“While this is not the place to examine in detail the many facets of this policy, it is necessary to remind ourselves that Mexico City is about much more than a policy on abortion, which continues to be the most emotive of all topics in this country. It is also about such things as freedom of speech, ideological imperialism, reproductive choice and national sovereignty.” Statement by Duff Gillespie to the US Committee on Foreign Affairs, 2007
The Mexico City Policy, referred to in the quote above, or Global Gag Rule as it is commonly known, is not new. It is a restriction that previous United State’s governments have placed upon grantees. What is new about the recent iteration of the rule is that it now binds all overseas NGO recipients of "global health assistance furnished by all departments or agencies" (amounting to over US $9 billion) rather than just those who are funded through reproductive health budget lines.
Those of us working on gender and sexual and reproductive health have been disheartened by President Trump’s reinstatement (and widening) of the Mexico City Policy which limits new US government overseas grantees from providing abortion, information on abortion, and advocating for safe abortion. It has been unlawful to use US funds for abortion services abroad since 1973. Yet, we know that unsafe abortion accounts for 13% of maternal deaths globally and safe abortion is an integral part of reproductive health and rights.
Those NGOs and their sub-grantees, working on sexual and reproductive health and rights in low- and middle-income countries, who receive USAID health assistance are now bound by additional restrictions that mean that they cannot perform abortions, discuss abortion or provide referrals to providers, or actively promote abortion as a method of family planning.
In practice, that means that if an organisation has a USAID grant, for health systems research or non-communicable diseases for example, it can no longer offer safe abortion services or advocate for them even if funded to do so by another government or private foundation. This stands even if the organisation is working in a country where abortion is legal.
Learning from our past
If the aim is to reduce the number of abortions taking place, then the Policy is a failure. The first quantitative analysis of the impact of the Mexico City Policy (from Bendavid et al.) demonstrated that rates of abortion in African countries where aid was cut the most went from “10.4 per 10,000 woman-years for the period from 1994 to 2001 to 14.5 per 10,000 woman-years for the period from 2001 to 2008”. Rather than reducing the number of abortions that were performed, it led to an increase in unsafe abortion. Unsafe abortion in low- and middle-income settings is often violent, bloody, disabling, and often terminal. In many settings, pregnancy and childbirth can kill you too. Access to contraceptive services and supplies are the answer.
Even in countries where abortion is legal, the Policy results in perverse effects. In South Africa, for example, it is easier to get information on – and proceed with – an illegal abortion from an informal provider (widely advertised on street lamps, and other informal media sources), than it is to get official National Department of Health information on, and undergo, a safe, and legal abortion. In countries like Nigeria, where abortion is illegal, informal, unhealthy abortions are routinely undertaken. The advice given to women when undergoing these abortions, alongside their own sense of shame and stigma, means that – even when it is obvious that something has gone wrong – women do not seek help until it is far too late. Illegal, unsafe abortion will always be available to those who feel desperate, and will continue to undermine all the good work being done by governments, NGOs, and research organisations to promote and enhance women’s reproductive health and rights.
If you care about the health of women and girls, the Policy should trouble you. The revised Mexico City Policy is likely to affect overall levels of funding for safe abortion and reproductive health services in low- and middle-income countries and for other health services. Assistance received by organizations from USAID goes towards much more than just abortion-related services (which often only make up a small proportion of an organization’s reproductive health services). Organizations which lose USAID funding as a result of the Policy will need to reduce the level of services provided. This will likely have knock on effects on the health workforce and vital health service provision, and arguably undermine our potential as a global community to achieve the Sustainable Development Goals and universal health coverage. For example, Population Action International report that when the Policy was previously enacted:
“In Kenya, the Family Planning Association of Kenya (FPAK), which does not provide abortion, had to cut its outreach staff in half, close three clinics that served 56,000 clients in traditionally underserved communities, and raise fees at the remaining clinics.”
If you think that evidence is important for decision-making, the Policy will disappoint you. Policy makers require inputs from implementers and civil society to make appropriate decisions about health care delivery. However, the enforcement of the Mexico City Policy can lead those with important knowledge to stay silent on issues related to reproductive health. Writing for Health and Human Rights in 2006, Bogecho and Upreti noted that:
“[S]ince the reinstatement of the Gag Rule, USAID's presence in Nepal has engendered a climate that imposes direct censorship on health groups by forcing them to avoid using the terms "reproductive rights" and "advocacy" in their work. This has created fear among health NGOs and has become an impediment to addressing the problem of unsafe abortion even though abortion is now legal.”
The ‘chilling effect’ of the Policy leads organisations to stop speaking on a host of sexual and reproductive health and rights issues for fear of defunding/censure. In 2008, the Johns Hopkins-run database, Popline, blocked searches using the word abortion. This was rectified when it was discovered but was believed to be an over-reaction by an administrator who feared government disapproval. There may be other cases of this ‘chilling effect’ that go unreported.
The governments of the Netherlands, Canada, and other countries have suggested that they would provide alternative financing to those affected by the Policy. However, it will be difficult to match the large budget of USAID for global health. Writing on Peru in 2006, Seevers suggested:
“The international community should not wait for NGOs to be punished by USAID for breaking their silence and speaking up about the dangers of unsafe abortions in order to offer them alternative funding. There needs to be a broader international response that not only addresses specific cuts to agencies that result from perceived Gag Rule violations, but one that also provides an alternate source of funding for NGOs that do not want to accept the USAID restrictions.”
This recommendation stands true today.
The full extent of the Policy is still currently unknown as guidance on how it should be implemented has not yet been issued. It is important that all scholars who believe in the right to health are vocal on this issue rather than leaving the onus of responsibility on women’s rights activists and those in the sexual and reproductive health sector.
As health systems researchers, it is important that we systematically track and research the impact of the Policy and that we are open about its effects on our own work. It has the potential to skew health financing, service delivery, governance, human resources for health, supplies of medicines and medical commodities, and the reliability of health information. As such, it is squarely a health system issue and one that should be of concern to all in our community.