Evolving capacity and decision-making in practice: adolescents' access to legal abortion services in Mexico City.

The rights of adolescents and young people in international law and agreements have evolved significantly from a focus on protection to a recognition of "evolving capacities" and decision-making ability. Unclear policies and regulations and variations in actual practice may leave providers with little clarity on how to support adolescent decision-making and instead create unintended barriers. This study in Mexico City in 2009 explored whether regulations and clinical attitudes and practice were supporting or hindering the access of adolescent girls aged 12-17 to information regarding abortion and to abortion services. We surveyed abortion clinic directors and staff, and adolescents arranging or just having had an abortion, and sent mystery clients to clinics to ask for information. While providers were generally positive about adolescents' ability to decide on abortion, they had different understandings about the need for adult accompaniment and who that adult should be, and mystery clients seeking information were more likely to receive complete information if accompanied by an adult. Clarification of consent and accompaniment requirements is needed, and providers need to be made aware of them; adolescents should have access to information and counselling without accompaniment; and improvements in privacy and confidentiality in public sector clinics are also needed. These all support complementary concepts of protection and autonomy in adolescent decision-making on abortion.

A harm-reduction model of abortion counseling about misoprostol use in Peru with telephone and in-person follow-up: A cohort study.

BACKGROUND: In Peru, abortion is legal only to preserve the life and health of the woman. A non-profit clinic system in Peru implemented a harm-reduction model for women with unwanted pregnancy that included pre-abortion care with instructions about misoprostol use and post-abortion care; they started offering telephone follow-up for clients in 2011. This study aimed to evaluate the effectiveness and safety of the harm-reduction model, and to compare outcomes by type of follow-up obtained. METHODS: Between January 2012 and March 2013, 500 adult women seeking harm-reduction services were recruited into the study. Telephone surveys were conducted approximately four weeks after their initial harm-reduction counseling session with 262 women (response rate 52%); 9 participants were excluded. The survey focused on whether women pursued an abortion, and if so, what their experience was. Demographic and clinical data were also extracted from clinic records. RESULTS: Eighty-six percent of participants took misoprostol; among those taking misoprostol, 89% reported a complete abortion at the time of the survey. Twenty-two percent obtained an aspiration after taking misoprostol and 8% self-reported adverse events including hemorrhage without transfusion, infection, or severe pain. Among women who took misoprostol, 46% reported receiving in-person follow-up (in some cases both telephone and in-person), 34% received telephone only, and 20% did not report receiving any form of follow-up. Those who had in-person follow-up with the counselor were most likely to report a complete abortion (<0.001). Satisfaction with both types of follow-up was very high, with 81%-89% reporting being very satisfied. CONCLUSIONS: Liberalization of restrictive abortion laws is associated with improvements in health outcomes, but the process of legal reform is often lengthy. In the interim, giving women information about evidence-based regimens of misoprostol, as well as offering a range of follow-up options to ensure high quality post-abortion care, may reduce the risks associated with unsafe abortion.

Patterns of men's use of sexual and reproductive health services.

CONTEXT: Men have been neglected as a target population for sexual and reproductive health services. As a result, little is known about the rates and antecedents of men's service utilization. METHODS: Data from the 2002 National Survey of Family Growth were used to examine utilization of sexual and reproductive health services among 3,611 men aged 20-44 who had ever had sex with a woman. Associations between demographic and behavioral variables and measures of service utilization were assessed in univariate and logistic regression analyses. RESULTS: Only 48% of men reported receiving sexual and reproductive health services in the past year. The testicular exam was the most commonly received service (35%), but half of men who had had a testicular exam had received no other sexual and reproductive health services. Levels of unmet need for services among men engaging in sexual risk behaviors were substantial (32-63%). The odds of having received nontesticular services were elevated among men who were nonwhite and older, engaged in sexual risk behaviors, had had a physical exam and had public health insurance. The odds of having received only a testicular exam were elevated among men who were white, had lower levels of sexual risk, had had a physical exam and had private or no insurance. CONCLUSIONS: Men who have sex with women are not receiving adequate levels of sexual and reproductive health care, and the care they receive is neither comprehensive nor integrated. Standards of clinical care need to be defined and communicated to men and providers.

Young Mexicans' hopes and fears about abortion and abortion law: a qualitative study in two cities.

BACKGROUND: In Mexico, abortion is legal only in limited, specific circumstances and unsafe abortion complications are estimated to be the fourth leading cause of maternal mortality. Our study sought to understand the opinions Mexicans hold about abortion and sexuality and to learn about their fears and hopes about more liberalized abortion laws in Mexico. METHODS: We carried out 12 focus groups with a total of 87 women and men, aged 18-24. Six focus groups took place in Mexico City and six in Merida, Yucatan. One reader thematically analyzed and coded discussion transcripts. RESULTS: Participants favoring highly restrictive abortion laws generally felt that pregnant women should "face the consequences" of having a baby, whereas those who favored less restrictive laws focused less on culpability and more on the woman's right to control her future. Mexico City participants generally had more liberal abortion opinions. Most Merida participants thought abortion was never legal, despite the fact that their state has the country's most liberal abortion laws. Many felt that, if abortion were legal, there would be more abortions but that it would likely be a safer procedure. CONCLUSIONS: Merida participants' more conservative attitudes may be a reflection of their lower educational levels and largerproportion of Catholic participants compared to the Mexico City groups. It is critical to introduce more balanced information that emphasizes the safety of abortions performed under legal conditions and address fears of greatly elevated abortion rates if abortion laws were liberalized. Mexican young adults need more scientific, balanced sources of information on abortion and abortion law.

Valuable safeguard or unnecessary burden? Characterization of physician consultations for oral contraceptive use in Mexico City.

CONTEXT: Given the safety and efficacy of oral contraceptives (OCs), many health professionals believe that these should be widely available over-the-counter (OTC). Opponents of OTC availability argue that without a physician's consultation, women will not be properly screened and will not use OCs correctly, thereby compromising safety and efficacy. However, little is known about the content or quality of physicians' consultations. METHODS: Trained simulated patients (SPs) attended 45 appointments with Mexico City public and private physicians to request a prescription for OCs. Immediately following each appointment, the SPs filled out a checklist regarding the information provided and examinations performed by physicians. RESULTS: Both public and private physicians asked a few questions and provided little information regarding screening, pill-taking instructions, side effect information and warning sign information. Despite the fact that all SPs were appropriate OC candidates, women were denied a prescription in seven (15.6%) appointments mostly because of their age (regarded as either too old or too young). CONCLUSION: In general, Mexican physicians are not providing women thorough information and screening in OC consultations, calling into question the assumption that a physician's appointment is necessary for or will ensure safe, proper OC use.

Decisionmaking regarding unwanted pregnancy among adolescents in Mexico City: a qualitative study.

Adolescents in Latin America and the Caribbean confront difficult decisions when faced with unwanted pregnancies, especially given the region's legal restrictions on and widespread cultural opposition to abortion. Little research has been conducted on pregnancy decisionmaking among young people in this region. This study examines the role of peers, partners, family members, and health-care providers in adolescents' decisionmaking regarding pregnancy continuation or termination in Mexico City shortly after abortion was legalized in 2007. Qualitative in-depth interviews and focus group discussions were conducted in 2009 with participants aged 13-17 who experienced an unwanted pregnancy. Although participants were able to formulate preferences regarding pregnancy resolution, parents' wishes usually prevailed when their wishes conflicted. Peers were generally found to be supportive, whereas the role of partners varied. Results indicate the need for comprehensive sexuality education to promote adolescents' autonomy, mechanisms other than legal mandates to encourage constructive parental involvement, and confidential counseling from health professionals offering options and supporting adolescents'ability to act on their decisions.

Linking cervical cancer to the human papillomavirus: findings from a qualitative study with Mexican women.

Cervical cancer is an important cause of mortality for women in developing countries. Researchers have established a link between cervical cancer and the human papillomavirus (HPV). We explored Mexican women's beliefs about cervical cancer and sexually transmitted infections (STIs), including HPV, to better understand the social implications of this linkage. We conducted eight focus groups with middle-aged and young women in Mexico City. Cervical cancer elicited different social and emotional responses than STIs; participants generally attached less culpability to it and saw it as more life threatening. Information campaigns should take into account differences in lay conceptions of these illnesses.

Policy implications of a national public opinion survey on abortion in Mexico.

In Mexico, recent political events have drawn increased public attention to the subject of abortion. In 2000, using a national probability sample, we surveyed 3000 Mexicans aged 15-65 about their knowledge and opinions on abortion. Forty-five per cent knew that abortion was sometimes legal in their state, and 79% felt that abortion should be legal in some circumstances. A majority of participants believed that abortion should be legal when a woman's life is at risk (82%), a woman's health is in danger (76%), pregnancy results from rape (64%) or there is a risk of fetal impairment (53%). Far fewer respondents supported legal abortion when a woman is a minor (21%), for economic reasons (17%), when a woman is single (11%) or because of contraceptive failure (11%). In spite of the influence of the Church, most Mexican Catholics believed the Church and legislators' personal religious beliefs should not factor into abortion legislation, and most supported provision of abortions in public health services in cases when abortion is legal. To improve safe, legal abortion access in Mexico, efforts should focus on increasing public knowledge of legal abortion, decreasing the Church's political influence on abortion legislation, reducing the social stigma associated with sexuality and abortion, and training health care providers to offer safe, legal abortions.