Failure to Fund: The Mexico City Policy’s Impact on Global Health

BY CAROLINE TANGOREN

On January 23^rd, just two days after the historic Women’s March on Washington demonstrated popular support for women’s rights, President Trump signed an executive order to reinstate the Mexico City Policy, dealing a horrible blow to women’s health globally.¹ Broadly speaking, this hot-topic policy prevents any international non-governmental organization (NGO) that provides or promotes abortions from receiving United States government funding. The Mexico City Policy, also known as “the Gag Rule,” has come and gone since its creation in 1984 under the Reagan Administration.² Unfortunately, the policy has become a high-profile piece of legislation in both international and domestic abortion politics. Many have argued, quite convincingly, that the Mexico City Policy is a gross violation of human rights enumerated in the United States Constitution and international law, as well as an illegitimate form of donor control.³ Even ignoring these more political issues, however, objective review of the Mexico City Policy demonstrates its failure: it has been unsuccessful in bringing about the desired reduction in abortions, and has negatively impacted healthcare provision for unrelated issues including child immunization, HIV prevention and treatment, and prenatal care.⁴ The consequences of these funding restrictions were evident, particularly for marginalized female populations, when the policy applied to a mere 6% of all US global health funding.^4,5 As the Trump Administration expands these funding restrictions to all global health aid, the detrimental health outcomes previously seen may only be exacerbated.⁶ The Mexico City Policy under the Trump Administration must be met with newfound opposition from legal and public health scholars. Advocacy, employing both ethical and empirical arguments, is vital to repealing the Gag Rule and protecting decades of progress in global health.

The Mexico City Policy’s Historical Origins

The first serious restrictions on foreign family planning aid came in 1973 with the Helms Amendment. This statutory ban, passed shortly after the Roe v. Wade decision made abortion legal in the United States, banned all US funds from the Foreign Assistance Act from paying for the performance of abortion as a method of family planning. The ban did not extend to abortion in cases of rape, incest, or threat to the life of the mother. While the Mexico City Policy has remained a controversial issue over the decades, there has been very little political discourse on the Helms Amendment.⁷

In the 1980s the Reagan administration was put under considerable pressure from anti-abortion and, in extreme cases, anti-family planning constituents to push the Helms Amendment even further. The result, announced at the 1984 International Conference on Population in Mexico City, was a set of serious restrictions on US family planning aid. The United States delegate stated that “the United States does not consider abortion an acceptable element of family planning programs.” As such, the United States would no longer contribute to any NGOs that “perform or actively promote abortion as a method of family planning in other nations.” The US cited the call for “legal protection for children before birth” under United Nations Convention on the Rights of the Child as a motivating factor for such restrictions.⁸ Ironically enough, in 2017 the United States is now the only state in the entire 193-state UN system that has yet to ratify the Convention on the Rights of the Child.⁹

The Mexico City Policy, or Gag Rule, consisted of three major restrictions. First, no USAID money could go to groups using even non-US funds to promote or provide abortions, or conduct research to improve abortion methods. The Gag Rule also prohibits aid recipients from lobbying, even with-non-US funds, for the liberalization or decriminalization of abortion. There could also be no public education campaigns on the benefits or availability of abortion as a family planning method. Finally, health workers in USAID-funded NGOs could not actively promote abortion as an option for their patients/clients. They could not refer women to an abortion provider in countries where abortion is legal in circumstances other than rape, incest, or life-threatening conditions.¹⁰

There are important nuances in the Gag Rule worth highlighting. First, these restrictions apply only to abortion as a family planning method, and do not apply to abortion in the case of rape, incest, or threat to the life of the mother. Furthermore, the restrictions previously applied only to funds awarded for family planning, not to grants for any other global health programming, such as HIV prevention and treatment. Additionally, NGOs that received USAID funding are not permitted to work with NGOs that do not follow the Gag Rule’s restrictions. For example, NGOs receiving contraceptives from the US are not allowed to distribute them in clinics that provide abortions.¹¹

The gag rule on lobbying applies to pro-choice groups only; anti-abortion groups have no such limitations on speech or political activism. Finally, physicians, nurses, and other family planning counselors are able to “passively respond” to clients’ specific questions about abortion. They cannot, however, initiate the conversation nor offer information outside the scope of the client’s questions. Such questions can only be answered after the provider is sure the client is pregnant and that said client has already decided to have a legal abortion. While the exceptions to provider silence were designed to lessen the most significant Gag Rule controversies, many NGOs feel abiding by the Mexico City Policy would still force them to compromise their ethics.¹⁰

The Mexico City Policy stayed in place from 1984 until 1993, when President Clinton rescinded it. During the Clinton administration, political turmoil surrounding the policy grew. President Clinton threatened to veto any bill put forward containing similar foreign aid restrictions. Anti-abortion leaders in Congress slowed down legislation on issues ranging from foreign assistance appropriations to trade in attempts to gain bargaining power on this particular issue. This fighting had substantial negative consequences for governmental functioning, including a government shutdown and delays in UN dues payments from 1995 to 1999. Finally, a compromise was struck: Republicans supported the repayment of almost $1 billion the US owed to the UN, and the Smith Amendment was passed. The Smith Amendment was a more tempered version of the Mexico City Policy in which foreign NGOs were subject to the same restrictions regarding abortion. Those that refused to comply, however, could still receive up to $15 million in funding.³

The Smith Amendment remained in effect until President Bush took office in 2001. President Bush reinstated the Mexico City Policy on the anniversary of the Roe v. Wade decision, and expanded the policy to include State Department funds used for family planning overseas. Importantly, however, the Bush Administration chose not to extend the policy to HIV/AIDS funding. The continued limitation on the policy suggests even proponents of the Gag Rule believed it had at least some negative health consequences. Furthermore, the restrictions on abortion lacked support when more generally applicable threats such as HIV/AIDS seemed to be involved, rather than threats to women’s health, alone. The policy remained in place until President Obama took office in 2009, at which point he, like Clinton, rescinded the policy.³

In January 2017, President Trump reinstated and drastically expanded the Mexico City Policy. The policy previously applied to only the family planning and reproductive health funds, a mere 6% of the global health budget.¹² President Trump expanded the policy to include all US global health assistance in all agencies and departments, not simply US family planning aid through USAID and the US Department of State. The current agencies and departments affected by the policy include USAID, the State Department, the Center for Disease Control and Prevention and the National Institutes of Health (under the Department of Health and Human Services), and the Department of Defense.¹³ Furthermore, abortion laws globally are relaxing such that many countries allow legal abortions in cases outside the Gag-Rule-approved situations of rape, incest, or threat to the life of the mother. In 2017 more NGOs may face situations in which Gag Rule restrictions limit discussions of legally permitted medical procedures.³ The expansion of the policy’s application and the relaxation – albeit limited – of abortion restrictions in foreign nations means more NGOs than ever will be put in a difficult position in choosing whether to comply with the Mexico City Policy’s restrictions.

The Global Gag Rule’s Impact on Health

When the Mexico City Policy was first enacted in 1984 and when the policy was reinstated in 2001, NGOs were immediately thrown into what many viewed as a lose-lose situation: rejecting the restrictions would cause a serious drop in funding, reduced service provisions, and poor health outcomes, while adherence to the policy prevented full disclosure of health information and options to clients, again resulting in poor health outcomes.¹⁰ While there is a lack of robust literature on the impact of the policy, available information overwhelmingly shows the validity of this catch-22. The Mexico City Policy has failed to reduce the number of abortions.³ Instead, it has resulted in decreased access to contraceptives, increased rates of unwanted pregnancies, increased abortion rates, and reduced access to non-abortion health care for hundreds of thousands of people around the globe.^{4, 14}

Decreased Access to Contraception

The US government is the largest purchaser and distributor of contraceptives internationally, and USAID is key in assisting the estimated 225 million women who have an unmet need for modern contraception.¹⁵ However, as demonstrated during the last active period of the policy, the Gag Rule severely reduces the availability of contraceptive use.^{3, 4, 13} A study of 20 Sub-Saharan African countries, for example, shows significantly different growth rates in the prevalence of contraceptive use for countries depending on the amount of USAID funding they received. If a country received more USAID funds than the average African nation, it was considered to have high-exposure to the Mexico City Policy. If it received below average funding, it was considered to have low-exposure. After the Mexico City Policy was reinstated in 2001, contraception use prevalence in low exposure countries grew 1.8% faster than contraception use prevalence in high exposure countries, reaching statistical significance.¹³

From 2001 to 2008, USAID stopped supplying contraceptives to any NGOs in 16 developing countries in Africa, Asia, and the Middle East. Many of these countries suffered from very high rates of HIV.⁴ For example, the Lesotho Planned Parenthood Association (LPPA) received 426,000 condoms and similar quantities of IUDs and oral contraceptives from 1998 to 2000. When the Gag Rule was put back in place in 2001, however, LPPA was ineligible for USAID-provided contraception. LPPA was the only recipient of USAID supplies, and thus from 2001 to 2008 no NGO in Lesotho received family planning aid or contraception supplies from the US government. This cutoff occurred at a time when one in four Lesotho women were HIV positive.⁴

In 13 other developing nations, USAID stopped supplying contraception to the leading providers of family planning services, such as Planned Parenthood Association of Zambia, who refused to follow the Gag Rule.⁴ While the Planned Parenthood Association of Zambia does not even provide abortions, it refused to limit its counseling or referral information. This was particularly important to the organization, as Zambia permits abortions under more liberal circumstances than the Gag Rule, including risk to the health of the mother. Thus, the Planned Parenthood Association of Zambia faced a 24% budget cut, and was forced to scale back its services. This was particularly impactful given Planned Parenthood’s key role in distributing contraceptives to smaller NGOs and government health centers. Proponents of this policy often say USAID could simply collaborate with other NGOs who comply with the Gag Rule to keep contraception access up.⁴ However, research suggests that these other NGOs may be less effective and experienced than larger aid recipients, such as Planned Parenthood in Zambia, and also may be more limited in their geographic reach.³

Even if the Planned Parenthood Association of Zambia had accepted the Gag Rule, the situation may not have been much better. NGOs in Romania, for example, accepted the Gag Rule and were forced to terminate their partnerships with abortion providers during the Bush Administration. Abortion is legal in Romania and very common: there is a substantial lack of family planning services, and the health system pays physicians more for providing abortions than contraception. The Mexico City Policy forced the division between these preventative and reactive approaches to unwanted pregnancies. Thus women who received abortions had more limited access to quality counseling or contraception to prevent future unwanted pregnancies. Research suggests this separation, driven by the Mexico City Policy, actually contributed to increases in induced abortions.^{3, 4} It is thus reasonable to assume that the expansion of the Mexico City Policy under the Trump Administration will result in a reduction in contraception use, regardless of whether or not NGOs accept or reject the Mexico City Policy. Such a reduction in contraception use will drive up the rate of unwanted pregnancies and, both tragically and ironically, contribute to an increased demand for the very procedure the policy seeks to eliminate.

Increased Rates of Abortion

When the Mexico City Policy was first in place from 1984 to 1992 there was no evidence that it reduced the incidence of abortion.³ Instead, as previously mentioned, the decreased access to contraception may have contributed to increased abortions in Romania and other Central and Eastern European nations with legal abortion such as Albania, Armenia, and Moldova.^{4, 16} The increase in abortions during active Gag Rule times was well quantified in the aforementioned study on Sub-Saharan Africa, as well.¹³ Low exposure countries had relatively consistent abortion incidences, ranging between 10 and 20 induced abortions per 10,000 women-years from 1994 to 2008. High exposure countries, however, saw an exponential growth increase when the Mexico City Policy was reinstated in 2001 (Figure 2). Further analysis found women in a high exposure country after 2001 were 2.55 times more likely to have received an induced abortion than women in a low exposure country, even after controlling for women’s place of residence, education attainment, and use of contraceptives, as well as funding for family planning and reproductive health from sources other than the US.¹³ These numbers include both safe and unsafe abortions, with the health and economic consequences of the latter being particularly extreme. The World Health Organization estimates that five million women are admitted to hospitals as a result of unsafe abortion every year in developing countries.¹⁷ The annual cost of treating major complications from unsafe abortions is approximately $680 million, thus putting significant strain on developing nations’ financial resources and health infrastructure.¹⁸

Maternal Mortality and General Health Services Impact

The negative impacts of the Mexico City Policy do not end with unwanted pregnancies and abortion. Instead, the Gag Rule forces noncompliant NGOs to lose significant funding and scale back vital health services. It allows abortion politics to dictate issues from HIV prevention to child immunization to malaria treatment.^{4, 19} As Trump’s expansion subjects even more funds to the Mexico City Policy’s restrictions, the consequences of the policy beyond 2017 may be even greater than in previous decades.

Most obviously, the policy hurts maternal health. The scaling back of family planning services and closure of clinics reduces women’s access to prenatal and postnatal services. This in turn reduces the likelihood of women having a skilled birth attendant present during delivery, and increases the risk of maternal death during childbirth. Nepal, for example, had the second highest maternal mortality rate in the region (527 maternal deaths for every 100,000 live births) when the Mexico City Policy was reinstated in 2001.²⁰ Many organizations refused to submit to the Gag Rule during this time because Nepal had some of the strictest abortion laws in the world: women could be imprisoned for seeking or receiving abortions for any reason whatsoever. The Ministry of Health was actively calling on NGOs to join in advocacy work and the expansion of abortion services, and thus NGOs refused to curtail their political activism to receive USAID funding. This activism ultimately resulted in the 2002 liberalization of abortion laws to make exceptions for rape, incest, and risk to the life of the mother. Even after 2002 NGOs felt continued education on unsafe abortions and health consequences was vital to fully realize the new law, and thus many continued to reject to the Gag Rule.¹⁵ From 2001 to 2008, Nepal lost approximately $100,000 per year in USAID funding. Due to significantly reduced budgets, many NGOs eliminated mobile clinics providing prenatal and postnatal care, among other reproductive services unrelated to abortion.²¹ Paradoxically, the Mexico City Policy even negatively impacts the health of women who carry their pregnancy to term.

The consequences of the policy are not limited to women, either. For example, the Family Planning Association in Kenya refused the Gag Rule restrictions and lost so much funding it was forced to close clinics serving 19,000 people. Marie Stopes International Kenya, a leading family planning organization with a particularly strong presence in marginalized rural areas, closed clinics serving over 300,000 men, women, and children. It laid off one fifth of its staff and increased client fees, as well. These clinics provided much more than family planning services: they provided malaria treatment and screening, HIV testing and counseling, and child immunizations.⁴

Ethiopia provides another poignant example of the reduced access to healthcare due to the Mexico City Policy. Organizations such as the Family Guidance Association of Ethiopia refused to curtail their public awareness campaigns on abortions. The Family Guidance Association of Ethiopia does not provide abortion services; however it frequently speaks to policymakers about the thousands of lives lost annually due to unsafe abortions. Its commitment to educating policymakers on this serious public health issue cost the organization over half a million dollars in USAID funding. As a result, the Family Guidance Association of Ethiopia closed several healthcare centers and clinics serving over 300,000 women and 229,000 men in urban Ethiopia. Rural areas were additionally hurt with the reduction or elimination of community-based distribution programs. These programs were often the only source of family planning services, HIV information, and health referrals in the most remote areas of the country.²² As clinics close and are forced to concentrate limited resources in particular programs or geographic regions, the Mexico City Policy exacerbates issues of inequitable access to quality healthcare on both a local and global scale.

Moving Forward: The HER Act

This article puts forth substantial evidence that the Mexico City Policy is, bluntly, a failure. It fails to promote US values abroad, such as free speech, political engagement, and gender equality. It fails to improve, or even maintain, healthcare access for men, women, and children. It even fails to achieve its main objective to reduce induced abortion rates. The Mexico City Policy imposes the conservative views of a minority of Americans on hundreds of thousands of individuals around the globe.^{3, 23}

With the consequences of the Gag Rule evident, policymakers have mobilized against these ineffective funding restrictions. Within 24 hours of Trump’s executive order expanding the Gag Rule, Vermont Senator Jeanne Shaheen and New York Representative Nita Lowey introduced the Global Health, Empowerment, and Rights (HER) Act in the Senate and House of Representatives, respectively.²³ The HER Act strives to permanently repeal the Mexico City Policy, stating that foreign NGOs shall not be ineligible for foreign aid “solely on the basis of health or medical services, including counseling and referral services, provided by such organizations with non-United States Government funds.” Organizations are also free to use non-United States Government funds for advocacy and lobbying activities.²³ While the Act has overwhelming Democratic support, it has important support from Republicans such as Maine Senator Susan Collins as well. The HER Act has been read twice and referred to the Committee on Foreign Relations, before hopefully returning to Congress for a vote.²⁴

Given the obvious inefficacy of the Mexico City Policy, the passing of the HER Act is vital for global health improvements and the realization of women’s reproductive rights. Regardless of the Policy’s discriminatory nature, violation of international law, and financial coercion of foreign NGOs, public health analyses alone demonstrate the Gag Rule’s failure. It reduces women’s access to contraception, increases rates of unwanted pregnancies, and actually contributes to increased abortion rates, all while putting unethical limitations on compliant healthcare providers’ free speech and professional judgment.^{3, 21, 23} Noncompliant NGOs are forced to reduce or eliminate health services, causing negative health outcomes unrelated to abortion and exacerbating inequality issues both within and across countries.⁴ The United States is the largest funder and implementer of global health projects in the world.⁵ With such power comes a responsibility to objectively evaluate policy outcomes and respond accordingly. Hopefully the recent HER Act will inspire such reflection and reverse these ludicrous funding restrictions. Then the United States may be able to use its wealth and international influence on global health to promote, rather than hinder, progress.

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References:

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15. Baird, K. (2004). Globalizing Reproductive Control: Consequences of the ‘Global Gag Rule’. Linking Visions: Feminist Bioethics, Human Rights, and the Developing World, Rosemarie Tong, Anne Donchin, and Susan Dodds (eds). Boulder, CO: Rowman & Littlefield, 133-145.
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18. Jones, A. A. (2004). The Mexico City Policy and its Effects on HIV/AIDS Services in Sub Saharan Africa. BC Third World LJ, 24, 187.
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20. The Global Gag Rule Impact Project (2006) Access Denied: The impact of the global gag rule in Nepal, Global Gag Impact Project, Washington, DC. Retrieved from https://www.engenderhealth.org/files/external/ggr/ggrcase_nepal.pdf.
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22. Pew research Center (2017). Public Opinion on Abortion: Views on abortion, 1995-2016. Retrieved from http://www.pewforum.org/2017/01/11/public-opinion-on-abortion-2/.
23. Global Health, Empowerment, and Rights Act, S. 210, 115^th Congress (2017).
24. United States Congress (2017). All Bill Information for S.210 – Global Health, Empowerment, and Rights Act. Retrieved from https://www.congress.gov/bill/115th-congress/senate-bill/210/all-info?r=1#major-actions.