Constructing a validated scale to measure community-level abortion stigma in Mexico.

OBJECTIVE: In Mexico, abortion stigma in the general population is largely unexplored. We developed a scale to measure abortion stigma at the community level, examine its prevalence and explore factors associated with abortion stigma in a nationally representative sample. STUDY DESIGN: Following intensive qualitative work to identify dimensions of the stigma construct, we developed a comprehensive list of statements that were cognitively tested and reduced to 33 to form a scale. We piloted the scale in a nationally and subregionally representative household public opinion survey administered to 5600 Mexican residents. RESULTS: Factor analysis tested the internal consistency and reliability of five previously hypothesized dimensions of abortion stigma: secrecy, religion, autonomy, discrimination and guilt/shame. Under the assumption that these dimensions were independent, confirmatory factor analysis indicated that each of these dimensions functioned as independent subscales. However, to test this assumption, we conducted exploratory factor analysis that revealed a strong codependence between discrimination, guilt/shame and religion statements, resulting in a 23-item four-factor model of abortion stigma and the elimination of the guilt/shame dimension. Both methods revealed a full scale and subscales with Cronbach's alphas between 0.80 and 0.90. Regression analyses suggested that older, less educated individuals living in the north of Mexico report higher levels of stigma, especially related to discrimination and religion. CONCLUSIONS: This community-level abortion stigma scale is the first to be developed and tested in Mexico. This tool may be used in Mexico and other similar country settings to document the prevalence of community-level abortion stigma, identify associated factors and test interventions aimed at reducing abortion stigma. IMPLICATIONS: Abortion stigma prevents women from accessing safe abortion services. Measuring community-level abortion stigma is key to documenting its pervasiveness, testing interventions aimed at reducing it and understanding associated factors. This scale may be useful in countries similar to Mexico to support policymakers, practitioners and advocates in upholding women's reproductive rights.

Health care experiences of HIV-infected women with fertility desires in Mexico: a qualitative study.

Increased access to antiretroviral therapy has enabled Mexican HIV-infected women to resume healthy sexual and reproductive lives and reduce the risk of mother-to-child transmission of HIV infection. However, little information is available on the experiences of HIV-infected women desiring children. In this qualitative study, we conducted in-depth interviews with 31 HIV-infected women in four Mexican cities. The findings indicated that most of the women were given limited information on their pregnancy options. With some exceptions, the women felt they were denied the option to have (or to have more) children and advised to undergo tubal ligations or abortions. The findings of this study indicate that ongoing efforts are needed to promote the reproductive rights of HIV-infected women in Mexico and to ensure that they receive options aligned with their fertility desires.

Ensuring intercultural maternal health care for Mayan women in Guatemala: a qualitative assessment.

Indigenous (Mayan) women in Guatemala experience a disproportionate burden of maternal mortality and morbidity, as well as institutional failures to respect their rights. The Guatemalan Ministry of Health has started to offer 'intercultural' services that respect Mayan obstetric practices and integrate them with biomedical care. We purposefully selected 19 secondary-level public health facilities of 9 departments that provided maternal healthcare to indigenous women. We carried out semi-structured interviews with biomedical providers (44), Mayan midwives or comadronas (45), and service users (18), exploring the main characteristics of intercultural care. We found that most facilities initiated the implementation of culturally appropriate services, such as accompaniment by a comadrona or family member, use the traditional teas or choosing the birthing position, but they still lacked standardisation. Comadronas generally felt excluded from the health system, although most biomedical providers reported that they were making important strides to be respectful and inclusive. Most users wanted the option of culturally appropriate services but typically did not receive them. In the health facilities, biomedicine is still the dominant discourse. Efforts at offering intercultural care still need strengthening and further monitoring. Involvement and participation of comadronas and indigenous women is key to moving forward to true intercultural services.

[Experiences of undocumented Mexican migrant women when accessing sexual and reproductive health services in California, USA: a case study]. / Experiencias de mujeres mexicanas migrantes indocumentadas en California, Estados Unidos, en su acceso a los servicios de salud sexual y reproductiva: estudio de caso.

This study focuses on the experience of Mexican women migrants in California, USA, with the use of formal health services for sexual and reproductive health issues. The authors used a qualitative interpretative approach with life histories, interviewing eight female users of healthcare services in California and seven key informants in Mexico and California. There were three main types of barriers to healthcare: immigration status, language, and gender. Participants reported long waiting times, discriminatory attitudes, and high cost of services. A combination of formal and informal healthcare services was common. The assessment of quality of care was closely related to undocumented immigration status. Social support networks are crucial to help solve healthcare issues. Quality of care should take intercultural health issues into account.

Experiencias de mujeres mexicanas migrantes indocumentadas en California, Estados Unidos, en su acceso a los servicios de salud sexual y reproductiva: estudio de caso / Experiences of undocumented Mexican migrant women when accessing sexual and reproductive health services in California, USA: a case study / Experiências de mulheres mexicanas migrantes sem documentação na Califórnia, Estados Unidos, no acesso aos serviços de saúde sexual e reprodutiva: estudo de caso

This study focuses on the experience of Mexican women migrants in California, USA, with the use of formal health services for sexual and reproductive health issues. The authors used a qualitative interpretative approach with life histories, interviewing eight female users of healthcare services in California and seven key informants in Mexico and California. There were three main types of barriers to healthcare: immigration status, language, and gender. Participants reported long waiting times, discriminatory attitudes, and high cost of services. A combination of formal and informal healthcare services was common. The assessment of quality of care was closely related to undocumented immigration status. Social support networks are crucial to help solve healthcare issues. Quality of care should take intercultural health issues into account.

El objetivo de este estudio fue conocer la experiencia de mujeres mexicanas migrantes en California, Estados Unidos, en torno a la utilización de los servicios formales de salud para resolver problemas relacionados con su salud sexual y reproductiva. El diseño fue cualitativo, con enfoque teórico metodológico de antropología interpretativa. Las técnicas utilizadas fueron historias de vida con mujeres usuarias de los servicios de salud en California y entrevistas breves con informantes clave. Se encontraron tres tipos de barreras principales para el acceso al sistema de salud: condición migratoria, idioma y género. Los tiempos de espera, actitudes discriminatorias y costo del servicio se expresaron como características que más incomodaron a las migrantes. La percepción de calidad de atención estuvo relacionada con la condición de ilegalidad migratoria. La red de apoyo tanto en México, como en California, colabora en la resolución de enfermedades. Se debe incorporar la perspectiva intercultural en los servicios.

O objetivo deste estudo foi conhecer a experiência de mulheres imigrantes mexicanas na Califórnia, Estados Unidos, sobre a utilização de serviços formais de saúde para resolver problemas relacionados com a saúde sexual e reprodutiva. O desenho foi qualitativo, com enfoque teórico-metodológico da Antropologia Interpretativa. As técnicas utilizadas foram relatos de histórias de vida de mulheres usuárias dos serviços de saúde na Califórnia e entrevistas breves com informantes-chave. Encontraram-se três tipos de barreiras principais para o acesso ao serviço de saúde: condições de imigração, idioma e gênero. Tempo de espera, atitudes discriminatórias e custo do serviço foram as características que mais incomodaram as imigrantes. A percepção de qualidade da atenção esteve relacionada com a condição de ilegalidade migratória. A rede de apoio, tanto no México quanto na Califórnia, colabora na resolução das enfermidades. Deve-se incorporar a perspectiva intercultural nos serviços de saúde.

Women's reports on postabortion family-planning services provided by the public-sector legal abortion program in Mexico City.

OBJECTIVE: To investigate patients' views of family-planning services provided in Mexico City during abortion care at public facilities and their acceptance of postabortion contraception. METHODS: In total, 402 women seeking first-trimester abortion care in Mexico City were surveyed. Logistic regression was used to test whether postabortion contraception varied according to abortion visit characteristics or patient sociodemographics. RESULTS: Most participants (328 [81.6%]) reported being offered contraception at their visit and 359/401 (89.5%) selected a contraceptive method for postabortion use, with 236/401 (58.9%) selecting an intrauterine device. Women who underwent surgical abortion were more likely than those who underwent medical abortion to report being offered contraception (P<0.001); women attended by a female physician were more likely than those attended by a male physician to report being offered contraception (P<0.05). Women who attended the general hospital were less likely to report being offered contraception (P<0.001). CONCLUSION: Public-sector facilities in Mexico City provide a high level of postabortion family-planning care, and uptake of postabortion contraception is high.

Barriers to the use of maternity waiting homes in indigenous regions of Guatemala: a study of users' and community members' perceptions.

Maternal mortality among indigenous women in Guatemala is high. To reduce deaths during transport from far-away rural communities to the hospital, maternity waiting homes (MWH) were established near to hospitals where women with high-risk pregnancies await their delivery before being transferred for labour to the hospital. However, the homes are under-utilised. We conducted a qualitative study with 48 stakeholders (MWH users, family members, community leaders, MWH staff, Mayan midwives and health centre and hospital medical staff) in Huehuetenango and Cuilco to identify barriers before, during and after the women's stay in the homes. The women most in need - indigenous women from remote areas - seemed to have least access to the MWHs. Service users' lack of knowledge about the existence of the homes, limited provision of culturally appropriate care and a lack of sustainable funding were the most important problems identified. While the strategy of MWHs has the potential to contribute to the prevention of maternal (as well as newborn) deaths in rural Guatemala, they can only function effectively if they are planned and implemented with community involvement and support, through a participatory approach.

Mexican women seeking safe abortion services in San Diego, California.

Except for in Mexico City, abortion is legally restricted throughout Mexico, and unsafe abortion is prevalent. We surveyed 1,516 women seeking abortions in San Diego, California. Of these, 87 women (5.7%) self-identified as Mexican residents. We performed in-depth interviews with 17 of these women about their experiences seeking abortions in California. The Mexican women interviewed were generally well-educated and lived near the U.S.-Mexican border; most sought care in the United States due to mistrust of services in Mexico, and the desire to access mifepristone, a drug registered in the United States for early medical abortion. Several reported difficulties obtaining health care in Mexico or reentering the United States when they had postabortion complications. Several areas for improvement were identified, including outreach to clinics in Mexico.

Public opinion on abortion in Mexico City after the landmark reform.

This article presents findings from three opinion surveys conducted among representative samples of Mexico City residents: the first one immediately prior to the groundbreaking legalization of first-trimester abortion in April 2007, and one and two years after the reform. Bivariate and multivariate analyses were performed to assess changes in opinion concerning abortion and correlates of favorable opinion following reform. In 2009 a clear majority (74 percent) of respondents were in support of the Mexico City law allowing for elective first-trimester abortion, compared with 63 percent in 2008 and 38 percent in 2007. A significant increase in support for extending the law to the rest of Mexico was found: from 51 percent in 2007 to 70 percent in 2008 and 83 percent in 2009. In 2008 the significant independent correlates of support for the Mexico City law were education, infrequent religious service attendance, sex (being male), and political party affiliation; in 2009 they were education beyond high school, infrequent religious service attendance, and ever having been married.

Public opinion on abortion in eight Mexican states amid opposition to legalization.

In opposition to Mexico City's legalization of first-trimester abortion, 17 Mexican states (53 percent) have introduced initiatives or reforms to ban abortion entirely, and other states have similar legislation pending. We conducted an opinion survey in eight states--four where constitutional amendments have already been approved and four with pending amendments. Using logistic regression analyses, we found that higher education, political party affiliation, and awareness of reforms/initiatives were significantly associated with support for the Mexico City law. Legal abortion was supported by a large proportion of respondents in cases of rape (45-70 percent), risk to a woman's life (55-71 percent), and risk to a woman's health (48-68 percent). A larger percentage of respondents favored the Mexico City law, which limits elective legal abortion to the first 12 weeks of gestation (32-54 percent), than elective abortion without regard to gestational limit (14-31 percent).

How often and under which circumstances do Mexican pharmacy vendors recommend misoprostol to induce an abortion?

CONTEXT: Misoprostol was used by women across Mexico to induce abortion even before 2007, when first-trimester abortion was legalized in Mexico City. Pharmacy vendors' misoprostol recommendation practices across subregions of Mexico after abortion legalization warrant examination. METHODS: Overall, 192 pharmacies in four regions of Mexico were randomly selected and visited by simulated clients presenting three scenarios (a young woman, an adult woman and a male partner). Bivariate and multivariate analyses were used to explore associations between pharmacy, vendor and client characteristics and drug access. RESULTS: In 558 encounters with simulated clients, 78% of vendors provided information about misoprostol-18% recommended it spontaneously and 60% recommended it only after the client asked specifically for the drug. Fifteen percent of vendors recommended a potentially effective misoprostol dosing regimen. Mexico City-based pharmacies and those in the Central region were significantly less likely than those in the North region to require a prescription to sell misoprostol (odds ratios, 0.2 and 0.3, respectively). Independent pharmacies and those from low-?income areas were significantly more likely to sell misoprostol by the pill than chain pharmacies and those in medium-income areas (3.2 and 2.7, respectively). CONCLUSIONS: Access to misoprostol is influenced by neighborhood socioeconomic level, pharmacy location and pharmacy type. The frequently inaccurate and incomplete information provided to clients about using misoprostol for abortion suggests the need to improve pharmacy vendor training in medication abortion options and to develop ways to directly inform women about misoprostol use.

Sociodemographic factors associated with obstacles to abortion care: findings from a survey of abortion patients in Mexico City.

BACKGROUND: First-trimester abortion was legalized in Mexico City in 2007, and services are now provided at public and private sites throughout the city. However, little is known about the obstacles women face when seeking abortion care. METHODS: We surveyed women who obtained abortion services (n = 398) at three public sector facilities in Mexico City to identify the obstacles women faced when obtaining abortions. We used logistic regression to test whether obstacles varied by sociodemographic characteristics. RESULTS: Women with low education were more likely than high school-educated women to report difficulty getting appointments. Unmarried women and women with low education were more likely than married women or high school educated women to report difficulty getting time off work for appointments and arranging for transportation to the facility. Separated or divorced women were more likely than married women to report partner or other family member opposition to the abortion. Women who lived outside of Mexico City were more likely than Mexico City residents to report difficulty with transportation. CONCLUSION: Education, marital status, and place of residence were associated with the obstacles women reported. Strategies to improve access to care should be targeted to the groups at highest risk of experiencing obstacles: Women with primary education or lower, single women, separated/divorced women, and those residing outside of Mexico City.

Abortion and women's roles in society: opinions from Tlaxcala, Mexico.

OBJECTIVE: We aim to assess the opinions of Mexicans in the state of Tlaxcala on abortion and other topics concerning women's reproductive health and status in society. MATERIAL AND METHODS: We summarize opinions on abortion and women's roles in society and perform logit regressions to assess characteristics correlated with support for abortion rights. RESULTS: A majority of respondents were against a woman's right to abortion when asked generally, but when asked about specific circumstances, a majority supported the right to abortion in five of the nine hypothetical circumstances proposed. In multivariate analysis, age, education, religion, religious service attendance, and views regarding women's roles in society had significant effects on support for the right to abortion. CONCLUSIONS: Our results demonstrate that residents of Tlaxcala view abortion as a personal decision and support a woman's right to abortion in more circumstances than currently allowed under state law.

Abortion and women's roles in society: opinions from Tlaxcala, Mexico / El aborto y el rol de las mujeres en la sociedad: resultados de una encuesta de opinión en Tlaxcala, México

OBJECTIVE: We aim to assess the opinions of Mexicans in the state of Tlaxcala on abortion and other topics concerning women's reproductive health and status in society. MATERIAL AND METHODS: We summarize opinions on abortion and women's roles in society and perform logit regressions to assess characteristics correlated with support for abortion rights. RESULTS: A majority of respondents were against a woman's right to abortion when asked generally, but when asked about specific circumstances, a majority supported the right to abortion in five of the nine hypothetical circumstances proposed. In multivariate analysis, age, education, religion, religious service attendance, and views regarding women's roles in society had significant effects on support for the right to abortion. CONCLUSIONS: Our results demonstrate that residents of Tlaxcala view abortion as a personal decision and support a woman's right to abortion in more circumstances than currently allowed under state law.

OBJETIVO: Describir opiniones sobre salud sexual y reproductiva, aborto y rol social de las mujeres entre un grupo de residentes de Tlaxcala, México. MATERIAL Y MÉTODOS: El análisis de regresión logística analizó características asociadas con una postura de apoyo al derecho al aborto. RESULTADOS: La mayoría no favoreció el derecho de las mujeres a interrumpir un embarazo cuando se preguntó de manera general. Al momento de circunscribirlo a circunstancias específicas, la mayoría estuvo a favor en cinco de las nueve de situaciones hipotéticas planteadas. En análisis multivariado, edad, escolaridad, religión, asistencia a servicios religiosos y opiniones sobre el rol social femenino fueron variables significativas del apoyo que se brinda a una mujer para ejercer su derecho a interrumpir un embarazo. CONCLUSIONES: Los residentes de Tlaxcala perciben el tema del aborto como una decisión personal y apoyan el derecho de una mujer a interrumpirlo especialmente bajo causales contempladas en la ley de Tlaxcala.

Exploring the costs and economic consequences of unsafe abortion in Mexico City before legalisation.

An assessment of abortion outcomes and costs to the health care system in Mexico City was conducted in 2005 at a mix of public and private facilities prior to the legalisation of abortion. Data were obtained from hospital staff, administrative records and patients. Direct cost estimates included personnel, drugs, disposable supplies, and medical equipment for inducing abortion or treating incomplete abortions and other complications. Indirect patient costs for travel, childcare and lost wages were also estimated. The average cost per abortion with dilatation and curettage was 143 US dollars. For manual vacuum aspiration it was 111 US dollars in three public hospitals and 53 US dollars at a private clinic. The average cost of medical abortion with misoprostol alone was 79 US dollars. The average cost of treating severe abortion complications at the public hospitals ranged from 601 US dollars to over 2,100 US dollars. Increasing access to manual vacuum aspiration and early abortion with misoprostol could reduce government costs by 62%, with potential savings of up to 1.6 million US dollars per year. Reducing complications by improving access to safe services in outpatient settings would further reduce the costs of abortion care, with significant benefits both to Mexico's health care system and women seeking abortion. Additional research is needed to explore whether cost savings have been realised post-legalisation.

Physicians' agreement with and willingness to provide abortion services in the case of pregnancy from rape in Mexico.

BACKGROUND: In Mexico, abortion is not penalized when a woman gets pregnant as a result of rape, yet access to abortion services is limited. Understanding physicians' opinions about abortion is critical to creating strategies that will broaden women's access to services. STUDY DESIGN: Multivariate logistic regression was performed using data collected from a sample of 1206 physicians in Mexico. The influence of independent variables on two outcomes was analyzed: physicians' agreement with abortion being legal in the case of pregnancy caused by rape and willingness to provide abortion services in such cases. RESULTS: Physicians who had performed legal abortions, knew about existing abortion legislation and practiced general or family medicine were significantly more likely to agree that abortion should be legal when pregnancy is caused by rape and were more likely to be willing to provide abortion in the case of rape. Physicians who held a negative attitude towards women who seek abortion and those with greater church attendance were less likely to agree with the legality of abortion. CONCLUSIONS: Physicians are among the most important gatekeepers to women's access to safe abortion services. A majority of Mexican physicians agree that abortion should not be legally penalized under certain circumstances. Yet, many also hold negative attitudes towards women who seek abortion. Physicians' support for women's access to safe abortion services is key to ensuring that such services will exist in Mexico.

Introducción de la anticoncepción de emergencia en la Norma Oficial Mexicana de Planificación Familiar (NOM-005-SSA2-1993) / Introducing Emergency Contraception in the Mexican Family Planning Official Norm

Objetivos: Entender el proceso de inclusión de las pastillas de anticoncepción de emergencia (PAE) en la Norma Oficial Mexicana de Planificación Familiar e identificar los factores que influyeron en este cambio. Material y métodos: Se realizaron entrevistas a profundidad con ocho tomadores de decisiones que ocupan cargos de alta jerarquía dentro de instituciones del gobierno estatal y federal. Resultados: El factor que determinó la inclusión de las PAE fue la extensa revisión de la evidencia científica que comprueba que no son abortivas, realizada por expertos del Centro Nacional de Equidad de Género y Salud Reproductiva. Además, el amplio apoyo de organizaciones civiles, la demanda de la población y la visión abierta del Secretario de Salud, contribuyeron de forma importante. La inclusión de las PAE en el cuadro básico de medicamentos fue vista como un paso lógico posterior a su inclusión en la Norma Oficial Mexicana. Conclusiones: La introducción de las PAE en México demuestra la importancia de la evidencia científica en la toma de decisiones. El proceso duró cerca de una década, lo cual refleja problemas en la traducción de los resultados de investigación en políticas públicas. Se deben tomar medidas para agilizar este proceso en beneficio de las mujeres y la sociedad en general.

OBJECTIVES: Understand the process of including Emergency Contraception (EC) in the Mexican Family Planning Norm (NOM) and identify factors that influenced this achievement. MATERIALS AND METHODS: We conducted in-depth interviews with eight prominent decision-makers of state and federal government institutions. RESULTS: The determining factor for the inclusion of EC in the Norm was the external review of scientific evidence, done by experts from the National Centre for Equity of Gender and Reproductive Health, proving that EC pills are not abortifacients. Other important factors that contributed to the inclusion were the ample support of civil organizations, the population's demand and the Minister of Health's support of EC. The inclusion of EC in the essential drug list was perceived as a logical next step after its inclusion in the NOM. CONCLUSIONS: The introduction of EC in Mexico highlights the importance of scientific evidence for decision-making. The process took about a decade, which reflects the complexity of converting research results into public policies. Measures should be taken to speed the processes that benefit women and society as a whole.

Introducing birth plans in Mexico: an exploratory study in a hospital serving low-income Mexicans.

BACKGROUND: Increased medicalization of childbirth in Mexico has not always translated into more satisfactory childbirth experiences for women. In developed countries, pregnant women often prepare written birth plans, outlining how they would like their childbirth experiences to proceed. The notion of expressing childbirth desires with a birth plan is novel in the developing world. We conducted an exploratory study to assess the feasibility and acceptability of introducing birth plans in a hospital serving low-socioeconomic status Mexicans and to document women's and health practitioners' perspectives on the advantages and barriers in implementing a birth plan program. METHODS: We invited 9 pregnant women to prepare birth plans during their antenatal care visits. The women also participated in interviews before and after childbirth. We also conducted in-depth interviews with 4 women who had given birth in the past year, and with 2 nurses, 2 social workers, and 1 physician to learn about their perspectives on the benefits and challenges of implementing a birth plan program. RESULTS: All 9 women who completed a birth plan found the experience highly satisfying, despite the fact that in some cases, their childbirths did not proceed as they had specified in their plans. Interviewed practitioners believed that birth plans could improve the childbirth experience for women and health care practitioners, but facilities often lacked space and financial incentives for birth plan programs. CONCLUSIONS: Our findings suggest that birth plans are acceptable and feasible in this study population. Facility administrators would need to commit to provide the physical space and financial incentives necessary to ensure successful implementation.

Analysis of the operational costs of using rapid syphilis tests for the detection of maternal syphilis in Bolivia and Mozambique.

OBJECTIVE: The objective of this study was to compare the costs of antenatal syphilis screening with the rapid plasma reagin (RPR) test and the immunochromatographic strip (ICS) test in low-resource settings. GOAL: The goal of this study was to assess the costs of introducing rapid syphilis tests to reduce maternal and congenital syphilis. STUDY DESIGN: Cost data were collected from participating study hospitals and antenatal clinics during 4 field visits to the 2 countries in 2003 and 2004. Health utilization outcome data on the number of women screened and treated routinely during the demonstration projects were used with unit cost data to estimate the incremental costs and average cost per woman screened and treated for maternal syphilis. RESULTS: In Mozambique, the average cost per woman screened was U.S. $0.91 and U.S. $1.05 for the RPR and ICS tests, respectively. In Bolivia, the average cost of screening was U.S. $1.48 and U.S. $1.91 using the RPR and ICS test, respectively. In health centers without laboratories, the cost per woman screened using the ICS test ranged from U.S. $1.02 in Mozambique to U.S. $2.84 in Bolivia. CONCLUSIONS: It is feasible to introduce rapid syphilis testing in settings without laboratory services at a small incremental cost per woman screened. In settings with laboratories, the cost of ICS is similar to that of RPR.