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Abortion Laws and Womens Health

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Abortion Laws and Womens Health Journal of Health Economics 76 (2021) 102413 Contents lists available at ScienceDirect Journal of Health Economics j ournal homepage: www.elsevier.com/locate/econbase ଝ Abortion laws and women’s health a,∗ b Damian Clarke , Hanna Mühlrad a Department of Economics, Universidad de Chile and IZA, Diagonal Paraguay 257, Santiago, Chile b IFAU – Institute for Evaluation of Labour Market and Education Policy & Department of Clinical Sciences, Danderyd Hospital (KI DS) | Karolinska Institutet, Sweden a r t i c l e i n f o a b s t r a c t Article history: We examine the impact of progressive and regressive abortion legislation on women’s Received 13 May 2020 health in Mexico. Following a 2007 reform in the Federal District of Mexico which Received in revised form decriminalised and subsidised early-term elective abortion, multiple other Mexican states 22 November 2020 increased sanctions on illegal abortion. We observe that the original legalisation resulted in Accepted 23 November 2020 a sharp decline in maternal morbidity, particularly morbidity due to haemorrhage early in Available online 13 December 2020 pregnancy. We observe small or null impacts on women’s health from increasing sanctions on illegal abortion. These results quantify the considerable improvements in non-mortal JEL classification: health outcomes flowing from legal access to abortion. I18 J13 © 2020 The Author(s). Published by Elsevier B.V. This is an open access article under the K38 CC BY license (http://creativecommons.org/licenses/by/4.0/). H75 Keywords: Abortion Maternal morbidity Maternal mortality Health care provision Political economy Legislative reform ଝ We thank the Editor Ana Balsa, two anonymous referees, Sonia Bhalotra, René Castro, Blair G. Darney, Dolores de la Mata, Hans Grönqvist, Randi Hjalmarsson, Lakshmi Iyer, Elin Larsson, Jason Lindo, Andreea Mitrut, Carol Propper and seminar audiences at IPAS Mexico, The LACEA Health Economics Network, the IZA Gender Workshop, CIDE Mexico, Colegio de Mexico, the Mexican Institute of Public Health, University of Gothenburg, SOFI Stockholm University, Karolinska Institute and CSAE Oxford. We thank Raffaela Schiavon for detailed discussions regarding the practical implementation of Mexico DF’s ILE reform and her generosity in sharing expertise. We are also grateful to Natalia Volkow at INEGI for providing access to disaggregated hospitalisation data, Alejandro del Valle for sharing data, and Cristhian Molina for excellent research assistance. Clarke acknowledges the generous support of FONDECYT Regular, grant number 1200634 from the Government of Chile and the institutional support of the Millennium Institute for Market Imperfections and Public Policy. This paper considerably extends and partially subsumes an earlier study by these authors called “The impact of abortion legalization on fertility and female empowerment: New evidence from Mexico”. ∗ Corresponding author. E-mail addresses: [email protected] (D. Clarke), [email protected] (H. Mühlrad). https://doi.org/10.1016/j.jhealeco.2020.102413 0167-6296/© 2020 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/ by/4.0/). D. Clarke and H. Mühlrad Journal of Health Economics 76 (2021) 102413 1. Introduction policies more generally—focuses on expansion in access, there are a number of papers which focus on contrac- Appeals to women’s health are frequently made when tions in policies. These include historical restrictions in debating the merits of abortion legislation. These calls are Romania (Pop-Eleches, 2010), the impact of parental con- made by both advocates of legal abortion as well as those sent or notification laws targeted at adolescents in the US advocating for abortion to become, or remain, illegal. The (Bitler and Zavodny, 2001; Joyce and Kaestner, 1996), and arguments backing up such claims are drawn from a range a recent hollowing out in the availability of providers due of sources, which are often correlational or based on small to state-specific legislation in the US (Fischer et al., 2018; 1 or non-representative samples of women. Lindo et al., 2019). However, the legalisation of abortion In this study, we present the first population-level evi- in Mexico DF, and the resulting spate of constitutional dence of the impact of sub-national variation in abortion changes increasing the harshness of sentencing of illegal laws on maternal morbidity, as well as mortality, using the abortion, provides the opportunity to examine the impact 2 universe of administrative health records from Mexico. of a contemporaneous series of restrictive and permissive We focus on a period in which considerable within-country abortion policies in a single country and time. reform of abortion policy was undertaken, with both a Reproductive health rights have been documented to sweeping legalisation in the Federal District of Mexico be of considerable economic significance. This fact has (Mexico DF) and increasing sanctions on (already illegal) been emphasised by a growing body of economic literature abortion in other regions. In this context, we are able to which has—empirically and theoretically—demonstrated determine to what extent change in abortion laws, absent how access to elective abortion and contraceptive meth- other major contraceptive revolutions, impact health indi- ods has shaped fertility patterns, marital markets, crime, cators for the population of affected women. We combine education, the labour market and female empowerment the state-level variation over time resulting from legislative (e.g., Ananat et al., 2007; Bailey and Lindo, 2017; Chiappori changes in abortion law with high-quality vital statistics and Oreffice, 2008; Guldi, 2008; Mitrut and Wolff, 2011; data recording over 30 million births, 18.4 thousand mater- Myers, 2017; Pop-Eleches, 2010). The impact of abortion nal deaths and 46 million inpatient cases for causes related laws on women’s health has received less attention, and to maternal health. To seek to understand the observed the causal relationship is yet to be established. To the best impact of abortion laws on health outcomes, we also take of our knowledge, this is the first study to provide well iden- advantage of rich administrative and survey data to identify tified population-level evidence of the impact of abortion the reform’s wider impact on birth rates, judicial sen- legalisation on maternal morbidity and mortality based tencing, and on sexual behaviour, and explore potential on within-country variation in abortion availability. While channels of health impacts, including improvements in the an association between abortion legalisation and lower quality of abortion care and changes in the composition of abortion-related complications has been documented in women giving birth. previous studies, comprehensively capturing the impact The environment under study provides a unique of the passage of abortion law on abortion-related mor- opportunity to examine simultaneous expansions and con- bidity is a considerable challenge, especially in clandestine 3 tractions of abortion policies. While much of the existing settings, where under-reporting may occur (Singh et al., 4 literature on the impact of abortion—and contraceptive 2010). Using two-way fixed effect (FE) models and panel event study methods (and synthetic controls as a robustness check), as well as recent advances in a literature exam- 1 The use of such arguments even when based on weak evidence is not ining causal estimation with time varying policy reform isolated to non-governmental organisations. Similar arguments are also (Rambachan and Roth, 2019; Goodman-Bacon, 2018), we made by politicians. One example is a fact sheet published on the website of the United States (US) Government’s National Cancer Institute by the observe consistent evidence to suggest that the legalisation Bush administration positing an (unfounded) link between abortion and of abortion in Mexico DF brought about a sharp reduction in breast cancer (Special Investigations Division, Committee of Government fertility (by 8%), haemorrhage in early pregnancy (by 35%) Reform, House of Representatives, 2003). 2 and abortion-related morbidity (by 20%). Event study esti- Associations between abortion legalisation and maternal mortality or morbidity have been documented in the medical and public health mates examining increases in sanctions on (already illegal) literature for multiple countries (Benson et al., 2011), including Albania abortion point to much smaller effects on these variables, (Sahatci, 1993), Bangladesh (Chowdhury et al., 2007), Nepal (Henderson which are generally not statistically significant. In general, et al., 2013), Romania (Serbanescu et al., 1995; Stephenson et al., 1992), we observe impacts on maternal mortality, which are hard Singapore (Singh and Ratnam, 2015) and South Africa (Rees et al., 1997). to consistently sign given that they are considerably less Existing studies are mainly based on reviews of medical charts at selected hospitals, for example in the US (Goldstein and Stewart, 1972; Stewart and precise, suggesting that when only examining impacts of Goldstein, 1971; Seward et al., 1973; Kahan et al., 1975), Guyana (Nunes and Delph, 1997), Nepal (Henderson et al., 2013) and South Africa (Mbele et al., 2006; Jewkes et al., 2002). We are aware of no prior studies which are based on population-level data, and based on within-country variation in abortion reforms. in the country, we document evidence
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