This article was originally published in the 2020 Spring Issue, and can be read here.
Authors: Sandy Shergill, Bowen Lan, Camille Zeitouni, Julia Biris, Salome Henry, Lily Yang, Rebecca Wan
The Mexico City Policy, also known as the Global Gag Rule, is a U.S policy that requires foreign non-governmental organizations (NGOs) receiving U.S. global health funding to certify that they will not perform or actively promote abortion as a method of family planning. In 2017, President Donald Trump expanded the policy’s reach to include all global health assistance funding from U.S. agencies and departments. It is estimated that 1,275 foreign NGOs and US$8.8 billion in global health funding are subject to Trump’s expanded policy. Globally, an additional 2.2 million abortions, including 2.1 million unsafe abortions, are estimated to occur from 2017 to 2020 under President Trump’s administration. The Global Gag Rule undermines local sovereignty and jurisdiction over reproductive health law in countries that require these funds to operate and provide comprehensive reproductive services. This case study will highlight the effects of this policy by evaluating its quantitative and qualitative impacts and discussing the future implications for countries impacted by the policy. Results of this report demonstrate the policy’s failures in both achieving its own goals as well as international aims to improve global health and women’s rights among others.
Background & Motivation for the Policy
The Mexico City Policy is a U.S. governmental policy that prevents the allocation of U.S federal funds to foreign NGOs that perform or promote abortion services or advocate for its decriminalization. President Ronald Reagan first introduced the Mexico City Policy in 1984 during the 2nd International Conference on Population in Mexico City. Prior to this policy, the Helms Amendment forbade foreign NGOs from offering and promoting abortion using US funds (1). However, after implementation of the Mexico City Policy, NGOs receiving US global family planning assistance were no longer permitted to offer or promote abortion services, even if they were using funds from other sources. Since the initial implementation, the policy has been rescinded during every Democratic term and reinstated in every Republican term (1). Yet, even when the Mexico City Policy is rescinded, the Helms Amendment still stands (2).
On January 23rd 2017, President Donald Trump reinstated and expanded the Mexico City Policy, renaming it “Protecting Life in Global Health Assistance.” Previously, the policy applied to aid from the department of family planning assistance totaling around $575 million (3). Trump’s extended policy now includes almost all bilateral global health assistance provided by all US agencies and departments, notably the US Agency for International Development (USAID), the Department of State, and the Department of Defense (DoD). Funding for maternal and child health, nutrition, HIV & malaria (under the President’s Malaria Initiative and President’s Emergency Plan for AIDS Relief), tuberculosis, neglected tropical diseases and global health security are newly affected.
The implications of this policy expansion are far-reaching; it is estimated to affect approximately $8.8 billion in global health aid (4). In March of 2019, Secretary of State Mike Pompeo extended “Protecting Life in Global Health Assistance” yet further, prohibiting NGOs receiving US funding from providing funds to any of their partner NGOs that perform or actively promote abortion as a method of family planning (3).
The Mexico City Policy and “Protecting Life in Global Health Assistance” are commonly referred to as the Global Gag Rule (GGR) in the literature. We will be using this term henceforth. This name for the policy reflects how the policy “gags” healthcare providers’ ability to provide comprehensive reproductive services and comply with the United Nations resolution of Sexual and Reproductive Rights of women.
Rights to Sexual and Reproductive Health
The history of American domestic reproductive health reform reflects the strong partisan divide on the issue of reproductive health care and abortion. The Roe v. Wade Supreme Court ruling in 1973 upheld a woman’s right to abortion as a constitutional right, thereby overturning state-specific laws criminalizing and restricting access to abortion services. A series of subsequent appeals and policy changes have further limited access to reproductive services for American women. The GGR is a clear ex- ample of domestic political values seeping into foreign aid policy, as well as the politicization of global health matters. This report will analyze the global health impacts of the GGR and offer a critical perspective discussing the policy’s failure to actually “protect life”. Throughout this case study, we will seek to understand how the GGR’s suspension of funding under President Donald Trump (January 23, 2017 to present) impacts the number of global organizations able to offer comprehensive reproductive services, including abortions, compared to the funding granted under Democratic Party presidents.
Goals of the Policy
The goal of the GGR is to prevent US taxpayer dollars from being used to perform or promote abortion, upholding pro-life conservative political values with the intent of reducing abortions. Using fiscal pressure, this effectively impedes an NGOs’ ability to provide and promote abortion services (1).
As such, the GGR requires that foreign NGOs accepting US funding certify that they will not “perform, actively promote or lobby for abortion as a method of family planning”; this clause includes using funds from any source towards this action. Organizations will thus only receive US global family planning and health assistance funding if these conditions are met (3).
GGR Key Details
Specific Policy Regulations
Foreign NGOs and agencies must comply with the updated USAID regulations in order to receive most forms of global health assistance and/or family planning funding assistance from the US. Foreign NGOs and agencies must not: 1. perform abortions, 2. actively promote abortions as a method of family planning and 3. fund partner organizations in violation of 1 and 2. Here, actively promoting abortions includes operating family planning counseling services about the availability of abortions, encouraging women to consider abortions, campaigning the benefits of abortions, or lobbying a foreign government to legalize abortions (5).
Scale of Intervention
The GGR has widespread international effects seen mostly in low income countries, most notably in Sub-Saharan Africa. With the US as one of the largest foreign aid donors (6), foreign NGOs and agencies who rely on receiving funds to carry out global health assistance are directly and dramatically affected. Many of these affected NGOs are large scale organizations that play a significant role domestically in promoting global health. Limitations in funding due to this policy result in severe adverse effects that impact hundreds of millions of people globally (7). Two of the largest international family planning agencies that have been affected by the GGR are the International Planned Parenthood Federation (IPPF) and Marie Stopes International (MSI). USAID is one of the largest bilateral agencies affected; it provides global health assistance to 64 countries, 37 of which have legalized abortion. Due to the restrictive measures of the GGR, legal abortion services in these 37 countries can no longer be provided by the NGOs that receive US funding under the GGR(8).
Impact
Rates of Abortions
One of the first studies assessing the impact of the GGR was conducted in Sub-Saharan Africa in 2011. As indicated, “the induced abortion rate in Sub-Saharan Africa rose in high-exposure countries relative to low-exposure countries when the Mexico City Policy was reintroduced”(9). High-exposure countries are defined as countries who received a higher amount of financial aid from the United States for family planning and reproductive health services. More recently, research by Brooks et al. in 2019, found that there was a 40% increase in abortions and a 14% reduction in use of contraceptives among women living in countries most affected by the GGR (high-exposure countries) during periods when the policy was enacted (during the Bush administration (2001-2008)), compared to when the GGR was not in effect with the Clinton (1995-2000) and Obama (2009-2014) administrations) (3). Furthermore, data from the same study, outlined in Figure 1, shows a clear difference between administrations for the abortion rates between countries most affected by the GGR (high-exposure countries) and countries least affected by the policy (low-exposure countries). It is apparent that under the Bush administration, the difference in abortion rates between high and low-exposure countries is much greater than the difference during the Clinton and Obama administrations (10). Thus, the data suggests a direct impact of the GGR on increasing abortion rates and that the GGR has failed to achieve its goal to reduce abortions. Due to the recency of the implementation of Trump’s expanded GGR, data has on the policy’s impacts on abortion rates is yet to be available. However, it can be predicted that if the historical trend follows, Trump’s extended policy will result in a significant increase in rates of abortion. In fact, it is estimated that from 2017 to 2020, under the Trump administration, there will be an additional 2.2 million abortions, including 2.1 million unsafe abortions, internationally (10).
Impact on NGOs
In order to project future impacts of the expanded GGR under the Trump administration, a study by Moss and Kates (2017) has estimated the number of NGOs and amount of related funding that would have been impacted if Trump’s expanded policy had been in effect between 2013 and 2015. 1,275 foreign NGOs (639 as prime recipients of U.S. global health assistance and 658 as sub-recipients) and approximately $2.2 billion in funding directed to these NGOs would have been subject to the policy. In addition, 469 U.S-based NGOs receiving U.S. global health assistance would have been required to ensure that their foreign NGO subrecipients were in compliance. Among prime recipients alone, 92% of the affected foreign NGOs and 88% of their funding would not have been impacted prior to President Trump’s expansion of the policy. Overall, the study claims that, although
it may be too soon to estimate the actual impacts of the expanded GGR, a significant number of NGOs across the globe will be newly affected by the expanded policy due to its extended reach on all major global health programs. However, it is also important to note that many NGOs chose not to accept US aid under these provisions and offset the loss of funding by acquiring aid elsewhere (8).
More recently, a report conducted by amfAR, the Foundation for AIDS Research, demonstrated in early 2019 that a third of the implementing partners previously receiving funding from the President’s Emergency Plan for AIDS Relief had to change their operational structure to comply with Trump’s expanded policy. These changes included decreased provisions to recipient populations of non-abortion related information related to HIV and contraception (12).
Impacts on Maternal Mortality
The World Health Organization has stated that a key step in reducing maternal deaths is for states to ensure access to comprehensive reproductive health services, including abortions (13). Research has stated that unsafe abortions are a preventable cause of maternal mortality. An observed reduction in organizations offering women’s health services internationally along with a global increase in abortion rates under the GGR indicates that women are forced to choose unsafe abortions to terminate pregnancies as an emergency family planning option (14).
Prior evidence indicates that more restrictive laws on abortions have been associated with higher proportions of women seeking unsafe abortions. While maternal mortality has been decreasing overall, Doctors Without Borders reported that unsafe abortions still account for 1 in every 12 maternal deaths globally. these deaths attributed to unsafe abortions are associated with infections, severe bleeding, and obstructed labour. Unsafe abortions account for injuries and disabilities in approximately 7 million women and for 22,000 reported deaths annually (15).
Long Term Health Impacts of GGR
Key stakeholders, including leaders of organizations receiving US global health funding, are unclear about the scope of applicability of the GGR. Many were aware that the funding impacted by the policy had expanded, but they were unaware that the policy does not restrict provision of post-abortion care and other reproductive health services. The policy is often misinterpreted as applying to all reproductive and maternal health care services. Some sub-recipients reported that the implementation of the policy was never explained to them (16).
Consequently, a “chilling effect” has been associated with the GGR, meaning that NGOs and health care providers restrict their activities beyond what is required by the policy in order to protect themselves from the reprimands of non-compliance. In order to be cautious, health providers refused to deliver health services that are permissible under the policy. The consequences of this includes reductions in the supply of contraceptives, removal of sexual and reproductive health care information, and even closure of clinics. The confusion and stigma surrounding the GGR leads to organizations intentionally avoiding being associated with any abortion services, even those permitted by the policy (17).
Furthermore, there is a significant burden on non-U.S. donors: without replacement funding from other sources, NGOs are forced to shut down many maternal healthcare clinics. Oftentimes, this is also associated with the closure of comprehensive health clinics that serve as the only source of healthcare in remote communities(16,17). Interviews with local providers and NGOs in South Africa, Kenya, Nepal and Nigeria reveal the extensive repercussions of the new policy(18). Access to abortion and reproductive services are becoming increasingly inaccessible.
Additionally, contraceptive services, antenatal care, HIV testing and treatment, and screening for cervical, breast, and prostate cancers are affected (7). The Lancet report highlights the importance of “coupling” or integrating certain interventions (e.g. reproductive planning and HIV) in under-resourced locations (7). Ultimately, the closing of clinics due to the reinstated GGR reveals the key role that these coupled services play in regions where risk factors are highly shared, and how the continued funding of NGOs is essential for general healthcare provision in these communities. For example, a case of the GGR’s widespread impact on funding for NGOs can be seen in Ethiopia. The US Centers for Disease Control and Prevention (CDC) withdrew a five-year grant that was awarded in 2017 (an average US$2 million per year) as a direct result of the Family Guidance Association of Ethiopia’s (FGAE) noncompliance with the GGR. Without short-term replacement funding, 10 CDC-supported, confidential, sex worker-friendly clinics and 21 additional clinics that provide integrated HIV/AIDS services would be forced to close (17).
Discussion on the Failures of the GGR
Failure to Decrease Abortion Rates and Maternal Mortality
The GGR was introduced as a means to limit global abortion rates; however, analyses on the policy have demonstrated the opposite effect. Brooks et al. (2019), found a 40% increase in the rates of abortion in countries with reduced services due to the GGR between 2000-2008, when the policy was in effect, compared to countries with minimal service disruption due to the GGR during the same time period or when the policy was not in effect (11). Their findings attributed this failure primarily to a reduced access to modern contraceptives (10).
The chilling effect also created uncertainty concerning which services NGOs were permitted to perform. Thus, many NGO-operated clinics reduced their maternal healthcare services to avoid losing US funding. Additionally, the reduced access to contraceptive supplies in a community is associated with an increase in unintended pregnancies. When legal abortion is not available, pregnant women often resort to unsafe illegal abortion, which has been shown to result in an increase in maternal mortality (7).
The Policy Lacked Participant Voice
A significant failure of the GGR was the lack of respect and inclusion of participant voices from the organizations affected by the policy. Research shows that independent country representatives oppose the implementation of the GGR. One interviewee stated, “Why a [low income] country like us decided that we need a provision that decriminalizes abortion in certain circumstances [is] because we know that it’s important…safe abortion important. …Safe abortion will save abortion will save lives.” (19). The GGR disrespected the political stances of many countries by forcibly restricting the accessibility of and discussion surrounding abortion. Consequently, it violates human rights by infringing on national sovereignty and priorities (9). Additionally, the policy neither made use of local knowledge nor was it culturally appropriate or adapted to the specific cultural contexts of each region it affects.
Furthermore, for many nations, US funding is essential to the operation of foreign NGOs that provide essential reproductive health services beyond just abortion. Due to the US’s global political power and influence as the largest foreign aid donor, it has the capacity to implement the GGR without consultations with international partners(6). In an American Governmental review conducted on the GGR’s implications within 6 months of instatement under the Trump administration, only 31 of approximately 1,275 organizations that lost direct funding were included in the data collection. Therefore, there is clearly a disproportionate representation of the magnitude of stakeholders affected by the policy and a lack of stakeholder engagement in shaping the policy or deciding whether it should be implemented in the first place (9).
The Implications of Foreign Policy: From Local Governance to Human Rights
The implementation of the GGR seriously undermines local sovereignty and jurisdiction over reproductive health law. It represents a more profound, yet subtle continuation of colonialism in foreign policy. The introduction of the GGR and its restrictions of organizational funding pose tremendous legal and administrative issues in countries with pre-existing abortion laws. As shown in Figure 2, in 37 of the countries subjected to the restrictions on organizational funding, abortion is legal for women in specific cases, such as in the case of rape or when there are detrimental health risks for the mother (7). The vast variety of laws surrounding abortion and reproductive health only serve to complicate the applicability and feasibility of GGR implementation. This policy demonstrates the delicate relationship between foreign policy administration and legal pluralism.
The GGR may also be viewed as a serious threat to human rights. It detracts significantly from Sustainable Development Goal 3: “to achieve gender equality and empowerment of all women and girls that includes a target to achieve universal access to sexual and reproductive health and rights” (21). In failing to meet this goal, other outcomes of women’s health have also been affected, including maternal mortality due to unsafe abortions.
Effects on United States Funding
The GGR is a policy that has an enormous impact on financing for global health assistance, as it applies to $8.8 billion in global health funding from the US government (8).
Currently, the US government is the largest contributor of global health assistance; these funds sustain critical programs which aim to improve the health and lives of people, and healthcare systems around the world (8). The expansion of the GGR under the Trump administration applies to all global health assistance funding from U.S agencies and departments. Before, only the department of family planning was affected by the GGR. This amounts to 15 times the amount of funding when compared to previous versions of the GGR (8). The consequences of this could derail years of progress in improving health care services and systems, particularly in low income countries (8).
MSI, an organization that provides contraception and safe abortion in various countries worldwide, estimates a funding loss of $30 million per year due to the GGR(23). Furthermore, MSI estimates that from 2017 to 2020, the loss of funding and related discontinuation of their organization’s services will result in $400 million in direct health care costs. Besides the economic impact of the GGR, MSI also estimates that the cuts to its programs will result in 1.6 million fewer women having access to contraceptives from their trained providers, 6.5 million unintended pregnancies, and 21,700 maternal deaths (8).
These statistics reflect the impact on MSI clients alone. The IPPF estimated that it too would lose $100 million in funding during the Trump administration’s expansion of the GGR (24). The estimated consequences of these cuts in funding include 20,000 preventable maternal deaths, 4.8 million unintended pregnancies, and 1.7 million unsafe abortions according to the IPPF. Furthermore, IPPF anticipated using these funds to pay for 70 million condoms to prevent unintended pregnancies, HIV, and other STIs; 725,000 HIV tests to enable people to know their HIV status; treatment for 275,000 pregnant women living with HIV; and treatment for 525,000 STIs (9,23). IPPF states that there has been a decrease in the scale of projects, less availability of technical assistance, difficulties for small healthcare enterprises to remain in operation, and communities have experienced a significant decrease in the provision of safe, comprehensive, rights-based healthcare by IPPF (24).
MSI and IPPF are only two of the NGOs impacted by the GGR and their combined loss in funding could lead to a total of 7.5 million unwanted pregnancies and 2.5 million unsafe abortions (25). However, the overall cuts in funding and decrease in comprehensive healthcare provision globally reach an even larger scale. Reports in 2017 estimated that the total amount of global health funding subject to cuts due to the GGR is between $8 and $9 billion (26). Crucial US funds to some of the most effective foreign NGOs in 60 low- and middle-income countries are impact- ed (27). The impact of the GGR is especially devastating considering that many NGOs provide comprehensive healthcare in areas where no other clinics or services are available (27).
Another important financial consider- ation is that family planning globally is currently a struggling sector in terms of funding. In 2017, funding did increase to $1.27 billion, although it was the first increase following 2 years of declines and did not reach the peak funding level of $1.43 billion in 2014 (23). Critically, the US provided 38% of total bilateral funding in 2017, making it the largest bilateral donor to family planning. As a result, the US GGR’s regressive and extreme policy poses a major threat at a time when contraceptive healthcare funding is already at crisis levels (23).
Future Implications
Even if overturned, the lasting impacts of the GGR will still remain. The local impact in communities forced to cancel health services and close clinics will not be immediately remedied if the policy is reversed. As well, many NGOs have been unable to continue operations due to a lack of funding and as such, the abortion services and other services they provided are no longer available.
The funding for the NGOs that remain will take time to resolve as these organizations are concerned that the next administration coming into office may have an even more extreme version of the GGR (8). Finally, this policy violates women’s rights in making decisions regarding their own body.
Ending this oppressive policy will require decisive legislative action. The Global Health, Empowerment and Rights (HER) Act, was reintroduced on February 7, 2019 by family planning champions in the US House and Senate. The HER act would allow foreign NGOs receiving US funding to use non-US funds to provide medical services that are legal domestically, including safe abortion (28). The HER Act would also support freedom of speech and democratic engagement by removing the prohibition on funding for health NGOs that use their own funds to advocate for the right to legal abortion. Additionally, this act aims to nullify any existing US policy that interferes with these provisions. Therefore, this legislation would permanently repeal the expanded GGR by prohibiting future administrations from inflicting assistance restriction on foreign health care providers and preventing any future US presidents from reinstating the GGR unilaterally (29). Although this is a critical first step to halt the detrimental effects of the GGR, the bill will not be enacted until the US Congress presents the Global HER Act to a future president who is willing to sign the bill into law (29).
Therefore, it is of critical importance that both the US Congress and a future president reach consensus to support reproductive health and rights of women and girls around the world.
Conclusion
The GGR is a global health failure that uses fiscal pressure to prevent foreign NGOs from providing and promoting abortion services, even when this is against evidence-based best clinical practices. The policy forces NGOs to apply restrictive policies that are not even applied to US citizens. Research done by many groups shows increasing abortion rates as a result of the policy, demonstrating its failure in its desired goal. Other consequences of the policy include decreased access to reproductive services and less comprehensive maternal care.
Trump’s expansion of the GGR has also left a substantial funding gap for global health. Despite this significant setback, other countries, including Canada, Norway, Sweden, and Denmark, among others, have stepped up. The Liberal Canadian government, under Prime Minister Justin Trudeau, has pledged to donate $1.4 billion CAD annually by 2023 for women’s and girls’ health (27). Furthermore, studies have shown that the effects of the GGR are reversible as data shows increased contraceptive use and a decrease in abortion rates when the policy is rescinded compared to when it is in effect. Nevertheless, cutting access to care and advocacy via the GGR results in cutting access to human rights. Case studies showing the impact of the GGR reveal that it not only cuts services, but breaks trust and relationships, thus impacting communities negatively in the long term (23). Finally, the vice-president of MSI, Marjorie Newman-Williams, stated that, “Evidence shows that by blocking funding to the world’s largest NGO providers of modern contraception, unintended pregnancies and abortions go up. As a result, women and girls are less able to complete their education, have a career, or pursue their dreams for the future” (25).
Limitations
We acknowledge our case study’s limitations as some of sources contain bias and have not undergone a rigorous peer-review process. We ultimately decided to include these numbers, as we found difficulty in accessing peer-reviewed sources concerning the impacts of the GGR. We understand abortion is difficult to study. The stigma around abortions discourages women from speaking out or seeking medical care. In many countries, numerous abortions are performed in unsafe conditions without proper medical assistance because women fear for their safety if their families and communities were to find out. Even in western countries such as our own, abortions are still debated and met with stigma. We urge our readers to continue to fight against the stigma surrounding abortion and promote women’s autonomy over their own body.
Acknowledgements
We would like to thank Dr. Angel Foster, Professor at the University of Ottawa for providing her feedback and expertise while developing and refining our case study. We also thank Dr. Madhukar Pai and Lena Faust for their guidance, feedback and support throughout the semester and in preparation of this case study.
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