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Abortion Legal Reform and Neonatal Mortality in Mozambique

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Abstract

Introduction

Abortion law reforms have been hypothesized to influence reproductive, maternal, and neonatal health services and health outcomes, as well as social inequalities in health. In 2014, Mozambique legalized abortion in specific circumstances. However, due to challenges implementing the law, there is concern that it may have negatively influenced neonatal outcomes.

Methods

Using a difference-in-differences design, we used birth history data collected via the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) between 2004 and 2018 to assemble a panel of 476 939 live births across 17 countries including Mozambique. We estimated the effect of the abortion reform on neonatal mortality by comparing Mozambique to a series of control countries that did not change their abortion policies. We also conducted stratified analyses to examine heterogeneity in effect estimates by household wealth, educational attainment, and rural/urban residence.

Results

The reform was associated with an additional 5.6 (95% CI = 1.3, 9.9) neonatal deaths per 1,000 live birth. There was evidence of a differential effect of the reform, with a negative effect of the reform on neonatal outcomes for socially disadvantaged women, including those with no schooling, in poorer households, and living in rural areas.

Discussion

Given the delay in implementation, our analyses suggest that abortion reform in Mozambique was associated with an initial increase in neonatal mortality particularly among socially disadvantaged women. This may be due to the delay in effective implementation, including the dissemination of clear guidelines and expansion of safe abortion services. Longer-term follow-up is needed to assess the impact of the reform after 2018, when services were expanded. Abortion legal reform without adequate implementation and enforcement is unlikely to be sufficient to improve abortion access and health outcomes.

Significance

AbstractSection What is Already Known on this Topic

While abortion reforms have been hypothesized to affect a host of maternal and neonatal outcomes, few empirical studies have examined the effect of abortion reforms on neonatal outcomes.

AbstractSection What this Study Adds

Due to challenges in the implementation of the 2014 abortion legalization in Mozambique, it may have negatively influenced neonatal outcomes, particularly for socially disadvantaged women. Abortion legalization alone without adequate implementation and enforcement is unlikely to be sufficient for substantial change in abortion access and health outcomes.

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Data Availability

We utilized the Demographic and Health Surveys (DHS) and UNICEF Multiple Indicator Cluster Surveys (MICS). Both are publicly available, but users must first register. Registration, which requires a summary of the proposed study and selection of country datasets, can be completed at: https://dhsprogram.com/data/new-user-registration.cfm and https://mics.unicef.org/visitors/sign-up respectively

Code Availability

Code for data analysis is available upon request from the corresponding author

References

  • Agadjanian, V. (1998). Quasi-legal Abortion Services in a sub-saharan setting: Users’ Profile and motivations. International Family Planning Perspectives, 24(3), 111–116.

    Article  Google Scholar 

  • Agadjanian, V., & Yabiku, S. T. (2015). Religious belonging, Religious Agency, and women’s autonomy in Mozambique. Journal for the Scientific Study of Religion, 54(3), 461–476.

    Article  PubMed  PubMed Central  Google Scholar 

  • Antón, J. I., Ferre, Z., & Triunfo, P. (2018). The impact of the legalisation of abortion on birth outcomes in Uruguay. Health Economics, 27, 1103–1119.

    Article  PubMed  Google Scholar 

  • Arroyave, F. A. B., & Moreno, P. A. (2018). A systematic Bibliographical Review: Barriers and facilitators for Access to Legal Abortion in Low and Middle Income Countries. Open Journal of Preventive Medicine, 8(5), 147–168.

    Article  Google Scholar 

  • Assembleia da República (2014). Boletim da República: Lei n°. 35/2014 de 31 de Dezembro, vol. I Série n. Maputo: 14° Suplemento Imprensa; 2014 i>https://www.wlsa.org.mz/wp-content/uploads/2017/11/Diploma_Ministerial_60-2017.pdf Accessed 19 February 2021. Retrieved from

  • Bahk, J., Yun, S. C., & Kim, Y. (2015). Impact of unintended pregnancy on maternal mental health: a causal analysis using follow up data of the Panel Study on Korean Children (PSKC). BMC pregnancy and childbirth, 15(85), 1–12.

    Google Scholar 

  • Barton, K., Redshaw, M., Quigley, M. A., & Carson, C. (2017). Unplanned pregnancy and subsequent psychological distress in partnered women: A cross-sectional study of the role of relationship quality and wider social support. Bmc Pregnancy and Childbirth, 17(1), 44. https://doi.org/10.1186/s12884-017-1223-x.

    Article  PubMed  PubMed Central  Google Scholar 

  • Clarke, D., & Muhlrad, H. (2021). Abortion laws and women’s health. Journal of Health Economics, 76, 102413. https://doi.org/10.1016/j.jhealeco.2020.102413.

    Article  PubMed  Google Scholar 

  • Corsi, D. J., Neuman, M., Finlay, J. E., & Subramanian, S. V. (2012). Demographic and health surveys: A profile. International Journal of Epidemiology, 41(6), 1602–1613. https://doi.org/10.1093/ije/dys184.

    Article  PubMed  Google Scholar 

  • Costs and consequences of the hidden debt scandal of Mozambique. (2021). Retrieved from Centro De Integridade Pública (CIP), Moçambique, and Chr. Michelsen Institute, Norway.

  • Daca, C., Sebastian, M. S., & Arnaldo, C. (2020). Socio-economic and demographic factors associated with reproductive and child health preventive care in Mozambique: a cross-sectional study. International Journal for Equity in Health, 19(200), 1–9.

    Google Scholar 

  • Delgado-Rodríguez, M., Gómez-Olmedo, M., Bueno-Cavanillas, A., & Gálvez-Vargas, R. (1997). Unplanned pregnancy as a major determinant in inadequate use of prenatal care. Preventive Medicine, 26(6), 834–838.

    Article  PubMed  Google Scholar 

  • Department for Economic and Social Affairs (2013). World population prospects: the 2012 revision. Retrieved from United Nations Secretariat.

  • Dickens, B., Cook, R., & Erdman, J. (2007). Achieving transparency in implementing abortion laws. International Journal of Gynecology and Obstetrics, 99, 157.

    Article  PubMed  Google Scholar 

  • Dott, M., Rasmussen, S. A., Hogue, C. J., et al. (2010). Association between Pregnancy Intention and Reproductive-health related behaviors before and after pregnancy recognition, National Birth defects Prevention Study, 1997–2002. Maternal and Child Health Journal, 14, 373–381.

    Article  PubMed  Google Scholar 

  • Frederico, M., Arnaldo, C., Decat, P., Juga, A., Kemigisha, E., Degomme, O., & Michielsen, K. (2020). Induced abortion: A cross-sectional study on knowledge of and attitudes toward the new abortion law in Maputo and Quelimane cities, Mozambique. Bmc Women’s Health, 20(1), 129. https://doi.org/10.1186/s12905-020-00988-6.

    Article  PubMed  PubMed Central  Google Scholar 

  • Gallo, M. F., Gebreselassie, H., Victorino, M. T., Dgedge, M., Jamisse, L., & Bique, C. (2004). An assessment of abortion services in public health facilities in Mozambique: Women’s and providers’ perspectives. Reproductive Health Matters, 12(24 Suppl), 218–226. https://doi.org/10.1016/s0968-8080(04)24027-7.

    Article  PubMed  Google Scholar 

  • Ganatra, B., Gerdts, C., Rossier, C., Johnson, B. R., Tuncalp, O., Assifi, A., & Alkema, L. (2017). Global, regional, and subregional classification of abortions by safety, 2010-14: Estimates from a bayesian hierarchical model. Lancet, 390(10110), 2372–2381. https://doi.org/10.1016/S0140-6736(17)31794-4.

    Article  PubMed  PubMed Central  Google Scholar 

  • Gipson, J. D., Koenig, M. A., & Hindin, M. J. (2008). The effects of unintended pregnancy on infant, child, and parental health: A review of the literature. Studies in Family Planning, 39(1), 18–38. https://doi.org/10.1111/j.1728-4465.2008.00148.x.

    Article  PubMed  Google Scholar 

  • Goçalves, M. (1972). Portuguese criminal code, with annotation and Commentary. Editora Almedina. (in Portuguese).

  • Grossman, M., & Jacobowitz, S. (1981). Variations in infant mortality rates among counties of the United States. Demography, 18(4), 695–713.

    Article  CAS  PubMed  Google Scholar 

  • ICF International. (2012). Demographic and Health Survey sampling and household listing manual. Maryland: ICF International.

    Google Scholar 

  • Ishola, F., Ukah, U. V., Alli, B. Y., & Nandi, A. (2021). Impact of abortion law reforms on health services and health outcomes in low- and middle-income countries: A systematic review. Health Policy Plan, 36(9), 1483–1498. https://doi.org/10.1093/heapol/czab069.

    Article  PubMed  Google Scholar 

  • Johnson, B. R., Lavelanet, A. F., & Schlitt, S. (2018). Global abortion policies database: A new approach to strengthening knowledge on laws, policies, and human rights standards. BMC International Health and Human Rights, 18, ARTN35.

    Article  Google Scholar 

  • Joyce, T. (1987). The Impact of Induced Abortion on Black and White Birth Outcomes in the United States. Demography, 24(2), 229–244.

    Article  CAS  PubMed  Google Scholar 

  • Kantorová, V. (2020). Unintended pregnancy and abortion: What does it tell us about reproductive health and autonomy. Lancet Glob Health, 8(9), 1106–1107.

    Article  Google Scholar 

  • Kayode, G. A., Ansah, E., & Agyepong, I. A. (2014). Individual and community determinants of neonatal mortality in Ghana: a multilevel analysis. Bmc Pregnancy And Childbirth, 14(165), 1–12.

    Google Scholar 

  • Khan, S., & Hancioglu, A. (2019). Multiple Indicator cluster surveys: Delivering Robust data on children and women across the Globe. Studies in Family Planning, 50(3), 279–286.

    Article  PubMed  PubMed Central  Google Scholar 

  • Lanham, J. T., Kohl, S. G., & Bedell, J. H. (1974). Changes in pregnancy outcome after liberalization of the New York State abortion law. American Journal of Obstetrics and Gynecology, 118(4), 485–492. https://doi.org/10.1016/s0002-9378(16)33688-2.

    Article  CAS  PubMed  Google Scholar 

  • Latt, S. M., Milner, A., & Kavanagh, A. (2019). Abortion laws reform may reduce maternal mortality: an ecological study in 162 countries. BMC Women’s Health, 19(1), 1–9.

    Article  PubMed  PubMed Central  Google Scholar 

  • Lavelanet, A. F., Schlitt, S., Johnson, B. R., & Ganatra, B. (2018). Global abortion policies database: A descriptive analysis of the legal categories of lawful abortion. BMC International Health and Human Rights, 18, ARTN44.

    Article  Google Scholar 

  • Martel, P., Mbofana, F., & Cousens, S. (2021). The polychoric dual-component wealth index as an alternative to the DHS index: Addressing the urban bias. J Glob Health, 11, 04003.

    Article  PubMed  PubMed Central  Google Scholar 

  • Miller, M. K., Stokes, C. S., & Warland, R. H. (1988). The effect of legalization and Public Funding of abortion on neonatal mortality: An intervention analysis. Population Research and Policy Review, 7(1), 79–92.

    Article  PubMed  Google Scholar 

  • Ministério da Saúde (2017). Boletim da República: Diploma Ministerial n°. 60/2017 de 20, vol. I Série n. Maputo: de Setembro; 2017. p. 147. http://www.wlsa.org.mz/wp-content/../Diploma_ministerial_60-2017.pdf. Accessed 17 Feb 2021.

  • Mitrut, A., & Wolff, F. C. (2011). The impact of legalized abortion on child health outcomes and Abandonment. Evidence from Romania. Journal of Health Economics, 30, 1219–1231.

    Article  PubMed  Google Scholar 

  • Oberman, M. (2021). How Abortion Laws Do and Don’t Work. Law, Gender & Society, 36, 163.

    Google Scholar 

  • Quick, J. D. (1978). Liberalized abortion in Oregon: Effects on Fertility, Prematurity, fetal death, and infant death. American Journal of Public Health, 68(19), 1003–1008.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Rosário, C., & Gianella, C. (2019). Evolução histórico-legal do processo de despenalização do aborto em Moçambique – períodos-chave na extensão do direito ao aborto. In A. Carlos, B. M. Cau, B. Chilundo, J. J. Picardo, & S. Griffin (Eds.), Planeamento Familiar e Políticas de Saúde Sexual e Reprodutiva em Moçambique (pp. 259–279). Madrid: CEPSA.

    Google Scholar 

  • Singh, S., Remez, L., Sedgh, G., Kwok, L., & Onda, T. (2018). Abortion Worldwide 2017: Uneven Progress and Unequal Access. Washington, DC: Guttmacher Institute.

    Book  Google Scholar 

  • StataCorp. (2016). Stata Statistical Software: Release 15. College Station. Texas: StataCorp LP.

    Google Scholar 

  • Strumpf, E. C., Harper, S., & Kaufman, J. S. (2017). In Methods in, & Social Epidemiology (Eds.), Fixed effects and difference in differences. Jossey-Bass.

  • Valente, C. (2017). Improved access to abortion, neonatal mortality, and gender bias: Evidence from Nepal. Economic and Social Research Council.

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Funding

Funds for this project were provided by the Fonds de recherche du Québec—Santé (FRQS) PhD scholarship (FI) and a Canadian Institute of Health Research (CIHR) Foundation grant (FRN 148467) (AN).

Author information

Authors and Affiliations

  1. Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, 2001 McGill College Avenue, Montreal, QC, H3A 17Y, Canada

    Foluso Ishola & Arijit Nandi

  2. School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada

    Foluso Ishola

  3. Chr. Michelsen Institute, P.O. Box 6033, N-5892, Bergen, Norway

    Carmeliza Rosario

  4. International Centre for Reproductive Health, Maputo, Mozambique

    Sally Griffin

  5. Instituto Nacional de Saúde, Marracuene, Mozambique

    Celso Khosa

  6. Institute for Health and Social Policy, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada

    Arijit Nandi

Authors
  1. Foluso Ishola
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  2. Carmeliza Rosario
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  3. Sally Griffin
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  4. Celso Khosa
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  5. Arijit Nandi
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Contributions

FI and AN contributed to the study conception and design, FI performed data collection and analysis and wrote the first draft of the manuscript. AN, CR, SG, and CK contributed to the writing of the manuscript. All authors read and approved the final version of the manuscript.

Corresponding authors

Correspondence to Foluso Ishola, Carmeliza Rosario, Sally Griffin, Celso Khosa or Arijit Nandi.

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Ethical Approval

This study used de-identified, publicly available secondary data. The DHS data collection procedures were reviewed and approved by the ICF Institutional Review Board (IRB). The MICS survey responds to local regulations and protocols regarding data collection and fieldwork. Each survey is approved by the relevant country-specific ethical review board that oversees research studies on human subjects in each of the participating countries.

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Ishola, F., Rosario, C., Griffin, S. et al. Abortion Legal Reform and Neonatal Mortality in Mozambique. Matern Child Health J 28, 587–595 (2024). https://doi.org/10.1007/s10995-023-03876-1

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