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On the fourth day of his administration, US president Donald Trump signed an executive order reinstating the Mexico City policy, also known as the Global Gag Rule (GGR). The policy doesn’t have a domestic impact, other than ideological, but it prevents US foreign aid from supporting international organizations that provide abortions, or as much as counsel women on the possibility of abortion.
The policy was introduced by Ronald Reagan in 1984, and has been repealed by every Democratic president since, only to be reinstated by each Republican one.
Trump followed the pattern but upped the ante: The 2017 version of the policy contains a seemingly small but deeply consequential expansion that requires not just organizations working in reproductive care, but most areas of health, to certify they were not discussing abortion, or advocating for its liberalization, in order to receive US funding.
Who pays for the gagging?
The US is the largest international donor to reproductive health international aid, funding nearly 30% of the sector. In 2017, this amounted to about $489 million, down from $533 million in 2016. The world is sensitive to America’s budget rules. As a consequence of the Mexico City Policy, for instance, a large part of NGOs working in reproductive health around the world have had to cancel programs, lay off personnel, and spend resources to find alternative funding to continue their work.
Although the gag rule is aimed at abortion, it ends up causing financial woes for organizations that provide other forms of family planning, including contraception and the prevention of sexually transmitted diseases, particularly HIV/AIDS.
We don’t yet know the exact number of women affected by all of the changes. Figures should come available in early 2019, but they will just be preliminary, as the full effects of the policy might take over five years to be assessed, Margaret Giorgio, a researcher at the Guttmacher Institute, a reproductive-health policy group, said on a recent panel at the International Conference on Family Planning.
Early estimates suggest millions of women have lost access to reliable contraception in the past year and a half, and more will follow them as US funds acquired prior to Trump’s order run out.
The US also has cut off funds to the UN Population Fund (UNFPA), which has drastically reduced the agency’s resources for contraception in emergency settings—like war zones, refugee camps, and places affected by natural disasters. The US previously contributed roughly $35 million a year to the emergency fund, Henia Dakkak, a senior advisor with UNFPA, told Quartz.
“Who is going to suffer?” she asked rhetorically. “The women, and the girls.”
The health, social, and economic impact of overpopulation and of unplanned, unwanted pregnancies is enormous. And unsafe abortions, which rise when safe abortion becomes less available, accounts for up to 14% of maternal mortality worldwide, according to the World Health Organization (WHO). That’s equal to roughly 45,000 deaths a year.
One step back, one step forward
The complicated nature of the policy, which has American legal experts and foreign aid workers struggling to pin down exactly what is or isn’t allowed under the new rules, may be prompting many organizations, out of fear of losing their funding, to self-censor or cut programs that they could have maintained, said Jonathan Rucks, who leads advocacy for the family planning organization PAI. (He spoke on the same panel as Giorgio.)
There is, however, another group of organizations getting cut off by choice.
According to the rule, abortions provided in cases of rape, incest, and life threatening conditions for the mother are allowed, and in many countries that receive US aid funds, that is all that the law permits anyway. But there are some groups that have ideologically rejected the idea of complying with US requirements that put women in danger and prevent them from providing comprehensive care that is legal in their countries. They deem abortion—either providing or consulting about it—too core to their mandate to sacrifice, so they will look for funding elsewhere.
Abortion has long been the elephant in the room when it comes to family planning. There is no mention of advancing abortion rights in the UN Sustainable Development Goals to be achieved by 2030. Even at a conferences focused on reproductive health, it is usually barely discussed in the open.
But Trump’s expanded Mexico City policy has been a wake-up call for abortion-rights advocates to realize the importance of their mandate. And so, while the presidential order was intended to force organizations to speak less about abortion, Trump’s policy actually did the opposite.
The global gag rule “has had the positive effect of putting the conversation on abortion on the table,” said Carole Sekimpi of international reproductive-care organization Marie Stopes, where she is director for Uganda. Sekimpi isn’t minimizing the impact of the cuts—her organization, for instance, lost key partners after local organizations rushed to distance themselves to a provider of abortion care—but she says not all is lost, and in fact this could be an opportunity. The policy is “building a movement of resilient people” who say that safe abortion “is what we stand for,” she said.
Indeed, much could be done to promote awareness and conversations about abortion, even in rich countries. Safe2Choose, an organization focused on providing online counseling on “medical abortion“—that is, abortion done exclusively through pills, which is faster and less intrusive—launched a live chat in several languages, targeting developing countries. The group was stunned to find that the US had become its fourth-biggest audience looking to learn how to get abortion pills and how they work. Similarly, HowToUseAbortionPill created an online education program for medical students and pharmacists. The website is translated in 24 languages and US users are its second top visitors.
How will reproductive-health organizations outside the US make up for the loss of funding? One way is to simply look for other donors; another is to work to make family-planning options commercially viable even in low-income markets. Sekimpi believes the current budge constraints, while unwelcome and no doubt difficult, might just be what is needed for the global health community to find new financial avenues. “There is a silver lining,” she says, “and resilient people will exploit it.”
Correction: The article was updated to reflect that Safe2Choose provides live chat on medical abortion, not general education.