Armstrong, Nicky

Coast, Ernestina

van der Meulen Rodgers, Yana

LSE Research Online

January 11, 2019Trump’s reinstatement and expansion of the global gagrule has harmful effects for women, men, and childrenblogs.lse.ac.uk/usappblog/2019/01/11/trumps-reinstatement-and-expansion-of-the-global-gag-rule-has-harmful-effects-for-women-men-and-children/Two years ago this month, President Trump reinstated and expanded theglobal gag rule – the perennial Republican policy which cuts US funding forany organisation worldwide which offers abortion services or counselling.Yana van der Meulen Rodgers , Ernestina Coast and Nicky Armstrong arguethat not only will the measure – which covers a pot of nearly $10 billion infunding for NGOs – be ineffective in reducing the number of abortions, it willalso harm women’s’ reproductive health as well as making other crucialhealth services less available to women, men, and children around the world.Who influences whether women in poorer countries can access abortionsand other sexual health services?  It may surprise you, but the US presidenthas an important part to play. This is because of the so called “global gagrule”(GGR), a US foreign policy that cuts family planning and reproductivehealth assistance to any healthcare provider overseas which offers andprovides abortions.Having previously been rescinded by President Obama in 2009, this policywas reinstated by Donald Trump in 2017 just three days after he enteredoffice. Under Trump, any non-governmental organisation abroad can onlyreceive US assistance if it does not use funding from any source to provideservices that relate to abortion, even counselling. The extension of the policy to cover allglobal health funding – including funding to organisations that treat HIV/AIDS, fightmalaria, and work in maternal and child health – has created a funding shortfall ofapproximately $8.8 billion.1/7The GGR has been applied in some form by every Republican president since RonaldReagan in 1984. Since then, the policy has remained a hallmark of Republicanadministrations, with Democratic presidents scrapping it and Republican presidentsreinstating it. The name ‘global gag rule’ comes from its prohibition of even counsellingwomen on abortion or advocating for its legalisation, effectively placing a gag on whathealthcare providers can say. Additionally, under the GGR, foreign NGOs cannot even usetheir own funding for abortion-related activities.In its official directive, the Trump administration referred to George W. Bush’s PresidentialMemorandum, which stated “It is my conviction that taxpayer funds should not be used topay for abortions or advocate or actively promote abortion, either here or abroad.” TheTrump administration ordered the Secretary of State to extend this Memorandum to “globalhealth assistance furnished by all departments or agencies.” The reinstatement of thispolicy by Trump was widely expected, but his expansion to cover all forms of global healthfunding generally took health care providers by surprise. While the GGR is intended toreduce abortion rates, when it was last invoked in 2001 by Republican President George W.Bush, it prompted an increase in the number of abortions in countries affected most by thewithdrawal of healthcare funding and where abortion laws are strictest. These countriesinclude Guinea, Mozambique, Zambia, and Senegal in Sub-Saharan Africa, and Bolivia andNicaragua in Latin America.Why do abortions go up when there is less healthcare funding available?We looked at Demographic and Health Survey (DHS) data from 51 developing countries,covering about 6.3 million women per year. When the GGR was in place in 2001, women inhighly exposed countries were more likely to have an abortion compared to women in lessexposed countries, and before the policy was re-imposed. Women in Latin Americabecame three times more likely to get an abortion and twice as likely in Sub-Saharan Africa. Abortion rates rose in both these regions despite their very restrictive legal regimes aroundabortion.  Latin America has some of the most restrictive abortion laws in the world (infact, four countries in that region – Honduras, Nicaragua, El Salvador, and DominicanRepublic – still have complete abortion bans in all circumstances, even in cases when thewoman’s life is in danger).  The implication of this research is that in these regions withrestrictive national abortion laws, more abortions were performed under unsafe conditionsthat heightened women’s risks of complications. Women will find a way to have an abortionif they need to, even if it is difficult, dangerous or expensive.The main reason that the GGR led to an increase in the likelihood of abortion in theseregions was the major disruptions to family planning services brought on by the withdrawalof healthcare funding.  A series of site visits and interviews led by Population ActionInternational in a number of developing countries indicate that the funding cuts beginningin 2001 resulted in clinic closures, health personnel layoffs, fewer services, and reducedcontraceptive supplies. This reduced access to contraception led to more unintendedpregnancies and thus higher abortion rates.  Although there is no data yet on whetherabortions have risen under Trump’s expansion of the GGR, new qualitative researchconducted in Kenya, Nigeria, and South Africa points to reductions in service delivery aswell as new fees for contraceptives that used to be free.2/7Of the countries exposed to the global gag rule (GGR), abortion rates only fell in South andSoutheast Asia. It is not clear why Asia stands out in this way, but a simple model suggeststhat the relatively high overall cost of abortion (including non-pecuniary costs) compared togiving birth in those countries is one of the reasons.  This isn’t to say that Asian countrieswere unaffected by the policy.CreditL WHITE HOUSE [Public domain], via Wikimedia Commons.With its pockets of overcrowding, gender inequality, and growing rates of HIV infection (in2017, countries in the Asia-Pacific reported 280,000 new HIV infections), this region cannotafford to see disruptions to its health services caused by US restrictions on global healthfunding.  Bilateral aid from developed countries is the dominant source of populationassistance, and the US is by far the single largest donor country, so any restrictions in USfunding will have a large effect (Figure 1).Figure 1 – Population Assistance by Source Country, 2012Source: Rodgers (2018)Unsafe abortions3/7Globally, abortion rates have fallen over time, as Figure 2 illustrates. Most of this declinehas occurred in developed countries, while the estimated decline in developing countries ismuch smaller.  Despite intense lobbying efforts by anti-abortion groups, strong stigmasagainst abortion, and highly restrictive abortion laws in many countries, abortion remains acommon gynaecological procedure across the globe.  One quarter of all pregnancies end inabortion, up from 23 percent in the early 1990s.Figure 2 – Global Estimates of Induced Abortion, 1990-1994 and 2010-2014Source: Sedgh et al. (2016)In the face of the overall decline in abortion rates, the absolute number of abortionsconsidered unsafe according to standards set by the World Health Organization hasremained high.  Between 2010 and 2014, about 25 million unsafe abortions took placeglobally each year. This figure appears to be on the rise since 2008, when approximately21.6 million unsafe abortions took place globally.  Moreover, data from the United Nationsindicate that countries with highly restrictive abortion laws have substantially higher unsafeabortion rates (Figure 3).Figure 3 – Unsafe Abortion Rates by National Abortion Law Restrictiveness4/7Source: Rodgers (2018)Abortion accounts for up to 31,000 deaths each year, representing about 10 percent ofmaternal fatalities around the world. Although this number of abortion-related deaths ishigh, it has declined considerably since 1990 when a staggering 546,000 maternal deathswere attributed to unsafe abortions.  These deaths and complications are entirelypreventable.  Investing in sexual and reproductive healthcare services, providing effectivecontraception, and improving women’s access to safe abortion are the key.Funding gapIt is still too early to tell exactly how much funding has been cut already under Trump, butprojections indicate that at least 1,275 foreign NGOs and close to $2.2 billion in fundingallocated to them could be subject to the terms of the 2017 expanded global gag rule.  Thisis a substantial sum of money that is difficult for other donor countries to match, althoughthere are efforts to do so.  The effects are projected to be most severe in Sub-SaharanAfrica, the region that is still most exposed to the wider effect of the GGR.Case study evidence from Mozambique in a new report by the Center for Health andGender Equity has documented some of these effects.  The Mozambican Association forFamily Development (AMODEFA), a leading provider of sexual and reproductive healthservices in Mozambique that includes HIV prevention and treatment, decided to not complywith the terms of the GGR.  It expects to lose two-thirds of its total budget and has alreadybeen forced to close clinics across the country and lay off 30 percent of its staff, resultingin a drastic reduction in services provided by clinics that did stay open.  For example, anAMODEFA clinic in the southern city of Xai Xai reported that the number of HIVconsultations it provided dropped from 6,799 to 833 by the end of 2017.This finding is not unique to Mozambique. New research by a team from amfAR, theFoundation for AIDS Research and Johns Hopkins University covering 45 countries showsthat one third of all implementing partners in the President’s Emergency Plan for AIDSRelief (Pepfar) programme have already reduced or stopped their services or anticipatedoing so as a result of the expanded GGR.  These services include the provision ofcontraception, cervical cancer screenings, and adolescent health guidance.5/7The policy could also have indirect “trickle” effects such as less investment in girls’schooling if parents believe their daughters will have reduced access to contraception laterin life and won’t be able to delay having children.Unintended consequencesEvidence suggests that the GGR – renamed by the Trump administration as “ProtectingLife in Global Health Assistance” – does not achieve its objectives in most countries thatreceive US foreign aid. Instead, it appears that the policy is counterproductive, places livesat risk, and has unintended effects.Critics of the GGR argue that a constructive and cost-effective approach for US financialassistance is to support the integration of family planning and safe abortion into a fullrange of reproductive health services.  For example, Barbara Crane, a former official withthe reproductive health organisation Ipas, made a strong case for integrated healthservices as the key for reducing unsafe abortions:“We need stronger health systems and we need integrated service delivery.  One of theproblems is that family planning has often been kept separate from other health servicedelivery and verticalized, and abortion even more so.  How do you break the cycle ofunwanted pregnancy and unsafe abortion? You need to help women have access to services.”The cost of providing this for women in a developing country runs to just $8.56 per persona year. It is imperative for US foreign aid policy to support this agenda rather thanmarginalise women and their reproductive health with ideologically-based fundingrestrictions.Please read our comments policy before commenting.Note:  This article gives the views of the author, and not the position of USApp– AmericanPolitics and Policy, nor of the London School of Economics.Shortened URL for this post: http://bit.ly/2TCHcXUAbout the authorsYana van der Meulen Rodgers – Rutgers UniversityProfessor Yana van der Meulen Rodgers (@YanaRodgers) is a Professor atRutgers University and Faculty Director of the Center for Women and Work.Yana is the author of the new book The Global Gag Rule and Women’sReproductive Health: Rhetoric versus Reality. Yana served as Presidentof the International Association for Feminist Economics in 2013-14, and shehas served as an associate editor for Feminist Economics since 2005.6/7Ernestina Coast – LSE Department of International DevelopmentProfessor Ernestina Coast (@LSE_ID) is Professor of Health andInternational Development in the Department of International Developmentat LSE. She is the Principal Investigator of “Improving adolescent access tocontraception and safe abortion in sub-Saharan Africa” and is the thematiclead for sexual and reproductive health on “Gender and Adolescence:Global Evidence”.Nicky Armstrong – LSE Global Health Initiative and Latin America CentreNicky Armstrong (@NickyArmstrong0) works in communications for boththe Global Health Initiative and the Latin America and Caribbean Centre  atthe LSE. Nicky also works with PEN focusing on the freedom of speech andhas a background in International Relations with a focus on US foreignpolicy and American exceptionalism.7/7

Trump’s reinstatement and expansion of the global gag rule has harmful effects for women, men, and children

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Trump’s reinstatement and expansion of the global gag rule has harmful effects for women, men, and children

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