The Global Gag Rule
The Global Gag Rule, which President Biden rescinded on January 28, 2021, remains one of the most odious policies ever enacted on foreign assistance funding. When in effect, it strips U.S. funding from foreign health care providers if they offer abortion services, counseling, or referral for abortion services, or engage in political advocacy around the issue of abortion—even if they undertake these activities with their own, separate, non-U.S. funding. It prevents organizations from speaking out about the impact of unsafe abortion in their own countries—and, to be clear, it’s not possible to have a serious discussion about women’s health and maternal mortality in the developing world without discussing the role of unsafe abortion. Finally, the Global Gag Rule’s effects are utterly contrary to the stated goal of its supporters: In 2019, independent researchers at Stanford University found that the version of the Global Gag Rule imposed by George W. Bush—a less expansive version than that imposed by Donald Trump—caused abortion rates in the countries most affected to increase by 40 percent between 2001 and 2008. The effects of the Trump version of the policy are still being studied, but we already know they are dire.
Here are just a few of the known effects of the Global Gag Rule during the Trump administration:
Family Health Options Kenya (FHOK) provided 3 million services to women and young people in some of the poorest and most vulnerable parts of the country in 2016 alone. Since 2009, the more than 12 million services FHOK provided helped reduce unmet need for contraceptives in the country, from 26 percent to 18 percent. As a result, the nation’s maternal mortality rate fell too. Abortion was recently made legal in more situations in Kenya, and FHOK is unwilling to deny accurate and complete information to the people it serves. As a result of the Global Gag Rule, FHOK lost $2.2 million in U.S. aid. The organization was forced to close three clinics (in Mombasa, Kitengela, and Isiolo), terminate mobile outreach services that reached 76,000 people annually, lay off 15 staff members, and drastically reduce the number of staffers in its Kibera clinic.
Melvine Ouyo, a former nurse at the Kibera clinic and a graduate of Harvard’s Kennedy School of Government, has seen the effects of the Global Gag Rule firsthand.
Especially when [patients] are bleeding, we refer them to other clinics for access to the theater or manual vacuum services. Clients will always tell you it was spontaneous. Others will have induced because they didn’t want to carry the pregnancy. Some will come asking for safe abortion service. We always want to help all the women who come to us. We normally take them through counseling: the pros and cons of safe abortion services. We do not offer safe abortion services here, so we link them once they’ve been through counseling and are unwilling to carry the pregnancy to term.
The clinic often sees clients who are desperately ill from an unsafe abortion gone wrong.
They are given herbs. Some of the herbs are actually inserted. Some have come to explain that they have even [inserted] Coca-Cola. There was actually a girl who was given herbs, inserted vaginally, then she inserted a needle. She started bleeding. The bleeding continued, she was feeling faint. Then she was rushed to the facility. Because I was not able to perform a manual vacuum aspiration—I didn’t have the equipment—I referred the client to the Nairobi West facility—it saved her life.
Having family planning in Kibera has helped women to not get pregnant, which has really impacted on the maternal mortality that is a result of unsafe abortion. So really, cutting on family planning would be injustice to the women.
Another organization in Kenya, the Kisumu Medical and Education Trust, provides health care and education to poor women in the country’s third largest city. It expected to receive about $2 million in grants between 2017 and 2021 (more than half its total budget). Because of the Global Gag Rule, it received nothing. The organization was founded by a nurse after she discovered that half of the women in her gynecological ward were there “because of the damage done by backstreet abortions.”
Providing counsel on safe, legal abortion is a critical part of the Trust’s mission to improve women’s health and lives. In order to stay open, the Trust has had to charge for contraceptives that were previously free—a cost that many of Kenya’s poor families are unable to bear. The result is as predictable as it is appalling: reduced contraceptive access and increased unintended pregnancy, unsafe abortion, and maternal mortality.
Profamilia has provided millions of vulnerable people medical checkups, critical reproductive health services, affordable contraceptives, health education, and gender-based violence programs since 1964. Colombia still faces numerous reproductive health challenges: Nearly 20 percent of girls ages 15–19 are either pregnant or are already mothers, and rural girls are 26.7 times more likely to become adolescent parents. Illegal abortion remains stunningly prevalent, with at least 400,000 procedures performed each year.
The Global Gag Rule ended funding for Profamilia’s program to reduce maternal mortality, its Zika prevention effort, and its outreach to conflict-afflicted communities. Young people in rural areas lost their only access to information and care, undermining the progress made in recent years. The organization was forced to close four of its clinics, which had served 60,000 people.
Niger has one of the most rapidly growing populations in the world. Between 1960 and today, it has grown from 3.5 million people to more than 21 million, and is likely to nearly triple by 2050. Half the population is under 15 years old, and more than 40 percent of its people earn less than $1 per day. Levels of contraceptive use are low, and women have a 1-in-23 chance of dying of pregnancy-related causes. By any measure, Niger is teetering on the edge of catastrophe. Marie Stopes International (MSI) began providing contraceptives and reproductive health care through mobile outreach in 2014, and opened its first clinic in 2016, with support from the U.S. government. That year alone, MSI served some 30,000 clients and provided contraceptives to more than 16,000 women and girls, preventing thousands of unsafe abortions. But, because MSI provides safe abortion in other countries, where it’s legal, the Global Gag Rule disqualified the agency from further support for its crucial work.
The maternal mortality rate in Nepal used to be the highest in the world, and the abortion law was, until recently, the most restrictive in the world. Women who had abortions—and survived—were routinely sentenced to long prison terms. In one infamous case, a 13-year-old girl was raped by a relative and made pregnant. Another relative took her for an illegal abortion. Yet another relative reported her to the authorities, and she was sentenced to 20 years in prison. When Nepal changed its abortion law in 2002, the Family Planning Association of Nepal (FPAN)—unwilling to deny women information about safe, legal abortion—immediately lost American funding for family planning services and contraceptive supplies. As a result, 60 health workers were laid off, mobile reproductive health clinics were eliminated, and the agency’s ability to provide access to a regular supply of birth control withered. After President Obama lifted the Global Gag Rule in 2009 and FPAN had its funding restored, Nepal’s maternal mortality rate fell by a third. That progress was disrupted under Trump’s Global Gag Rule.
The Planned Parenthood Association of Zambia (PPAZ) lost half of its annual operating budget in 2017. It had to close all but three of 16 sites working to provide HIV testing and treatment to residents of rural areas. PPAZ’s staffing has been decimated. One remaining center, in Nyangwena, serves 3,000 people over an enormous rural area, but has just two community workers delivering HIV care and one overseeing tuberculosis (TB) cases. Outreach efforts were eliminated, the number of people being tested for HIV and other STIs plummeted, and teen pregnancies increased. PPAZ’s program to offer in-home testing, distribute contraceptives within communities, and offer family planning information in schools was ended.
Looking to the Future
Despite President Biden’s repeal of the Global Gag Rule, lingering effects remain. It takes time for new money to make its way into the field, and even with renewed access to funds, some clinics that have been forced to close may not be able to re-open.
In addition, the risk that the Global Gag Rule may return under a future president inevitably has a chilling effect on providers. They may be reluctant to initiate programs or partnerships that will have to be ended within a few years, and the potential loss of funding makes the challenges of long-term planning even more pronounced.
The only way to ensure that the Global Gag Rule never returns is through permanent, legislative repeal via the Global HER Act, which would prevent a future president from unilaterally reinstating the policy.