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OBJECTIVE: To describe utilization of prenatal care and outcomes of low birth weight and preterm birth among adolescent births in Mexico. METHODS: We used birth certificate data and included live births to individuals 10-24 years, 2008-2019. Our outcomes were binary measures of adequate prenatal care, low birth weight, and preterm birth. We compared adolescents (10-14 years, 15-16, and 17-19) to those 20-24 years. We included individual-, clinical-, and municipality-level variables, used multivariable logistic regression, and calculated adjusted predicted probabilities. We also tested whether receipt of prenatal care moderated the relationship of age with preterm birth and low birth weight. RESULTS: We included a total of 12 106 710 births to women 10-24 years. The adjusted predicted probability of adequate prenatal care increased with age: 56.07% (95% CI 55.82-56.31%) adjusted probability among adolescents 10-14 years compared with 65.51% (95% CI 65.48%-65.55%) among individuals 20-24 years. Receipt of adequate prenatal care in part mitigated disparities in preterm birth and low birthweight across all age groups: 7.30% (95% CI 7.17%-7.43%) adjusted probability of delivering a preterm infant among those 10-14 years who received adequate prenatal care compared with 9.37% (95% CI 9.20%-9.53%) among those 10-14 years without adequate prenatal care. CONCLUSION: In Mexico, adolescent pregnancies are associated with inadequate prenatal care as well as higher odds of preterm delivery and low birth weight. Youngest adolescents (10-14 years) have the highest probability of adverse outcomes. Adequate prenatal care may help partially mitigate disparities in poor perinatal outcomes.

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Ensuring sexual and reproductive health, and rights for adolescents entails the prevention of early pregnancies, which are widely recognized as a public health problem. Based on the ecological model for early pregnancy, this article identifies the healthcare requirements for preventing unintended adolescent pregnancies in predominantly indigenous communities in Chiapas, Mexico. Using a convergent parallel mixed-methods study design, we surveyed adolescents (12-15 years old) and health personnel, organized focus groups with adolescents and their parents, and conducted in-depth interviews at the individual, family, school and community levels. Results showed that adolescents recognized their right to receive sexuality education (64.5%) as well as information on contraceptive methods (53.0%), with indigenous language speakers and individuals living in overcrowded households less likely to know about these rights. Parents of adolescents knew little about contraception and pregnancy. School teachers lacked necessary tools for offering comprehensive sexuality education. A traditional, patriarchal perspective predominated among participants, fostering gender inequalities. In conclusion, it is essential to implement multifocal strategies under a human-rights, intercultural, and health-equity approach. Special attention should be directed to the spheres in which adolescents interact, and efforts should focus on improving knowledge, empowering adolescents, and enhancing their access to sexual and reproductive health resources.

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OBJECTIVE: To evaluate prenatal care utilization, low birth weight, and preterm birth among women aged 35 years and older in Mexico from 2008 to 2019. METHODS: We conducted a historical cohort study of all singleton live births in Mexico from 2008 to 2019. Outcomes were inadequate prenatal care, preterm birth, and low birth weight. We compared outcomes among women aged 35-39, 40-44, and 45-49 years with births to women aged 20-34 years. We used logistic regression to account for individual, health system, and contextual confounders. RESULTS: We included a total of 19 526 922 births; 2 325 725 (11.9%) were to women aged 35 years and older. Women aged 45-49 years had the lowest levels of education, were more likely to be uninsured, and came from highly marginalized municipalities while those aged 35-39 years had the highest levels of education and insurance and came from the least marginalized municipalities. The odds of inadequate prenatal care (adjusted odds ratio [aOR] 1.12; 95% confidence interval [CI] 1.09-1.15), preterm birth (aOR 2.05; 95% CI 1.97-2.13), and low birth weight (aOR 2.03; 95% CI 1.95-2.12) were highest for women aged 45-49 years, compared with women aged 20-34 years. The odds of adverse perinatal outcomes increased progressively with age, but the odds of inadequate prenatal care (aOR 0.77; 95% CI 0.76-0.77) were lowest for women aged 35-39 years, when compared with women aged 20-34 years. CONCLUSION: Women who deliver at 35 years and over are a heterogeneous group in Mexico. Being 35 years old and older is associated with increases in preterm birth and low birth weight neonates. Women who give birth between 45 and 49 years may be especially vulnerable.

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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.

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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.

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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.

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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.

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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.

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First-trimester abortion became legal in Mexico City in April 2007. Since then, 216 755 abortions have been provided, initially in hospitals, by specialized physicians using surgical techniques. With time and experience, services were provided increasingly in health centers, by general physicians using medical therapies. Meanwhile, abortion remains legally restricted in the remaining 31/32 Mexican states. Demand and need for abortion care have increased throughout the country, while overall abortion-specific mortality rates have declined. In an effort to ensure universal access to and improved quality of reproductive and maternal health services, including abortion, Mexico recently expanded its cadres of health professionals. While initial advances are evident in pregnancy and delivery care, many obstacles and barriers impair the task-sharing/shifting process in abortion care. Efforts to expand the provider base for legal abortion and postabortion care to include midlevel professionals should be pursued by authorities in the new Mexican administration to further reduce abortion mortality and complications.

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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.

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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.

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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.

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OBJECTIVE: First-trimester abortion is widely available in Mexico City since legalisation in 2007, but few data exist surrounding pharmacy staff knowledge and sales practices. We describe misoprostol availability, whether a prescription is required, and knowledge of the legal status of abortion and uses for misoprostol among pharmacy staff in Mexico City. METHODS: Data were collected from 174 pharmacies in Mexico City. One employee at each pharmacy was asked about availability, need for prescription, indications for misoprostol, and sociodemographic information. Our primary outcome was availability of misoprostol. We used descriptive and bivariate statistics to compare knowledge and practices by type of pharmacy and staff gender. PATIENTS AND PUBLIC INVOLVEMENT: No patients were involved in this study. RESULTS: Of the 174 pharmacies, 65 were chain and 109 small independent. Misoprostol was available at 61% of sites. Only 49% of independent pharmacies sold misoprostol, compared with 81.5% of chain pharmacies (p<0.05). Knowledge of indications for misoprostol use was similar. The majority (80%) of respondents knew that abortion was legal in Mexico City, and 44% reported requiring a prescription for sale of misoprostol, with no significant difference between male and female staff or by pharmacy type. CONCLUSIONS: Availability, requirement of a prescription, and knowledge of indications for use of misoprostol varies among pharmacies, resulting in differential access to medical abortion. Pharmacies may be a good place to target education for pharmacy staff and women about safe and effective use of misoprostol for abortion.

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PURPOSE: Mexico has implemented comprehensive sexuality education. We hypothesized that young women who received sexuality education as adolescents would be more likely to report modern contraceptive use at first sexual intercourse. METHODS: We used a nationally representative survey of Mexican women aged 20-24 years who were asked about experiences during adolescence. We defined our treatment variable in three mutually exclusive groups: comprehensive sexuality education (receipt of education in nine topics); incomplete sexuality education (receipt of at least one topic in each of three themes); or no sexuality education. Our outcome was use of modern contraception at first sexual intercourse. We included individual- and household-level sociodemographic factors. All presented data used survey weights. We used multivariable logistic regression and predicted probabilities to estimate the association between sexuality education and using modern contraception at first intercourse. RESULTS: In our sample (n = 2,725; population N = 4,008,722), 60.6% of participants reported receipt of comprehensive, 15.6% of incomplete, and 23.9% of no sexuality education; 62.5% reported utilizing a modern method of contraception at first intercourse. Women who reported receiving comprehensive (adjusted odds ratio: 2.3, 95% confidence interval [CI]: 1.7, 3.2) or incomplete (adjusted odds ratio: 2.4, 95% CI: 1.3, 4.2) sexuality education had higher odds of using contraception at first intercourse compared with no sexuality education. The absolute multivariable probabilities of using modern contraception at first intercourse were 57.5% (95% CI: 55.2%-59.8%), 60.4% (95% CI: 56.0%-64.9%), and 37.6% (95% CI: 33.9%-41.3%) among comprehensive, incomplete, and no sexuality education, respectively. CONCLUSIONS: Sexuality education is associated with contraception use at first intercourse among young women in Mexico.

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BACKGROUND: Data on utilisation of in-facility second-trimester abortion services are sparse. We describe temporal and geographical trends in utilisation of in-facility second-trimester abortion services across Mexico. METHODS: We used 2007-2015 data from Mexico's Automated Hospital Discharge System (SAEH) to identify second-trimester abortive events (ICD O02-O08) in public hospitals across Mexico's 32 states. We described utilisation, calculated rates using population data, and used logistic regression to identify woman- and state-level factors (municipality-level marginalisation, state-level abortion law) associated with utilisation of second-trimester versus first-trimester services. RESULTS: We identified 145 956 second-trimester abortions, or 13.4% of total documented hospitalizations for abortion between 2007 to 2015. The annual utilisation rate of second-trimester abortion remained constant, between 0.5 to 0.6 per 1000 women aged 15-44 years. Women living in highly marginalised municipalities had 1.43 higher odds of utilising abortions services in their second versus their first trimester, when compared with women in municipalities with low marginalisation (95% CI 1.18 to 1.73). Living in a state with a health or fetal anomaly exception to abortion restrictions was not associated with higher utilisation of second-trimester abortion services. CONCLUSIONS: Our results suggest there is a need for all types of second-trimester abortion services in Mexico. To improve health outcomes for Mexican women, especially the most vulnerable, access to safe second-trimester abortion services must be ensured through the implementation of current legal exceptions and renewed attention to the training of healthcare providers.

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Abstract Introduction Although the international literature suggests that women who interrupt a pregnancy in safe conditions do not develop mental health problems, it continues to be a highly stigmatized issue by broad social sectors. It is therefore not surprising that abortion stigma is one of the main factors associated with the presence of mental health problems in women who abort voluntarily. This study explores the association between perceived abortion stigma and depressive symptomatology. Method In a non-probabilistic convenience sample, 114 users of a Legal Interruption of Pregnancy Clinic in Mexico City were interviewed with a structured instrument. Results Respondents obtained low scores of internalized stigma and reported feeling confident that they had made the right decision to terminate their pregnancies, and at peace with themselves. The highest scores for abortion stigma were reported in the group with high depressive symptomatology, with no statistically significant differences being observed due to the sociodemographic characteristics explored. The participants in this study were more concerned about what others might think about their decision to terminate a pregnancy and about how their abortion might affect their relationship with them. Discussion and conclusion These concerns highlight the need to reduce the negative social stigma surrounding abortion and to provide interventions in the same direction among women who interrupt a pregnancy legally in order to reduce the risk of mental health problems such as depression.

Resumen Introducción A pesar de que la literatura internacional señala que las mujeres que interrumpen sus embarazos en condiciones seguras no desarrollan problemas de salud mental, sigue siendo una situación altamente estigmatizada por amplios sectores sociales. Por ello, no es de sorprender que el estigma por abortar sea uno de los principales factores asociados con la presencia de malestares en la salud mental de algunas mujeres que abortan voluntariamente. Este trabajo explora la asociación entre el estigma percibido por abortar y la sintomatología depresiva. Método En una muestra no probabilística y por conveniencia, 114 usuarias de una Clínica de Interrupción Legal del Embarazo de la Ciudad de México fueron entrevistadas con un instrumento estructurado. Resultados Las participantes obtuvieron bajas puntuaciones de estigma internalizado, reportaron sentirse seguras y en paz con ellas mismas por haber decidido interrumpir sus embarazos. Las puntuaciones más altas de estigma por abortar se reportaron en el grupo con sintomatología depresiva elevada, sin que existieran diferencias significativas por las características sociodemográficas exploradas. Las participantes en este estudio estaban más preocupadas por lo que otros pudieran pensar por su decisión de interrumpir su embarazo y por cómo podría afectar el aborto su relación con estas personas. Discusión y conclusión Estas preocupaciones evidencian la necesidad de disminuir el estigma social negativo que rodea al aborto y plantear intervenciones que actúen en el mismo sentido entre las mujeres que interrumpen legalmente un embarazo para disminuir el riesgo de presentar problemas de salud mental como la depresión.

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OBJECTIVES: In the Mexico City Metropolitan Area, only women in the city center have local access to legal first-trimester abortion. We quantify how this legislative discrepancy affects access to legal, public-sector abortion across the metropolitan area. STUDY DESIGN: In this observational study, we used a dataset representing 67.2% of all abortions occurring between 2010 and 2012 in Mexico City's public abortion program and census population data. We calculate utilization rates for 75 municipalities in the metropolitan area for 2010-2012. We compare utilization between municipalities with and without local legal access, adjusting for differences in sociodemographic drivers of abortion demand. We explore the effects of local abortion legality, travel time and socioeconomic status (SES). RESULTS: Women who had to travel into the city center for legal abortions used services at only 18.6% (95% CI 13.3%-33.0%) of the expected rate if they had local access, adjusting for sociodemographic factors. After controlling for travel time and SES, women who lived where abortion is illegal had a 58.6% (95% CI 21.5%-78.1%) reduction in access, and each additional 15 min of travel further reduced access by 33.7% (95% CI 18.2%-46.3%). Women who travel to seek legal abortions are more likely to have completed secondary education compared to other reproductive age women in their municipality (p = <.00001). CONCLUSIONS: We find that, in the Mexico City Metropolitan Area, both living where abortion is illegal and having to travel further to access services substantially reduce access to legal, public-sector abortion. These burdens disproportionately affect women of lower SES. IMPLICATIONS: Both local legality and proximate access are key to ensuring equity in access to public-sector abortion. Legalization of abortion services across the greater Mexico City Metropolitan Area has the potential to increase equity in utilization and meet unmet demand for legal abortion.

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RESUMEN

OBJECTIVE: To identify socio-demographic factors associated with presenting for abortion services past the gestational age (GA) limit (12 weeks), and thus not receiving services, in Mexico City's public sector first trimester abortion program. METHODS: We used clinical data from four high volume sites in the Interrupción Legal de Embarazo (ILE) program, 2007-2015. We used descriptive statistics to quantify the proportion of women who did not receive an abortion due to presenting past the gestational age limit. We used multivariable logistic regression to identify associations between women's characteristics and presenting past the GA limit and calculated predicted probabilities of late presentation for key characteristics. RESULTS: Our sample included 52,391 women, 8.10% (n = 4,246) of whom did not receive abortion services due to presenting past the GA limit. Adolescents (12-17) made up 8.69% of the total sample and 13.40% of those presenting past the GA limit (p< 0.05). In multivariable analyses, all age groups of adult women had significantly lower odds than adolescents of presenting past the limit (aOR = 0.77, aOR = 0.63, aOR = 0.58 and aOR = 0.37 for 19-24, 25-29, 30-39, and > = 40 years' old respectively). Women living in Mexico City and with higher levels of education had lower odds of presenting past the GA limit, and there was an educational gradient across all age groups. In the multivariable predicted probability models, adolescents at every level of education have significantly higher probabilities of not receiving an abortion due to presenting past the gestational age limit compared with adults (among women with a primary education: 11.75% adolescents vs. 9.02-4.26% across adult age groups). CONCLUSIONS: Our results suggest that continued efforts are needed to educate women, especially younger and less educated women, about early pregnancy recognition. In addition, all women need information about the availability of first trimester legal abortion to ensure timely access to abortion services.

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