abortion services; and are no longer required to have an operating room in order to provide medical abortions. Also, dilation and curettage (D&C) is no longer referred to as a standard legal abortion procedure. Finally, the updated guidelines specify that general practitioners can provide legal abortion services.

The current regulations stipulate that only specialist physicians are allowed to carry out the procedures in surgical settings, creating unnecessary barriers to access. However, international recommendations and best practices suggest that midlevel providers can provide equal care to women.1–3 By early 2013, with the support of the World Health Organization (WHO), and in collaboration with the INSP and the Population Council’s Mexico Office, the MOH finalized a research study (a randomized controlled trial) which generated scientific evidence to document that nurses can manage early medical abortions as effectively as physicians. In parallel, the MOH and Ipas Mexico are working toward the inclusion of midlevel providers as authorized legal abortion providers in the LA program. Additionally, the MOH is restructuring the LA program to broaden access for specific groups such as teenagers by modifying the current requirement for minors to be accompanied by a parent or legal guardian in order to access the services. Furthermore, the MOH is strengthening the mechanism used to expedite legal abortion referrals from hospitals to health centers specialized in legal abortion services. The MOH is also planning to make their post-abortion counseling on contraceptive use more interactive by introducing a client-friendly counseling tool, the “Balanced Counseling Strategy” (BCS), which has been tested in several countries and proven to be more effective than

Looking forward: The future of the la program

traditional contraception counseling.4 This strategy involves a set of steps to determine the method that best suits the client according to her/ the couple’s preferences and reproductive intentions. The counselor uses cards including basic information about contraceptive methods, and through a process of discarding cards, the client determines the best option for her/their situation. Once a method is chosen, the client is given a brochure with specific information about the method chosen. To further improve the range of contraceptive options, the MOH is in the final steps toward introducing Essure®—a female sterilization technology. Essure uses a hysteroscopy method (it does not require incision or general anesthesia) and involves placement of a tiny device into the fallopian tubes around which scar tissue grows, and after about three months the tubes are blocked. As soon as it is available, the method will be offered in the selected health centers. With the support of the Population Council, the MOH is in a process of transition from written patient records to an electronic record system, which will streamline monitoring and provide rapid access to information on the population served, as well as highlight gaps in program delivery. The system is already in practice in the network of Mexico City MOH hospitals and the BVA and Santa Catarina health centers, but will be expanded to the Mexico España health center and other centers to be opened in the near future. The MOH will also continue to collaborate with research institutions to build a database on the LA program to ensure the sustainability of the program in the future.

References 1. 2.

Chong, Y.S., Mattar, C.N. (2006) Mid-level providers: A safe solution for unsafe abortion. Lancet, December 2, 368(9551): 1939–1940. Warriner, I.K., Meirik, O., Hoffman, M., Morroni, C., Harries, J., My Huong, N.T., Vy, N.D., Seuc, A.H. (2006) Rates of complication in first-trimester manual vacuum aspiration abortion done by doctors and mid-level providers in South Africa and Vietnam: A randomized controlled equivalence trial. Lancet, December 2, 368(9551): 1965–1972. Berer, M. (2009) Provision of abortion by mid-level providers: International policy, practice and perspectives. Bulletin of the World Health Organization, 87(1): 58–63. Population Council. (n.d.) The Balanced Counseling Strategy: A Toolkit for Family Planning Service Providers. Retrieved from: http://www.popcouncil.org/ publications/books/2008_BalancedCounselingStrategy.asp. Accessed May 15, 2012.

6. The effect of the law reform and the implementation of the LA program

The Mexico City abortion law reform and its implementation, through the LA program, has marked an important accomplishment for womenâ&#x20AC;&#x2122;s sexual and reproductive rights. The beneficiaries of the LA program include not only women but also their children, families, and societyâ&#x20AC;&#x201D;for present and future generations. While the full impact of the seven-year old Mexico City LA program cannot yet be measured, we highlight the main effects that we have observed. Improved health The fact that almost 90,000 women have accessed legal abortion services suggests that the program is fulfilling a public health need. Furthermore, none of these 90,000 procedures, performed under legal conditions within the first trimester in the MOH public health services have ended in a maternal death. This means that the mortality rate associated with legal abortion in Mexico City is comparable to the international statistics previously mentioned. Women choosing to terminate a pregnancy have access to a safe and legal procedure and are less likely to put their health and life at risk undergoing clandestine procedures.

An island of liberties

None of the women fulfilling the eligibility criteria of the Mexico City MOH LA program had adverse health consequences. The rate of complications, as reported in Section 4, is insignificant. This is explained in part by the fact that there has been a reduction in the use of invasive procedures such as D&C, and an increase in the use of modern technologies such as MVA/EVA and medical abortion. The MOH provides immediate treatment to the few women with mild complications and none have had any long-term consequences. Anecdotal information from health care providers in Mexico City has shown that while before the law reform they regularly treated patients with severe complications from unsafe abortions, the frequency with which they see such patients has now diminished to almost zero (interviews from a study by Contreras and colleagues, 20111). However, it is true that abortion-related deaths have not yet been entirely eradicated in Mexico City.2 Box 13. Women’s testimonies “It was difficult to decide to interrupt the pregnancy because my family is very Catholic, but it was the best decision for me. I didn’t want to become a mother yet, I wanted to finish my studies and become a professional.” (Hortensia, 24-year old psychology student from Mexico City) “I had a relationship with my boyfriend for two years and we used condoms. But after a party we had unprotected sex and I got pregnant. I was very upset. I would like to be a mother, but I felt this was not the right moment. I didn’t have a stable job, and my dad was very ill. I started to have problems with my boyfriend. I couldn’t be a mother at that moment, but more importantly, I didn’t want to. I talked with a friend and she advised me to go to the hospital, where they treated me very well. I had an abortion, and although it was a hard decision, I never regretted it. I want a better life for myself, and for my children. I have a good job now, I feel good, strong, and eager to live my life.” (Ximena, 26-year-old woman from Mexico City) “I have six children. I have not told my family because they would never permit it.…The youngest girl is four-and-a-half years old, and I’ve been told that I need to take better care of her. I have made this decision for my six children, because I am concerned about the other kids.” (Verónica, 39-year-old woman from the state of Mexico)

The effect of the law reform and the implementation of the la program

Some women may still have insufficient knowledge of the legal status and availability of safe and free services, or abortion stigma may prevent them from seeking a legal abortion in the available facilities. Some may have had second-trimester pregnancies. This underscores the importance of continuous awareness raising activities by the Mexico City MOH and allied organizations. Improved access Another important accomplishment of the law reform and the LA program is that anyone can access the services, irrespective of their age or health insurance coverage. This especially benefits vulnerable groups, such as women in condition of poverty, young people, students, and victims of GBV or rape. Women who are victims of rape can receive authorization for an abortion up to 20 weeks. The services are also available for women coming from other Mexican states, and who do not reside in Mexico City, representing more than 25 percent of the legal abortion users. All are offered respectful services, without discrimination. Womenâ&#x20AC;&#x2122;s testimonies, as displayed in Box 13, show how the freedom to choose has had an important impact on their lives. Access to legal abortion has also improved for women falling within the indications of the previous restrictive Mexico City law. While during the six years before the law reform, only 66 women accessed legal abortion services under these indications, the legal abortion databases from the two clinics with the highest volume of patients show that since 2007, 1,838 women have sought services for other legal indications, such as rape, fetal malformations and risk to the womanâ&#x20AC;&#x2122;s health or life. This number is probably higher as women may choose to say that the abortion is their own decision, and not provide any further explanation. The LA program has helped women in other states outside Mexico City to have options when faced with an unwanted pregnancy. Only 1 percent of the women from other states came to Mexico City because they had had trouble accessing abortion services under legal indications in their

An island of liberties

own states. The other 99 percent accessed services in Mexico City for reasons that do not fall under the legal indications in their own states; meaning that the current laws in the majority of states are not realistic and do not meet the demand. Improved contraceptive use The Legal Abortion law of 2007 also included an important element: improvement in the uptake of family planning methods. The program offers counseling on family planning and contraceptive methods and the proportion of women opting for a contraceptive method following a legal abortion is high (82 percent).3 All women are offered a postcoital method (emergency contraception) as well as condoms after their procedure. The low rate of women having repeat abortion procedures, 1 percent, may reflect the high acceptance of post-abortion contraception and the programâ&#x20AC;&#x2122;s relative success in providing access to and information on correct usage of contraceptive methods for all women accessing LA in Mexico City.3 It also suggests that, contrary to the concern among some opponents of the legal reform, women are not using LA as their primary method of fertility control, even though it is legal.3 An upcoming prospective study will follow women for a longer period to evaluate the continuation of the contraceptive method they choose after their abortion. The study will provide additional data on the impact of the efforts to improve contraceptive use among women who have accessed the program. Although we have no data available yet on the impact of the MOH sexual and reproductive health campaign carried out conjointly with other NGOs and institutions, we estimate that it has improved awareness among the general public on the importance of contraception. New abortion incidence studies would be needed to assess whether the induced abortion rates have diminished in Mexico City.

The effect of the law reform and the implementation of the la program

Lower costs A study conducted in Mexico City, after the decriminalization of elective abortion in the first 12 weeks of pregnancy, has determined that the provision of safe abortion is cost-effective (for both the health system and for the women seeking abortions), resulting in reduced complications, decreased mortality, and substantial cost savings compared with unsafe abortion. It demonstrates that investing in safe abortion services is likely to be one of the most cost-effective decisions that Mexico, or for any other country where unsafe abortion is prevalent,4 could make. Positive effect on public opinion At the time of the law reform, significant and generally favorable media coverage informed the public about the law and contributed to an increased awareness about the positive consequences of this legal change. Furthermore, the decriminalization of abortion may have made public expression of support more socially acceptable, as it is no longer an illegal procedure.5 As mentioned in Section 2, since the law was approved seven years ago, the publicâ&#x20AC;&#x2122;s favorable opinion about elective termination of pregnancy increased from 38 percent (pre-reform) to 74 percent (in 2009). Similarly, support for the extension of the law to other states increased from 51 percent in 2007 to 83 percent in 2009. Upcoming studies at the national level will show whether the Mexico City law reform has also influenced national public opinion on elective first-trimester pregnancy termination. The abortion law has initiated a public debate in Mexico and in other countries about the public health, legal, social, and ethical aspects of elective legal abortion.

Referencias 1. 2.

Secretaría de Salud del Distrito Federal (SSDF). (2007) Reporte Diario de Actividades, Programa de Interrupción Legal del Embarazo. August 7. Consejo Nacional de Población (CONAPO). (2009) Principales Indicadores de Salud Reproductiva. ENADID. Retrieved from: http://www.conapo.gob.mx/work/ models/CONAPO/Resource/216/1/images/4Anticoncepcionen.pdf. Accessed September 10, 2012. Mondragón y Kalb, M., Ahued Ortega, A., Morales Velázquez, J., Diaz Olavarrieta, C., Valencia Rodríguez, J., Becker, D., García, S.G. (2011) Patient characteristics and service trends following abortion legalization in Mexico City, 2007–10. Studies in Family Planning, 423: 159–166. Hu, D., Grossman, D., Levin, C., Blanchard, K., Goldie, S.J. (2009) Costeffectiveness analysis of alternative first-trimester pregnancy termination strategies in Mexico City. BJOG: An International Journal of Obstetrics and Gynaecology, 116(6): 768–779. Wilson, K., García, S., Díaz-Olavarrieta, C., Villalobos-Hernández, A., Valencia Rodríguez, J., Sanhueza Smith, P., Burks, C. (2011) Public opinion on abortion in Mexico City after the landmark reform. Studies in Family Planning, 42(3): 175–182.

â&#x20AC;&#x153;Even if this law is repealed, nothing and no one can erase the experience of freedom that women in Mexico City are able to exercise,â&#x20AC;? Marta Lamas

Conclusions

The last seven years have been a decisive time for sexual and reproductive rights in Mexico City, with clear advances in women’s access to safe and legal abortion. Approximately 117,000 women have benefited from the legal abortion program offered by the Mexico City MOH. On International Women’s Day in 2012, Mayor Marcelo Ebrard again expressed his pride over this accomplishment—which has prominently placed gender equality on Mexico’s political agenda. The Mexico City government and its MOH have proven their ability to transcend public moral debate by putting in place a pragmatic evidence-based strategy for the protection of public health: the LA program. We hope that this account of the Mexico City experience will inspire policymakers and the public health community in other countries to legalize and institute their own LA programs. We believe that for the case of Mexico City, four factors have been key for meeting its success: 1) political will; 2) support from NGOs and the organized civil society; 3) the use of medical abortion, first with the misoprostol-only regime, and later with the gold-standard regime with mifepristone and misoprostol; and, finally, 4) the response from women demanding high-quality public care.

The law could not have been applied successfully without the political will to quickly mobilize human and material resources to support the program. The MOH’s strategic partnerships with NGOs and other institutions were without a doubt crucial throughout all the stages of the implementation of the LA program. The decision to transfer the services from hospitals to health centers, and to adopt the gold standard in medical abortion provision, enabled the MOH to meet the increasing demand for services. In a time of financial scarcity and competing priorities, the MOH was nevertheless authorized to open three designated health centers that could offer the high-quality care needed. Finally, women from Mexico City and the rest of the country have requested, in an informed and empowered way, high-quality services and have in this way upheld their own rights. Still, significant challenges remain to be overcome in promoting women’s access to legal abortion, including favorable public policies that define legal abortion services as an essential part of comprehensive reproductive health and family planning. With the presidential and Mexico City government elections in 2012, the political arena may have changed little, but new leaders, may have other perspectives and ideas about the implementation of the LA program. However, the continuity of the LA program is assured, and with the support of pro-choice allies and a favorable public opinion, we are confident that the sexual and reproductive health services provided by Mexico City’s MOH will continue to improve and maintain its basic principle: respect for women’s right to decide about their sexual and reproductive health.

Designed in Mexico â&#x20AC;˘ 2014