Factors Associated with Support for Adolescent Access to Contraception Among Mexican Catholic Parents.

We used a nationally representative survey of 2186 Mexican Catholic parents to assess two outcomes: support for adolescent access to modern contraception and whether adolescents unaccompanied by an adult should have access to contraceptive methods. A majority (85%) of Mexican Catholic parents support adolescent access to modern contraceptive methods, but there was less support (28%) for access to contraception unaccompanied. Further, our results show strong support (92%) for sex education in schools. Parents who believe that good Catholics can use contraception had higher odds of support for adolescent access and unaccompanied access to modern contraception. Mexican Catholic parents support adolescent access to modern contraception, but support for unaccompanied access to contraception is lower. This may reflect an interest in being involved, and not necessarily opposition to contraceptive use. Measures of Catholicism that focus on behaviors may better explain opinions about adolescent access to contraception.

Early termination of pregnancy: differences in gestational age estimation using last menstrual period and ultrasound in Mexico.

BACKGROUND: Gestational age estimation is key to the provision of abortion, to ensure safety and successful termination of pregnancy. We compared gestational age based on reported last menstrual period and ultrasonography among a large sample of women in Mexico City's public first trimester abortion program, Interrupcion Legal de Embarazo (ILE). METHODS: We conducted a retrospective study of 43,219 clinical records of women seeking abortion services in the public abortion program from 2007 to 2015. We extracted gestational age estimates in days based on last menstrual period and ultrasonography. We calculated the proportion of under- and over-estimation of gestational age based on last menstrual period versus ultrasonography. We compared overall differences in estimates and focused on discrepancies at two relevant cut-offs points (70 days for medication abortion eligibility and 90 days for ILE program eligibility). RESULTS: On average, ultrasonography estimation was nearly 1 (- 0.97) days less than the last menstrual period estimation (SD = 13.9), indicating women tended to overestimate the duration of their pregnancy based on recall of date of last menstrual period. Overall, 51.4% of women overestimated and 38.5% underestimated their gestations based on last menstrual period. Using a 70-day limit, 93.8% of women who were eligible for medication abortion based on ultrasonography would have been correctly classified using last menstrual period estimation alone. Using the 90-day limit for ILE program eligibility, 96.0% would have been eligible for first trimester abortion based on last menstrual period estimation alone. CONCLUSIONS: The majority of women can estimate gestational age using last menstrual period date. Where available, ultrasonography can be used, but it should not be a barrier to providing care.

[Provision of immediate postpartum contraceptivemethods in Mexico, 2018-19]. / Provisión de métodos anticonceptivos en el posparto inmediato en México, 2018-19.

OBJECTIVE: To identify sociodemographic and health services factors associated with receipt of immediate post-partum (IPP) contraception and the type of contraceptive method received. MATERIALS AND METHODS: We used the National Health and Nutrition Survey (Ensanut), 2018-19, which contains information on 4 548 women aged 12-49 years who gave birth. We described receipt of IPP contraception and method type and used multivariable logistic (n=4 544) and multinomial regression (n=2 903) to examine receipt of any modern method and type of method. RESULTS: 65% of women received IPP contraception. 56.8% of adolescents received long-acting reversible contraception (43.7% IUD & 13.1% implant). Being indigenous, having only one child, or receiving care in State Health Services/IMSS-Prospera or private sector facilities were associated with lower odds of receiving IPP contraception. CONCLUSIONS: We identify progress in the IPP contraception coverage among adoles-cents. Disparities persist in receipt of IPP contraception by type of health insurance.

OBJETIVO: Analizar la anticoncepción posparto (APP) y tipo de método anticonceptivo recibido según características sociodemográficas y de atención del parto de las mujeres. MATERIAL Y MÉTODOS: Se analizaron datos de la Encuesta Nacional de Salud y Nutrición (Ensanut) 2018-19 en4 548 mujeres de 12-49 años que tuvieron un parto. Se ajustaron modelos de regresión logística (n=4 544) y multinomial (n=2 903) con variables dependientes APP y tipo de anti-conceptivo recibido. RESULTADOS: Se encontró que 65% de las mujeres recibieron APP,y 56.8% de las adolescentes un método reversible de larga duración (43.7% DIU y 13.1% implantes). Ser indígena, tener un hijo, o recibir atención en los servicios estatales de salud/IMSS-Prospera o privadas, se asocia con menores posibilidades de APP. CONCLUSIONES: Se identificaron progresos en la cobertura de APP en las adolescentes. Persisten brechas de acuerdo con el asegura-miento en salud tanto en la recepción de APP como en el tipo de método recibido.

Are overweight and obesity associated with increased risk of cesarean delivery in Mexico? A cross-sectional study from the National Survey of Health and Nutrition.

BACKGROUND: In Mexico, obesity is a major public health problem; 71% of adults are overweight or obese. The proportion of deliveries by cesarean is also very high (45%). Women of reproductive age with overweight or obesity may be at higher risk of cesarean. METHODS: We conducted a cross-sectional study to test the association between overweight and obesity (using body mass index, BMI) and cesarean delivery in Mexico using data from the 2012 National Survey of Health and Nutrition (ENSANUT). Our sample included women of reproductive age at the time of survey who reported a live birth between 2006 and 2012. We used bivariate statistics and a multivariate logistic regression model to test the association between measured BMI and self-reported cesarean delivery. We included individual, clinical, and household level confounders and used survey weights to produce population estimates. RESULTS: Our sample consisted of 4,570 women (population N = 7,447,541). Overall, 44% of the women reported a cesarean at last delivery. We found differences in the proportion of cesarean delivery by BMI group (normal = 39%; 95% CI [35-43]; overweight = 42%; 95% CI [38-45]; obesity = 52%; 95% CI [48-57]; p < 0.001). In multivariable models controlling for socio-demographic and clinical characteristics, we found a strong and independent association between obesity and cesarean delivery among multiparous women, compared with multiparous women with normal BMI (obesity aOR: 1.60; 95% CI [1.21-2.12]). CONCLUSIONS: We provide new evidence about the proportion of women with overweight and obesity who deliver in Mexico. Multiparous women with obesity are at higher risk of cesarean delivery in Mexico than multiparous women with normal body mass index. Given the high prevalence of both obesity and cesarean delivery in Mexico, this relationship is salient for women, health care providers, and the health system. Efforts to reduce the cesarean deliveries rate need to take the obesity epidemic into account.

Access to abortion under the heath exception: a comparative analysis in three countries.

BACKGROUND: Despite Britain, Colombia, and some Mexican states sharing a health exception within their abortion laws, access to abortion under the health exception varies widely. This study examines factors that result in heterogeneous application of similar health exception laws and consequences for access to legal abortion. Our research adds to previous literature by comparing implementation of similar abortion laws across countries to identify strategies for full implementation of the health exception. METHODS: We conducted a cross-country comparative descriptive study synthesizing data from document and literature review, official abortion statistics, and interviews with key informants. We gathered information on the use and interpretation of the health exception in the three countries from peer-reviewed literature, court documents, and grey literature. We next extracted public and private abortion statistics to understand the application of the law in each setting. We used a matrix to synthesize information and identify key factors in the use of the law. We conducted in-depth interviews with doctors and experts familiar with the health exception laws in each country and analyzed the qualitative data based on the previously identified factors. RESULTS: The health exception is used broadly in Britain, somewhat in Colombia, and very rarely in Mexican states. We identified five factors as particularly salient to application of the health exception in each setting: 1) comprehensiveness of the law including explicit mention of mental health, 2) a strong public health sector that funds abortion, 3) knowledge of and attitudes toward the health exception law, including guidelines for physicians in providing abortion, 4) dissemination of information about the health exception law, and 5) a history of court cases that protect women and clarify the health exception law. CONCLUSIONS: The health exception is a valuable tool for expanding access to legal abortion. Differences in the use of the health exception as an indication for legal abortion result in wide access for women in Britain to nearly no access in Mexican states. Our findings highlight the difference between theoretical and real access to legal abortion. The interpretation and application of the health exception law are pivotal to expanding real access to abortion.

Adolescents and Long-Acting Reversible Contraception: Lessons from Mexico.

Objectives We describe current use of long acting reversible contraception LARC (tier 1), hormonal (tier 2), barrier and traditional contraceptive methods (tier 3) by adolescent women in Mexico. We test whether knowledge of contraceptive methods is associated with current use of LARC. Methods We used the 1992, 1997, 2006, 2009 and 2014 waves of a nationally representative survey (ENADID). We used information from n = 10,376 (N = 3,635,558) adolescents (15-19 years) who reported ever using any contraceptive method. We used descriptive statistics and logistic regression models to test the association of knowledge of method tiers with use of tier 1 (LARC) versus tier 2, tier 3, and no contraceptive use. Results Over time, LARC use in the overall sample was flat (21 % in 1992, 23 % in 2014; p = 0.130). Among adolescents who have had a pregnancy, LARC use has increased (24 % in 1992 to 37 % in 2014). Among adolescents who did not report a pregnancy, current LARC use has remained low (1 % in 1992 and 2 % in 2014). We found positive association between LARC use and knowledge of tier 1 methods. In the overall sample LARC use is strongly correlated with exposure to marriage compared to use of tier 2 or tier 3 methods. Discussion Among adolescents in Mexico who are currently using modern methods, LARC use is relatively high, but remains primarily tied to having had a pregnancy. Our study highlights the need to expand access to LARC methods outside the post-partum hospital setting.

Emergency Contraception in Mexico: Trends in Knowledge and Ever-Use 2006-2014.

Objectives A package of interventions to introduce emergency contraception (EC) to Mexico was implemented, resulting in the addition of EC to the national family planning guidelines in 2004. We describe EC knowledge and use among women in Mexico over time. Methods We used the 2006, 2009, and 2014 of waves of a nationally representative demographic survey (ENADID). We assessed EC knowledge and usage in women ages 15-29 who are not using permanent methods and tested whether EC knowledge and use is changing over time after controlling for socio-demographic characteristics using logistic regression. Results Our sample included n = 99,223 (population N = 40,234,355) women ages 15-29. Overall, knowledge of EC increased over time: 62% in 2006 to 79% in 2009 to 83% in 2014 (p < 0.001). Among young women who have used contraception (n = 42,883; N = 16,816,701), the proportion that reported EC use increased from 3 to 11% to 29% (p < 0.001). Compared to non-users, women who had ever used EC were more likely to be using no method of contraception (44 vs. 35%) or barrier method (22 vs. 17%). Demographic factors including lower wealth, lower education, indigenous status and rural living are significantly associated with less EC knowledge and use. Stratified multivariate analysis found that demographic disadvantages magnify lower EC use among rural residents compared to non-rural residents. Conclusions for Practice Knowledge and use of EC are growing rapidly in Mexico, but disparities persist in demographically disadvantaged women, particularly those living in rural areas. Women who use EC appear to be at higher risk of unintended pregnancy based on current contraceptive use.

True Love: Effectiveness of a School-Based Program to Reduce Dating Violence Among Adolescents in Mexico City.

Dating violence is a significant problem in Mexico. National survey data estimated 76 % of Mexican youth have been victims of psychological aggression in their relationships; 15.5 % have experienced physical violence; and 16.5 % of women have been the victims of sexual violence. Female adolescents perpetrate physical violence more frequently than males, while perpetration between genders of other types of violence is unclear. Furthermore, poor, marginalized youth are at a higher risk for experiencing dating violence. "Amor… pero del Bueno" (True Love) was piloted in two urban, low-income high schools in Mexico City to prevent dating violence. The intervention consisted of school-level and individual-level components delivered over 16 weeks covering topics on gender roles, dating violence, sexual rights, and strategies for coping with dating violence. The short-term impact was assessed quasi-experimentally, using matching techniques and fixed-effects models. A sample of 885 students (381 students exposed to the classroom-based curriculum of the individual-level component (SCC, IL-1) and 540 exposed only to the school climate component (SCC)) was evaluated for the following: changes in dating violence behaviors (psychological, physical and sexual), beliefs related to gender norms, knowledge, and skills for preventing dating violence. We found a 58 % (p < 0.05) and 55 % (p < 0.05) reduction in the prevalence of perpetrated and experienced psychological violence, respectively, among SCC, IL-1 males compared to males exposed only to the SCC component. We also found a significant reduction in beliefs and attitudes justifying sexism and violence in dating relationships among SCC, IL-1 females (6 %; p < 0.05) and males (7 %; p < 0.05).

Reclassifying causes of obstetric death in Mexico: a repeated cross-sectional study.

OBJECTIVE: To describe causes of maternal mortality in Mexico over eight years, with particular attention to indirect obstetric deaths and socioeconomic disparities. METHODS: We conducted a repeated cross-sectional study using the 2006-2013 Búsqueda intencionada y reclasificación de muertes maternas (BIRMM) data set. We used frequencies to describe new cases, cause distributions and the reclassification of maternal mortality cases by the BIRMM process. We used statistical tests to analyse differences in sociodemographic characteristics between direct and indirect deaths and differences in the proportion of overall direct and indirect deaths, by year and by municipality poverty level. FINDINGS: A total of 9043 maternal deaths were subjected to the review process. There was a 13% increase (from 7829 to 9043) in overall identified maternal deaths and a threefold increase in the proportion of maternal deaths classified as late maternal deaths (from 2.1% to 6.9%). Over the study period direct obstetric deaths declined, while there was no change in deaths from indirect obstetric causes. Direct deaths were concentrated in women who lived in the poorest municipalities. When compared to those dying of direct causes, women dying of indirect causes had fewer pregnancies and were slightly younger, better educated and more likely to live in wealthier municipalities. CONCLUSION: The BIRMM is one approach to correct maternal death statistics in settings with poor resources. The approach could help the health system to rethink its strategy to reduce maternal deaths from indirect obstetric causes, including prevention of unwanted pregnancies and improvement of antenatal and post-obstetric care.

[Does public health insurance improve health care? The case of prenatal care for adolescents in Mexico]. / ¿El aseguramiento público en salud mejora la atención en los servicios? El caso de la atención prenatal en adolescentes en México.

OBJECTIVE:: To test the association between public health insurance and adequate prenatal care among female adolescents in Mexico. MATERIALS AND METHODS:: Cross-sectional study, using the National Health and Nutrition Survey 2000, 2006, and 2012.We included 3 978 (N=4 522 296) adolescent (12-19) women who reported a live birth.We used logistic regression models to test the association of insurance and adequate (timeliness, frequency and content) prenatal care. RESULTS:: The multivariable predicted probability of timely and frequent prenatal care improved over time, from 0.60 (IC95%:0.56;0.64) in 2000 to 0.71 (IC95%:0.66;0.76) in 2012. In 2012, the probability of adequate prenatal care was 0.54 (IC95%:0.49;0.58); women with Social Security had higher probability than women with Seguro Popular and without health insurance. CONCLUSION:: Having Social Security is associated with receipt of adequate prenatal care among adolescents in Mexico.

Effectiveness and safety of medication abortion via telemedicine versus in-person: A cohort of pregnant people in Colombia.

OBJECTIVE: To compare the effectiveness and safety of medication abortion (MAB) via telemedicine versus in-person in pregnant people with less than 12 gestational weeks in Colombia. STUDY DESIGN: A retrospective cohort study was conducted with 23,362 pregnant people who requested MAB service from Profamilia (a Colombian non-governmental organization) in 2021-2022. The outcomes were success and safety of MAB. We performed a descriptive and a multivariate statistical analysis using the binary regression model to obtain an adjusted Odds Ratio (aOR) to identify factors associated with abortion success. RESULTS: In comparison to in-person care (n = 20,289), individuals in telemedicine (n = 3073) were predominantly from urban areas, belonged to a lower socioeconomic stratum, single and did not identify with any ethnic group. In-person users tended to have higher levels of education and accessed the service through private insurance (p < 0,05). There were no differences in the odd of a successful abortion based on the modality of care (aOR 1.18; 95% CI=0.87-1.59). The results were also the same with sensitivity analysis stratified: pregnant people who were nine weeks gestation or less (aOR 0.86; 95% CI=0.63-1.17) or more (aOR 0.87; 95% CI=0.28-2.65). CONCLUSION: Telemedicine is an effective and safe option for MAB, as in-person care. Telemedicine has the potential to increase abortion access by extending the availability of providers and offering people a new option for obtaining care conveniently and privately, especially for women with disadvantaged socioeconomic and educational background. IMPLICATIONS: This study demonstrates that medication abortion (MAB) administered via telemedicine produces outcomes akin to those of in-person care, providing a compelling rationale for its adoption, particularly in underserved regions. This approach can be replicated in other countries in Latin America and the Caribbean.

Trends in subdermal contraceptive implant use in Mexico 2009-2018: A population-based study.

OBJECTIVE: To describe subdermal implant use in Mexico over time, by state and by age. METHODS: We conducted a repeated cross-sectional study using the 2009, 2014, and 2018 waves of the National Survey of Demographic Dynamics (Encuesta Nacional de la Dinámica Demográfica [ENADID]). Our outcome was current use of contraception, by type, with a focus on the implant. We used visualizations, descriptive and bivariate statistics, and multinomial models to assess change over time, geographic patterns, method mix, and factors associated with implant use (vs intrauterine device [IUD] or other hormonal methods). RESULTS: Implant use is increasing over time in Mexico, from 1.1% of women who have ever used a method in 2009 to 4.5% in 2018 (P < 0.001); the change is greatest among adolescents (2.5% in 2009 to 12.2% in 2018; P < 0.001). Change in implant use as a fraction of modern method use was heterogeneous across Mexican states. The adjusted relative likelihood of using an implant compared with IUD was 34% higher for adolescents compared with women aged 20-29 years (relative risk ratio 1.34, 95% confidence interval 1.16-1.55, P < 0.001), controlling for other variables in the model. CONCLUSION: Use of subdermal implants is increasing over time in Mexico and is concentrated among adolescents. Implants have the potential to expand access to highly effective contraception in Mexico.

Travelling for abortion services in Mexico 2016-2019: community-level contexts of Mexico City public abortion clients.

OBJECTIVE: To describe the community context of women who travel to access Mexico City's public sector abortion programme and identify factors associated with travelling from highly marginalised settings. METHODS: We used data from the Interrupción Legal de Embarazo (ILE) programme (2016-2019) and identified all abortion clients who travelled from outside Mexico City. We merged in contextual information at the municipality level and used descriptive statistics to describe ILE clients' individual characteristics and municipalities on several measures of vulnerability. We also compared municipalities that ILE clients travelled from with those where no one travelled from. We used logistic regression to identify factors associated with travelling to access ILE services from highly marginalised versus less marginalised municipalities. RESULTS: Our sample included 21 629 ILE clients who travelled to Mexico City from 491 municipalities within all 31 states outside Mexico City. The majority of clients travelled from the least marginalised (81.9%) and most populated (over 100 000 inhabitants; 91.3%) municipalities. Most (91.2%) ILE clients came from municipalities with adolescent fertility rates in the bottom three quintiles. Clients with a primary or secondary education (vs high school or more) and those from a municipality with a high adolescent fertility rate (top two quintiles) had higher odds of travelling from a highly marginalised (vs less) municipality (adjusted odds ratio (aOR) 1.46, 95% CI 1.35 to 1.58 and aOR 1.89, 95% CI 1.68 to 2.12, respectively). CONCLUSION: ILE clients travel from geographically and socioeconomically diverse communities. There is an unmet need for legal abortion across Mexico.

Patterns in Contraceptive Use Among Women of Mexican Origin in the United States and in Mexico.

OBJECTIVE: To examine current contraceptive use by parity among four ethnicity and nativity groups: non-Latina White women in the United States, Mexican-American women in the United States, foreign-born women of Mexican origin in the United States, and Mexican women in Mexico. METHODS: We combined nationally representative data from sexually active women, aged 15-44 years, and not seeking pregnancy from the U.S. National Survey of Family Growth and the Mexican National Survey of Demographic Dynamics. This is a secondary binational analysis. Using multivariable logistic regression, we estimated the prevalence of moderately or most effective contraceptive method use (compared with least effective or no contraceptive method) by ethnicity and nativity and tested the interaction between ethnicity and nativity and parity. RESULTS: Compared with non-Latina White women, women of Mexican origin had lower odds of using a moderately or most effective contraceptive method (adjusted odds ratio [aOR] [95% CI] Mexican-American women: 0.69 [0.54-0.87]; foreign-born women: 0.67 [0.48-0.95]; Mexican women in Mexico: 0.59 [0.40-0.87]). Among parous women, the adjusted probability of using a moderately or most effective contraceptive method was approximately 65% among all four groups. Contraceptive method use did not differ by parity among non-Latina White women. However, parous Mexican-American women were 1.5 times more likely to use moderately or most effective contraceptive methods than nulliparous Mexican-American women (adjusted probability 66.1% vs 42.7%). Parous foreign-born women were 1.8 times more likely to use most or moderately effective contraceptive methods than their nulliparous counterparts (64.5% vs 36.0%), and parous Mexican women in Mexico were three times more likely to use moderately or most effective contraceptive methods (65.2% vs 21.5%). CONCLUSION: Findings suggest that access to effective contraception is limited outside the context of childbearing for women of Mexican origin in the United States and, to an even larger extent, in Mexico.

Adolescent Reproductive Health Outcomes Among Mexican-Origin Women on Both Sides of the U.S.-Mexico Border.

PURPOSE: Much reproductive health research on the Latina population overlooks heterogeneity by national origin, nativity, and age and also ignores how U.S.-based populations differ from those in "sending" nations. The purpose of this study is to describe a history of adolescent birth, age at first sex, and contraceptive use at first sex in the Mexican-origin population in both the United States and Mexico. METHODS: We developed a binational dataset merging two comparable nationally representative cross-sectional surveys in the United States and Mexico and used covariate balancing propensity scores to balance the age structure of our four samples: U.S.-born Latinas of Mexican origin, foreign-born Latinas of Mexican origin, U.S.-born non-Latina Whites, and Mexican women residing in Mexico. We used a negative binomial regression and calculated the predicted probability of experiencing at least one adolescent birth for each ethnicity/nativity group, stratified by 5-year age group. We also described age and contraceptive use at first sex. RESULTS: Foreign-born Latinas of Mexican origin and Mexicans in Mexico had similar adjusted probabilities of reporting an adolescent birth (30.1% and 29.9%, respectively), which were higher than those of Mexican-Americans (26.2%) and U.S.-born non-Latina Whites (11.6%). History of an adolescent birth is declining across all four groups among younger ages. Differences do not appear to be driven by the timing of first sex but by contraceptive use, which is increasing among younger age groups. DISCUSSION: Access to and use of effective contraception rather than timing of initiation of sexual activity is a key determinant of U.S. Latina and Mexican adolescent births.

Relationship Between Abortion at First Pregnancy and Live Births by Young Adulthood: A Population-Based Study Among Mexican Women.

STUDY OBJECTIVE: To identify factors associated with having an abortion (spontaneous or induced) at the time of first pregnancy, and to test the association between abortion in the first pregnancy and the number of live births among young women 20-24 years of age. DESIGN: Cross-sectional study. SETTING: We used a nationally representative survey of Mexican women 20-24 years of age with data at time of survey and retrospective measures of exposures in adolescence. We include 1913 women who reported ever having a pregnancy. MAIN OUTCOMES: Our outcomes were history of abortion (spontaneous or induced) and number of live births by 20-24 years of age. We used multivariable logistic regression models to estimate the association between sociodemographic factors at the time of pregnancy and abortion history, and between abortion history and number of live births. RESULTS: Among women 20-24 years of age who ever had a pregnancy, 15.5% reported an abortion in the first pregnancy, and 84.4% never had an abortion. Among women who had an abortion in the first pregnancy, 62.3% did not report any live birth by age 20-24 years. Young women living with their parents (adjusted odds ratio [AOR] = 1.87; confidence interval [CI] = 1.16-3.02) or with a partner with a higher educational level (AOR = 4.64; CI = 1.05-20.44) had greater odds of having an abortion in the first pregnancy. Compared with women who never had an abortion, women who reported an abortion in the first pregnancy had lower odds (AOR = 0.02; CI = 0.01-0.03) of having 1 or more children by the age of 20-24 years. CONCLUSION: Young women who reported abortion in the first pregnancy had fewer live births at ages 20-24 years compared to women with no history of abortion.

Preventing first births among adolescents in Mexico City's public abortion programme.

INTRODUCTION: We examined parity and age among women seeking an abortion in Mexico City's public first-trimester abortion programme, Interrupcion Legal de Embarazo (ILE). We hypothesised that younger women, especially students, used abortion to prevent first births while older women used abortion to limit births. METHODS: We used clinical data from a sample of 47 462 women who had an abortion between 2007 and 2016 and classified them as nulliparous or parous according to previous births prior to the abortion. We used logistic regression to identify sociodemographic and clinical factors associated with using abortion to prevent a first birth (nulliparous) versus limiting births (parous) and calculated absolute multivariable predicted probabilities. RESULTS: Overall, 41% of abortions were in nulliparous women seeking to prevent a first birth, and 59% were in women who already had one or more children. The adjusted probability of using abortion to prevent a first birth was 80.4% (95% CI 78.3 to 82.4) for women aged 12-17 years and 54.3% (95% CI 51.6 to 57.0) for women aged 18-24 years. Adolescents (aged 12-17 years) who were employed or students had nearly 90% adjusted probability of using abortion to prevent a first birth (employed 87.8%, 95% CI 82.9 to 92.8; students 88.5%, 95% CI 82.9 to 94.1). At all ages, employed women and students had higher probabilities of using abortion to prevent a first birth compared with unemployed women and women who work in the home. CONCLUSION: Legal first-trimester abortion services in Mexico can help prevent first births in adolescents, especially students.

Contraceptive Receipt Among First-Trimester Abortion Clients and Postpartum Women in Urban Mexico.

CONTEXT: In Mexico, first-trimester abortion is legal in Mexico City and is available in the public and private sectors. Understanding subsequent contraceptive uptake and method mix among first-trimester abortion clients relative to that of women who deliver a live birth at a health facility could help identify where improvements in care following an obstetric event can be made across the health system. METHODS: This article uses a retrospective cohort study to compare uptake of contraception prior to discharge between abortion clients in Mexico City's public abortion program and postpartum women from urban settings. The two data sources were clinical records of 45,233 abortion clients in Mexico City and information from a population-based survey of 1,289 urban women on their immediate postpartum contraceptive adoption. The primary outcome investigated was receipt of any reversible modern contraceptive method; secondary outcomes were level of method effectiveness and method type. Logistic regression and calculated multivariable probabilities were used to control for the effects of sociodemographic factors across the two data sources. RESULTS: The adjusted probability of uptake of any reversible modern method of contraception was higher among abortion clients than among postpartum women (67% vs. 48%). However, among all women who had received a contraceptive method, abortion clients had a lower adjusted probability of having received a long-acting reversible contraceptive than did postpartum women (49% vs. 82%) and a higher probability of having received a moderately effective method (38% vs. 13%). The adjusted probability of implant uptake was higher among abortion clients than among postpartum women (9% vs. 3%), while the adjusted probability of IUD uptake was lower (38% vs. 78%). CONCLUSIONS: Women receiving abortions in Mexico City's public abortion program were more likely than urban postpartum women to receive a reversible modern contraceptive method before leaving the facility. Women should be offered the full range of contraceptive methods after any obstetric event, to help them prevent unintended pregnancy and avoid short interpregnancy intervals.

RESUMEN Contexto: En México, el aborto de primer trimestre es legal en la Ciudad de México y está disponible en los sectores público y privado. Comprender la forma en que las clientas de aborto de primer trimestre adoptan el uso de anticonceptivos y la combinación de métodos subsiguientes en comparación a como lo hacen las mujeres que dan a luz a un nacido vivo en una institución de salud, podría ayudar a identificar dónde, en el sistema de salud, se pueden realizar mejoras en la atención después de un evento obstétrico. Métodos: Este artículo utiliza un estudio de cohorte retrospectivo para comparar la adopción de anticonceptivos por parte de clientas de servicios de aborto que participan en el Programa de Interrupción Legal del Embarazo en el sector público de la Ciudad de México y las mujeres posparto de entornos urbanos, previo a ser dadas de alta de la institución de salud. Las dos fuentes de datos fueron los registros clínicos de 45,233 clientas de servicios de aborto en la Ciudad de México y la información de una encuesta poblacional aplicada a 1,289 mujeres urbanas sobre su adopción inmediata de anticonceptivos posparto. El resultado primario investigado fue la recepción de cualquier método anticonceptivo moderno reversible; los resultados secundarios fueron el nivel de efectividad del método y el tipo de método. Se utilizó regresión logística y probabilidades multivariadas calculadas para controlar los efectos de los factores sociodemográficos en las dos fuentes de datos. Resultados: La probabilidad ajustada de la adopción de cualquier método anticonceptivo moderno reversible fue mayor entre las usuarias de aborto que entre las mujeres en período posparto (67% vs. 48%). Sin embargo, en el total de mujeres que habían recibido un método anticonceptivo, las clientas de servicios de aborto tuvieron una probabilidad ajustada menor de haber recibido un anticonceptivo reversible de acción prolongada que las mujeres posparto (49% frente a 82%) y una probabilidad más alta de haber recibido un método anticonceptivo moderadamente eficaz (38% vs. 13%). La probabilidad ajustada de adopción del implante fue mayor entre las usuarias de aborto que entre las mujeres en período posparto (9% vs. 3%), mientras que la probabilidad ajustada de adopción del DIU fue menor (38% vs. 78%). Conclusiones: Las mujeres que se recibieron servicios de aborto en el Programa de Interrupción Legal del Embarazo en el sector público de la Ciudad de México tuvieron más probabilidades que las mujeres urbanas en período posparto de recibir un método anticonceptivo moderno reversible antes de ser dadas de alta de la institución de salud. A las mujeres se les debe ofrecer la gama completa de métodos anticonceptivos después de cualquier evento obstétrico, para ayudarlas a prevenir embarazos no deseados y evitar intervalos cortos entre embarazos.

RÉSUMÉ Contexte: Au Mexique, l'avortement au premier trimestre de la grossesse est légal dans la ville de Mexico et peut être obtenu dans le secteur public et privé. Comprendre l'adoption ultérieure de la contraception par les patientes de l'avortement au premier trimestre et leur éventail de méthodes, par rapport aux femmes qui accouchent d'un enfant vivant en structure sanitaire pourrait aider à identifier les possibilités d'amélioration des soins après un événement obstétrical dans l'ensemble du système de santé. Méthodes: Sur la base d'une étude de cohorte rétrospective, cet article compare l'adoption de la contraception avant la sortie de la structure de soins, entre les patientes ayant subi un avortement dans le cadre du programme public d'avortement de Mexico et les femmes post-partum en milieu urbain. Les deux sources de données considérées sont les dossiers cliniques de 45 233 patientes de l'avortement à Mexico et l'information obtenue d'une enquête en population relative à 1 289 femmes urbaines concernant leur adoption immédiate de la contraception après l'accouchement. Le résultat principal examiné était l'obtention d'une méthode contraceptive moderne réversible quelconque; les résultats secondaires étaient le niveau d'efficacité de la méthode et le type de méthode. Pour les deux sources de données, les effets de facteurs sociodémographiques ont été contrôlés par régression logistique et probabilités multivariables calculées. Résultats: La probabilité corrigée d'adoption d'une méthode de contraception moderne réversible quelconque s'est avérée supérieure parmi les patientes de l'avortement (67% contre 48% chez les femmes post-partum). Cependant, sur la totalité des femmes ayant reçu une méthode contraceptive, les patientes de l'avortement présentaient une moindre probabilité corrigée d'avoir obtenu une méthode réversible à longue durée d'action (49% contre 82% des femmes post-partum) et une plus forte probabilité d'avoir obtenu une méthode modérément efficace (38% contre 13%). La probabilité corrigée d'adoption de l'implant s'est révélée supérieure parmi les clientes de l'avortement (9% contre 3% chez les femmes post-partum), tandis que la probabilité corrigée d'adoption du DIU était plus faible (38% contre 78%). Conclusions: Les femmes qui obtiennent un avortement dans le cadre du programme public d'avortement de Mexico étaient plus susceptibles que leurs homologues post-partum urbaines de recevoir une méthode contraceptive moderne réversible avant de quitter la structure. La gamme complète de méthodes contraceptives doit être proposée aux femmes après tout événement obstétrical, pour les aider à éviter les grossesses non planifiées et les intervalles de grossesse courts.

Con la ley y sin la ley/With and without the law: Utilization of abortion services and case fatality in Mexico, 2000-2016.

OBJECTIVE: To describe utilization of health services for, and case fatality from, abortion in Mexico. METHOD: A historical cohort study using a census of state-level aggregate hospital discharge and primary care clinic data across Mexico's 32 states from January 2000 to December 2016. Abortive events and changes over time in utilization per 1000 women aged 15-44 years, and case fatality per 100 000 abortion-related events were described by year, health sector, and state. Associations of location (Mexico City vs 31 other states) and time (Mexico City implemented legal abortion services in 2007) with outcomes were tested by linear regression, controlling for secular trends. RESULTS: The national abortion utilization rate was 6.7 per 1000 women in 2000, peaked at 7.9 in 2011, and plateaued to 7.0 in 2016. In Mexico City, utilization peaked at 16.7 in 2014 and then plateaued. Nationwide, the case-fatality rate declined over time from 53.7 deaths per 100 000 events in 2000 to 33.0 in 2016. Case fatality declined more rapidly in Mexico City than in the other 31 states to 12.3 in 2015. CONCLUSION: Case fatality from abortive events has decreased across Mexico. Where abortion became legal, utilization increased sharply but plateaued afterward.