Orientations to motherhood and male partner support among women in Mexico and Mexican-origin women in the United States

Previous studies suggest that favorable pregnancy outcomes among Mexican immigrant women in the United States may be attributed to a protective sociocultural orientation, but few have explored the attitudes and values that shape Mexican women's perceptions of motherhood. This exploratory study examines orientation towards motherhood among Mexican and Mexican-origin women living in Mexico and the United States and their perceptions of their male partners' attitudes and roles. Focus groups were conducted with 60 pregnant low-income women in rural and urban communities in Mexico with high rates of migration to the US, among immigrant communities in rural and urban California and with US-born women of Mexican descent (Mexican Americans) in urban California. Notable differences were observed between women in Mexico and the US and between immigrant and Mexican American women in California as more women articulated life plans. Life plans seemed to reflect both processes of individuation and changing gender roles. While participants in Mexico largely abided by the conventional discourse on motherhood and domesticity, immigrants in California alternated between this ethos and the discourse of working mother, depending on financial resources. In contrast, Mexican American participants assumed multiple roles. These differing orientations may be linked to other factors, including fertility control, the amount and type of partner support, and stress during pregnancy.     

Dietary Associations of Household Food Insecurity among Children of Mexican Descent: Results of a Binational Study

Background/objectiveChildren of Mexican descent frequently experience household food insecurity both in the United States and Mexico. However, little is known about the associations of food insecurity with dietary intake. This study aimed to understand the level of perceived food insecurity and its association with dietary intake among children of Mexican descent residing in the United States and Mexico.DesignThis cross-sectional study utilized data from a 2006 binational study of 5-year-old children of Mexican descent living in migrant communities in California and Mexico.MethodsIn California, children were 301 participants from the Center for the Health Assessment of Mothers and Children of Salinas study, a longitudinal birth cohort in a Mexican immigrant community. Mexican children (n=301) were participants in the Proyecto Mariposa study, which was designed to capture a sample of women and their children living in Mexico who closely resembled the California sample, yet who never migrated to the United States. Household food insecurity was measured using the US Department of Agriculture Food Security Scale and dietary intake was assessed with food frequency questionnaires. Analysis of variance was used to examine unadjusted and adjusted differences in total energy, nutrient intake, and consumption of food groups by household food security status.ResultsApproximately 39% of California mothers and 75% of Mexico mothers reported low or very low food security in the past 12 months (P<0.01). Children in the United States experiencing food insecurity consumed more fat, saturated fat, sweets, and fried snacks than children not experiencing food insecurity. In contrast, in Mexico food insecurity was associated with lower intake of total carbohydrates, dairy, and vitamin B-6.ConclusionsPrograms and policies addressing food insecurity in the United States and Mexico may need to take steps to address dietary intake among children in households experiencing food insecurity, possibly through education and programs to increase resources to obtain healthful foods.     

HIV infection in mobile populations: the case of Mexican migrants to the United States.

OBJECTIVE: Previous studies have indicated varying rates of HIV infection among labor migrants to the United States of America. Most of these studies have been conducted with convenience samples of farmworkers, thus presenting limited external validity. This study sought to estimate the prevalence of HIV infection and risk factors among Mexican migrants traveling through the border region of Tijuana, Baja California, Mexico, and San Diego, California, United States. This region handles 37% of the migrant flow between Mexico and the United States and represents the natural port of entry for Mexican migrants to California. METHODS: From April to December 2002 a probability survey was conducted at key migrant crossing points in Tijuana. Mexican migrants, including ones with a history of illegal migration to the United States, completed an interview on HIV risk factors (n = 1 429) and an oral HIV antibody test (n = 1,041). RESULTS: Despite reporting risk factors for HIV infection, none of the migrants tested positive for HIV. CONCLUSIONS: Our findings contrast with previous estimates of HIV among labor migrants in the United States that were based on nonprobability samples. Our findings also underline the need for early HIV prevention interventions targeting this population of Mexican migrants.     

Decriminalization of Abortion in Mexico City: The Effects on Women’s Reproductive Rights

In April 2007, the Mexico City, Mexico, legislature passed landmark legislation decriminalizing elective abortion in the first 12 weeks of pregnancy.In Mexico City, safe abortion services are now available to women through the Mexico City Ministry of Health’s free public sector legal abortion program and in the private sector, and more than 89 000 legal abortions have been performed. By contrast, abortion has continued to be restricted across the Mexican states (each state makes its own abortion laws), and there has been an antichoice backlash against the legislation in 16 states.Mexico City’s abortion legislation is an important first step in improving reproductive rights, but unsafe abortions will only be eliminated if similar abortion legislation is adopted across the entire country.In April 2007, the Mexico City, Mexico, legislature passed landmark legislation decriminalizing elective abortion in the first 12 weeks of pregnancy. The law included a provision that abortion services be available to women at Mexico City (Distrito Federal) Ministry of Health (MOH-DF) facilities in the city, free of charge for Mexico City residents and on a sliding fee scale for those outside Mexico City. In addition, the law strengthened sexual education curricula in schools and called for widespread access to contraceptive methods. Shortly after being passed, the law was challenged in the Mexican Supreme Court by groups opposed to the legislation, but in August 2008, the Supreme Court voted to uphold the law.1,2In Mexico, abortion laws are made at the state level, and before this reform, across all of Mexico’s states and in the Federal District (or Mexico City, the capital), abortion was permitted under very limited circumstances such as in cases of rape, fetal malformation, or when the survival or health of a woman was in danger. Even when abortions were legally permitted, however, numerous barriers made accessing a legal abortion extremely difficult.3,4 Despite these barriers, abortion was commonly practiced. One study estimated the induced abortion rate in Mexico in 2006 to be 33 abortions per 1000 women aged 15 to 44 years, a comparatively high rate by global standards.5 However, because of the legal restrictions, the vast majority of abortions in Mexico took place clandestinely, often in unsafe circumstances, sometimes causing severe health consequences for women. From 1990 to 2008, 7.2% of all maternal deaths in Mexico were abortion-related.6 Another study estimated that in 2006, 149 700 women were hospitalized from complications following induced abortions nationally.5Inequity was an important dimension of unsafe abortion in Mexico. A study that used data from the 2006 Mexican National Demographic Survey found the risk of having an unsafe abortion was highest for poor women, those with low levels of education, and those who belonged to indigenous groups.7 The abortion reform in Mexico City responded to the gravity of this public health problem, delivering a major victory for women’s reproductive rights by departing from the restrictive abortion laws in the rest of the country.The Mexico City abortion law reform is significant not only for Mexico, but also for the entire Latin American and Caribbean region, which continues to have some of the most restrictive abortion laws globally. Virtually all abortions (95%) in the Latin American and Caribbean region are unsafe, and unsafe abortions cause an estimated 12% of all maternal deaths.8,9 Only a few countries and territories in this region have progressive abortion legislation, including Cuba, Guyana, Puerto Rico, and Uruguay, where first-trimester abortion was decriminalized in 2012.10,11We describe developments since this landmark reform was passed, both in Mexico City and in the states of Mexico. We highlight the development of the public sector legal abortion program by the MOH-DF, including important trends in this program. We also discuss the backlash that has occurred since abortion decriminalization.     

Denial of Abortion Because of Provider Gestational Age Limits in the United States

Objectives. We examined the factors influencing delay in seeking abortion and the outcomes for women denied abortion care because of gestational age limits at abortion facilities.Methods. We compared women who presented for abortion care who were under the facilities’ gestational age limits and received an abortion (n = 452) with those who were just over the gestational age limits and were denied an abortion (n = 231) at 30 US facilities. We described reasons for delay in seeking services. We examined the determinants of obtaining an abortion elsewhere after being denied one because of facility gestational age limits. We then estimated the national incidence of being denied an abortion because of facility gestational age limits.Results. Adolescents and women who did not recognize their pregnancies early were most likely to delay seeking care. The most common reason for delay was having to raise money for travel and procedure costs. We estimated that each year more than 4000 US women are denied an abortion because of facility gestational limits and must carry unwanted pregnancies to term.Conclusions. Many state laws restrict abortions based on gestational age, and new laws are lowering limits further. The incidence of being denied abortion will likely increase, disproportionately affecting young and poor women.The majority of abortions in the United States are in the first trimester of pregnancy, but 8.5% (approximately 100 000) occur after 13 weeks’ gestation.1 Most women having second trimester abortions would have liked to have had the procedure earlier,2 and women report a number of delaying factors, including cost and access barriers and late detection of pregnancy.2–4 These delays can result in women being denied care because they present with pregnancies beyond an abortion provider’s gestational age limit and are unable to obtain an abortion elsewhere. (An “abortion provider” is a facility where abortions are performed.5) Little is known about how frequently this occurs and what happens to women denied abortion care.The 1973 Supreme Court Roe v. Wade6 decision established the point of potential fetal viability as the threshold after which states could restrict women’s access to abortion care as long as they allowed for exceptions to preserve the life and health of the pregnant woman. However, Roe v. Wade did not specify a gestational age for viability. Many states have established an upper gestational limit, most commonly after 24 weeks from a woman’s last menstrual period, and some states have done so without the required exceptions.7 At least 8 states have recently reduced or plan to reduce the upper gestational limit to 20 weeks, and 1 state to 18 weeks.8 Individual abortion providers can set their limits at lower gestational ages, and do so based on the availability of trained physicians, clinician and staff comfort, and facility regulations. According to a national survey of abortion providers, 23% offer abortions after 20 weeks’ gestation, and 11% do so at 24 weeks.5 Because fewer providers offer abortion care after the first trimester, women must travel longer distances to obtain later abortions. Because later abortions are more complex procedures, often occurring over 2 or more days, they are also more costly; the average charge for an abortion at 10 weeks is $543 compared with $1562 for an abortion at 20 weeks.5 Some women must also arrange for childcare, take time off work or other responsibilities, and incur transportation and hotel expenses; raising these funds results in additional delays.9We sought to describe the characteristics associated with being turned away because of provider gestational age limit, and the efforts such women make to obtain a desired abortion. Additionally, we explored the factors associated with obtaining a desired abortion elsewhere. Finally, we estimated the incidence of women being denied an abortion in the United States because of provider gestational limits.     

Abortion, contraceptive use, and adolescent pregnancy among first-year medical students at a major public university in Mexico City.

OBJECTIVE: If properly trained, medical students could become future opinion leaders in health policy and could help the public to understand the consequences of unwanted pregnancies and of abortions. The objective of this study was to analyze the frequency of unwanted pregnancies and induced abortions that had occurred among women who were first-year medical students at a major public university in Mexico City and to compare the experiences of those women with the experiences of the general population of Mexican females aged 15 to 24. METHODS: In 1998 we administered a cross-sectional survey to all the first-year medical students at the National Autonomous University of Mexico, which is the largest university in Latin America. For this study we analyzed 549 surveys completed by female students. RESULTS: Out of the 549 women, 120 of them (22%) had been sexually active at some point. Among those 120 sexually active students, 100 of them (83%) had used a contraceptive method at some time, and 19 of the 120 (16%) had been pregnant. Of those 19 women who had been pregnant, 10 of them had had an illegal induced abortion (in Mexico, abortions are illegal except under a small number of extenuating circumstances). The reported abortion rate among the female medical students, 2%, was very low in comparison with the 11% rate for women of similar ages in the Mexican general population. CONCLUSIONS: The lower incidence of abortion among the female medical students indicates that when young Mexican women have access to medical information and are highly motivated to avoid unintended pregnancy and abortion, they can do so.     

Impact of immediate postabortal insertion of intrauterine contraception on repeat abortion

BACKGROUND: Of the 1.3 million abortions performed annually in the United States, approximately half are repeat procedures. Immediate postabortal intrauterine device (IUD) insertion is a safe, effective, practical and underutilized intervention that we hypothesize will significantly decrease repeat unintended pregnancy and abortion. STUDY DESIGN: All women receiving immediate postabortal IUD insertion in eight clinics of a Northern California Planned Parenthood agency during a 3-year period comprise the IUD cohort. We selected a cohort of controls receiving abortions but choosing other, non-IUD contraception on the day of the abortion visit in a 2:1 ratio matched by date of abortion. We obtained follow-up data on repeat abortions within the agency for both cohorts through 14 months after the 3-year period. We evaluated differences in repeat abortion between cohorts. All analyses were intent-to-treat. RESULTS: Women who received an immediate postabortal IUD had a lower rate of repeat abortions than controls (p<.001). Women who received a postabortal IUD had 34.6 abortions per 1000 woman-years of follow-up compared to 91.3 for the control group. The hazard ratio for repeat abortion was 0.38 [95% confidence interval (CI), 0.27-0.53] for women receiving a postabortal IUD compared to controls. When adjusted for age, race/ethnicity, marital status, and family size, the hazard ratio was 0.37 (95% CI, 0.26-0.52). CONCLUSION: Immediate postabortal intrauterine contraception has the potential to significantly reduce repeat abortion.     

It Is Time to Integrate Abortion Into Primary Care

The Roe v Wade decision made safe abortion available but did not change the reality that more than 1 million women face an unwanted pregnancy every year. Forty years after Roe v Wade, the procedure is not accessible to many US women.The politics of abortion have led to a plethora of laws that create enormous barriers to abortion access, particularly for young, rural, and low-income women. Family medicine physicians and advanced practice clinicians are qualified to provide abortion care.To realize the promise of Roe v Wade, first-trimester abortion must be integrated into primary care and public health professionals and advocates must work to remove barriers to the provision of abortion within primary care settings.THE 1973 ROE V WADE decision1 removed many legal obstacles to abortion and was a public health watershed. The availability of safe abortion services led to dramatically decreased rates of maternal morbidity and mortality in the United States,2 as in most countries that have removed legal impediments to abortion care.According to the most recent available data, approximately 1.2 million women obtain safe, legal abortions from skilled clinicians in the United States every year.3 The political debate over abortion has largely ignored the public health fact that the Roe v Wade decision did not create or change the need for abortion; legalization simply made abortion safe. Maternal death from unsafe abortion in the United States became a negligible statistic after 1973. Abortion is now one of the safest medical procedures available; only 0.3% of abortion patients experience a complication that requires hospitalization.4Unwanted pregnancy continues to be a reality of women’s lives. One in three women in the United States will seek an abortion before she is aged 45 years.3 For these women, restrictive laws driven by ideology, not science, are undermining the promise of Roe v Wade in many parts of the country. State restrictions—including waiting periods, parental consent requirements for minors, lack of insurance coverage or Medicaid coverage for abortion, and expensive and unnecessary building requirements for facilities that provide abortions—create almost insurmountable barriers to access, especially for rural, young, and low-income women. There are ever-increasing restrictions passed at the state and federal levels, and antiabortion activists have directed a relentless campaign of violence and harassment at clinics and clinicians who provide the service. Many medical residencies lack training opportunities, leading to a lack of skilled abortion providers. The cumulative result of these regulations, the harassment, and the lack of training is a shrinking number of sites that offer abortion services.Specialized abortion clinics performed 70% of all abortions in 2008,3 yet the hostile political climate those opposed to abortion have created is forcing the numbers of these clinics to decline every year. The number of abortion providers has declined dramatically, from 2908 in 1982 to 1787 in 2005. Eighty-seven percent of all US counties lacked an abortion provider in 2008; 35% of US women live in those counties.3Abortion services are concentrated in cities.3 Almost all nonmetropolitan counties (which is 97% of all US counties) lack an abortion provider.3 In eight states (Arkansas, Idaho, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, and Wyoming) there are abortion clinics in only one city in the entire state. The result of the shortage of providers is that although abortion is one of the most common medical procedures performed in the United States, in many areas of the country women must travel for hours and deal with long delays to get the reproductive health care they need.Primary care clinicians provide personalized continuous preventative health care to patients throughout their reproductive years. Physician assistants, nurse midwives, and nurse practitioners (collectively, advanced practice clinicians, or APCs) and family physicians provide the majority of well-woman care to patients throughout the country. The skills needed to provide abortions—including the ability to assess gestational age, provide counseling, provide medications, perform manual or electric vacuum aspiration, and conduct postabortion follow-up—are in the scope of practice of primary clinicians. Many primary care clinicians who specialize in women’s health have specialized training. They perform suturing, colposcopy, intrauterine device insertions, endometrial biopsy, and gynecological care; and prescribe medications for family planning. These skills are comparable to those required to perform a first-trimester abortion.The provision of first-trimester abortion care is clearly within the scope of practice of primary care clinicians. In fact, since 1973 physician assistants have provided abortions in Montana and Vermont. Beginning in the early 1990s, advocates and professional groups came together to begin state-by-state advocacy to clarify the laws and scope of practice issues and promote the involvement of APCs in abortion care. APCs have been legally recognized as competent to substitute for physicians in the performance of many tasks.5 Several studies6,7 have compared complication rates and patient satisfaction between abortions physicians provide and those APCs provide. These studies consistently show that APCs with the requisite skills, training, and experience are fully competent to provide medical and first-trimester surgical abortions safely. As a result of state-by-state advocacy, APCs are now providing medication abortion in 18 states. APCs provide aspiration abortions in Montana, New Hampshire, Oregon, and Vermont.Additionally, APCs are providing aspiration abortion in California through a five-year demonstration project (Health Workforce Pilot Project No. 171) under the auspices of the University of California, San Francisco. Nurse practitioners, certified nurse midwives, and physician assistants have been trained to provide first-trimester aspiration abortion, and the project is being carefully evaluated. To date, 41 APCs at sites across California have been trained through the project. Nearly 8000 patients have received abortion care from these trained nurse practitioners, certified nurse midwives, and physician assistants. The project has conducted a study to compare the outcomes of these early abortions that APCs performed to a comparable number that physicians performed. The data show similar rates of high patient satisfaction and low complications in both groups.8Nurse practitioners, certified nurse midwives, and physician assistants have been increasing their commitment to abortion care, and there has also been remarkable advocacy among family medicine physicians. Several organizations (e.g., the Reproductive Health Access Project and the Center for Reproductive Health Education in Family Medicine [RHEDI]) have worked to increase training in abortion procedures in family medicine residency programs and to increase advocacy among family medicine professional organizations. Family physicians currently provide abortions at many of the freestanding clinics around the United States. Studies have shown that abortion care that family doctors provide have low rates of complication9,10 and that many patients would prefer to get their abortion from their family physician.11As more primary care clinicians are being trained and expressing interest in providing abortions, new technologies are making it possible for women to diagnose and end their pregnancies earlier. Inexpensive and accurate pregnancy tests now allow many women to determine whether they are pregnant within two weeks after unprotected intercourse. Advances in ultrasound have made it possible to confirm a pregnancy very early on. These advances have contributed to women in the first trimester coming in earlier to end an unwanted pregnancy. Eighty-eight percent of women who have abortions get the procedure in the first 12 weeks of pregnancy, and 61.8% of women have their abortion before the ninth week.4 All these women could be treated in a primary care setting.Yet most of the primary care clinicians who currently provide abortions do so at freestanding abortion sites.3 Too often when a patient seeks an abortion from her primary care clinician at her medical home, she is referred to another health care provider,12 even though trained family medicine doctors, nurse practitioners, certified nurse midwives, and physician assistants can provide first-trimester abortions. Although there are certainly primary care clinicians who do not want to provide abortions to their patients, many qualified and trained clinicians are willing but unable to offer this care because of burdensome, politically motivated restrictions that are not derived from science, public health considerations, or good medicine.Family medicine practices and physicians and community health centers are key health access points for low-income and rural women. Community health centers are the medical and health care home for more than 20 million people nationally, and community health center patients are disproportionately low income, uninsured or publicly insured, and minority.13 If abortion care were available in these centers and in family medicine practices, more women would be able to end their unwanted pregnancies without having to travel hundreds of miles or face delays that push them into getting abortions later in their pregnancy.Unfortunately, most federally qualified community health centers do not offer abortion services because of the Hyde Amendment, a legislative provision barring the use of federal funds to pay for abortions. Additionally, many of the federally qualified community health centers rely on malpractice coverage from the federal government, which does not cover abortion care. Family doctors who want to provide early abortion care in their practices must purchase extremely expensive obstetrical coverage, even though many other procedures routinely performed in family medicine have a higher complication rate than do first-trimester abortion procedures. APCs face other barriers; in many states, APCs are prevented from providing abortions or are limited to providing only medication abortion because of laws promoted by those who seek to restrict abortion access and because of resistance to expanding the scope of APCs’ practice to include abortion care.14The World Health Organization recently issued technical and policy guidelines for safe abortion worldwide. The guidelines state,

Both vacuum aspiration and medical abortion can be provided at the primary care level on an outpatient basis and do not require advanced technical knowledge or skills, expensive equipment such as ultrasound, or a full complement of hospital staff (e.g., anaesthesiologist). 15

The United States needs to step up to the World Health Organization standard. Health care reform has identified the importance of promoting high-quality, continuous, accessible, and cost-effective care in primary care settings. It is time for the promise of legal abortion to be available to every woman in the United States, rural or urban, low-income or middle class. Public health professionals and advocates must work together to find strategies to expand access to abortion by removing restrictions on the primary care clinicians who are trained and willing to provide the service. Forty years after Roe v Wade, it is time to integrate first-trimester abortion into primary care.     

State family planning and abortion expenditures: their effect on public health.

OBJECTIVES. This study examines whether state family planning expenditures and abortion funding for Medicaid-eligible women might reduce the number of low-birthweight babies, babies with late or no prenatal care, and premature births, as well as the rates of infant and neonatal mortality. METHODS. Using a pooled time-series analysis from 1982 to 1988 with the 50 states as units of analysis, this study assessed the impact of family planning expenditures and abortion funding on several public health outcomes while controlling for other important variables and statistical problems inherent in pooled time-series studies. RESULTS. States that funded abortions had a significantly higher rate of abortions and significantly lower rates of teen pregnancy, low-birthweight babies, premature births, and births with late or no prenatal care. States that had higher expenditures for family planning had significantly fewer abortions, low-birthweight babies, births with late or no prenatal care, infant deaths, and neonatal deaths. CONCLUSIONS. Funding abortions for Medicaid-eligible women and increasing the level of expenditures for family planning are associated with major differences in infant and maternal health in the United States.     

Strategies for securing funding for abortion under the Hyde Amendment: a multistate study of abortion providers' experiences managing Medicaid

Objectives. We investigated systematic barriers, identified by previous research, that prevent women from obtaining Medicaid coverage for an abortion even when it should legally be available: when the pregnancy resulted from rape or incest or threatens the mother''s life. We also aimed to document strategies to improve access to federal Medicaid funding in qualifying cases.Methods. We conducted in-depth interviews from 2007 to 2009 with representatives of 49 facilities that provided abortions in 11 states. Interviews focused on participants’ experiences and strategies in seeking federal Medicaid funding for abortions. We coded data both inductively and deductively and analyzed them thematically.Results. Common strategies described by the few participants who secured Medicaid funding for abortions in cases of rape, incest, and life endangerment were facility-level interventions, such as developing relationships with Medicaid staff, building savvy billing departments, and encouraging clients to advocate for themselves, as well as broader legal and collaborative strategies.Conclusions. Multipronged state-level interventions that combine advocacy, legal, and on-the-ground resources show the most promise of increasing access to federal Medicaid funding for abortion care.Low-income women''s access to reproductive health care services in the United States is limited by many health care providers’ difficulties navigating the Medicaid reimbursement system.^1,2 Addressing the challenges providers experience securing reimbursements is critical to ensuring access to reproductive health care for a significant number of low-income women. Indeed, Medicaid, a joint federal and state project, is the largest health insurance program in the United States.³ In 2006 it provided coverage for 7.3 million women, or 12% of all women of reproductive age.⁴Since 1976, the Hyde Amendment has prevented women on Medicaid from using their insurance for abortion care, with few exceptions. Currently, the amendment prohibits the use of federal funds for abortions except when the pregnancy results from rape or incest, or when it endangers the mother''s life. States have the option to use their own funding to expand Medicaid coverage for abortions in a broader range of circumstances, but only 17 do. Thirty-two states ban the use of state Medicaid funding for abortions except in the cases outlined by the Hyde Amendment; South Dakota, in open violation of federal law, covers abortions only when the mother''s life is endangered.⁵A growing body of evidence shows that the implementation of these exceptions is inconsistent and that several systematic barriers prevent health care providers from securing Medicaid coverage for women seeking abortions for pregnancies in cases of rape, incest, or life endangerment.^6–8 Identified obstacles to securing federal Medicaid funding include complex paperwork requirements, inconsistent support from Medicaid when filing claims, and frequent inappropriate denials of submitted claims.⁶When Medicaid coverage for abortion care is inaccessible or denied, low-income women must scramble to find other resources to cover the cost of the procedure. The search for funding for an abortion can force women to delay a desired abortion or continue an unwanted pregnancy.^6–13 In some cases, women with life-endangering conditions must delay treatment while they raise money for their abortion.⁶What strategies can be used to prevent women in these circumstances from being denied timely access to abortion services? We investigated abortion providers’ experiences navigating obstacles to securing Medicaid coverage for qualifying abortions for their clients.     

Measuring Tijuana residents' choice of Mexican or U.S. health care services

There is growing concern that the indigent health care burden in the southwestern United States may be caused partly by Mexican residents who cross the border to use U.S. health services. This article describes the first attempt to measure the extent of this use by border residents. It also compares factors associated with their use of health care services in both the United States and Mexico. Data were obtained from a household survey conducted in Tijuana, Mexico, near the California border, using a random, stratified analytic sample of 660 households that included a total of 2,954 persons. The dependent variables--extent and volume of contacts with health professionals--were examined according to sociodemographic characteristics, insurance coverage, payment modality, type of visit, and health care setting. The results indicate that 40.3 percent of the Tijuana population used health services exclusively in Mexico during a 6-month period, compared with only 2.5 percent who used services in the United States. Of the Mexican users of U.S. services, the largest proportion appeared to be older people, lawful permanent residents or citizens of the United States who are living in Mexico, and persons from high- or middle-income sectors. In addition to the low level of use of U.S. health services, the findings show that more than 84 percent of the visits were to providers in the private sector and, for 59 percent of the visits, a fee for services was implied. Overall, this border population does not seem to be a drain on the U.S. public health system.(ABSTRACT TRUNCATED AT 250 WORDS)     

Abortion surveillance--United States, 1997.

PROBLEM/CONDITION: In 1969, CDC began abortion surveillance to document the number and characteristics of women obtaining legal induced abortions, to monitor unintended pregnancy, and to assist efforts to identify and reduce preventable causes of morbidity and mortality associated with abortions. REPORTING PERIOD COVERED: This report summarizes and reviews information reported to CDC regarding legal induced abortions obtained in the United States in 1997. DESCRIPTION OF SYSTEM: For each year since 1969, CDC has compiled abortion data by state where the abortion occurred. The data are received from 52 reporting areas in the United States: 50 states, the District of Columbia, and New York City. RESULTS: In 1997, a total of 1,186,039 legal abortions were reported to CDC, representing a 3% decrease from the number reported for 1996. The abortion ratio was 306 legal induced abortions per 1,000 live births, and since 1995, the abortion rate has remained at 20 per 1,000 women aged 15-44 years. The availability of information about characteristics of women who obtained an abortion in 1997 varied by state and by the number of states reporting each characteristic. The total number of legal induced abortions by state is reported by state of residence and state of occurrence; characteristics of women obtaining abortions in 1997 are reported by state of occurrence. Women who were undergoing an abortion were more likely to be young (i.e., aged < 25 years), white, and unmarried; approximately one half were obtaining an abortion for the first time. More than one half of all abortions for which gestational age was reported (55%) were performed at < or = 8 weeks of gestation, and 88% were performed before 13 weeks. Overall, 18% of abortions were performed at the earliest weeks of gestation (< or = 6 weeks), 18% at 7 weeks of gestation, and 20% at 8 weeks of gestation. From 1992 through 1997, increases have occurred in the percentage of abortions performed at the very early weeks of gestation. Few abortions were provided after 15 weeks of gestation--4% of abortions were obtained at 16-20 weeks, and 1.4% were obtained at > or = 21 weeks. A total of 19 reporting areas submitted information regarding abortions performed by medical (nonsurgical) procedures, comprising < 1% of procedures reported by all states. Younger women (i.e., aged < or = 24 years) were more likely to obtain abortions later in pregnancy than were older women. INTERPRETATION: From 1990 through 1995, the number of abortions declined each year; in 1996, the number increased slightly, and in 1997, the number of abortions in the United States declined to it lowest level since 1978. PUBLIC HEALTH ACTIONS: The number and characteristics of women who obtain abortions in the United States should continue to be monitored so that trends in induced abortion can be assessed and efforts to prevent unintended pregnancy can be evaluated.     

Out-of-Pocket Costs and Insurance Coverage for Abortion in the United States

BackgroundSince 1976, federal Medicaid has excluded abortion care except in a small number of circumstances; 17 states provide this coverage using state Medicaid dollars. Since 2010, federal and state restrictions on insurance coverage for abortion have increased. This paper describes payment for abortion care before new restrictions among a sample of women receiving first and second trimester abortions.MethodsData are from the Turnaway Study, a study of women seeking abortion care at 30 facilities across the United States.FindingsTwo thirds received financial assistance, with those with pregnancies at later gestations more likely to receive assistance. Seven percent received funding from private insurance, 34% state Medicaid, and 29% other organizations. Median out-of-pocket costs when private insurance or Medicaid paid were $18 and $0. Median out-of-pocket cost for women for whom insurance or Medicaid did not pay was $575. For more than half, out-of-pocket costs were equivalent to more than one-third of monthly personal income; this was closer to two thirds among those receiving later abortions. One quarter who had private insurance had their abortion covered through insurance. Among women possibly eligible for Medicaid based on income and residence, more than one third received Medicaid coverage for the abortion. More than half reported cost as a reason for delay in obtaining an abortion. In a multivariate analysis, living in a state where Medicaid for abortion was available, having Medicaid or private insurance, being at a lower gestational age, and higher income were associated with lower odds of reporting cost as a reason for delay.ConclusionsOut-of-pocket costs for abortion care are substantial for many women, especially at later gestations. There are significant gaps in public and private insurance coverage for abortion.     

Social stigma and disclosure about induced abortion: results from an exploratory study

It is well recognised that unsafe abortions have significant implications for women's physical health; however, women's perceptions and experiences with abortion-related stigma and disclosure about abortion are not well understood. This paper examines the presence and intensity of abortion stigma in five countries, and seeks to understand how stigma is perceived and experienced by women who terminate an unintended pregnancy and influences her subsequent disclosure behaviours. The paper is based upon focus groups and semi-structured in-depth interviews conducted with women and men in Mexico, Nigeria, Pakistan, Peru and the United States (USA) in 2006. The stigma of abortion was perceived similarly in both legally liberal and restrictive settings although it was more evident in countries where abortion is highly restricted. Personal accounts of experienced stigma were limited, although participants cited numerous social consequences of having an abortion. Abortion-related stigma played an important role in disclosure of individual abortion behaviour.     

Women's experiences with legal abortion in Mexico City: a qualitative study

In April 2007, elective first-trimester abortion was legalized in Mexico City. As of June 2011, more than 60,000 women from Mexico City and other Mexican states have obtained legal abortions in the city's public hospitals and health centers, with private facilities providing additional abortion services. This study examines women's experiences of abortion services in one public and two private clinic settings in 2008. Twenty-five in-depth interviews were conducted: 15 with women who obtained abortions in a public health center and 10 who obtained the procedure at either of two private clinics. Participants were highly satisfied with services at both public and private sites, although some had to go to more than one site before receiving services. None expressed doubts about their decision to have an abortion, and they felt unanimously that they were treated with respect. Furthermore, participants were pleased with the counseling they received and most accepted a contraceptive method after the procedure.     

Resistance and vulnerability to stigmatization in abortion work

The stigma surrounding abortion in the United States commonly permeates the experience of both those seeking this health service as well as those engaged in its provision. Annually there are approximately 1.2 million abortions performed in the United States; despite that existing research shows that abortion services are highly utilized, women rarely disclose their use of these services. In 2005 only 1787 facilities that offer abortion services remained, a drop of almost 40 percent since 1982 (Jones, Zolna, Henshaw, & Finer, 2008). While it has been acknowledged that all professionals working in abortion are labeled to some degree as different, no published research has explored stigmatization as a process experienced by the range of individuals that comprise the abortion-providing workforce in the USA. Using qualitative data from a group of healthcare professionals doing abortion work in a Western state, this study begins to fill that gap, providing evidence of how the experience of stigma can vary and is managed within interactions in the workplace, in professional circles, among family and friends, and among strangers. The analysis shows that the experience of stigma for those providing abortion care is not a static or fixed loss of status. It is a dynamic situation in which those vulnerable to stigmatization can avoid, resist, or transform the stigma that would attach to them by varying degrees within selective contexts.     

How commonly do US abortion clinics offer contraceptive services?

Background

About half of US women having abortions have already had at least one prior abortion. Facilitating access to contraception may help these women avoid subsequent unintended pregnancies. Information is needed to document the availability of contraceptive services in abortion care settings in the United States.

Study Design

Data for this cross-sectional mixed-methods study were collected between December 2008 and September 2009 and come from two sources: 15 semistructured telephone interviews and 173 structured questionnaires administered to a nationally representative sample of eligible facilities. Respondents were administrators at large (400+ abortions per year), nonhospital facilities that provide abortion services in the United States.

Results

Virtually all (96%) abortion clinics incorporate contraceptive education into abortion care, and the three most common methods reported to be distributed are the birth control pill (99%), the vaginal ring (61%) and Depo-Provera (58%). Almost one-third reported being able to offer post-abortion intrauterine device insertion. Most facilities (82%) accept some form of insurance for either contraceptive or abortion services, and those with a broader family planning focus are significantly more likely to do so. Administrators at the majority of facilities (56%) report that patients most commonly do not pay additional fees for contraceptive services because they are included in the cost of abortion services.

Conclusion

Although almost all large, non-hospital abortion providers in the United States are able to provide some level of contraceptive care to their abortion patients, the degree to which they are able to do so is influenced by a wide range of factors.     

Abortion in the United States: incidence and access to services, 2005

CONTEXT: Accurate information about abortion incidence and services is necessary to monitor levels of unwanted pregnancy and women's ability to access abortion services. METHODS: All known abortion providers in the United States were contacted for information about abortion services in 2004 and 2005. This information, along with data from the U.S. Census Bureau, was used to examine national and state trends in numbers of abortions and abortion rates, proportions of counties and metropolitan areas without an abortion provider, and accessibility of abortion services. RESULTS: An estimated 1.2 million abortions were performed in the United States in 2005, 8% fewer than in 2000. The abortion rate in 2005 was 19.4 per 1,000 women aged 15-44; this rate represents a 9% decline from 2000. There were 1,787 abortion providers in 2005, only 2% fewer than in 2000. Some 87% of U.S. counties, containing 35% of women aged 15-44, did not have an abortion provider in 2005. Early medication abortion, offered by an estimated 57% of known providers, accounted for 13% of abortions (and for 22% of abortions before nine weeks' gestation). The average amount paid for an abortion at 10 weeks was $413-after adjustment for inflation, $11 less than in 2001. CONCLUSION: The numbers of abortions and the abortion rate continued their long-term decline through 2005. Reasons for this trend are unknown but may include improved access to and use of contraceptives or decreased access to abortion services.     

Differences in energy, nutrient, and food intakes in a US sample of Mexican-American women and men: findings from the Third National Health and Nutrition Examination Survey, 1988-1994

As Mexican-American women and men migrate to the United States and/or become more acculturated, their diets may become less healthy, increasing their risk of cardiovascular disease. Data from the Third National Health and Nutrition Examination Survey (1988-1994) were used to compare whether energy, nutrient, and food intakes differed among three groups of Mexican-American women (n = 1,449) and men (n = 1,404) aged 25-64 years: those born in Mexico, those born in the United States whose primary language was Spanish, and those born in the United States whose primary language was English. Percentages of persons who met the national dietary guidelines for fat, fiber, and potassium and the recommended intakes of vitamins and minerals associated with cardiovascular disease were also compared. In general, Mexican Americans born in Mexico consumed significantly less fat and significantly more fiber; vitamins A, C, E, and B6; and folate, calcium, potassium, and magnesium than did those born in the United States, regardless of language spoken. More women and men born in Mexico met the dietary guidelines or recommended nutrient intakes than those born in the United States. The heart-healthy diets of women and men born in Mexico should be encouraged among all Mexican Americans living in the United States, especially given the increasing levels of obesity and diabetes among this rapidly growing group of Americans.