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

Abstract

BackgroundDespite 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.MethodsWe 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.ResultsThe 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.ConclusionsThe 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.

Utilisation of second-trimester spontaneous and induced abortion services in public hospitals in Mexico, 2007–2015

“…Furthermore, we found health and fetal anomaly exceptions in the state laws were not associated with higher utilisation of second-trimester abortion services. The potential under-utilisation of second-trimester abortion services may be due to poor implementation of all legal exceptions 7. For example, while Jalisco passed a law in 2009 that mandated institutions to provide abortion in cases of rape, there have only been 16 cases documented 28.…”

“…Two-thirds of countries with laws regulating second-trimester abortion allow it only to save the woman’s life 3. While many countries do have exceptions permitting second-trimester abortion, such as the woman’s physical or mental health, rape, fetal anomalies, or socioeconomic reasons, access to services under these exceptions varies by country 5–7. The unmet need for second-trimester abortion remains unknown since many national vital statistics systems do not specifically capture incidence of second-trimester abortions 2…”

“…In Mexico City, one of Mexico’s 32 states, women have had access to first-trimester abortion in the private and public sectors since 2007 8. In Mexico’s 31 other states, abortion at all gestational ages remains restricted 7. Gestational age (GA) measures the age of a pregnancy and is reported in weeks.…”

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

“…rape, health, fetal malformation). However, research does not support this hypothesis: full implementation of legal exceptions is known to be lacking . Woman may also have greater access to misoprostol outside facilities and present for care to confirm a safe induced abortion process: local evidence suggests that misoprostol is widely available in the country and in the capital city, but the incidence of use or women's knowledge about safe use is unknown …”

“…Access to induced abortion under the rape exception has been legal nationwide since 2016 . Other exceptions, such as risk to a woman's life (23 states) or health (15 states), or fetal anomalies (16 states), are allowed in some states but not others …”