10.5061/DRYAD.D6B23
Koch, Elard
MELISA Institute
Chireau, Monique
Duke University
Pliego, Fernando
National Autonomous University of Mexico
Stanford, Joseph
University of Utah
Haddad, Sebastián
Calhoun, Byron
West Virginia University
Aracena, Paula
MELISA Institute
Bravo, Miguel
MELISA Institute
Gatica, Sebastián
Universidad Anáhuac
Thorp, John
University of North Carolina
Data from: Abortion legislation, maternal healthcare, fertility, female
literacy, sanitation, violence against women, and maternal deaths: a
natural experiment in 32 Mexican states
Dryad
dataset
2014
gynaecology
Maternal medicine
Obstetrics
2014-12-09T15:41:30Z
2014-12-09T15:41:30Z
en
https://doi.org/10.1136/bmjopen-2014-006013
16181980 bytes
2
CC0 1.0 Universal (CC0 1.0) Public Domain Dedication
Objective: To test whether there is an association between abortion
legislation and maternal mortality outcomes after controlling for other
factors thought to influence maternal health. Design: Population-based
natural experiment. Setting and data sources: Official maternal mortality
data from 32 federal states of Mexico between 2002 and 2011. Main
outcomes: Maternal mortality ratio (MMR), MMR with any abortive outcome
(MMRAO) and induced abortion mortality ratio (iAMR). Independent
variables: Abortion legislation grouped as less (n=18) or more permissive
(n=14); constitutional amendment protecting the unborn (n=17); skilled
attendance at birth; all-abortion hospitalisation ratio; low birth weight
rate; contraceptive use; total fertility rates (TFR); clean water;
sanitation; female literacy rate and intimate-partner violence. Main
results: Over the 10-year period, states with less permissive abortion
legislation exhibited lower MMR (38.3 vs 49.6; p<0.001), MMRAO (2.7
vs 3.7; p<0.001) and iAMR (0.9 vs 1.7; p<0.001) than more
permissive states. Multivariate regression models estimating effect sizes
(β-coefficients) for mortality outcomes showed independent associations (p
values between 0.001 and 0.055) with female literacy (β=−0.061 to −1.100),
skilled attendance at birth (β=−0.032 to −0.427), low birth weight
(β=0.149 to 2.166), all-abortion hospitalisation ratio (β=−0.566 to
−0.962), clean water (β=−0.048 to −0.730), sanitation (β=−0.052 to −0.758)
and intimate-partner violence (β=0.085 to 0.755). TFR showed an inverse
association with MMR (β=−14.329) and MMRAO (β=−1.750) and a direct
association with iAMR (β=1.383). Altogether, these factors accounted for
(R2) 51–88% of the variance among states in overall mortality rates. No
statistically independent effect was observed for abortion legislation,
constitutional amendment or other covariates. Conclusions: Although less
permissive states exhibited consistently lower maternal mortality rates,
this finding was not explained by abortion legislation itself. Rather,
these differences were explained by other independent factors, which
appeared to have a more favourable distribution in these states.
Table 1Current abortion legislations based on criminal exemptions from
prosecution of abortion in 32 Mexican states exhibiting a more (m) or less
(l) permissive abortion legislation.Table1.xlsTable 2Average change per
year in different maternal mortality outcomes by place of residence and
occurrence in groups of Mexican states with more or less permissive
abortion legislation and the entire country (2002-2011) based on
Autoregressive Integrated Moving Average (ARIMA) models.Table2.xlsTable
3Comparative analysis of average mortality outcomes by residence and
occurrence for groups of Mexican states exhibiting a more or less
permissive abortion legislation, 2002-2011.Table3.xlsTable 4Comparative
analysis of average mortality outcomes by residence and occurrence for
groups of states with or without constitutional amendment protecting the
unborn from conception, 2008-2011.Table4.xlsTable 5Independent variables
in each Mexican state: frequencies and analyses of normal
distribution.Table5.xlsTable 6Univariate associations between 10
independent variables and maternal mortality outcomes for 32 Mexican
states, 2002-2011.Table6.xlsTable 7Explanatory models for trends on
maternal mortality ratio (MMR), maternal mortality ratio with an abortive
outcome (MMRAO), and induced abortion mortality ratio (iAMR) in 32 Mexican
states after refinement, 2002-2011.Table7.xlsTable 8Alternative
explanatory regression models for MMR, MMRAO and iAMR after refinement
considering independent variables excluded from the explanatory models
because of collinearity.Table8.xlsTable 9Comparison of different
indicators of maternal healthcare and human development between groups of
states with less and more permissive abortion legislation.Table9.xlsBox
1Evidence-based public health interventions to improve maternal health in
Mexico.Box1.xlsTable S1Detailed description of independent variables
considered in the natural experiment of 32 Mexican states on maternal
mortality outcomes.TableS1.xlsTable S2Observed live births by place of
residence in 32 Mexican states exhibiting a more (m) or less (l)
permissive abortion legislation, 2002-2011.TableS2.xlsTable S3Observed
live births by place of occurrence in 32 Mexican states exhibiting a more
(m) or less (l) permissive abortion legislation,
2002-2011.TableS3.xlsTable S4Total maternal deaths by place of residence
in 32 Mexican states exhibiting a more (m) or less (l) permissive abortion
legislation, 2002-2011.TableS4.xlsTable S5Maternal deaths with abortive
outcome by place of residence in 32 Mexican states exhibiting a more (m)
or less (l) permissive abortion legislation, 2002-2011.TableS5.xlsTable
S6Induced abortion-related deaths by place of residence in 32 Mexican
states exhibiting a more (m) or less (l) permissive abortion legislation,
2002-2011.TableS6.xlsTable S7Total maternal deaths by place of occurrence
in 32 Mexican states exhibiting a more (m) or less (l) permissive abortion
legislation, 2002-2011.TableS7.xlsTable S8Maternal deaths with abortive
outcome by place of occurrence in 32 Mexican states exhibiting a more (m)
or less (l) permissive abortion legislation, 2002-2011.TableS8.xlsTable
S9Induced abortion-related deaths by place of occurrence in 32 Mexican
states exhibiting a more (m) or less (l) permissive abortion legislation,
2002-2011.TableS9.xlsTable S10Maternal mortality ratio (MMR) by place of
residence in 32 Mexican states exhibiting a more (m) or less (l)
permissive abortion legislation, 2002-2011.TableS10.xlsTable S11Maternal
mortality ratio with abortive outcome (MMRAO) by place of residence in 32
Mexican states exhibiting a more (m) or less (l) permissive abortion
legislation, 2002-2011.TableS11.xlsTable S12Induced abortion mortality
ratio (iAMR) by place of residence in 32 Mexican states exhibiting a more
(m) or less (l) permissive abortion legislation,
2002-2011.TableS12.xlsTable S13Maternal mortality ratio (MMR) by place of
occurrence in 32 Mexican states exhibiting a more (m) or less (l)
permissive abortion legislation, 2002-2011.TableS13.xlsTable S14Maternal
mortality ratio with abortive outcome (MMRAO) by place of occurrence in 32
Mexican states exhibiting a more (m) or less (l) permissive abortion
legislation, 2002-2011.TableS14.xlsTable S15Induced abortion mortality
ratio (iAMR) by place of occurrence in 32 Mexican states exhibiting a more
(m) or less (l) permissive abortion legislation,
2002-2011.TableS15.xlsTable S16Explanatory models for trends on maternal
mortality ratio (MMR), maternal mortality ratio with an abortive outcome
(MMRAO), and induced abortion mortality ratio (iAMR) in 32 Mexican states
before refinement, 2002-2011.TableS16.xlsFigure 1Mortality ratios and the
proportion of abortion-related deaths by place of residence in states with
less and more permissive abortion legislation. Left panels illustrate
trends in MMR (top panel), MMRAO (middle top panel), iAMR (middle bottom
panel), and the proportion of abortion-related deaths (bottom panel) by
place of residence between 2002 and 2011 in Mexican states, grouped as
with less permissive (in dark green) or more permissive (in cyan) in terms
of abortion legislation in their criminal code (see Material and Methods).
For comparison, trends for the whole Mexican country (all states) are
depicted as dotted lines. Right panels show average ratios and proportion
of abortion-related deaths for each group (dark green and cyan bars,
respectively), and the whole Mexican country (hollow bars). *
p<0.05 using Z-test. Abbreviations: iAMR, induced abortion
mortality ratio; MMR, maternal mortality ratio; MMRAO, maternal mortality
ratio with an abortive outcome.Figure 2Mortality ratios and the proportion
of abortion-related deaths by place of occurrence in states with less and
more permissive abortion legislation. Left panels illustrate trends in MMR
(top panel), MMRAO (middle top panel), iAMR (middle bottom panel), and the
proportion of abortion-related deaths (bottom panel) by place of
occurrence between 2002 and 2011 in Mexican states, grouped as with less
permissive (in dark green) or more permissive (in cyan) in terms of
abortion legislation in their criminal code (see Material and Methods).
For comparison, trends for the whole Mexican country (all states) are
depicted as dotted lines. Right panels show average ratios and proportion
of abortion-related deaths for each group (dark green and cyan bars,
respectively), and the whole Mexican country (hollow bars). *
p<0.05 using Z-test. Abbreviations: iAMR, induced abortion
mortality ratio; MMR, maternal mortality ratio; MMRAO, maternal mortality
ratio with abortive outcome.Figure 3Average mortality ratios in states
with more or less permissive abortion legislation between 2002 and 2011.
Political maps of Mexican states are shown for average MMR (top panel) and
average iAMR (bottom panel) for the 2002-2011 period, indicating whether
they exhibit less (orange dots) or more (yellow dots) permissive abortion
legislation, in terms of abortion legislation in their criminal code (see
Material and Methods). Increasing blue colour indicates an increase in MMR
or iAMR, on a quintile scale (see legend of each panel). Abbreviations:
Ag., Aguascalientes; Co., Colima; FD., Federal District; iAMR, induced
abortion mortality ratio; MMR, maternal mortality ratio; Mo., Morelos;
Tl., Tlaxcala.Figure 4Mortality ratios and the proportion of
abortion-related deaths by place of residence in states with or without a
constitutional amendment to protect the unborn starting at conception.
Left panels illustrate trends for MMR (top panel), MMRAO (middle top
panel), iAMR (middle bottom panel), and the proportion of abortion-related
deaths (bottom panel) by place of residence between 2008 and 2011 in
Mexican states, grouped as with amendment (in dark green) or without
amendment (in cyan) in terms of abortion legislation in their criminal
code (see Material and Methods). Right panels show average ratios and
proportion of abortion-related deaths for each group (dark green and cyan
bars, respectively). * p<0.05 using Z-test. Abbreviations: iAMR,
induced abortion mortality ratio; MMR, maternal mortality ratio; MMRAO,
maternal mortality ratio with abortive outcome.Figure 5Mortality ratios
and the proportion of abortion-related deaths by place of occurrence in
states with or without a constitutional amendment to protect the unborn
starting at conception. Left panels illustrate trends for MMR (top panel),
MMRAO (middle top panel), iAMR (middle bottom panel), and the proportion
of abortion-related deaths (bottom panel) by place of occurrence between
2008 and 2011 in Mexican states, grouped as with amendment (in dark green)
or without amendment (in cyan) in terms of exhibiting or not a
constitutional amendment to protect the unborn starting at conception
(Figure S1, Supplementary Material). Right panels show average ratios and
proportion of abortion-related deaths for each group (dark green and cyan
bars, respectively). * p<0.05 using Z-test. Abbreviations: iAMR,
induced abortion mortality ratio; MMR, maternal mortality ratio; MMRAO,
maternal mortality ratio with abortive outcome.Figure 6Mortality ratios
and the proportion of abortion-related deaths by place of residence in
states with or without a constitutional amendment to protect the unborn
starting at conception: focus on the Federal District. Left panels
illustrate trends for MMR (top panel), MMRAO (middle top panel), iAMR
(middle bottom panel), and the proportion of abortion-related deaths
(bottom panel) by place of residence between 2008 and 2011 in Mexican
states, grouped as with amendment” (in dark green), without amendment (in
cyan), and the Federal District (in green) in terms of exhibiting or not
an constitutional amendment (the Federal District of Mexico was not
included in this group to be illustrated separately) to protect the unborn
starting at conception (Figure S1, Supplementary Material). Right panels
show average ratios and proportion of abortion-related deaths for each
group (dark green, cyan, and green bars, respectively). * p<0.05
using Z-test. Abbreviations: iAMR, induced abortion mortality ratio; MMR,
maternal mortality ratio; MMRAO, maternal mortality ratio with abortive
outcome.Figure 7Mortality ratios and the proportion of abortion-related
deaths by place of occurrence in states with or without constitutional
amendment to protect the unborn starting at conception: focus on the
Federal District. Left panels illustrate trends for MMR (top panel), MMRAO
(middle top panel), iAMR (middle bottom panel), and the proportion of
abortion-related deaths (bottom panel) by place of occurrence between 2008
and 2011 in Mexican states, grouped as with amendment (in dark green),
without amendment (in cyan), and the Federal District (in green) in terms
of exhibiting or not a constitutional amendment (the Federal District of
Mexico was not included in this group to be illustrated separately) to
protect the unborn starting at conception (Figure S1, Supplementary
Material). Right panels show average ratios and proportion of
abortion-related deaths for each group (dark green, cyan, and green bars,
respectively). * p<0.05 using Z-test. Abbreviations: iAMR, induced
abortion mortality ratio; MMR, maternal mortality ratio; MMRAO, maternal
mortality ratio with abortive outcome.Figure 8Proportional contribution of
independent variables to observed differences in maternal mortality
outcomes among Mexican states in primary and alternative multivariate
regression models. Abbreviations: iAMR, induced abortion mortality ratio;
MMR, maternal mortality ratio; MMRAO, maternal mortality ratio with
abortive outcome.Figure S1Mexican states with and without constitutional
amendment to protect the unborn starting at conception between 2008 and
2011. Political maps of Mexican states are shown for 2008 (top panel),
2009 (middle panel), and 2010 (bottom panel), indicating whether they
exhibit a constitutional amendment to protect the unborn starting at
conception1 in dark green (with amendment) and cyan (without amendment).
The state of Chihuahua enacted its political constitution in 1994; Baja
California, Morelos, and Sonora in 2008; Campeche, Chiapas, Colima,
Durango, Guanajuato, Jalisco, Nayarit, Oaxaca, Puebla, Querétaro,
Quintana Roo, San Luis Potosí, and Yucatán in 2009; and Tamaulipas in
2010. Campeche revoked the amendment in 2010. Ag, Aguascalientes; Co,
Colima; FD, Federal District; Mo, Morelos; Tl, Tlaxcala.
Coahuila
Michoacán
Chiapas
Baja California Sur
Puebla
Yucatán
Baja California
Veracruz
Guanajuato
Sonora
Nayarit
Morelos
Oaxaca
México
Aguascalientes
Guerrero
Hidalgo
Distrito Federal
Chihuahua
Tlaxcala
Nuevo León
Durango
Tabasco
Sinaloa
Campeche
Quintana Roo
Querétaro
San Luis Potosí
Jalisco
Zacatecas
Colima
Tamaulipas