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Original research
COVID-19 pandemic exacerbation of disparities in access to public abortion services in Mexico
  1. Elizabeth Kravitz1,
  2. Biani Saavedra-Avendaño2,
  3. Blair G Darney3,4
    1. 1Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
    2. 2Ipas LAC, Mexico City, Mexico
    3. 3Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
    4. 4Instituto Nacional de Salud Pública, Cuernavaca, Morelos, Mexico
    1. Correspondence to Dr Blair G Darney; darneyb{at}ohsu.edu

    Abstract

    Background We describe clients in Mexico City’s public abortion programme, Interrupción Legal de Embarazo (ILE), during the COVID-19 pandemic and test whether the pandemic exacerbated inequities in access.

    Methods We conducted a cohort study of all abortions in the ILE programme from 1 January 2019 to 30 June 2022. We compared patients from within and outside the Mexico City Metropolitan area (ZMVM) by pandemic stage (pre-, acute-, mid- and late-COVID periods) and assessed changes in client characteristics (adolescent age, education, weeks’ gestation) by place of residence (ZMVM vs outside the ZMVM) using linear probability models clustered on state.

    Results We included 45 031 abortions. The proportion of abortions to women who travelled from outside the ZMVM decreased from 6.5% pre-COVID to 4.4%–4.8% in in the acute, mid- and late-COVID periods. The adjusted probability of being an adolescent who travelled from outside the ZMVM dropped between pre-COVID (14.4%, 95% CI 12.7% to 16.1%) and mid-COVID (9.3%, 95% CI 7.9% to 10.7%). The proportion of abortions to women with a high school education stayed fairly flat among those travelling, while it rose among those residing in the ZMVM. The adjusted probability of presenting at 11 gestational weeks or greater was higher among women residing in the ZMVM in the pre-pandemic period; this flipped during all pandemic stages, with a higher probability of presenting at 11 weeks or greater among those who travelled from outside the ZMVM.

    Conclusions The COVID-19 pandemic exacerbated existing disparities in who can access ILE services. To reduce inequities in access to essential health services, public sector abortion services should be made available in all Mexican states.

    • COVID-19
    • abortion, induced
    • family planning services
    • Reproductive Rights
    • Reproductive Health Services
    • Sexual Health

    Data availability statement

    Data are available in a public, open access repository.

    http://creativecommons.org/licenses/by-nc/4.0/

    This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

    https://doi.org/10.1136/bmjsrh-2024-202294

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      WHAT IS ALREADY KNOWN ON THIS TOPIC

      • Prior research has demonstrated inequities in access to Mexico City’s public abortion programme, Interrupcion Legal de Embarazo (ILE). During the COVID-19 pandemic, despite abortion services being an essential service, there was a decrease in the overall volume of abortion services.

      WHAT THIS STUDY ADDS

      • This study reveals heightened disparity in utilisation of services by age, education and, to a lesser extent, weeks’ gestation, especially for those travelling from outside the Mexico City Metropolitan Area (ZMVM) during the COVID-19 pandemic.

      HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICY

      • In order to reduce inequities in access to essential health services, public sector abortion services should be made available and accessible in all Mexican states.

      Introduction

      In 2007, abortion was decriminalised in Mexico City (Ciudad de México, CDMX; formerly known as the Districto Federal or DF), and the Interrupcion de Legal Embarazo (ILE) programme began providing abortion services under 13 gestational weeks in the public sector at no cost for residents, and a small sliding scale fee for those travelling from outside the Mexico City area.1 To date, the ILE programme has provided close to 275 000 abortions and has also impacted the public and political discourse on abortion in Mexico, leading the way for additional state-level decriminalisation.1 2

      In Mexico, abortions are provided by physicians in the public and private sectors; however, private providers are not subject to mandatory reporting on volume or type of service provided, and thus private sector abortion data is limited.3 Abortion is provided in health facilities by physicians, and misoprostol is widely available in pharmacies without a prescription; self-managed abortion is understood to be widespread but incidence data is lacking. This analysis focuses on the public sector in Mexico City, the ILE programme, as it provides abortion services to the most underserved individuals. Despite this, disparities in utilisation of ILE services persist. Previous research indicates discrepancies in access based on factors such as age, education and distance to care, with older, married and better-educated individuals being more likely to access ILE abortion services.4–6

      The ILE programme, in line with a worldwide decrease in access to sexual and reproductive health services, experienced disruptions due to the COVID-19 pandemic, although being deemed an essential service.7 Stay-at-home orders issued on 24 March 2020 (known as “quédate en casa”) required all but essential workers to remain in their homes. Stay-at-home orders resulted in an overall decrease in the number of abortions provided, despite abortion being declared an essential health service.8 9 In this study, we build on previous work to describe in more detail ILE clients throughout the COVID-19 pandemic. We compare ILE clients from the Mexico City metropolitan area with clients who travelled for care. We assess changes in client characteristics (age, education, weeks’ gestation) by place of residence (greater Mexico City metropolitan area versus outside the Mexico City metropolitan area) and by phase of the pandemic. We test for differential changes in client composition by age and education, which would indicate exacerbated inequities in access to public sector abortion in Mexico City during the COVID-19 pandemic.

      Methods

      We conducted a retrospective cohort study using de-identified, open-access, individual-level clinical data from the administrative records of the Interrupción Legal del Embarazo (ILE) programme from January 2019 to June 2022 (n=45 031 abortions), split into four periods: a year before the COVID-19 pandemic and stay-at-home orders (2019–24 March 2020), during the acute pandemic (25 March 2020–31 December 2020), the mid-pandemic (2021) and late pandemic (January–June 2022). Data are at the abortion level and include basic individual sociodemographic characteristics and abortion procedure-related information of women obtaining abortions.10

      Our outcomes were client age, education and weeks’ gestation. We grouped age as ≤19 years, 20–29 years and ≥30 years. We selected 19 years as it is the cut-off for adolescent pregnancy, as defined by the WHO.11 We classified educational level as having completed primary school or less, secondary/9th grade, high school/12th grade, and greater than high school. We also included an indicator of student status – whether the woman reported being a current student – to capture those still in school. We classified weeks’ gestation as up to and including 10 weeks compared with 11 weeks and over. We chose this cut-off because medication abortion is standard in the ILE programme at 10 weeks and under, with aspiration reserved for 11 weeks and over, except in some circumstances (eg, aspiration may be preferred for a woman who has travelled and needs to travel home quickly).12

      Travelling from outside the Mexico City metropolitan area was our main exposure. To assess place of residence, we grouped state of residence by regions: North (Baja California, Sonora, Chihuahua, Coahuila, Nuevo León and Tamaulipas); North-West (Baja California Sur, Sinaloa, Nayarit, Durango and Zacatecas); North-Centre (Jalisco, Aguascalientes, Colima, Michoacán and San Luis Potosí), Centre (Guanajuato, Querétaro, Hidalgo, Morelos, Tlaxcala and Puebla); South (Guerrero, Oaxaca, Chiapas, Veracruz, Tabasco, Campeche, Yucatán and Quintana Roo). The Centre region is closest to Mexico City (within about a 5-hour drive). The other regions are much further away, entailing either about a 2-hour plane ride or an overnight bus ride. We then created a binary indicator of travel for regression modelling: the Mexico City Metropolitan Area (Zona Metropolitana del Valle de Mexico, or ZMVM for Spanish initials), which includes 16 Mexico City municipalities (similar to US counties), and 59 from the adjacent State of Mexico, or other place of residence. We also included marital status (single or married or cohabiting) in our descriptive analysis.

      We used descriptive statistics and bivariate tests (χ2 test) to examine differences in sociodemographic characteristics of women who received abortion care at the ILE programme before, during and late in the COVID-19 pandemic. Next, we described the distribution of women’s sociodemographic (such as age and schooling) and clinical (weeks’ gestation) outcomes information by place or residence: living in the ZMVM area or outside it and by the three COVID-19 analytic periods (before, during, late pandemic). To identify any differential changes in client characteristics during the COVID-19 pandemic by place of residence, we developed three linear probability models with age group, a binary indicator of having graduated from high school, and a binary indicator of gestation age less than or equal to 11 weeks as the dependent variables.13 Models were adjusted for year and place of residence (ZMVM area or not) and we clustered on state. We calculated the adjusted marginal predicted probabilities of being an adolescent (≤19 years old vs older) and having high school or higher (vs lower educational level) education by place of residence (ZMVM versus outside the ZMVM) and the analytical COVID-19 periods (before, acute, mid- and late pandemic). We next tested the interaction of pandemic time period and place of residence and calculated probabilities.

      Patient and public involvement statement

      There was no patient or public involvement in this analysis.

      Results

      In this study we included a total of 45 031 abortions. In table 1, the number of abortions decreased sharply in the acute COVID period; by late-COVID, volume rebounded overall but not completely for women travelling from outside the ZMVM (pre-COVID, 6.5% of abortions were to women residing outside the ZMVM; 4.4%–4.8% in the acute, mid- and late-COVID periods). We observe progressively less utilisation of ILE services, as a proportion of all abortions, among those travelling from outside the ZMVM.

      View this table:
      Table 1

      Sociodemographic characteristics of women obtaining abortions in the Mexico City public abortion programme (Interrupcion de Legal Embarazo, ILE) by COVID-19 pandemic stage

      In bivariate analyses, we show that both within and outside the ZMVM, the majority of ILE clients are aged between 20–29 years and the smallest proportion are adolescents. Of patients from outside the ZMVM, the proportion of adolescents as a proportion of all clients was stable in the acute pandemic, dropped in the mid-pandemic, and increased in the late pandemic, still below the pre-COVID proportion (figure 1). Within the ZMVM, the proportion of adolescents decreased in the acute pandemic, and remained at that proportion throughout the pandemic (figure 1). Clients travelling from outside the ZMVM are more likely to have a higher degree of education (high school or higher) than clients residing in the ZMVM (figure 2). This disparity exists both before and throughout the COVID-19 pandemic. In the pre-COVID period, among clients from outside the ZMVM, 80% had a high school or higher education, compared with 65% of clients from within the ZMVM, and these percentages remained relatively stable throughout the pandemic for both clients from within and outside the ZMVM. In other words, those patients who utilised ILE services were more likely to have a high school or higher education if coming from outside the ZMVM. Finally, compared with those living within the ZMVM, patients outside the ZMVM were more likely to present at 11 or more weeks (thus closer to the legal limit; online supplemental figure 1). During the acute COVID period, the percentage of patients from the ZMVM presenting at 11 weeks or greater was 6.0%, compared with 9.1% of patients travelling from outside the ZMVM. As the pandemic continued, there was an increasing proportion of abortions presenting at 11 weeks or greater for ILE clients travelling from outside the ZMVM (pre-COVID 6.8% to late-COVID 9.6%, p<0.01; online supplemental figure 1).

      Supplemental material

      Figure 1
      Figure 1

      Proportion of abortions to women aged ≤19, 20–29 and ≥30 years in Mexico City's public abortion programme (Interrupcion de Legal Embarazo, ILE) by place of residence and COVID-19 pandemic stage. Pre-covid was defined as January 2019– 24 March 2020, acute COVID was defined as 25 March 2020–31 December 2020, mid-COVID was defined as 01 January 2021– 31 December 2021 and late-COVID was defined as 01 January 2022–30 June 2022. ZMVM: Mexico City Metropolitan Area (Zona Metropolitana del Valle de Mexico, or ZMVM for Spanish initials). χ2 test shows by place of residence within the ZMVM (p<0.0001) and outside the ZMVM (p=0.03).

      Figure 2
      Figure 2

      Proportion of abortions by educational level in Mexico City's public abortion programme (Interrupcion de Legal Embarazo, ILE) by place of residence and COVID-19 pandemic stage. Pre-covid was defined as January 2019– 24 March 2020, acute COVID was defined as 25 March 2020–31 December 2020, mid-COVID was defined as 01 January 2021– 31 December 2021 and late-COVID was defined as 01 January 2022–30 June 2022. ZMVM: Mexico City Metropolitan Area (Zona Metropolitana del Valle de Mexico, or ZMVM for Spanish initials). χ2 test shows by place of residence within the ZMVM (p<0.0001) and outside the ZMVM (p=0.110).

      Figure 3 presents adjusted probabilities of presenting to ILE services as an adolescent, education of high school or above, or weeks’ gestation 11 or above by place of residence and period of the pandemic. Among ILE clients residing in the ZMVM, there is a steady decrease in probability of presenting as an adolescent as the pandemic continues from 14.7% (95% CI 14.1% to 15.3%) in the pre-COVID period to 12.3% (95% CI 12.1% to 12.5%) in the late-COVID period (figure 3). This trend is different for clients residing outside the ZMVM. Clients residing outside the ZMVM initially had increased probability of being an adolescent in the acute COVID period (15.6%, 95% CI 12.1% to 19.1%) then decreasing probability in the mid-COVID period (9.3%, 95% CI 7.9% to 10.7%), and finally rebounding in late COVID (12.4%, 95% CI 8.9% to 15.9%); however, still remaining below pre-pandemic probabilities (figure 3). Differences in education by residence were persistent: women coming from outside the ZMVM had a higher adjusted probability of having a high school education or above (73.2%, 95% CI 71.3% to 75.1% in the pre-COVID period and 74.4%, 95% CI 70.7% to 78.1% in the late-COVID period) compared with local women (65%, 95% CI 64.7% to 65.4% in the pre-COVID period and 68.0%, 95.0% CI 67.5% to 68.4% in the late-COVID period; figure 3). The adjusted probability of presenting at 11 or more gestational weeks was similar in the pre-COVID period for those residing inside the ZMVM and those travelling from outside the ZMVM (figure 3). Travelling from outside the ZMVM was associated with a higher probability of presenting at 11 or greater weeks during all periods of the pandemic, but these differences did not reach statistical significance. Full regression model results are provided in online supplemental table 1.

      Supplemental material

      Figure 3
      Figure 3

      Adjusted probabilities of presenting to Interrupcion de Legal Embarazo (ILE) services as an adolescent, education of high school or above, or 11 or more gestational weeks by place of residence and COVID-19 pandemic stage. Pre-covid was defined as January 2019– 24 March 2020, acute COVID was defined as 25 March 2020–31 December 2020, mid-COVID was defined as 01 January 2021– 31 December 2021 and late-COVID was defined as 01 January 2022–30 June 2022. ZMVM: Mexico City Metropolitan Area (Zona Metropolitana del Valle de Mexico, or ZMVM for Spanish initials). Associated p-values and confidence intervals are provided in online supplemental table 1.

      Discussion

      Overall, we report decreased utilisation as well as increasing inequities in use of abortion services in Mexico City’s ILE programme by clients travelling from outside the ZMVM during the COVID-19 pandemic. First, we find progressively less utilisation of ILE services for travelling from outside the ZMVM. Second, we show that clients travelling from outside the ZMVM had higher levels of education, a decreasing proportion of adolescents and a (non-significant) increasing proportion of patients presenting at 11 or greater weeks (close to the ILE programme limit of 12 weeks 6 days) compared with patients residing in the ZMVM closer to ILE services.

      Our findings highlight an ongoing demand for public abortion services from women residing far from the ZMVM. ILE data have consistently shown that 5% of ILE patients come from outside Mexico City and the adjacent State of Mexico (where 25% of ILE patients live).9 Our measure improves on previous work that uses state as a measure of travel, to measure travel using municipalities in the Mexico City Metropolitan area (all 16 in Mexico City and 59 from the adjacent State of Mexico). While the ZMVM is the most densely populated region of Mexico, and we would not anticipate that say 20% of ILE clients would come from the Southern region, any changes in the proportion of abortions to patients from regions outside the ZMVM during the COVID-19 pandemic may indicate access inequities. It is important to note that we cannot observe demand that is not met, but previous work comparing observed abortions with expected abortions has suggested that increasing travel time is associated with unmet demand.5 Mexico’s highest federal court (Supreme Court of Justice of the Nation, SCJN) has recently ruled that the criminalisation of abortion is inconsistent with the federal constitution at the state and federal levels, opening the way to decriminalisation in Mexico’s 32 states and in the federal health systems.14 15 However, access to abortion in states in which abortion is decriminalised is variable despite federal efforts to support service provision through technical guidance.12 16 17 In order to reduce inequities in access to essential health services, public sector abortion services should be made available and accessible in all Mexican states where abortion has been decriminalised, and made available and accessible for victims of rape, for post-abortion care, and under state-level exceptions in all of Mexico’s 32 states.18

      We found that the proportion of adolescents accessing ILE services remains a small proportion of abortions, especially among those travelling from outside the ZMVM. For patients within the ZMVM, this proportion decreased as the pandemic continued, in contrast to the breakdown of patients travelling from outside the ZMVM, which has an immediate small increase in the acute period, followed by a decrease, and then rebound, still below pre-COVID levels. This decrease in presentation to ILE suggests a lack of access to these services, which we hypothesise may be secondary to decreased knowledge of services, financial ability to travel, cultural stigma in less populated, marginalised communities, and the geographic barrier of travelling long distances limiting adolescents travelling from more marginalised communities.6 Improving access to first-trimester abortion by adolescent clients can prevent first births in adolescents, and has been shown to decrease total fertility by age 24 years.19 Access to abortion services for adolescents needs to be a priority, in line with the goals of the National Adolescent Pregnancy Prevention Policy (known as the ENAPEA in Spanish).20

      A smaller proportion of abortions in the ILE programme were to clients with lower levels of education during the COVID-19 pandemic, regardless of place of residence (within or outside the ZMVM); however, those who travelled had higher levels of education than the average among those who resided in the ZMVM, suggesting that higher education is associated with the ability to travel for care. A higher proportion of those who travelled for care had high school and university degrees than among residents of the ZMVM. This is notable: this analysis focuses on the public sector, which serves poor women; even among this population of underserved individuals, we observe inequities by education. These findings support previous work that compared women who travel to ILE services with the average in their home municipalities and reported higher levels of education than municipality-level averages.6

      Finally, we show an increasing proportion of abortions at a gestation of 11 weeks or greater as the pandemic continued for clients travelling from outside the ZMVM. The 11th week of gestation approaches the legal limit in Mexico City; thus, this finding serves as an indicator of lack of early access to abortion services. Access to abortion at 13 weeks and above remains very restricted in Mexico; therefore, early access is essential. Prior literature in Mexico has demonstrated that key vulnerable populations, including adolescents and women with lower levels of education, are more likely to present for second-trimester (versus first-trimester) abortion under narrow exceptions21 and to be denied abortion services due to presenting beyond the legal limit.4 21

      Prior work has described inequities in who is able to travel to Mexico City for abortion services; our results demonstrate that the pandemic exacerbated these existing inequities. Our findings support global evidence of the impact of the COVID-19 pandemic on access to reproductive health services. Our findings leverage patient-level data to provide specific indications of how increased inequities are playing out (eg, by age and educational status) beyond overall drops in numbers of abortions. A scoping review of 26 quantitative and qualitative studies published on abortion and contraceptive access during the COVID-19 pandemic in low- and middle-income countries demonstrated increases in demand, reductions in service provision, and increased barriers to abortion and contraception during the COVID pandemic compared with before the pandemic.22 Various studies in the review provided evidence for emerging barriers including a lack of supplies and resources to identify pregnancies leading to delayed diagnosis (clinic appointments or pregnancy tests), a lack of knowledge on access/perceived availability of services (eg, that services were still available during the pandemic), inadequate/reduced transportation, fear of infection, lack of transportation, clinic closure, and inability to travel given lockdown restrictions. In the scoping review, surveys have demonstrated additional barriers in the adolescent population secondary to decreasing availability of contraceptive resources in part due to diversion of funds away from adolescent sexual and reproducitive health towards other COVID-19 responses.22 Of note, this scoping review commented on a lack of available nationally representative data on the impact of the pandemic on key vulnerable groups which our study, using patient-level clinical data from all abortions in Mexico City’s public sector abortion programme, aims to address.

      Strengths of this study include its large sample size utilising publicly available abortion-level data and reproducible analyses. This dataset is reflective of an organisation in the public sector offering free or significantly reduced cost abortion services, and therefore possesses the demographics of the clients that this study was focused on analysing, namely those most vulnerable to the COVID-19 pandemic and with inequities to accessing healthcare.

      Our study has limitations. First, we are unable to evaluate the demographic and volume of patients that were unable to access these services or may have been turned away after presentation after the gestational week cut-off. Second, we do not have data on self-managed abortions (SMAs) that occur outside the formal health system, which is increasingly common in Mexico.23 Women outside the ZMVM may be utilising SMAs and therefore not be using ILE services. Third, we also do not include data on private sector services either in Mexico City or the states. However, private sector services are generally not accessible to women with low incomes, which is the population served by ILE and state-level public services; nor are private sector data publicly available. Additionally, due to the small number of abortions provided to clients travelling from outside the ZMVM, we were unable to assess any changes in states that recently decriminalised abortion (Oaxaca, 2019; Hidalgo, 2021; Veracruz, 2021; Coahuila, 2021; Baja California, 2021; Colima, 2021; Sinaloa, 2022; Guerrero, 2022; Baja California Sur, 2022; Quintana Roo, 2022; and, most recently, Aguascalientes in 2023). A final limitation is that the pre-COVID, acute-COVID, mid-COVID and late-COVID periods were unequal in length, thus interpretations of the exact volume of abortion services are limited. Future work using more years of ILE data and/or state-based health system data are needed to evaluate changes in travelling to ILE and accessibility of abortion services in states that have recently decriminalised abortion.

      In conclusion, our analyses demonstrate heightened disparities in utilisation of public sector abortion services during the COVID-19 pandemic in Mexico, especially by those travelling from outside the ZMVM. The proportion of abortions in adolescents and those with lower levels of education who were able to travel to ILE (ie, key vulnerable populations) decreased. To reduce inequities in access to essential health services, public sector abortion services should be made available and accessible in all Mexican states.

      Data availability statement

      Data are available in a public, open access repository.

      Ethics statements

      Patient consent for publication

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      Footnotes

      • X @elizkravitz, @biani_saavedra

      • Contributors BGD, EK and BS-A designed the project. BS-A performed the data analysis. EK drafted the manuscript. BGD, EK and BS-A contributed to revisions. BGD is guarantor.

      • Funding BGD is supported by a Garcia-Robles COMEXUS-Fulbright Award, Mexico, 2023–2024.

      • Competing interests None declared.

      • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

      • Provenance and peer review Not commissioned; externally peer reviewed.

      • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.