Unsafe abortion constitutes a significant public health problem throughout the world. WHO defines unsafe abortion as a procedure for terminating a pregnancy either by persons lacking the necessary skills, or in an environment lacking the minimal medical standards, or both. Approximately 20 million women undergo an unsafe abortion each year; an estimated 70,000 women die from related complications, such as uterine perforation, sepsis or poisoning, and countless others suffer short and long-term consequences, such as chronic pain and infertility. Globally, 13-14% of all pregnancy-related deaths is attributable to unsafe abortion, while in some settings this figure rises to as high as 60%. This translates into 75-80,000 women each year who die because of restrictive abortion legislation, lack of implementation of existing legislation allowing abortion under certain conditions, and the lack of accessible safe services. In developing countries, 65% of all women face legal restrictions related to abortion, while in developed countries 71% has unrestricted access to safe abortion services.

Women in developing countries experience the greatest risk of death and morbidity due to unsafe abortion. The highest proportion of maternal mortality due to unsafe abortion (21%) is seen in Latin America and the Caribbean. In Mexico, an estimated 40% of all pregnancies end during early stages, one-half due to induced abortion and the other half due to spontaneous abortion or miscarriage. Access to safe abortion services is restricted for women throughout Mexico, because of the high cost and the lack of health-care providers and institutions offering the service when legal. Penal Codes in all 31 Mexican States and the Federal District (Mexico City) define at least one situation in which abortion is exempt from penalty. Similarly, in all states women have the right to an abortion when the pregnancy is the result of rape.

Because of restricted access to safe abortion services, complications due to unsafe abortion comprise the fourth most important cause of maternal mortality in Mexico. One-third of women experiencing abortion, whether spontaneous or induced, requires hospitalisation.
As a signatory to the 1994 Programme of Action of the International Conference on Population and Development (ICPD), Mexico recognised unsafe abortion as a public health problem and committed itself to addressing it as such. During the five-year review of ICPD implementation, Mexico reaffirmed this commitment and agreed that, "…In circumstances where abortion is not against the law, health systems should train and equip health-service providers and should take other measures to ensure that such abortion is safe and accessible". But in practice, few resources have been designated so far. Important strategies have been developed by NGOs however, in collaboration with public health systems, legislators and other relevant sectors to address unsafe abortion. Two main strategies are:
1)  the development of post-abortion care programmes that utilise manual vacuum aspiration (MVA) to treat incomplete abortion
2 ) the creation of legal abortion services for women survivors of sexual violence.

Post-abortion care

Since the 1994 ICPD, the post-abortion care (PAC) model has been widely recommended as a strategy for breaking the cycle of repeat abortions and helping to reduce maternal morbidity and mortality. The model seeks to improve services for patients with complications from spontaneous or unsafely induced abortion. PAC incorporates three interrelated, essential services for all women treated for abortion complications:

1. Emergency treatment services for complications of spontaneous or unsafely induced abortion;
2. Post-abortion contraceptive counselling and method provision;
3. Links between emergency abortion treatment services and comprehensive reproductive-health care.

PAC programmes that utilise manual vacuum aspiration (MVA) for treatment of incomplete abortion were initiated in public health systems in 1988. A first pilot programme took place in secondary state hospitals in the state of Michoacan, followed in 1992 by pilot programmes in Social Security hospitals. Currently, the four largest health systems covering the majority of the population have recognised the importance of high quality PAC programmes and have invested significant human and financial resources to make PAC available. In July 2000, the Secretariat of Health distributed technical guidelines for the prevention and management of obstetric haemorrhage to all public health units. These guidelines stress the importance of providing PAC services, indicating MVA as the first option for managing incomplete abortions. Post-abortion contraceptive education and counselling are other key PAC components.

Legal abortion services for survivors of sexual violence

In Mexico, all 32 states have independent and different abortion legislation. In all states, abortion is legal for women whose pregnancy is the result of rape, but access to abortion services is still limited. In response, Ipas Mexico and the Mexico City Department of Health initiated a joint project in August 2000, to provide comprehensive care, including legal abortion services for survivors of sexual violence. Continuous consciousness-raising and in-depth training on the legal, clinical and mental health aspects of sexual violence and legal abortion take place with health-care providers in public hospitals. A model of care was developed in collaboration with health-care providers, based on three basic premises:

• Care should be women-centred, prioritising the needs of survivors of sexual violence.
• Health-care facilities are key locales and health-care professionals key actors in the prevention and treatment of violence again women.
• Comprehensive care includes specialised medical services (such as legal abortion), as well as psychological and legal support.

By February 2002, 468 health-care providers from 15 hospitals in Mexico City had participated in workshops on sexual violence and legal abortion. A questionnaire among workshop participants shows that a large majority supports access to legal abortion services (as defined in Mexico City's Penal Code: in cases of rape, forced artificial insemination, grave danger to the woman's health, accident, congenital or genetic malformation of foetus), in all public hospitals. Eighty percent would participate in legal termination of pregnancy in cases of rape, if supported by their institution. To date, the project has documented much interest in sexual violence and abortion, as well as high levels of support for legal abortion in case of rape. Health professionals recognise the need for further training, both in medical school curricula and in-service training.

Conclusions

Abortion is a significant and common experience among women worldwide, including Mexico. As a signatory to the Programme of Action of ICPD and ICPD+5, Mexico has publicly committed itself to investing in training, equipment and services for legal abortion and PAC. Innovative strategies for increasing access to these services are being implemented by NGOs and the public health sector. Continued action in these areas will decrease unsafe abortion as a cause of preventable death and disability among women in Mexico.