The devastating impact of Trump's global gag rule

Abstract

About 56 million abortions are done annually, and almost half (25 million) are unsafe, of which 97% occur in developing countries. An estimated 8% of all maternal deaths are due to abortion, leaving a massive unmet global need for access to safe abortion services. Despite this situation, the USA, the world's largest global health donor, takes a hardline stance against abortion both at home and abroad. On June 5, the International Women's Health Coalition launched Crisis in care: year two impact of Trump's global gag rule, detailing the direct effect of anti-abortion policies and the broader ways in which they are threatening the work of non-governmental organisations (NGOs) that support women and vulnerable groups around the world. The latest global gag rule—also known as the expanded Mexico City Policy and, officially, as the “protecting life in global health assistance” policy—was issued by Donald Trump on Jan 23, 2017. Every Republican president since Ronald Reagan has used a version of the Mexico City Policy, which bans foreign NGOs that receive US Government family planning assistance from using funds from any source to provide abortion services, counselling, or referrals, or advocate for liberalisation of their country's abortion laws. The Trump administration goes further, applying these restrictions to nearly all federal global health assistance, including, for the first time, HIV funding through the President's Emergency Plan for AIDS Relief (PEPFAR). The policy affects around US$9 billion in US foreign assistance and foreign NGOs must now choose between complying with these restrictions or losing access to US funding. Integration of sexual and reproductive health services with, for instance, HIV and maternal and child health care makes sense because it recognises the presence of shared risk factors or concurrence of needs. By co-locating and improving linkages between services, integration can improve efficiency and health outcomes. In this context, the International Women's Health Coalition shows what can happen when providers are forced to forego US funding or stop abortion-related activities. 118 interviews with health service providers, civil society organisations, government agencies, and anti-abortion groups in Kenya, Nepal, Nigeria, and South Africa revealed that access to services for abortion and post-abortion care has been reduced, along with contraceptive services, antenatal care, HIV testing and treatment, and screening for cervical, breast, and prostate cancer. They also report a shrinking of civil society spaces, with some stakeholders concerned that the policy will exacerbate divisions between the HIV/AIDS and sexual and reproductive health and rights communities. Indeed, the spirit of the global gag rule is inherently anti-democratic, insofar as it blocks local organisations that receive US global health funding from advocating for law reform in their own countries. These findings echo those of the Foundation for AIDS Research, which found that a third of 286 PEPFAR implementing partners surveyed had altered their organisational operations or service delivery in response to the global gag rule, including reducing sexual and reproductive health and pregnancy counselling, information on legal abortion services, youth outreach, contraception services, and HIV counselling, testing, and treatment. Both reports highlight that the most vulnerable and marginalised populations—including young women, LGBT people, and sex workers—have been the worst affected by the changes. The effects of the Trump global gag rule on a broad range of sexual and reproductive health services is particularly concerning in light of recent global data from WHO on the persistently high prevalence and incidence of sexually transmitted infections. That the global gag rule might ultimately prove to increase the number of abortions by reducing access to modern contraception is not just an unfortunate irony. Rather, it reveals the way in which the policy has little to do with fostering health and everything to do with politics. Abortion is the rallying cry that unites conservative attempts to control and coerce women. By targeting funding for abortion, the global gag rule weaponises US global health funding against sexual and reproductive health and rights more broadly, with the most severe consequences affecting the most vulnerable. Two years on from its reinstatement, evidence shows that for care to be effective it must be holistic, comprehensive, and patient centred. There can be no right to health without the right to access safe abortion.