Published byEmily Christopher
Published on16 February 2017
The impacts of new American president Donald Trump’s policies on health care and health research in Africa are already starting. On 23 January 2017 President Trump reinstated the Mexico City Policy, and expanded its scope to include all global health funding provided by the US government (1).
The Helms amendment of 1973 prevents international NGOs that receive US federal family planning funding from using that funding to provide abortions, as it states that “No foreign assistance funds may be used to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortions (2).” The Mexico City Policy takes things a step further by preventing international NGOs that receive US family planning funding from using any other sources of funding to pay for abortion services, including performing, counseling on or referring patients for abortion, as well prohibiting engagement in local advocacy efforts to liberalize or decriminalize abortion (3, 4, 5).
Trump’s reinstatement of the Mexico City Policy is not surprising. Ever since Ronald Regan created it in 1984, it’s been rescinded by Democratic presidents and reinstated by Republican presidents (6). As America’s government changes, the strings attached to US federal funding change.
What’s different about Trump’s version of the policy is the application of the above-mentioned conditions to all global health funding provided by the US government. His memorandum directs “…the Secretary of State, in coordination with the Secretary of Health and Human Services, to the extent allowable by law, to implement a plan to extend the requirements of the reinstated Memorandum to global health assistance furnished by all departments or agencies (1).” This expansion to “global health assistance furnished by all departments or agencies” extends the reach of the policy from around $575 million [the amount allocated to bilateral family planning assistance in 2016] to as much as $9.5 billion in global health assistance from the United States (7).
The United States is the largest donor to international reproductive health efforts, accounting for over 40 percent of all funds categorized by the UN as “international population assistance,” including aid for family planning, maternal and child health, and HIV/AIDS programs (5). The African continent houses about two-thirds of USAID’s family planning priority countries, and is highly dependent on USAID funds (8).
“Attempts to stop abortion through restrictive laws – or by withholding family planning aid – will never work, because they do not eliminate women’s need for abortion. This policy only exacerbates the already significant challenge of ensuring that people in the developing world who want to time and space their children can obtain the contraception they need to do so.” – Marjorie Newman-Williams, Vice-President and Director of Marie Stopes International’s international operations (9)
The historical effects of the “global gag rule” (as the Mexico City Policy is referred to by critics) have been overwhelmingly negative. In the past, affected NGOs have been forced to choose between providing critical health services to a population in need, and accepting US funding to do so. Family planning programs have had to downsize, reduce services, or even shut their doors entirely. These clinics often serve as the only family planning resource for their communities. As a result, the women who attend these clinics have lost access to important family planning services, which increases their risk for unsafe abortions resulting from preventable, unintended pregnancies (3).
A 2011 study examined the relationship between the Mexico City Policy’s reinstatement by George W Bush in 2001 and the probability of induced abortion in sub-Saharan African women. The authors found significant evidence to support an association of the Mexico City Policy with increased abortion rates in sub-Saharan Africa. “Overall, the induced abortion rate increased significantly 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 (P = 0.01).” The study looked at induced abortion in countries with high and low exposure to the policy (“…classified as high or low according to whether the level of per capita financial assistance provided to the country for family planning and reproductive health by the United States was above or below the median for the period from 1995 to 2000.”) The graph below shows the induced abortion rate trends between high and low exposure countries. Women in countries with high exposure to the 2001 Mexico City Policy were more likely to have an induced abortion than those in low-exposure countries, with an adjusted odds ratio of 2.55 (95% CI: 1.76-3.71) (6).
The Mexico City Policy’s restrictions can also lead to a lack of trust between providers and patients, since providers may be obligated by the policy to provide incomplete information regarding family planning options. The American Congress of Obstetricians and Gynecologists states that the policy’s terms “violate basic medical ethics by jeopardizing a health care provider’s ability to recommend appropriate medical care (10).”
“As in the past, the Global Gag Rule will not prevent abortions. What it will do is shutter clinics, limiting access to contraception, HIV testing, counseling and treatment, safe delivery and newborn care, and other critical health services (10).”
According to the WHO, 21,6 million women experience unsafe abortions worldwide each year, with 18,5 million of these occurring in developing countries. These countries are the primary recipients of US federal global health funding. Of those women experiencing unsafe abortion, 47 000 die each year. Deaths due to unsafe abortion account for nearly 13 percent of all maternal deaths (11).
In Africa alone, nearly 1.6 million women are treated for complications from unsafe abortions each year (12).
Now that President Trump’s version of the Mexico City Policy is in effect, not only are family planning organizations at risk, but the viability of all global health providers who receive US federal funds is threatened. This change could affect organizations that provide life-saving treatment for HIV, malaria, tuberculosis and other global scourges that threaten the lives of people most in need of the services these organizations provide.
Several major international organizations have pledged to stop taking US federal funding as a result of this new policy. The International Planned Parenthood Federation said in a statement that it “will not support policies which actively restrict or take away an individual’s right to choose (13).” Marie Stopes International has also refused to accept the conditions imposed by President Trump’s executive order (9).
If health care providers affected by the gag rule are forced to close or cut back on services, countless of the world’s poorest women could find themselves without access to the health services they need.
Africa depends on US funding for many critical public health services. President Trump’s dramatically expanded version of the global gag rule will have negative and far-reaching consequences for years to come. It is important that affected organizations search for alternative funding sources in order to continue to provide appropriate, ethically- and legally-sound care to the populations they serve.
- Presidential Memorandum Regarding the Mexico City Policy, 82 Fed. Reg. 8495 (25 January 2017). https://www.whitehouse.gov/the-press-office/2017/01/23/presidential-memorandum-regarding-mexico-city-policy. Accessed 14 February 2017.
- USAID’S Family Planning Principles and U.S. Legislative and Policy Requirements. 26 January 2017. https://www.usaid.gov/what-we-do/global-health/family-planning/usaids-family-planning-guiding-principles-and-us. Accessed 14 February 2017.
- Barot S. and Cohen SA. The Global Gag Rule and Fights over Funding UNFPA: Issues That Won’t Go Away. Guttmacher Policy Review. 2015; 18(2): 27-33. https://www.guttmacher.org/gpr/2015/06/global-gag-rule-and-fights-over-funding-unfpa-issues-wont-go-away. Accessed 14 February 2017.
- The Henry J. Kaiser Family Foundation. The Mexico ity Policy: An Explainer. 23 January 2017. http://kff.org/global-health-policy/fact-sheet/mexico-city-policy-explainer/. Accessed 14 February 2107.
- Cincotta RP and Crane BB. The Mexico City Policy and U.S. Assistance. Science. 2001; 294(5524): 525-526.
- Bendavid E, Avila P, Miller G. United States aid policy and induced abortion in sub-Saharan Africa. Bulletin of the World Health Organization. 27 September 2011.
- With a Stroke of the Pen Trump’s Global Gag Rule Dramatically Expands Harmful Health Impacts. Washington Memo. 25 January 2017. http://pai.org/newsletters/stroke-pen-trumps-global-gag-rule-dramatically-expands-harmful-health-impacts/. Accessed 14 February 2017.
- Sieff K. Trump’s revival of the antiabortion ‘gag rule’ could have a big impact in Africa. Washington Post. 24 January 2017. https://www.washingtonpost.com/world/africa/trumps-revival-of-the-antiabortion-gag-rule-could-have-a-big-impact-in-africa/2017/01/24/2ec882e6-e23e-11e6-a419-eefe8eff0835_story.html?utm_term=.541e40b93020. Accessed 14 February 2017.
- Marie Stopes International. Re-enactment of the Mexico City Policy. 23 January 2017. https://mariestopes.org/news/2017/1/re-enactment-of-the-mexico-city-policy/. Accessed 14 February 2017.
- An Attack on Women Everywhere: Stop Trump’s Global Gag Rule. 2017. http://pai.org/gag-rule/#0. Accessed 14 February 2017.
- World Health Organization. Prevention Unsafe Abortion. Sexual and Reproductive Health. 2017.
- Singh S and Maddow-Zimet I. Facility-based treatment for medical complications resulting from unsafe pregnancy termination in the developing world , 2012: a review of evidence from 26 countries. BJOG: 2016; 123(9): 1489-1498.
- International Planned Parenthood Federation. Support Us. 2017. http://www.ippf.org/support-us. Accessed 14 February 2017.