This article was originally published in the 2018 Spring Issue, and can be read here.
Authors: Saina Beitari, Emily Heer, Chloé Laflamme, Megha Patel, Debanjali Purkayastha, and Michelle Rugamba
In 1973, the U.S. Congress passed the Helms Amendment under the Foreign Assistance Act, stating that U.S. governmental funds could not be used to finance abortions as a method of family planning, or to motivate or coerce any person to practice abortions (1). In 1984, this policy, in turn, influenced President Ronald Reagan’s authorization of the Mexico City Policy, also known as the Global Gag Rule (GGR). The policy restricts U.S. funding to those foreign organizations providing voluntary abortion services, including services that do not use American funds directly to finance abortion (2). For instance, even if an organization undertakes abortion services financed internally or through non-U.S. funds, it is not eligible to receive U.S. federal funding to support programs unrelated to abortion (1). Since the Reagan era, this policy, having resulted in a significant loss of U.S. funding for many organizations worldwide, has been implemented by every Republican administration and rescinded by every Democratic administration (3).
Despite much international attention given to its improvement in recent years, maternal health remains a significant global health challenge (4). In 2015, an estimated 303,000 women worldwide died of preventable pregnancy or childbirth-related causes including hemorrhage, infection, unsafe abortion, and obstructed labour (4, 5). It is further estimated that, as of 2015, 99% of maternal deaths occurred in developing countries, with sub-Saharan Africa and South Asia being the regions most affected (4). In much of the developing world, access to vital medicines and reproductive health services pose significant challenges to sustaining the maternal health of women and girls.
Over the last decade, the U.S. has been, according to the Kaiser Family Foundation, “the largest funder and implementer of global health programs worldwide” (6). In fact, global health has been a significant component of the country’s “international development portfolio, accounting for about 24% of the international affairs budget,” totalling $10.4 billion in 2017, up from $5.3 billion in 2006 (6). However, the Trump administration has proposed a slash in global health funding for 2018. Despite the U.S. having maternal and child health (MCH) as one of its main global health priorities, the proposed budget only allocates $1.05 billion to MCH, a cut of more than $200 million from 2017. Given the U.S.’s crucial role in global health initiatives, these funding cuts will dramatically impact efforts towards improving MCH worldwide.
Trump and the Global Gag Rule
On January 23, 2017, three days after his inauguration, U.S. President Donald Trump released a presidential memorandum reinstating the Mexico City Policy. In May of that year, the then Secretary of State Rex Tillerson endorsed the “Protecting Life in Global Health Assistance” implementation plan as the newest iteration of the GGR. The policy was expanded: Global Health Assistance now includes support for any international health programs funded by U.S. government departments or agencies, such as the Centre for Disease Control, whereas previous iterations only applied to the US Agency for International Development (USAID) (1). Under Trump’s GGR, organizations that independently provide family planning services will not qualify for USAID funding regardless of their primary mandate (3, 7). For example, organizations focused on combating Zika or HIV/AIDS with auxiliary service provision in family planning, previously eligible for U.S. funding, would now be barred from receiving federal funds (1). In addition, Trump’s GGR restricts U.S. funding not only to foreign NGOs but to all other recipients that enable the provision of safe abortion services, which could include foreign governments as well as U.N. agencies (2). Under the Bush administration’s President’s Emergency Plan for AIDS Relief (PEPFAR), organizations that included HIV treatment as part of a package with reproductive or maternal health care could still receive HIV/AIDS assistance, even if they could not receive funds for family planning assistance. No such exemption, however, exists under Trump’s GGR (7).
Impact of GCR
Trump’s GGR has both direct and indirect impacts on affected countries’ economic health. While previous iterations of GGR imposed $600 million cuts, Trump’s GGR suspends $9 billion in funding for family planning, significantly impacting the budget of organizations such as Planned Parenthood International which is projected to lose $100 million over the next four years. Marie Stopes International, an NGO focused on maternal health, reports that, without alternative sources of funding between 2017 and 2020, Trump’s GGR could result in 6.5 million unintended pregnancies, 2.2 million abortions, 2.1 million unsafe abortions, and 21,700 maternal deaths (8). Moreover, the costs of treating medical complications from unsafe abortion by themselves can impose a significant financial burden on public healthcare systems in the developing world (9).
On a broader scope, Trump’s GGR can negatively impact economic growth in affected countries. The economic health of developing countries is directly correlated with reduced fertility (10). When women have increased control over their fertility by having safe access to abortions and contraception, high school dropout rates decrease and employment opportunities increase, potentially leading to growth in GDP (11). In addition, a reduction in fertility rates changes the age structure of the population, leading to a period of one or more decades when the dependency ratio—the ratio of children and the elderly to the working-age population—declines, potentially improving a country’s GDP (12).
Impacts on maternal health, family planning and child health
Though the purported goal of the GGR is to reduce the incidence of abortion, there is no evidence to suggest that it has been successful in its mandate (12). In 2011, the World Health Organization (WHO) investigated the relationship between the reinstatement of the GGR and probability of a woman obtaining an abortion (13). The study found that, under Bush’s GGR, women in countries most affected by GGR were 2.7 times more likely to have an abortion (13). Due to the limitations of the self-reported data, it is likely that the number of abortions is an understatement because of the stigma and legal restrictions around abortion in many of these countries.
One of the immediate consequences of the GGR is the disruption of family planning services in countries heavily dependent on U.S. foreign assistance for the implementation of these programs. Some organizations that provide reproductive health and family planning services have refused to comply with the policy due to their insistence on providing abortion services, often facing severe consequences. In 2002, after local family planning associations in 16 developing countries rejected the GGR policy, USAID contraceptive donations to these associations were terminated (14). For example, having rejected the GGR, the Planned Parenthood Association of Zambia (PPAZ) lost 24% of its core grant and had to scale back on its community- based distribution programs—a key source for distribution of free contraceptives, including condoms, to smaller NGOs and rural populations (15, 16).
Moreover, such disruptions to family planning services limit access to contraceptives and decelerate the uptake of modern contraceptives, therefore increasing the incidence of unwanted pregnancies. For example, a study investigating the effect of the GGR in Ghana found that unwanted pregnancies in the country’s rural regions increased by 12% after the implementation of the policy (17). In fact, every year, 25 million unsafe abortions occur worldwide, and their often fatal consequences account for 13% of all maternal deaths (18, 19). While there is no direct evidence showing that the GGR increases maternal mortality (12), increases in unwanted pregnancy and decreases in access to safe abortions are both associated with more unsafe abortions and maternal deaths.
Finally, the use of contraceptives has a powerful impact on child survival by increasing the interval between successive pregnancies, in turn reducing the risk of adverse maternal, perinatal, and infant outcomes (20, 21). Limited access to contraceptives and the increase in unwanted fertility translates to inappropriate child spacing, endangering the survival and health of all children and the mother (12). In fact, the Ghana study cited above found that children conceived under the GGR have statistically significant growth deficits (17).
Impact on services related to HIV and other infectious diseases
Many NGOs in low- and middle-income countries use an integrated model of care, where the organizations provide reproductive and maternal health care, primary care, infectious disease counselling and treatment, nutritional counselling, and many other services in one setting. This approach reduces the costs of having distinct clinics for each service, makes care more accessible and efficient for patients, and, importantly, integrates HIV services and reproductive health.
As mentioned earlier, Trump’s GGR does not include Bush’s PERFAR or any other exemptions (3). As such, organizations that provide treatment and care for HIV, tuberculosis, malaria, maternal health, nutrition, or any other global health challenge, have to abide by GGR restrictions to be eligible for funding, and lack of compliance would entail far-reaching consequences at every level of prevention (22). At the primary level, the goal is to reduce the incidence (new cases) of disease. Under the GGR, limited funding for contraceptives and reduced resources for HIV-related community outreach and educational programs will further enable HIV transmission, hindering primary prevention efforts (23). Further, since non- compliant organizations have to cut back on testing resources or to simply shut down, secondary prevention strategies—aimed at identifying HIV-positive individuals to prevent further transmission—will also be vulnerable. Finally, tertiary prevention efforts, aimed at treating those with a disease and ensuring adherence to treatment, will also face impediments under Trump’s GGR: many organizations either close or operate at reduced capacity, and treatment prices may increase. As well, the possibility of the disintegration of care means that those who normally accessed care at a particular clinic may have to visit multiple locations, leading to a potential decrease in adherence to treatment and reduction in the effectiveness of antiretroviral therapy.
It is important to note that the GGR can impede healthcare services relating to other infectious diseases, as well. However, this paper focused on the case of HIV due to the previous existence of the PEPFAR exemption.
An Unfair Burden
The GGR disproportionately affect the most vulnerable in every community. When faced with funding cutbacks, it is common for organizations to scale back their community outreach programs due to these programs’ high resource requirements, hence depriving marginalized and at-risk populations of necessary care. For example, the slum neighbourhood of Eastleigh, Kenya, is home to many refugees from the Congo, Ethiopia, and Somalia, but has no government-run clinic (23). The Family Planning Association of Kenya was the only NGO providing reproductive health services in this area, including HIV counselling and testing. In 2001, community health workers reached 56,000 people with reproductive health information, education, and counselling, made 30,000 referrals, provided 75,000 people with contraceptives, and distributed 89,600 condoms. After the GGR was reinstated, the organization had to reduce community-based distribution efforts by half (23). Additionally, if lack of funding compels clinics to increase prices for services, the only people who will be able to access care are those who could already afford it, leaving the low income populations without options.
Future Directions and Canada’s Chance
In order to provide a funding platform for organizations that do not sign the GGR, Lilianne Ploumen, the Dutch Minister of Foreign Trade and Developmental Cooperation, launched the SheDecides campaign in January 2017 (24). The campaign’s goal is to end reliance on single donors, offset the damage caused by the GGR, and enable communities to maintain access to sexual and reproductive health services (2, 24). Overall, the initiative’s mandate is to improve access to maternal care, contraceptives, and abortion services for millions of women around the world (24). In March 2017, an international conference was held in Brussels to raise awareness and funds for the SheDecides campaign, bringing together political leaders from more than 50 countries, organizations, and foundations to discuss the large funding gap caused by the GGR and raise $600 million to overcome the funding shortfall. While only $190.1 million was raised during the conference, advocates believe the gap will soon be bridged by funding from highly-industrialized countries (25). Canada currently has the highest pledge of $20 million to the SheDecides fund (25). Though the campaign is promising, the pledging countries could still be doing more. For instance, Canada’s overall foreign aid budget is less than 0.3% of its GNP, short of the 0.7% target set by the UN (25). Unfortunately, this trend is consistent among many donor countries, and, moreover, countries often contribute far less than they pledge (7). As such, the challenges of retention and compliance ought to be overcome if SheDecides is to be successful.
With Canada’s Feminist International Assistance Policy, the Trudeau government has already made a pledge to support efforts to empower women and girls worldwide. Facilitating the provision of access to information, services, and resources for women regarding reproductive health is a crucial component of this empowerment. In addition to the contribution to SheDecides, Canada has also promised $650 million to fund reproductive health and support services (26). However, this investment is a drop in the $9 billion bucket left empty by Trump’s GGR. In times like these, the Trudeau government could become a leader in the efforts to improve MCH on a global scale. We look forward to seeing Canada take a bigger role in initiatives prioritizing gender equality and the empowerment of women and girls globally.
All authors listed contributed equally to this project. We acknowledge the work of Dr. Madhukar Pai and Emily McLean.
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