Effect of US policies on women's health worldwide

Abstract

In your Nov 8 Editorial1The Lancet USA continues war over abortion.Lancet. 2003; 362: 1509Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar addressing the US abortion divide, you call on US policymakers to stop waging “war over abortion” and instead “provide comprehensive contraceptive services to the poor”, asserting that “it would do more to reduce abortion than passing bans”. The same suggestion holds for the White House itself, which 3 years ago reimposed the “global gag rule” banning abortion counselling and referral in US-subsidised nongovernmental family planning clinics around the world. But, in the developing world, unlike in the USA, such bans do more than restrict access to abortion services. Indeed, a new report, Access Denied: U.S. Restrictions on International Family Planning (http://www.globalgagrule.org, accessed Dec 22, 2003) shows that the global gag rule jeopardises the health of women and their families by impeding access to a wide array of life-affecting reproductive health services. Aimed at abortion, the gag rule eliminates access to family planning, AIDS-related services, and maternal care. The report, prepared by a coalition of organisations called the Global Gag Rule Impact Project, was the result of research in Ethiopia, Kenya, Romania, and Zambia from July, 2002, to May, 2003. Research teams visited health facilities and interviewed health providers, policymakers, programme managers, and donors. The resulting case studies document that the gag rule reduces access to health services and contraception in each of the four countries investigated. In Kenya, for example, where 24% of married women lack access to family planning and 15% of all adults are infected with HIV/AIDS, the gag rule has had devastating effects. Kenya's two most prominent family planning nongovernmental organisations (NGOs) closed five of their well established clinics, eliminating access to family planning, prenatal and postnatal obstetric care, well-baby care, cervical cancer screening, immunisations, and HIV/AIDS prevention services, including counselling and testing. Four of these clinics served nearly 24 000 clients each year and another was the only source of health care for a community of 300 000 people. In Ethiopia, where there are 1800 maternal deaths per 100000 deliveries and just 8% of women use contraceptives, two NGOs have lost access to US-donated contraceptives, including male and female condoms. At the same time, evidence is replete, worldwide, that greater access to contraceptives reduces reliance on abortion. An analysis of 11 countries2Marston C Cleland J Relationships between contraception and abortion: a review of the evidence.Int Fam Plan Persp. 2003; 29: 6-13Crossref PubMed Scopus (140) Google Scholar shows that increased contraceptive use and effectiveness leads to reduced abortion rates when other factors—such as fertility—are held constant. In an analysis of trends in Kazakhstan, for example, abortion decreased by 50% as contraceptive prevalence increased the same amount during the 1990s.3Westoff CF The substitution of contraception for abortion in Kazakhstan in the 1990s. Macro International, Calverton, MD2000Google Scholar In Turkey, where the abortion rate declined from a peak of 45 abortions per 1000 married women in 1988 to 25 per 1000 in 1998, an increased use of modern methods of contraception accounted for 87% of the decline in abortion.4Senlet P Curtis SL Mathis J Raggers H The role of changes in contraceptive use in the decline of induced abortion in Turkey.Stud Fam Plan. 2001; 32: 41-52Crossref PubMed Scopus (27) Google Scholar A study in Bangladesh found that lower abortion rates resulted from access to higher-quality family planning services.5Rahman M DaVanzo J Razzaque A Do better family planning services reduce abortion in Bangladesh?.Lancet. 2001; 358: 1051-1056Summary Full Text Full Text PDF PubMed Scopus (47) Google Scholar These findings underscore how misplaced and heavy-handed such bans are, especially in the context of the realities of medical care in the poorest regions of the world. While US policymakers wage an ideological war in the ether, the restrictions imposed on international family planning erode the services that can prevent abortion on the ground. Engender Health was a partner in the Global Gag Rule Impact Project and a contributor to the development of the report Access Denied: US Restrictions on International Family Planning.