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Introduction: In 2017, Chile decriminalized abortion on three grounds: (i) if the pregnant person's life is at risk, (ii) fetal nonviability, and (iii) rape or incest. This multicase study explores the experiences of pregnant people legally entitled to but denied access to legal abortion in Chile. Methods: Through a snowball sampling approach, we recruited adult Chilean residents who sought, were eligible for, and were denied a legal abortion after September 2017. We conducted semistructured interviews with participants to explore their experiences in seeking and being denied legal abortions. We recorded and transcribed the interviews, then coded and analyzed the transcriptions to identify common themes. Results: We identified four women who met the eligibility criteria. The interviews revealed five common themes in their experiences: (i) disparate levels of social support in accessing abortion, (ii) abundant access barriers, (iii) forced pregnancy, (iv) abortion stigma, and (v) a failure of the law to provide access to abortion. Discussion and Health Equity Implications: Although the 2017 law expanded legal access to abortion in Chile, significant barriers remain. Compounded with social stigma, and the socioeconomic disparities in abortion access, pregnant people continue to face insurmountable obstacles in obtaining legal abortions, even when their lives are at risk and the pregnancy is not viable. The state must prioritize equity of access to legal abortions. Future studies should continue to explore the challenges people face accessing legal abortion care to inform strategies to ensure people are able to obtain the quality care that they are legally entitled to.
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The disruption caused by the COVID-19 pandemic on health services around the world boosted interest over telehealth models of care. In Brazil, where abortion is heavily restricted, abortion seekers have long relied on international telehealth services to access abortion pills. We conducted a cross-sectional multilevel study to assess the effect of individual and contextual social factors on utilization of one such service. For the individual-level, we analyzed data from the records of abortion seekers contacting this feminist international telehealth organization during 2019 (n = 25,920). Individual-level variables were age, race, education level and pregnancy length. Contextual-level units were states, for which we used data from the national Demographic Census and Household Surveys. Contextual-level variables were household income per capita, adjusted net school attendance rate, percentage of racialized women and income Gini Index. We fitted five multilevel Poisson Mixed-effects models with robust variance to estimate prevalence ratios (PR) of service utilization, which was defined as receiving abortion pills through the service. We found that only 8.2% of requesters got abortion pills through the service. Utilization was higher among women who were older, white, more educated and 5-8-weeks pregnant. Independently of this, service utilization was higher in states with higher income and education access, with lower proportions of racialized women, and located in the South, Southeast and Central-West regions. We concluded that while feminist telehealth abortion initiatives provide a life-saving service for some abortion seekers, they are not fully equipped to overcome entrenched social inequalities in their utilization, both at individual and contextual levels.
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OBJECTIVE: A recent publication [Koch E, Chireau M, Pliego F, Stanford J, Haddad S, Calhoun B, Aracena P, Bravo M, Gatica S, Thorp J. Abortion legislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: a natural experiment in 32 Mexican states. BMJ Open 2015;5(2):e006013] claimed that Mexican states with more restrictive abortion laws had lower levels of maternal mortality. Our objectives are to replicate the analysis, reanalyze the data and offer a critique of the key flaws of the Koch study. STUDY DESIGN: We used corrected maternal mortality data (2006-2013), live births, and state-level indicators of poverty. We replicate the published analysis. We then reclassified state-level exposure to abortion on demand based on actual availability of abortion (Mexico City versus the other 31 states) and test the association of abortion access and the maternal mortality ratio (MMR) using descriptives over time, pooled chi-square tests and regression models. We included 256 state-year observations. RESULTS: We did not find significant differences in MMR between Mexico City (MMR=49.1) and the 31 states (MMR=44.6; p=.44). Using Koch's classification of states, we replicated published differences of higher MMR where abortion is more available. We found a significant, negative association between MMR and availability of abortion in the same multivariable models as Koch, but using our state classification (beta=-22.49, 95% CI=-38.9; -5.99). State-level poverty remains highly correlated with MMR. CONCLUSION: Koch makes errors in methodology and interpretation, making false causal claims about abortion law and MMR. MMR is falling most rapidly in Mexico City, but our main study limitation is an inability to draw causal inference about abortion law or access and maternal mortality. We need rigorous evidence about the health impacts of increasing access to safe abortion worldwide. IMPLICATIONS: Transparency and integrity in research is crucial, as well as perhaps even more in politically contested topics such as abortion. Rigorous evidence about the health impacts of increasing access to safe abortion worldwide is needed.