Factors affecting the persistent use of sharp curettage for abortion in public hospitals in Mexico

Abstract

Objectives: Dilation and curettage is an outdated abortion procedure no longer recommended by the World Health Organization. However, use of dilation and curettage remains high in some countries, including Mexico. We aim to understand the factors that contribute to persistent use of dilation and curettage in Mexico. Methods: We conducted a mixed-methods study in two phases: (1) secondary quantitative data analysis from 40 Ipas-supported public hospitals in Mexico and (2) 28 in-depth interviews in 9 Ipas-affiliated hospitals with doctors, nurses, and hospital administrators. Results: Among our sample, 41% of abortions less than 13 weeks performed in 2019 were treated with dilation and curettage, while this increased to 67% of abortions at or above 13 weeks. Only 18% of induced abortions were performed with dilation and curettage compared to 44% of post-abortion care procedures. The main factor identified as determining use of dilation and curettage in in-depth interviews was availability of abortion supplies, both in terms of cleaning, storage, and maintenance of supplies and in the budgeting and procurement of supplies. Other factors included confidence in the efficacy of other methods, attitudes toward different methods, skill and training, and perceived benefits to patients. Conclusion: Ensuring supplies for recommended abortion methods are available is a key lever for any intervention aimed at reducing dilation and curettage use. However, as the doctor performing the abortion decides which method to use, individual factors such as lack of skill and mistrust in other procedures can become a particularly obstinate barrier to recommended method use. Localizing decision-making power in the hands of doctors is problematic in that it places the doctor’s preference above that of the person receiving the abortion. It is important to look deeply at the power structures that contribute to doctor-oriented models of abortion care.

Cost Analysis of Surgical and Medical Uterine Evacuation Methods for First-Trimester Abortion Used in Public Hospitals in Mexico

“…The first is in relation to current international recommendations, which establish that health services should switch from sharp curettage to manual vacuum aspiration or medical abortion and, if possible, prohibit the practice of sharp curettage. For instance, in Mexico, many hospitals practice sharp curettage as the first choice of treatment for first-trimester abortion, 17 despite the global guidance and trends by WHO and FIGO against it. 7 , 10 Although both procedures have similar success rates, 33 , 34 the evidence has shown a higher rate of complications pain, and discomfort for women treated with sharp curettage and also, higher costs, as has been corroborated in this study.…”

“…Among the relevant factors identified that contribute to the routine use of this method were the availability of supplies, including budgeting and procurement, and the confidence and training of personnel in other methods. 17 The emergence of new technologies forces health systems to implement policies that promote the use of safe procedures at the lowest cost. For this reason, it is important for healthcare providers and decision-makers to evaluate efficient ways to allocate resources.…”

“…Among the relevant factors identified that contribute to the routine use of this method were the availability of supplies, including budgeting and procurement, and the confidence and training of personnel in other methods. 17 …”