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The Growing Toll of the Global Gag Rule

A new study shows abortions actually go up when the U.S. pulls funding from NGOs offering abortion referrals. That's only one way underserved populations suffer.

Mozambican women wait for care at a maternity ward in 2018 (Gianluigi Guercia/AFP/Getty Images)

Xai-Xai, a peaceful coastal town a few hours north of Mozambique’s capital, sits in a province with the highest rate of HIV/AIDS in the country. One-quarter of the population in this region is HIV-positive, a figure which along with tuberculosis contributes significantly to high maternal-mortality rates. Sixteen percent of residents have malaria.

In regions where clinics depend on funding for specific services—say, testing and treatment for HIV/AIDS under the U.S. President’s Emergency Plan for AIDS Relief program, or for malaria under the President’s Malaria Initiative—one-stop shops for medical care aren’t a given. But here in Xai-Xai, residents can go to a clinic run by an NGO called the Mozambican Association for Family Development (AMODEFA) for family planning, tuberculosis testing, information on drug use, HIV prevention, and referrals for treatment in youth clinics. Many young people in Mozambique born with the virus aren’t aware of their status, so AMODEFA began a pilot program encouraging parents to explain HIV to their children.

On January 23, 2017, however, much of AMODEFA’s work came to an abrupt halt. The reason was the Republican U.S. administration’s desire to limit abortions abroad—a reinstatement of what’s known as the “global gag rule.” Since last week, that step has seemed particularly ironic. Last Thursday, peer-reviewed medical journal The Lancet published a study confirming what reproductive health experts have long suspected: Surveying 26 countries in sub-Saharan Africa between 1995 and 2014 (a time period during which the gag rule was reinstated by Republican administrations and rescinded by Democratic ones), the countries relying heavily on U.S. aid saw much higher rates of abortion40 percent more—when the gag rule was in place. In other words, in addition to the steep costs imposed on other forms of health care when the gag rule is instituted, it has the exact opposite effect of what conservative policymakers say they intend.

Since 1973, the Helms Amendment has prohibited federal dollars from going toward abortions in other countries. In 1984, the Reagan administration intensified that policy with what has since come to be known as the global gag rule, which prevents foreign health nonprofits that receive U.S. funds from even mentioning abortion—even if a patient asks about it, and even if it’s legal.

In 2017, the Trump administration expanded the rule far beyond any previous iteration. Earlier versions of the gag rule said international family-planning NGOs could not “perform or actively promote abortion as a method of family planning.” The Trump version, officially, and according to experts somewhat misleadingly titled “Protecting Life in Global Health Assistance,” expanded the ban to all foreign health organizations receiving U.S. dollars. Under this new iteration of the ban, it doesn’t matter whether an NGO is preventing and treating HIV/AIDS, malaria, tuberculosis, poor sanitation, or malnutrition; if it “promotes” abortion—i.e. so much as offers a referral to a local abortion provider, according to Secretary of State Mike Pompeo’s clarification earlier this year—U.S. aid is yanked. The U.S. is the largest global health donor in the world, spending $7.4 billion in 2018, often in parts of the world where alternate funding is not available. The effect of such a policy is enormous.

To retain funding, foreign nonprofits aren’t allowed to discuss abortion with political leaders and government officials, or suggest policy recommendations, or promote changes to a country’s laws that involve abortion. They can’t make referrals to local abortion providers or run public information campaigns on abortion. If a patient asks her doctor where she might find an abortion—even if abortion is legal in that country, as it is in half of the countries affected by the rule—the doctor risks losing a major source of funding for answering. (So far, First Amendment protections have kept conservative administrations from applying the gag rule to U.S.–based organizations, meaning American NGOs like Pathfinder International can continue to offer HIV prevention services with governmental funds while offering abortion services using other funds. But this discrepancy may soon end if the Trump administration’s domestic gag rule proposal continues to survive court challenges.)

In theory, the policy allows for advice and referrals in cases of rape, incest, or life-threatening complications. But in practice, when organizations don’t know exactly what “actively promoting” abortion means, they tend to shy away from the conversation entirely.

“It’s incredibly sinister. And when it comes to development assistance for health, it’s actually deadly,” said Asia Russell, the Uganda-based executive director of the nonprofit Health GAP (Global Access Project). In the shadow cast by the global gag rule, she says, unsafe abortions—a major contributor to women’s health issues and maternal death—increase dramatically. And this revised rule prevents women from accessing other important, life-saving health services as well.

“Women in particular need one-stop shopping. They’re trying to make money to put their kids through school, they’re trying to care for those kids—they’re trying to do everything,” Russell told me. “If you tell a woman, ‘Go to these three clinics,’ they won’t. They’ll go to the one that they think is the most important.” That might mean taking their child for a nutritional assessment rather than treating their own cervical cancer, for example. Clinics that do everything—including reproductive health—are becoming more rare under the gag rule.

In Mozambique, where first-trimester abortion has been legal since 2014, AMODEFA refused to sign the gag rule—and lost 60 percent of their budget.

Forced to lay off one-third of its staff, AMODEFA closed clinics across the country and dramatically reduced the services at the clinics that remained open, including in Xai-Xai. Half of AMODEFA’s innovative youth clinics were shuttered. Family planning and contraceptive services, HIV testing and treatment, tuberculosis care, and other health initiatives have all suffered as a result. The clinic in Xai-Xai, where one-quarter of people live with HIV, went from testing nearly 6,000 people for HIV in a four-month period to fewer than 700 soon after the policy took place. Male condom consultations dropped from nearly 100,000 to about 11,000 people. And gynecological exams and cancer prevention services stopped entirely.

It’s effects like these that cause abortions to increase rather than decrease under the gag rule. The new Lancet study found that between 1995 and 2014, whenever international patients stopped receiving contraceptives and family planning advice due to the gag rule being reinstated, rates of pregnancy—and abortions—shot up. It’s not the first study to suggest this effect.

In 2011, researchers from Stanford University concluded that abortions doubled in sub-Saharan Africa during the Bush administration. In 2018, Rutgers University professor Yana Rodgers published figures suggesting “women in Latin America were three times more likely to have an abortion while the global gag rule was in effect.”

“It’s hard to imagine a framing of the policy that is both able to simultaneously restrict funding for abortion and actively promote contraception,” Nina Brooks, the lead author of the new Lancet study and a doctoral student at Stanford, told me.

Marie Stopes International (MSI) offers programs around the world to help women and girls access contraception, family planning, abortion, and other services. Although MSI conducts abortions with non–U.S. funding, its U.S. funds went toward contraception and family planning. MSI refused to sign the gag rule, and lost about $80 million in U.S. aid.

“People think this rule prevents U.S. funding from going to abortion. Well, that’s always been the case,” Kimberley Lufkin, head of U.S. communications for MSI, told me. “This is really just for contraception.” One MSI program, for instance, focused on traveling to rural communities to offer family planning and contraception in pop-up clinics. In the wake of the gag rule, 20 of these mobile clinics in Madagascar and five in Uganda were shuttered. “The women live in remote villages, where it would take them three days to walk to a clinic,” Lufkin says. “We used to come to them, and now they really don’t have anywhere else to go.”

The trend toward higher rates of abortion can be halted entirely when the gag rule is lifted, the Lancet report’s authors say. “Our hope is that one would look at the unintended consequences that we find and realize that no matter what your view on abortion, this doesn’t seem like a good policy,” Grant Miller, director of the Stanford King Center for International Development and one of the study’s authors, told me.

AMODEFA has continued to operate as many clinics as possible despite the massive funding cuts. Their stance on abortion has not changed. In fact, they are trying to open two more abortion clinics to fill the void left by the rule—and to keep women from turning to more dangerous options. What effects the rule will have on HIV, tuberculosis, and other health issues in Mozambique, and around the world, is still unknown.