The Effect of Abortion Reform on Fertility and Mortality: Evidence from Mexico

56 Pages·2016·0.69 MB·English

The Effect of Abortion Reform on Fertility and Mortality:
Evidence from Mexico
Preliminary
Damian Clarke1 and Hanna Mu¨hlrad2
2University of Gothenburg , [email protected]
1University of Oxford , [email protected]
January 31, 2016
Abstract
We examine the effect of a large-scale, elective, free abortion program implemented
in Mexico City in 2007. Prior to this program, all states and districts in Mexico had
very limited (or no) access to elective abortion. A localized reform to Mexico City
resulted in a sharp increase in the request and use of early term elective abortions:
approximately 90,000 abortions were administered by public health providers in the
4 years following the reform. Difference-in-difference estimates of the effect on the
reform suggest that this program resulted in a reduction in births by 2.2 to 3.8 %,
and a sharp fall in the rate of maternal deaths, by 11.8 to 23.1 %. In this study we
provide evidence using national vital statistics from Mexico suggesting that access to
legal and safe abortion procedures result in decreased fertility and potentially lower
rates of maternal mortality.
Keywords: Fertility, Maternal Mortality, Legalizing Abortion, Mexico
JEL Codes: I15, I18, O15.
1
1 Introduction
In 2007, Mexico City passed a groundbreaking law legalizing elective abortion during the
firsttrimester. AbortionlawsaredeterminedatstatelevelintheUnitedStatesofMexico,
where Mexico City (the federal district of Mexico) has its own legislative assembly. This
reformprovidedallwomenwhoresideinMexicoCitywithaccesstolegalandsafeabortion
procedures free of charge during the first trimester for all reasons. The law was a radical
change to previous legislation in Mexico City and to the rest of the states of Mexico where
abortionisbannedinallbutextremecircumstancesofrape, tosavethemother’slife, orin
cases of fetal malformation. Moreover, by legalizing abortion, Mexico City distinguishes
itself from nearly all countries in Latin America and the Caribbean which remain highly
restrictive towards elective abortion.1
Whenlookingatregionaldifferencesinabortions,theLatinAmericaandtheCaribbean
(LAC) region stands out as the region with the highest estimated number of unsafe abor-
tions2 in the world with 31 abortions per 1,000 women in fertile ages 15-44 compared to
the worldwide rate of 14 per 1,000. The high number of unsafe abortions in the LAC
region corresponds to an estimated 4.2 million unsafe induced abortions each year. It is
further estimated that these procedures account for 12 % of all maternal deaths in the
LACregion(WHO2011). Legalrestrictionsandlowaccessibilitytocontraceptivesarethe
main causes of unsafe abortions, implying that legalizing elective abortion could serve as
aneffectivemeasureforreducingunwantedbirthsandmaternalmortality(seeforinstance
Grimes et al. (2006)).
The estimated incidence of induced abortions is not lower in countries with more
restrictive abortion laws. For instance, the estimated number of induced abortions in
Latin America is 32 abortions per 1,000 while the abortion rate in Western Europe, where
abortionishighlyavailable,is12abortionsper1,000women(Sedghetal.2012). Moreover,
in countries with legal barriers and other obstacles to accessing induced abortions, women
1AccordingtothemostrecentUnitedNationsfigures(?),MexicoisoneofonlythreecountriesinLAC
(alongwithUruguayandGuyana)tobeclassedasthe“Leastrestrictive”inabortionpolicy,implyingthat
abortions are permitted for economic or social reasons on request.
2WHO defines unsafe abortion as ”a procedure for terminating an unintended pregnancy carried out
either by persons lacking the necessary skills or in an environment that does not conform to minimal
medical standards, or both”
2
with an unwanted pregnancies are faced with options such as self-evoked abortions or
taking illegal assistance from medical workers or traditional care givers. While induced
abortion in safe and legal settings are described as one of the safest medical procedures
in medicine 3, abortions is under illegal settings is associated with a radically higher risk
of mortality and morbidity with an estimated worldwide mortality rate of 365 deaths
per 100,000 procedures. Maternal deaths originating from unsafe abortion procedures are
mainly caused by hemorrhage, infection, sepsis, trauma to the genital area, and severe
damage to the intestines. The predominant majority of unsafe abortions take place in
developing countries (98 %), where the estimated proportion of unsafe abortion of total
abortions are 56 % compared to only 6 % in developed countries (WHO 2011).
Within the economic literature, evidence has been found of decreased fertility and
improved later life conditions for cohorts born after abortion legalization. These studies
suggest that access to legal abortion increase the opportunity for optimal childbearing (in
terms of optimal timing as well as preferred number of children), providing cohorts born
after abortion legalization with improved educational attainment, decreased criminality
and reduced child morbidity and mortality (Ananat et al. 2009; Charles & Stephen 2002;
Donohue & Levitt 2001;John J. Donohue & Levitt 2004; Gruber et al. 1997; Pop-Eleches
2006). Legalizingabortionhasalsobeenshowntoreducefertilitywhichimproveswomen’s
labor market outcomes Angrist & Evans (1996) as well as increasing women’s choice set
and household bargaining power, and consequently empowering women (Oreffice 2003).
This study contributes to the existing literature by providing evidence of a causal
relationship between access to legal and safe abortion and unintended pregnancies and
maternal mortality in a developing country using vital statistics. To the best of our
knowledge this is the first study to evaluate the overall effect on fertility and maternal
mortality from the 2007 abortion reform using the full set of available vital statistics
of fertility and mortality for the period 2002-2011. Despite increasing attention being
paid to rates of morbidity and mortality following unsafe abortion procedures (Grimes
et al. 2006, Brown 2007, Kulczycki 2011), adequately measuring the impact of access (or
lack thereof) to safe abortion is often hindered by poor and incomplete vital registration
systems, and a paucity of appropriate (quasi-)experimental variation in access to safe
3Forinstance,indevelopedcountries,themortalityratefromlegalabortionproceduresarelessthan1
per 100,000 abortion procedures (Grimes et al. 2006).
3
abortion (Grimes et al. 2006). Moreover, many previous studies examine the effect from
abortion legalization which took place in conjunction with other major reforms regarding
access to contraceptives. In contrast to those contexts, free access to contraception has
been provided by the government since 1974 in Mexico4. This study further contributes
to the existing literature by studying abortion legalization in a setting where the right
to contraception enjoys constitutional protection and in the absence of contemporaneous
radical societal changes in terms of sexual and reproductive health rights.
By using the 2007 abortion reform in Mexico City, we study the effect of free access
to legal and safe abortion services on fertility outcomes and maternal mortality. This
analysis is carried out using Mexican censal data from National Institute of Statistics and
Geography (INEGI) on all registered births and maternal deaths during 2002-2011. We
use a quasi-experimental set up to take advantage of state-level variation provided by
the abortion reform, employing a difference in difference design to determine the reform’s
effect.
The results indicate that providing access to safe and legal abortions free of charge
resulted in a decrease in fertility by 2.2 to 3.8 % and a reduction in maternal mortality by
11.8 to 23.1 % among women aged 15-44. Our results show that there are heterogeneous
effects across ages. The reduction in fertility and maternal mortality is highest among
teenage women (15-19), for which our results suggest a 7.1 % decrease in number of
births and 57.2 % decrease in the number of maternal deaths. This is in line with higher
risks of maternal mortality among young mothers. Moreover, we further investigate the
potential changes in the composition of mothers. The findings show that conditional
on motherhood, the probability of teenage births decrease by 5.0 %, the probability of
having a first birth increases (compared to higher order births) and that the average age
by parity (birth order) increases. These results are robust to alternative specifications,
although somewhat sensitive to using number of births or log number of births as the
dependent variable. Furthermore, we examine the parallel trend assumption and show
supporting findings in favor of common trends in births but weaker support for maternal
mortality,whichisperhapsunsurprisinggiventherelativeinfrequencyoftheseevents,and
resultingperiod-by-periodvariation. Ourresultssuggestthatlegalizingelectiveabortionis
4Contraceptivesweremadeavailablebythesocalled”General Population Law”, passedin1974(Gire,
2009).
4
potentially important for preventing unwanted pregnancies and maternal mortality. This
result is highly relevant when considering the achievement of international development
goals, including the Millennium and Sustainable Development Goals (MDGs and SDGs).
This paper is structured in the following way. Section 2 presents a description of the
reform followed by a literature review. In sections 3-5, the data and empirical strategy
are described followed by Section 5 in which the results are presented. In Section 6 the
findings are discussed, concluding the study.
2 Background
2.1 The Reform and context
Eventhough67%ofallwomeninMexicousemoderncontraceptivemethods(and5%uses
traditionalandlesssafemethods),itisestimatedthatmorethanhalfofallpregnanciesare
unintended. As a result, 54 % of these pregnancies are terminated (Juarez et al. 2013). In
1975 the so called General Population Law was passed, which meant that the government
had to supply family planning services, providing contraceptives, via the public health
care sector free of charge. This law strongly attributed to the sharp decrease of roughly 6
children per women in 1975 to nearly 2 in 2009 (Juarez et al. 2013).
There are 32 federal entities in Mexico, consisting of 31 federal states and one federal
district. Abortion laws in Mexico are determined at state level where Mexico City, the
administrative capital and federal district of Mexico (here after referred to as state) has
it’s own legislative power, similarly to the US, with the ability to regulate the abortion
laws. Mexico City contains approximately 8 % (8.9 million) of the entire population and
is the only state that allows for elective abortion during the first trimester. In Figure 4, a
map of Mexico is presented.
Considering the highly conservative abortion legislation in the entire Latin American
and Caribbean (LAC) region, the abortion reform in Mexico City is distinguishable as
a major social and political reform. Abortions are a criminal offense in many Mexican
5
states, where women suffering from miscarriages are at risk of being prosecuted and sen-
tenced to jail for not protecting their fetus. Before the reform was passed in Mexico City,
abortion laws were rather uniform across the states of Mexico. Abortion was illegal with
the exception of pregnancies resulting from rape, or pregnancies that pose a threat to the
mother’s life and for some states, in case of severe malformation. In practice however,
legal abortions have been described by human rights organizations as extremely difficult
to access due to rigid legal barriers even for women who do meet the prerequisite for
accessing legal abortion. Legal barriers that cause protracted processes, usually involving
multiple governmental entities to review the decision, in addition to social stigma explains
the low number of legal abortions prior the reform. For example, in the densely populated
Mexico City, only 62 abortions were legally performed during 2001-2007 due to these cir-
cumstances, (Becker 2013). As a substitute to legal options, abortions were performed
under clandestine and not unusually unsafe settings. In 2009 alone, records from public
hospitals show that an estimated 159 000 women were treated for abortion-related com-
plications. Moreover, the estimated national abortion rate in Mexico is 38 abortions per
1000womenintheages15-44(Juarezetal.2013), whichisconsideredhighinternationally
(Becker 2013).
Duetothehighnumberofunsafeabortionsaswellasagrowingmovementforwomen’s
reproductivehealthrights5, thelegislativeassemblyoftheFederalDistrictofMexicoCity
(Mexico DF) voted to legalize elective abortion (termed legal interruption of pregnancy)
on April 26, 2007, reforming article 144 of the penal code of Mexico DF. This immediately
permitted women with residency in the Federal District to request legal interruption of
pregnancy up to 12 weeks of gestation free of charge in a selected number of public health
clinics (Contreras et al. 2011). On August 29 in 2008 this decision was ratified by the
Supreme Court of Mexico. The reform makes Mexico City, together with Cuba and
Uruguay, the most liberal jurisdiction in terms of abortion legislation in Latin America
(Fraser 2015).
The reform implied that elective abortion was made available through both the public
and private sector. The public health care sector in Mexico is divided at both federal
and state level, where the Ministry of Health (MOH) in Mexico City provides abortion
5For a broader discussion on how the reform came about see Kulczycki (2011).
6
procedures at a selected number of MOH-DF hospitals. Other MOH facilities (federal
or state funded) are not legally required to provide abortion procedures. The MOH-DF
offers abortion procedures free of charge for all residents of Mexico City over 18 years. For
women under the age of 18, permission from a parent or guardian is needed. According
to a qualitative study by Tatum et al (2012), parental consent may have a significant
impact on the decision making and outcome. The consequences from parental consent
on access to abortions are not straight forward. Parental involvement can lead to women
being refrained from access abortion or forced to undergo an abortion. Moreover, parental
consentmaybelessstrictattheprivateclinics. WhilethePublicHospitalsrequireparental
consent, only one out of three of the abortion providers in private health clinics required
parental consent (Schiavon et al. 2010).
Women with residency outside Mexico City can also access the reform but are charged
with a sliding fee scale determined with regard to the woman’s socioeconomic background
(Mondrag´on y Kalb et al. 2011). In 2008, 73 % of all women who received an abortion
through the public health care were women living in Mexico City, 24 % were living in the
state of Mexico (which shares a border with Mexico City) and 3 % were living in other
states.
Approximately 90,000 abortions were carried out during 2007-2012 at the MOH-DF
facilities. However, this only accounts for the procedures performed at the public sector
MOH-DF facilities and not the private sector. The MOH-DF program offers both surgical
and medical abortion procedures and is the main provider of medical abortion. Medical
abortion is considered the most innovative discovery in reproductive health since the in-
vention of the oral contraceptives (the pill) and is the safest and most effective method
available. A medical abortion is a non-invasive procedure that causes contractions of the
womb terminating the pregnancy. Medical abortion procedures constitutes 66 % of all
abortion procedures in the MOH-DF program where Misoprostol (sometimes referred to
asCytotec,Arthrotec,Oxaprost,Cyprostol,Mibetec,ProstokosorMisotrol)wasthemain
regimen until 20116 (Winikoff & Sheldon 2012).
The reform also includes free post-abortion contraceptives, that is women who have
6In 2011, Mifepristone was introduced.
7
had an abortion will also get family planning counseling and free contraceptives.7 Records
from public hospitals show that the demand for post-abortion contraceptives is high and
that approximately 82 % of all women accept contraceptives. This high number explains
the low prevalence of repeated abortion procedures (Becker 2013).
2.2 Related Literature
2.2.1 Fertility
There is a growing body of literature regarding reproductive health policies within eco-
nomics. Abortionpolicyisatopicthathasgainedgroundduringrecentdecades,providing
evidence of both short and long term consequences from abortion legalization and decrim-
inalization. Within economics, there are a few proposed theoretical frameworks analyz-
ing abortion policies8 and multiple empirical studies usually based on quasi-experimental
methods.
From a theoretical point of view (see for instance Levine & Staiger (2004) and Ananat
et al. (2009)), fertility decisions can be viewed as sequential choices of first becoming preg-
nant and then whether or not to give birth. Access to legal and safe abortion procedures
decreases the “cost” of interrupting a pregnancy. This may imply two different effects
on fertility decisions. First, better access to abortion reduces the probability of birth ex
post becoming pregnant. Second, improved access to abortion can alter ex ante behavior
and thus positively affect the number pregnancies since opting out from pregnancy is less
costly. However, due to lack of data on abortions prior to legalization of abortion, most
studies analyze the effect on overall fertility while fewer study behavioral responses.
Indeed, there are several studies with empirical evidence showing that abortion legal-
ization has a negative effect on birth rates. One of the most studied abortion policies,
is the US Supreme Court decision in the 1970s (Roe v Wade) legalizing elective abortion
7However, it should be noted the Ministry of Health (MOH) already offers free contraceptives, which
isprotectedintheconstitutionsincetheGeneralPopulationLawwaspassedin1974(Juarezetal.2013).
8see for instance Akerlof et al. (1996), Levine & Staiger (2004) and Ananat et al. (2009)
8
in all states 9. As a result from legalizing elective abortion, fertility decreased by 5 %
with a particularly strong effect on teenage fertility with a decline of 12 % (Levine 2004).
Likewise, a negative impact on fertility has also been found in former Soviet countries in
Eastern Europe (Levine 2004). Among these studies are, Pop-Eleches (2006) who studies
the 1966 Romanian ban on abortion during the rule of the communist dictator Ceaus-
escu. The results show a radical increase in the total fertility rate (from 1.9 in 1966 to
3.7 children the year after). In contrast to the evidence from the US reform, women most
inclined to access abortions before the ban were women with high socio economic status.
Analogous to previous findings, a large decrease in fertility by 8 % was found in Nepal
when legalizing abortion(Valente 2010).10
A few studies have found evidence of behavioral responses (see Levine and Staiger
(2004) for a review). These studies are mostly based on minor US policy reforms restrict-
ing access to abortion by reducing Medicaid funding and introducing parental consent
laws. Although, studies on the restriction of Medicaid funding provide evidence on behav-
ioral response, the evidence from studies regarding the parental consent laws is less clear.
Moreover, some of these studies have encountered criticism for not paying attention to
other policies and circumstances important for identification (Guldi, 2008) and (Coleman
Guttmacher Institute). Evidenceoutside theUS, isprovided by Levineand Staiger(2004)
showthatbehavioralresponsesarefoundwhenanalyzingpregnancies, abortionsandbirth
rates in Eastern Europe. However, one concern with this study on behavioral responses
is the issue of not being able to account for illegal abortions other than showing that
maternal mortality is constant. It is possible that maternal mortality is a less accurate
indicator of illegal abortions in developed countries.
StudiesontheimpactofabortionlegalizationonfertilityoutcomesinMexicoCityare,
to the best of our knowledge, scarce for the exception of a study by Gutierrez-Vazquez
9see for instance Ananat et al. (2009), Angrist & Evans (1996), Donohue & Levitt (2001), Charles &
Stephen (2002)
10In addition to short run effects, several papers examine the long run effect of abortion policies. From
the US abortion policy, improved health and labor market outcomes have been found for the second
generation. Forinstance,studiesshowimprovedoutcomesintermsoflowerchildmorbidityandmortality
(Gruberetal.1997),sharpdeclineincriminality(Donohue&Levitt2001),moreschoolingandlesswelfare
recipients (Ananat et al. 2009) and reduced risk of substance abuse amongst adults (Charles & Stephen
2002). Similar results are found in Romania for the second generation. When controlling for various
background covariates, infant mortality as well as later in life outcomes are worse for children born after
the ban compared to those born prior (Pop-Eleches 2006) and (Mitrut & Wolff 2010).
9
& Parrado (2015). In this study, national vital statistics are used to examine the ef-
fect on fertility across ages. However, only a small amount of data is used comparing
outcomes between three different years (1990, 2000 and 2010). Particularly, their ”double-
difference” coefficient is a simple comparison between 1990-2000 and 2000-2010, which is
not a consistent way of using a difference in difference method11, especially because the
treatment group in not correctly specified when using the entire period 2000-2010 as the
post treatment period while the reform took place in 2007.
2.2.2 Maternal mortality
Studies on maternal mortality are most common in the public health and medical liter-
ature, but also some studies within economics relating to this paper. For instance, Jay-
achandran & Lleras-Muney (2008) show a positive relationship between reduced maternal
mortality and human capital investment amongst women in Sri Lanka and Jayachandran
et al. (2009) provide evidence of decreased mortality after introducing the sulfa drug in
the US.
There are multiple studies within the public health literature arguing that low acces-
sibility to legal abortion causes higher incidence of maternal death and poorer maternal
health outcomes. Amongst them are Singh & Ratnam (2015). By using data on abortion-
related hospitalizations from sex Latin American countries, an estimated 800 000 hospi-
talizations occur annually in Latin America, as consequences following unsafe abortions.
A study by Grimes et al. (2006) uses a cross-country comparison approach examining the
relationship between legal status of abortion and maternal health. They conclude that
unsafe abortion is mostly common in countries where abortion is heavily restricted or
illegal. They further show that morbidity and mortality related to complications from
unsafe procedures are more predominant in places without legal access to abortion. Ad-
ditionally, they emphasize that legal restrictions of abortion contribute to a substantial
economic burden for the health care system, mis-allocating resources from other vital
health care programs. Legal restrictions also generate indirect costs for society such as
children growing up without mothers and deteriorating early childhood investments.
11See for instance Wooldridge 2010.
10