Abortion legislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: a natural experiment in 32 Mexican states

Abstract

ObjectiveTo test whether there is an association between abortion legislation and maternal mortality outcomes after controlling for other factors thought to influence maternal health.DesignPopulation-based natural experiment.Setting and data sourcesOfficial maternal mortality data from 32 federal states of Mexico between 2002 and 2011.Main outcomesMaternal mortality ratio (MMR), MMR with any abortive outcome (MMRAO) and induced abortion mortality ratio (iAMR).Independent variablesAbortion legislation grouped as less (n=18) or more permissive (n=14); constitutional amendment protecting the unborn (n=17); skilled attendance at birth; all-abortion hospitalisation ratio; low birth weight rate; contraceptive use; total fertility rates (TFR); clean water; sanitation; female literacy rate and intimate-partner violence.Main resultsOver the 10-year period, states with less permissive abortion legislation exhibited lower MMR (38.3 vs 49.6; p<0.001), MMRAO (2.7 vs 3.7; p<0.001) and iAMR (0.9 vs 1.7; p<0.001) than more permissive states. Multivariate regression models estimating effect sizes (β-coefficients) for mortality outcomes showed independent associations (p values between 0.001 and 0.055) with female literacy (β=−0.061 to −1.100), skilled attendance at birth (β=−0.032 to −0.427), low birth weight (β=0.149 to 2.166), all-abortion hospitalisation ratio (β=−0.566 to −0.962), clean water (β=−0.048 to −0.730), sanitation (β=−0.052 to −0.758) and intimate-partner violence (β=0.085 to 0.755). TFR showed an inverse association with MMR (β=−14.329) and MMRAO (β=−1.750) and a direct association with iAMR (β=1.383). Altogether, these factors accounted for (R2) 51–88% of the variance among states in overall mortality rates. No statistically independent effect was observed for abortion legislation, constitutional amendment or other covariates.ConclusionsAlthough less permissive states exhibited consistently lower maternal mortality rates, this finding was not explained by abortion legislation itself. Rather, these differences were explained by other independent factors, which appeared to have a more favourable distribution in these states.

Mortalidad materna y leyes de aborto en México: comentarios al artículo de Koch y colaboradores

“…Señor editor: Un estudio realizado por Koch y colaboradores que analizó la asociación entre la legislación de aborto y la razón de mortalidad materna (RMM) a nivel estatal en México, concluyó que los estados con legislación restrictiva "muestran consistentemente menor RMM". 1 El estudio presenta importantes sesgos y limitaciones:…”

Abortion and sex-related conditions in substance-dependent Brazilian patients

“…The SADD is a scale consisted of 15 questions related to the alcohol dependence severity, classified on a scale from 0 to 20, and scored as follows: mild (0-9), moderate (10)(11)(12)(13)(14)(15)(16)(17)(18)(19) and severe (≥ 20). The Brazilian version and the original English version of the SADD are highly correlated and the coefficient of internal consistency is 0.79 33 .…”

“…Programmes and health services might not yet be prepared to recognize the specific needs required by this population 10,47 .…”

“…Yet, there have been discussions and advances in some Latin American countries, such as Mexico and Uruguay, where abortion was legalized despite the Christian population majority 9,10 .…”

Commentary: The proposed legislation on termination of pregnancy does not protect women or children in Malawi and is not fit for the intended purpose: Christian Medical and Dental Fellowshipi position

“…Loosening abortion restrictions did not produce a drop in maternal mortality rates. 5 ) The study suggests that developing countries do not need to relax abortion laws to reduce maternal mortality rates.…”