Women's abortion seeking behavior under restrictive abortion laws in Mexico

Abortion is regulated in Mexico at the state level, and it is permitted under certain criteria in all 32 states, except in Mexico City where first-trimester abortion is decriminalized. Yet, more than a million abortions occur in Mexico each year. But most terminations occurring outside of Mexico City are clandestine and unsafe due to profound stigma against the procedure, lack of trained providers, lack of knowledge of where to find a safe abortion and poor knowledge of the laws. While this situation is moderated by the increasing use of misoprostol, a relatively safe method of abortion, the safety of the procedure cannot be assured in restrictive legal contexts. The purpose of this study is to explore women’s experiences with induced abortion in three federal entities with different legal contexts, and whether abortion seeking behavior and experiences differ across these settings. The study was carried out in three states, representing three different degrees of restrictiveness of abortion legislation. Queretaro with the “most restrictive” law, Tabasco with a “moderately restrictive” law, and Mexico state with the “least restrictive” law. We hypothesize that women living in more restrictive states will resort to the use of more unsafe and risky methods and providers for their abortion than their counterparts in less restrictive states. Women who recently obtained abortions were selected through snowball sampling and qualitative data were collected from them using semi-structured indepth interviews. Data collection took place between mid-2014 and mid-2015, with a final sample size N = 60 (20 from each state). Various themes involved in the process of abortion seeking behavior were developed from the IDIs and examined here: women’s knowledge of the abortion law in their state, reasons for having an abortion; the methods and providers used and women’s positive and negative experiences with abortion methods and providers used. Our results indicate that abortion safety is not associated with the restrictiveness of abortion legislation. Findings show that there is a new pattern of abortion service provision in Mexico, with misoprostol, a relatively safe and easy to use method, playing an important role. Nevertheless, while access to misoprostol tends to increase the safety of abortion, the improvement is moderated by women and their informants (relatives, friends and partners) not having accurate information on how to safely self-induce an abortion with misoprostol. On the other hand, some women manage to have safe abortion in illegal setting by going to Mexico City or with the support of NGOs knowlegeable on abortion. Findings demonstrate the importance of decriminalization of abortion, but meanwhile, harm reduction strategies, including promotion of accurate information about self-use of misoprostol where abortion is legally restricted will result in safe abortion.

vary across the different legal contexts in Mexico, or the impact that misoprostol has had on the approaches women use to access abortion. The purpose of this study is to explore women's experiences of induced abortion in three federal entities with three very different legal contexts, and investigate if abortion seeking patterns and experiences differ across these settings. To do so, we use qualitative data from women who recently had an induced abortion.

Study setting
This study was carried out in 3 states of Mexico: Queretaro, Tabasco and the State of Mexico. These states represent 3 different degrees of restrictiveness of abortion legislation. Queretaro has the "most restrictive" abortion law (exception criteria: rape and guilty by imprudence -imprudencial o culposo, refers to involuntary abortion by the woman or doctor-, Tabasco has a "moderately restrictive" abortion law (exception criteria: rape, guilty by imprudence, to save the life of a pregnant woman, and artificial insemination without the consent of the woman), and the State of Mexico has the "least restrictive" abortion law (exception criteria: rape, guilty by imprudence, to save the life of the woman, and serious genetic or congenital malformation). One noticeable difference between the states is their geographical distance to Mexico City, where women are allowed to obtain a safe legal abortion in the first trimester without restriction to reason. The state of Mexico borders Mexico City, with the capital of the state of Mexico very near to Mexico City (about 1 hour 20 minutes by public transport and 1 hour by car); the capital of Queretaro is located in the center of the country, north of Mexico City (3 hours by public transport and 2 hours by car), and the capital of Tabasco, on the east coast, is very far from Mexico City (13 hours by public transport and 10 hours 20 minutes by car).
Despite the abortion legislation and geographical differences, demographic indicators do not vary much among these states (See S1 Appendix). Tabasco is a more conservative society in terms of their reproductive health behavior. Abortion rates are relatively high in the three states, with Tabasco having the highest incidence of abortion and abortion complications in the country. The proportion of population that is poor in the three states is not negligible ranging from 26 to 37%.

Data source and data collection
This qualitative study used semi-structured in-depth interviews to collect information from a sample of women with abortion experience. The interviewers focused on women's experiences seeking an abortion in an illegal setting. A snowball purposive sampling approach was employed. Recruitment of the seed participants was carried out at clinics that provide clandestine safe abortion services; two clinics that meet this criterion were selected in the capital of each of the study states. These clinics provide general sexual and reproductive health services and were accessible to a great majority of the population. In order to be eligible for the study, women needed to be between the ages of 18 and 44 years and belong to the low or middle low socio-economic stratum. Before conducting the interviews with the seed participants and the other participants identified through the snow ball approach, a six-question questionnaire was applied to ensure that the participants belonged to the socio-economic stratum desired. The questionnaire and scores for the socio-economic strata were designed by Asociación Mexicana de Agencias de Inteligencia de Mercado y Opinión (AMAI), and are widely used in Mexico [15]. To diversify the pool of participants, two seed stems were chosen from each clinic, the seeds attended the clinic to terminate a pregnancy and were asked to be part of the study, and if they accepted, an in-depth interview (IDI) was carried out before they were discharged from the clinics or at a later date and at a place of the woman's choice. At the end of this interview, the woman was asked if she knew other women who had an induced abortion-if she answered yes, she was asked if she would be willing to refer them to the study team. With each new participant, a similar referral approach was followed.
All participants consented to being audio-recorded and the interview time ranged between 45 to 90 minutes. The interviews were conducted in Spanish, digitally recorded, transcribed verbatim, and translated into English. The field team, consisting of two female interviewers and a supervisor, had substantial experiences in conducting qualitative interviews. The team was trained by the authors and the interviewers reported to the supervisor and the authors. Both interviewers carried out the interviews in each of the three settings. They adopted a friendly and non-judgmental attitude to establish 'rapport' and 'trust' and listen attentively and respectfully to the stories shared by the interviewee. Data were collected between mid-2014 and mid-2015, and the final sample size was 60 (the interviewees' characteristics are shown in S2 Appendix). Refusal to participate was low (8%). The project was approved by the Guttmacher Institute's Institutional Review Board (IRB) and the MSI Ethics Review Committee (identifier IRB00002197 and 016-12-FT-A respectively).
For the analysis, the Spanish transcripts were analyzed independently using a holistic content approach in order to understand the full portrayal of each interviewee's life [16] We first familiarized ourselves with the data by reading transcripts for each state at a time (and hearing the tapes when needed). Then we proceed to develop codes for each transcript of each of the states and identify relevant themes using an Inductive Thematic Analysis [17] through an interaction with the data.

Limitations of the study
Our qualitative study is not representative of women having clandestine abortion in the three states studied as it is not based on a random sample. However, efforts were made to have a wide representation of middle and low income women in each of the states by starting our snow ball sampling in each state with a seed consisting of 4 initial women (2 women in 2 clinics), who then referred us to other women who did not attended the clinic for the pregnancy termination. In addition, the study is based on self-report of women with respect to their abortion experience and whether or not misoprostol was used. Women may not know exactly what medication and/or dosage was given or used by the provider to terminate the pregnancy.

III. Results
This section presents findings from four aspects related to the process of abortion seeking behavior: women's knowledge of the abortion law in their state, the reasons for having an abortion, the methods and providers used and the positive and negative experiences with the methods and providers used. The analysis focuses on the women's experiences and the similarities across the three settings.

a) Knowledge of abortion law
Women's knowledge of the abortion legislation in their state (as well as their knowledge of its legal status in Mexico City) may influence the type of procedure they choose. For instance, in the state with the least restrictive law, women might be better informed of the legislation, know abortion is safe in Mexico City, and might attempt to have a safer abortion compared to their counterparts in the state with the most restrictive legislation where women may have less knowledge of the legislation and safer methods.
In each of the three study states, women have been jailed for abortion. However, the precise number of women jailed in Mexico for having an abortion is unavailable. A BBC report [18] mentions that since 2009 criminalization of women who have abortions increased due to the legalization of abortion in Mexico City (2007): 700 women were reported to have been imprisoned, and another 623 cases are going through the judicial processes. GIRE [19] mentions that around 500 judicial inquiries related to abortion are filed every year, and from 2007 to 2016 there have been 98 women sentenced due to the crime of abortion, but this count is incomplete as only some states report the information by sex.
In our sample, most women thought that abortion was prohibited in their states, (53 out of 60), and in general, respondents' knowledge of abortion law did not vary by setting. Only a few participants mentioned some specific legal criteria under which terminations were possible, but their knowledge was erroneous: none of the women knew the specific legal criteria for abortion in their state, or the penalties for a woman who had an induced abortion.
What comes out strongly from the narratives of the women in all three settings is their fear of being jailed for having an induced abortion.
Sofia, from the State of Mexico, said even to tell her story made her scared: Despite the extensive media exposure of the legalization of abortion in Mexico City (the case was taken to the high court of the country, and sessions in favor and against the legalization of abortion in Mexico City were nationally televised), only one third of the women in the study were aware that abortion is legal in Mexico City. Thus, women in our sample from the State of Mexico tended to be more aware of the legality of the procedure in Mexico City, most likely because of the proximity of the city to them.
Laura's narrative below represents the voices of the women who knew about the change of abortion legislation in Mexico City.

b) Reasons for abortion
The reasons why women choose to have an abortion were varied, with no clear patterns across the three states. The most cited reasons were economic reasons -almost two thirds of the women-, followed by problems with partner -almost half of them-. Other reasons were mentioned, including not wanting to have a child at that moment or none at all (spacing or limiting), not wanting to be a single mother, too old to be a mother, not being in a committed relationship, and wanting to continue studying, among other circumstances. In two cases (one in the State of Mexico and another in Tabasco), the women were raped and that was the reason they sought an induced abortion. In about half of the cases multiple reasons were mentioned.
Economic reasons, which were the most commonly mentioned, were present in many of the narratives. For example, Carmelita from Tabasco felt her financial situation was already too strained to add another child. Another very common reason in the three states for not having the child and seeking an abortion was the bad relationship women had with their partner. Some partners were violent to the women, while others had drinking or drug problems or were unfaithful.

Interviewer
Sofía, for example, said that she sought an abortion because of the bad relationship with her partner:

c) Method and providers of abortion
Women's selection of abortion methods and providers involves many issues, including economic consideration, knowledge of the type of methods available and knowledge about where to obtain them, among other. In some cases, there is really no selection of the method and/or provider because only one is available or accessible to women. This section describes the methods and providers used by the participants and how they chose the method and/or provider.

Methods
Among participants in Queretaro the main method used was misoprostol (17 out of 20 women). Limited use of other methods was reported, including MVA. All participants in this state succeeded in having the abortion with one attempt.
In the State of Mexico, misoprostol is also commonly used among participants (15 out of 20 women), but it is used less as the sole method than in Queretaro. Fewer women in the State of Mexico used MVA than in Queretaro, and while no participants in Queretaro used D&C, some did in the State of Mexico. In the State of Mexico, 4 women made two attempts to complete the procedure, as the first attempt failed.
Participants in the State of Tabasco presented a very different scenario. Still, misoprostol was the key method used for abortion (10 of 20) and it was commonly used among the participants to self-induce the termination. But in most cases, it was used in combination with another method, usually herbal teas, drinks, remedies, traditional medicine. Possibly, incorrect usage of misoprostol (too low dosage) is prevalent in this state as around half of the women completed the abortion in one attempt, a larger number of women had to have a second attempt to achieve the abortion, and even one woman had a third attempt to finally terminate the pregnancy. Often, the traditional method was provided by a traditional midwife. Also, in many cases, the women seeking abortion did not know whether other medicines, such as misoprostol, were added to the drink and the amount added to the concoction.
The methods chosen by women were usually those recommended by close friends, relatives or partners, those who they trust. Only in a few occasions did women depend on the internet as the source of their methods. The case of Gabriela represents those of many women in the study. She took the decision to terminate the pregnancy; she told her sister who advised her to use misoprostol, guided her on how to use it and stayed with her during the abortion process. In Queretaro and the State of Mexico, some of the participants who self-induced the abortion with misoprostol got help from an NGO. The adequate advice women received from knowledgeable NGO providers led to the women having successful and safe medical abortion terminations. Clara's experience represents the stories of women who self-induced with misoprostol with the help of an NGO. She did not know what to use or do to terminate the pregnancy, so she talked to her friend who introduced her to one of her friends who took her to Gloris who worked in an NGO focusing on of reproductive health and safe abortion. There she received help on what method to use, what she should expect from the procedure and the safety and steps she would need to take, such as having an ultrasound before and after the pregnancy termination, a 24-hour hotline support, and counsel with respect to whether she really wanted to have the abortion. Participants in Tabasco who self-induced the abortion using misoprostol combined with traditional methods-concoction and other traditional methods-generally had experiences that were similar to that of Maria Fernanda. She and her partner choose to use misoprostol through the advice of friends. However, in this case, the information given was to take misoprostol with coconut water in the morning before breakfast. The method did not work, so they resorted to a second attempt, using traditional methods obtained through a traditional midwife.

Providers
Some women choose to self-induce the abortion not consulting or going to a provider. However, other do choose to go to a provider to have the abortion termination. The providers most commonly resorted to are gynecologists and traditional midwives. Among participants in Queretaro and the State of Mexico, the gynecologists they sought were very diverse and different in each of the study areas, for example, some terminations were done by gynecologists well trained in abortion in a legal setting, others convinced their gynecologists to perform the abortion and others found a gynecologist that advertised their services in an illegal setting In rare occasions was a nurse or pharmacist sought.
In the state of Queretaro and the State of Mexico some participants (5 and 4 out of 20 respectively) had a safe abortion in Mexico City. This is not surprising since both states are not far from Mexico City. The providers of these abortions were gynecologists who were well trained in abortion methods and worked in health facilities (public and private clinics) that were known for providing high quality abortion services. The providers sought by participants in the state of Tabasco presented a completely different pattern than women from the other 2 states. No woman went to Mexico City to have a safe legal abortion, which may be understandable as the state is farther to the capital of the country relative to the other two states; it takes about 13 hours by public transportation to travel from the capital of Tabasco to Mexico City. None of the 20 participants in Tabasco sought an abortion from medical personnel (doctor or nurse). Instead, women either self-induced their abortions or seek the help of a traditional midwife to terminate the pregnancy.
In Tabasco, also the provider they resorted to came from the advice of close friends/relatives/partner. But a few participants, like Cynthia, followed their neighbors' foot-steps by using providers that the neighbors had used. In this case, Cynthia's neighbor took her daughter to a traditional midwife for pregnancy termination. For her own abortion Cynthia decided to also go to the same traditional midwife. Participants in Queretaro and the State of Mexico, who went to Mexico City to have a legal safe abortion relied on the internet. Some did not know that abortion was legal in Mexico City, but when they searched on the internet and found that abortion was performed legally they felt that was the best option for them. Others heard from a friend or someone else close that abortion was legal in Mexico, then they used the internet to investigate more. They became convinced that it was better to have the abortion in a place where it is legal, as they believed it was going to be a safe abortion. When Emma needed to have an abortion, she and her friend discovered on the internet that abortion was legal in Mexico City. They both preferred the option of having the procedure where it is legal. In summary, methods and providers chosen usually come from the advice of a close friend/ relative/partner, those who they trust. Misoprostol is used in the three states extensively, either alone or in combination with other methods. But there is a gradient of use by the state of the participants: it was mostly used by participants in Queretaro, followed by those in the State of Mexico, and then by those in Tabasco. In contrast with the other settings where no woman went to a traditional provider (i.e. the State of Mexico) and where only 2 women did (i.e. in Queretaro), all participants in Tabasco that went to a provider to have an abortion used traditional midwives. No medical personnel was sought for abortion by participants in Tabasco. The method and provider used for abortion are relevant for successful termination of pregnancy. It is therefore not surprising that in Queretaro, all participants succeeded in having their abortions with one attempt; in the State of Mexico, four women made two attempts to complete the procedure-i.e., two methods were used sequentially before the abortion was completed; and in Tabasco, 8 participants had to have two attempts to complete the procedure, and one had to have a third attempt.
The findings suggest that the degree of restrictiveness of the abortion legislation does not relate to the type of method and provider used, and to the safety of the procedure. On the other hand, proximity to Mexico City, where abortion is legal, has the beneficial effect of obtaining a legal and safe abortion for women.

d) Women's positive and negative experiences with method and provider used
Women's abortion experiences varied widely depending on the method they used and the provider used (if any). In the following section, we highlight four types of providers and methods to illustrate the diversity of women's experiences in an illegal setting: 1) self induced abortion by the women using misoprostol; 2) women seeking abortion with traditional midwives using misoprostol and other remedies; 3) women obtaining abortions from doctors in an illegal setting and 4) women having legal abortion in Mexico City. Women using the same type of method and provider may end up having different outcomes, one with a positive experience or a safe abortion and the other with a negative consequence or an unsafe abortion. d.1. Experiences of women who self-induced abortions using misoprostol alone. Although the use of misoprostol was common among the study participants, the stories of women using this method were often dissimilar. In part, this is due to variation in the doses of the misoprostol used, which were often incorrect. The women did make efforts to find the correct approach and doses of misoprostol use for an abortion. They all searched for information with their friends, on the internet, and with relatives, among others. But the information given was not always adequate. The women ended up following the information given by who they trusted most, or that sounded the most reliable, and this process often led to use of incorrect doses. Daniela, from Queretaro, self induced the abortion with misoprostol and had a sucessful story. She obtained the information from the Internet and her partner was with her all the time: A very different story was narrated by Paola. She ended up in the hospital to complete the self-induced abortion with misoprostol and had a D&C with local anesthesia. A friend told her to take four pills of cytotec to abort (two vaginally and two swallowed). One factor that often led to a more positive experience in our participants' cases was being guided through the process by an NGO. These stories were common; women found the NGOs through referrals from friends or the internet, and the NGOs' staff advised them to have an ultrasound, gave them the pills, instructed them on how to use them, informed them what they would experience, and told them to have a follow up ultrasound and a doctor visit. What was more important to many women, however, is that staff of the NGOs were with them during the procedure by phone, reassuring them; in addition, the doctors the women visited for the ultrasound and the followup visit were often friendly doctors that wanted to help women in this illegal setting.
Cruz told us her story.

d.2. Experiences with traditional midwives using misoprostol and other remedies.
Seeking help from traditional midwives was more commonly reported in Tabasco than in the other studied areas. Narratives of abortion procedure done by traditional midwives were found to be both positive and negative, and ranged along the spectrum of safety. Many of the traditional midwives used misoprostol.
The case of Carmelita who lived in Tabasco, is similar to those of other women who relied on traditional midwives to terminate the pregnancy. Most women reported some familiarity with the traditional midwives, as they are birth attendants and the provider of traditional medicine in the community. Usually, women seeking an abortion stayed at the traditional midwife's home during the procedure. The traditional midwife cares for the woman throughout the process, and some of them give antibiotics and medicine for the pain. However, we do not know with precision the dosis used of misoprotol inserted in the vagina and if the concoctions also had misoprotol, but in this case the experience for the woman perspective was positive.

boiled cactus and other leaves. That tea is for cleaning everything inside and prevent an infection. I stayed there until the afternoon. I recovered and I felt normal. I was not bleeding much, it was like a menstruation. I left and went with my mother and stayed with her 3 days to recover. (Tabasco, P17, 29 years, complete secondary, married, 2 children)
However, not all women who went to traditional midwives had such a good experience. A few women who went to a traditional midwife reported that they were massaged. In one case the midwife introduced her hand in the uterus to remove the placenta and any remains of the fetus. The narrative of Mary from Tabasco demonstrates how bad an experience and unsafe an abortion through a traditional midwife could be. The result could have been fatal, but in this case it was not, but certainly it was very unsafe abortion.  , P14, 23 years, incomplete primary, consensual union, 3 children)

d.3. Experiences of abortion performed by doctors in an illegal setting.
While many would assume that medical doctors perform safer abortions than other providers, this is not always the case in our sample. Several women from Queretaro and State of Mexico chose to have an abortion in their area with a gynecologist believing the procedure would be well performed-here we present two contrasting cases of women who went to gynecologists who advertised doing abortions in an illegal setting. In both cases the same method was used, misoprostol and MVA with paracervical local anesthesia, but the women's experiences were radically different. A paracervical block is an anaesthetic procedure used in obstetrics and gynecology, whereby a local anaesthetic is injected into between two and six sites at a depth of 3-7 mm alongside the vaginal portion of the cervix in the vaginal fornices. For more information on this topic refer to findings from a randomized controlled trial of paracervical block for pain control in first-trimester surgical abortion [20].
Karina described the procedure, the extreme pain she experienced and her inability to walk after the procedure, characteristics associated with perforation of the uterus. . . . I was scared, . . . He put me in a stretcher, . . ., I was given a hospital gown. He told me it was not going to hurt much. He put me on anesthesia.

Interviewer: With intravenous solution?
Participant: . . . No, he did not inject me, but he put a liquid through a vaginal foley . . . and there he injected a sedative or a liquid. I was crying because I was worried for my health, as I have never done anything like this . . . But the doctor told me to be calm, that I was going to be fine. That I was going to feel very little pain and then I was not going to feel anything.
Then he inserted a tube . . . and I saw a hugh syringe that he inserted, and then I did not feel anything from the waist down. . . . I did not see but my partner saw everything. . .

d.4. Experiences with legal abortion in Mexico
City. Some women from Queretaro and the State of Mexico decided to have a legal safe abortion and went to Mexico City, in abortion clinics with an approved medical provider. Most women went to private clinics, but a few attended Mexico City government facilities for services free of charge. For the women who opted to go to Mexico City to have a legal abortion, the experience was positive. In both, private and public clinics, they received clear information from the doctor about the procedure and what they would feel. They were treated in a positive way and they were even given a hot drink at the recovery room and asked to wait until fully recovered and ready. They were given preventive medicine like antibiotics and pain killers, and did not have complications; in addition, the clinic had a 24 hours service line where they could call if they had a problem. Here we present two cases, one of the women that choose to go to a private clinic in Mexico City and another that was helped by an NGO to attend a government facility that provides free services for women in Mexico City.
Maria Jose is from Queretaro, and was originally planning to have the abortion in her state. However, after a bad experience with fake providers of abortion in Queretaro (pro-life centers advertising that they do abortions) she decided to seek the abortion in Mexico City where it is legal. She narrates her positve story:

Interviewer: Did they give you some medication or prescription?
Participant: Yes, they gave me a prescription. They gave me antibiotic and medicine for the pain. . . .

Interviewer: Do you think the service was good?
Participant: The truth yes. It was very clean. The clinic was very pretty. It was a new house, it did not look like a hospital. . . . The doctor explained to me everything from the beginning how it would be, what I was going to feel. Everything went very well. I was lucky to find a good place, and that everything went well.

Interviewer: Did they give you an open line in case you had a complication?
Participant: Yes, they gave me the phone number for the clinic, a switchboard and from there they could reach the doctor 24 hours a day. I did not have to phone. I felt very well after the procedure [no complications].
(Queretaro, P9, 33 years, complete high school, single, 1 child) This section clearly exemplifies the difficulties women encounter in quest of a safe abortion and a good experience having the procedure, from the perspectives of our study participants. Their stories are diverse and the experience of pregnancy termination may be good or bad even using the same method and type of provider. Although, some of the women may not know for sure the qualifications of the providers or the methods used, in general, the narratives provided seem plausible in the context of restrictive abortion laws. Legal restrictions on abortion put women in a difficult situation. While they generally do not prevent abortions from taking place, they make it difficult to ascertain the quality of abortion services or the reliability of the provider, as the health providers could act as impostors. Restrictive abortion laws, result in providers not being accountable to norms or WHO standards [21][22][23][24]. Furthermore, seeking a knowledgeable health provider with the right skills to perform an abortion is difficult because of the clandestine environment and the lack of liability for their work. Furthermore, self-inducing the termination of pregnancy by women with the correct procedure and doses is not guaranteed as information is often not available. Women tend to trust the information provided by their close friends and family, who do not necessarily have correct information regarding methods and providers. A relevant finding is that all the women who went to Mexico City to have a safe abortion had a good experience. Similarly, women who self-induced the abortion with the help of an NGO who gave them correct information about misoprostol use and supported them during the process had good experiences.

IV. Discussion and recommendation
Mexico, characterized by abortion legislation specific to each state, and where the law is restrictive in all of them with the exception of Mexico City, provides the opportunity to compare abortion seeking behavior among states with different levels of restrictiveness of abortion legislation. In this exploratory study, the assumption considered is that where legislation is more restrictive the options of having an abortion with safer methods and providers would be more limited and those available would be riskier compared to those in states with less restrictive abortion legislation. Findings from this study about the condition under which women have abortion contribute to the scarce literature on the topic in Mexico and Latin America.
Regarding women's knowledge about abortion legislation, no difference is found among participants by state or level of legal restriction. Most women thought that abortion was prohibited in their states, but did not know the legal criteria under which abortion is allowed. Only one third of our respondents knew that pregnancy termination was allowed in Mexico City. A general feeling among them was the fear of being jailed because of having an abortion, and despite this apprehension they sought the procedure. As mentioned by other investigators and shown by our qualitative data analyzed [25,26] restrictive laws do not eliminate the practice of abortion, women continue to seek abortion in legally abortion restrictive settings.
Women seek an abortion for various reasons. Research on the topic has cited economic reasons as a common motivation for seeking an abortion in many LDCs, but women also report multiple and overlapping reasons for ending an unintended pregnancy [25,[27][28][29][30]. Findings from our study supports the available literature and women in the three states present similar reasons. The economic reason is the most commonly reported for having an abortion. Many other reasons were mentioned, and nearly half of them gave multiple reasons for seeking an abortion in each of the states examined.
Various abortion methods and providers are reportedly to be used in each of the three study areas. However, similar to the findings in other studies (e.g. [25]), evidence from the three study states suggests a high use of misoprostol which appear to be on the rise. Studies have indicated that in highly restrictive contexts, clandestine abortions are now safer because fewer occur with the use of dangerous and invasive methods [25,30], and our findings support this evidence as women do not reported the use of more invasive methods (insertion of hangers, etc.).
Misoprostol seems to be used extensively for abortion is the three states, either alone or combined with other methods. But there is a gradient of use by state: the medication is used more in Queretaro, followed by the State of Mexico, and then by Tabasco.
Our findings indicate that there is a new pattern of abortion service provision in Mexico where misoprostol plays an important role, changing from no use of misoprostol before 1995 [9,31] to 29% using the method among women seeking abortions in 2007 [14], and to the vast majority of women currently using misoprostol, as shown in this study. [14] However, we found that the use of misoprostol may not have concomitantly increased the safety of the procedure. For instance, women usually do not have the accurate information on how to safely self-induce an abortion: informants about misoprostol might not also have the correct information (on the dosage, when and how to take the misoprostol), and to obtain the correct information seems to be fortituous. Furthermore, some providers who use the method often recommend different dosages and approaches of introducing the pill into the body and some use it along with concoctions, including traditional herbs, teas and other substances.
Our findings indicate that there is no clear relationship between the restrictiveness of abortion legislation and the safety of abortion (including use of appropriate methods and providers). In Queretaro, the state with the "most restrictive" abortion law, all participants completed their abortions in the first attempt, 12 women self induced the abortion and some of them had good information about the use of misoprostol, and 5 went to Mexico City to have a legal abortion with a trained provider. In the State of Mexico, with the "least restrictive" abortion law, 4 out of 20 women did not achieve the abortion in the first attempt. Five women self induced the abortion, and a large proportion of them went to a gynecologist, 4 of them went to Mexico City to have a legal abortion with a trained provider. The State of Tabasco with a "moderate restrictive" abortion law, has the poorest pathway to abortion, no medical profesional was involved in the abortion procedure, mainly women self induced or the abortion was performed by traditional midwives. Eight women completed their abortion in 2 attempts and 1 woman in three attempts, no woman in this state went to Mexico City to have a legal abortion. Two factors seem to explain the lack of association between restrictiveness of abortion law and the safety of abortion in our study. It seems evident that being near Mexico City, where abortion is legal up to 12 weeks, has had a beneficial effect for women living in the 2 states that are nearer to Mexico City (Queretaro and the State of Mexico). Secondly, information about how to obtain and use safer abortion methods and providers seem to diffuse better among women in Queretaro and the State of Mexico than in Tabasco. These two reasons tend to produce, at least partly, better abortion outcomes than in Tabasco, and that may be independent of the level of restrictiveness of their abortion legislations.
The last section of the findings explores through the narratives of women their experiences with methods and providers chosen. It is interesting to observe the different outcomes when the same type of method and provider, suggesting that in addition to the type of methods and providers used, how methods are used and steps taken by providers are crucial abortion outcomes. Women who self-induced abortion, or who sought the procedure from a gynecologist in an illegal setting or from a traditional midwife, using the same methods, can come out with vastly different outcomes. In some cases, the experience was extremely bad and risky while for other women it was a relatively safe and less traumatic experience. In contrast, women who went to a safe provider in Mexico City always had a good experience with abortion. The procedure was performed safely with no complications. Similarly, women who selfinduced the abortion with misoprostol with the support of an NGO knowledgeable of the use of the medication, had a safe abortion with no complications.
From this analysis, four observations can be made. First, that a high proportion of women self-induced the abortion using misoprostol suggests that use of the method has increased over time and has shaped the pattern of abortion in our study areas, and perhaps the country as a whole. Second, that Queretaro and the State of Mexico are geographically nearer to Mexico City where abortion in legal, than Tabasco resulted in women from the first two states benefiting from the liberal abortion law in Mexico City. As noted earlier, no woman from Tabasco, which is the farthest from Mexico City, travelled to the city for an abortion to take advantage of the availability of safe legal abortion. Third, women from Queretaro and the State of Mexico also benefited from telephone hotlines and NGO dedicated to harm reduction; in all of these cases, women who self induced the abortion with misoprostol and who had the help of the hotline-NGO had no complications and their abortion experiences were positive. Fourthly, the degree of legislative restrictions does not seem to be associated with the pattern of abortion methods or providers used or the outcome of the procedure. Nevertheless, legislation restriction in general (i.e. independently of the degree of restrictiveness) makes erratic the outcome of the process of abortion, in some cases, women may end up with a safe abortion and in another occasions not. Some abortion providers who advertise themselves as gynecologist were either not well trained on abortion methods recommended by WHO [22] or were not legitimate gynecologist (i.e. fake or impostors), as mentioned in the narratives of the women. Evidently, in settings with restrictive laws, women will have abortions with providers that advertise their services as gynecologist or medical personnel even if they are not medical personnel. Such providers are very common in restrictive settings since they are not accountable to a government institution because of the clandestine nature of their abortion services. The consequence is that many of those abortions end up being unsafe, some with very serious complications.
To address the challenges and problems faced by women living in the states of Mexico with restrictive abortion laws, we offer the following recommendations. Certainly, effort should continue to be made to achieve legalization of abortion in all states. This is essential for reducing unsafe, clandestine procedures and making abortion safe. A situation with liberal abortion laws and policies that make safe abortion available to all sub-groups of women is the ultimate goal that will ensure the well-being of women and their families. But achieving legalization of abortion often takes a long time.
In the meantime, we recommend that some immediate actions be taken to improve the pathway to and safety of abortion in restrictive settings in Mexico. It appears that Queretaro and the State of Mexico have a greater presence of NGOs and their harm reduction strategies have resulted in positive outcomes with respect to abortion access in those states. Furthermore, information about Mexico City laws and services would not have diffused to remote areas, as evident from the findings in Tabasco. Therefore, in the meantime and before decriminalization of the law is achieved, we recommend the following immediate actions: First, effort to promote harm reduction strategies in different states of the country, in particular those with a limited presence or none of reproductive health NGOs, and states far away from Mexico City, as our findings indicate, self-induced abortions using misoprostol with adequate information, such as from NGOs with hotline services, do result in positive experiences and safe abortions, despite the legal restrictions. Second, promotion of accurate information about self-use of misoprostol where abortion is legally restricted is recommended, this information may be provided by NGOs but also by medical personnel. This approach was successfully used in Uruguay before the legalization of abortion: doctors gave precise information on medical abortion but could not perform the abortion as it was illegal. As WHO recommended, adequate information about misoprostol should be accessible in restrictive setting, since people will use the method with or without correct information. Third, to achieve the goal of improving access to correct information about misoprostol use and prevent women from seeking unsafe abortions using dangerous methods and untrained providers, certain specific strategies can be developed and utilized by NGOs and friendly reproductive health services to reach women. Examples include use of the internet, social media and street market exhibition with information and links/referral to safe abortion services in Mexico City. Fourth, post abortion care (PAC) services should continue to be made available in public and private facilities and access should be enhanced for all categories of women. Effort should be made to ensure that all facilities allowed to provide PAC are equipped with WHO recommended methods of PAC provision and that facility staff members are adequately trained in the use of those methods and in discharging their responsibilities without judgmental attitudes towards women seeking PAC.
Findings from this study suggest the need for future research, to address gaps in the literature on abortion in Mexico. Specifically, there is need for more research to better understand the practices around use of traditional medicine, midwives and concoctions for abortion in the country. Many women in the state of Tabasco resort to these types of providers for abortion. Yet little is known about the ramifications of abortions obtained through these providers and methods, including the complications associated with them. It is of policy and program importance to learn more about how the traditional midwives practice abortion provision and the information and advice they give to women regarding preventing future unintended pregnancies and in case they develop complications due to the abortion. Further research is also needed about self-use of misoprostol for abortion by women. Several women in this study who used misoprostol do not know exactly what they were given by the provider. It will be informative to know how women who self-induced using misoprostol seek and obtain the method. For example, it will be helpful to know where they get the method from in a restrictive setting, the quality of the medication as well as the adequacy of information they received.
Supporting information S1 Appendix. Socio-demographic and geographical characteristics of the study sites. (DOCX)

S2 Appendix. Study participant's characteristics.
(DOCX) their supervisor, Mónica González. We are very grateful to all women who participated in this study, for giving their time and for trusting us by sharing their personal stories with us.