tag:theconversation.com,2011:/us/topics/global-gag-rule-35295/articlesGlobal gag rule – The Conversation2021-02-04T07:00:08Ztag:theconversation.com,2011:article/1544342021-02-04T07:00:08Z2021-02-04T07:00:08ZUS anti-abortion “gag rule” hits women hard: what we found in Kenya and Madagascar<figure><img src="https://images.theconversation.com/files/381893/original/file-20210202-19-1ketyl0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A coalition of physicians, AIDS activists and medical students protest Trump's global gag rule, which expands the policy restriction to all US health funding. </span> <span class="attribution"><span class="source">Photo by Erik McGregor/LightRocket via Getty Images</span></span></figcaption></figure><p>US President Joe Biden <a href="https://www.nytimes.com/2021/01/29/world/asia/gag-rule-abortion.html">has reversed</a> a Trump administration policy that prohibited US funding for nongovernmental groups that provide or refer patients for abortions. </p>
<p>The Global Gag Rule, also known as the Mexico City Policy, was enacted in 1984 by President Ronald Reagan. Since its introduction, the policy has been instated by each <a href="https://srhrforall.org/download/prescribing-chaos-in-global-health-the-global-gag-rule-from-1984-2018/?wpdmdl=1064&refresh=601310b387a7d1611862195">Republican president and rescinded by each Democrat president</a>.</p>
<p>Under President Donald Trump the policy was made more stringent on two occasions – once in 2017 when his administration passed the Protecting Life in Global Health Assistance policy and again in 2019 with a further expansion of its implementation.</p>
<p>The Global Gag Rule <a href="https://globalgagrule.org/understanding-the-policy/">requires</a> non-governmental organisations (NGOs) based outside the US that receive US government global health assistance to certify that they will not use any funding to provide legal abortion services, referrals, or information to clients, or to advocate for the liberalisation of a country’s abortion law. It also applies to non-US based NGO sub-grantees of organisations getting money – even if they don’t receive US global health assistance. The policy <a href="https://www.kff.org/global-health-policy/fact-sheet/mexico-city-policy-explainer/">applies to US government and non-US government funds alike</a>.</p>
<p>The policy allows for <a href="https://globalgagrule.org/understanding-the-policy/">limited exceptions</a>. For example, NGOs may provide information, referrals or services for legal abortion in cases of rape, incest, or when the pregnancy threatens the life of the pregnant person. However, <a href="https://www.tandfonline.com/doi/full/10.1080/26410397.2020.1831717?af=R">our research shows</a> that these exceptions are not always understood or followed in practice. </p>
<p>We collaborated with the African Population Health Research Centre and L’Institut National de Santé Publique et Communautaire to study the effects of the Global Gag Rule <a href="https://www.tandfonline.com/doi/full/10.1080/26410397.2020.1794412?src=recsys">in Kenya</a> and <a href="https://www.tandfonline.com/doi/full/10.1080/26410397.2020.1838053?src=recsys">Madagascar</a>. In both countries, we found that the Global Gag Rule weakened national health systems by disrupting NGO partnerships and fragmenting service delivery. In turn, this created barriers to women’s sexual and reproductive healthcare access.</p>
<p>Our research provides fresh evidence of the devastating effect that the Gag Rule has had on projects, particularly over the past four years. It points to the importance of the repeal, but also underscores why, to truly pave the way towards reversing the effects of the Gag Rule, the US Congress must permanently repeal it through <a href="https://www.congress.gov/bill/116th-congress/house-bill/1055">legislation</a>. </p>
<h2>What we found</h2>
<p>Research participants in <a href="https://www.tandfonline.com/doi/full/10.1080/26410397.2020.1794412?src=recsys">Kenya</a> described increased difficulties referring women for contraception, legal abortion, and post-abortion care. This is because some organisations chose to end sexual and reproductive health programmes that included abortion in order to receive US government funding.</p>
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<a href="https://theconversation.com/insights-into-how-the-us-abortion-gag-rule-affects-health-services-in-kenya-145777">Insights into how the US abortion gag rule affects health services in Kenya</a>
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<p>Additionally, we found that some organisations unnecessarily restricted their family planning or post-abortion care services, which are permitted, due to confusion about the policy’s stipulations or fear of losing US government funding opportunities.</p>
<p>In <a href="https://www.tandfonline.com/doi/full/10.1080/26410397.2020.1838053?src=recsys">Madagascar</a>, we found evidence of negative effects on women’s access to family planning services. This was true even though abortion is illegal there. </p>
<p>The impact on one NGO illustrates how. The NGO was a major partner to Madagascar’s Ministry of Health. It provides safe abortion in other countries where it’s legal. But the NGO lost US government funding after declining to sign the Global Gag Rule. As a result, it stopped receiving funding and supplies from USAID. This meant that it had to reduce family planning outreach in some rural areas, and ended support to nearly 200 public and private health facilities.</p>
<p>Women described facing many barriers when trying to access contraceptives. These included higher fees to obtain a contraceptive method, stock-outs in many health facilities, and having to travel to multiple locations in search of their preferred method. </p>
<p>One woman in Madagascar mentioned that buying the method is a “problem because the money is needed to buy food for the family, but you have to take some out to buy the method.” </p>
<p>Some women ended up with an unintended pregnancy because they could not obtain their contraceptive method. </p>
<h2>Expansion under Trump</h2>
<p>Under former Republican presidents the Gag Rule applied only to US government family planning assistance. This stood at <a href="https://pai.org/resources/with-a-stroke-of-the-pen-trumps-global-gag-rule-dramatically-expands-harmful-health-impacts/">$575 million in 2016</a>. </p>
<p>But the changes made by Trump expanded the policy to apply to most categories of US government global health assistance – which in 2016 stood at <a href="https://pai.org/resources/with-a-stroke-of-the-pen-trumps-global-gag-rule-dramatically-expands-harmful-health-impacts/">US$9.5 billion</a>. </p>
<p>This meant that a greater number of NGOs working in a variety of health areas – from HIV to nutrition to child health – were newly affected. </p>
<p>One huge implication was that, for the first time, the Global Gag Rule was attached to President’s Emergency Plan For AIDS Relief (PEPFAR) funding. In the case of Kenya, this made up to <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-6008-2">58% of HIV funding</a> to Kenya. </p>
<p>As a result, we found that the delivery of the country’s HIV and sexual and reproductive health services has been fractured. </p>
<p>NGO representatives said they were forced to choose between US government funding and projects related to HIV and other sexual and reproductive health services, despite <a href="https://www.usaid.gov/global-health/health-areas/hiv-and-aids/technical-areas/promoting-integration-family-planning-hiv-and">USAID’s own promotion of integrated services</a>.</p>
<p>In addition, the policy’s on-again-off-again history makes it very difficult to repair the damage it causes. Even when the policy is not in effect, some NGOs <a href="https://www.nytimes.com/2021/01/31/opinion/women-health-abortion-her-act.html">are wary</a> of rebuilding or reinvesting in abortion-related work, for fear of its reinstatement.</p>
<h2>What now?</h2>
<p>The repeal of the Global Gag Rule by President Biden is a necessary step towards improving women’s sexual and reproductive health and rights worldwide. But it will not be enough to reverse the effects that it’s had over the last four years. </p>
<p>Clear communication and guidance about the policy reversal from US government donors to global health implementing partners – in multiple languages – will be critical to end its implementation and mitigate against the rampant confusion and fear that it has created for civil society across countries. It will take NGOs time to re-establish relationships and services that they ended.</p>
<p>In addition to permanently repealing the Gag Rule, there needs to be renewed investment in comprehensive sexual and reproductive health information and services from the US government and national governments in order to rebuild and strengthen national health systems and contraceptive supply chains.</p><img src="https://counter.theconversation.com/content/154434/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sara E Casey receives funding from the William and Flora Hewlett Foundation and the David and Lucile Packard Foundation.</span></em></p><p class="fine-print"><em><span>Emily A Maistrellis receives funding from the William and Flora Hewlett Foundation and the David and Lucile Packard Foundation. </span></em></p><p class="fine-print"><em><span>Terry McGovern receives funding from William and Flora Hewlett Foundation and the David and Lucile Packard Foundation.</span></em></p>Trump’s expanded global gag rule weakened national health systems and created barriers to women’s sexual and reproductive healthcare access.Sara E Casey, Assistant Professor, Heilbrunn Department of Population and Family Health, Columbia UniversityEmily A Maistrellis, Public Health Researcher, Mailman School of Public Health, Columbia UniversityTerry McGovern, Chair, Heilbrunn Department of Population and Family Health, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1457772020-09-30T15:06:00Z2020-09-30T15:06:00ZInsights into how the US abortion gag rule affects health services in Kenya<figure><img src="https://images.theconversation.com/files/356925/original/file-20200908-18-1ezluo5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">US President Donald Trump speaks at the 47th March For Life rally on the National Mall, January 24, 2019 in Washington, DC.</span> </figcaption></figure><p>The Mexico City Policy – often referred to as the “Global Gag Rule” – is a US government policy <a href="https://trumpglobalgagrule.pai.org/understanding-the-policy/">that requires</a> non-governmental organisations (NGOs) that are not based in the US and that receive US global health assistance to certify that they will not provide, refer for, counsel on, or advocate for abortion as a method of family planning. The rule <a href="https://www.kff.org/global-health-policy/fact-sheet/mexico-city-policy-explainer/">also applies</a> to any non-US funding that the organisation may receive. </p>
<p>The policy was rescinded by President Obama in 2009 but then <a href="https://www.whitehouse.gov/presidential-actions/presidential-memorandum-regarding-mexico-city-policy/">reinstated and expanded</a> by President Trump in 2017. While prior iterations applied only to family planning assistance (US$575 million in 2016), <a href="https://pai.org/newsletters/stroke-pen-trumps-global-gag-rule-dramatically-expands-harmful-health-impacts/">Trump’s new version</a> extends the restrictions to nearly all US global health assistance – an estimated US$9.5 billion – which includes funding for HIV/AIDS, malaria, and maternal and child health. For example, it now <a href="https://gh.bmj.com/content/4/5/e001786">means that</a> an organisation that provides HIV care and treatment with US funding may not also provide safe abortion.</p>
<p>The global gag rule includes exceptions for cases of rape, incest, and to save the life of the woman; however, these are rarely applied in practice. </p>
<p>For over 50 years US Global Health Assistance <a href="https://www.usaid.gov/global-health">has provided</a> support to developing countries around three strategic priorities: to prevent child and maternal deaths, control the HIV/AIDS epidemic, and combat infectious diseases. </p>
<p>Kenya relies heavily on foreign aid to finance its sexual and reproductive health services. The vast majority of this aid (<a href="https://stats.oecd.org/">95% in 2018</a>) comes from the US government. There are also <a href="https://www.gao.gov/assets/710/705388.pdf">approximately</a> 71 active US global health awards to various NGOs that were subject to this rule.</p>
<p>The African Population and Health Research Center, in partnership with the Global Health Justice and Governance Program of Columbia University, carried <a href="https://www.tandfonline.com/doi/full/10.1080/26410397.2020.1794412">out a study</a> to establish how Trump’s expanded rule affected sexual and reproductive health services including family planning, safe abortion, and post-abortion care in Kenya. </p>
<p><a href="https://www.tandfonline.com/doi/full/10.1080/26410397.2020.1794412">We found</a> that in the first 18 months, the expanded rule’s effects transcended the limitation of abortion care. It affected funding and disrupted collaboration and health promotion activities. It also strengthened opposition to sexual and reproductive health and rights.</p>
<p>These losses weaken NGO support to the Kenyan health system and, we believe, will likely have a substantial impact on clients seeking sexual and reproductive health services.</p>
<p>Our findings call for harm mitigation interventions by advocates, donors and policymakers in Kenya and the United States. </p>
<h2>Implications</h2>
<p>We drew our data from in-depth interviews conducted in September 2018 and March 2019 with representatives of 18 local and international NGOs. These implemented sexual and reproductive health, HIV or other health services. We also interviewed 37 health workers whose facilities received support from an NGO for their services, meaning they could be affected by the policy via these NGOs.</p>
<p>We found that the policy had far-reaching implications. </p>
<p>NGOs were forced to choose between providing safe legal abortion services and accepting US global health funding. NGOs that turned down US funding had to then find replacement funding from other sources. This led to health facilities being closed, frequent contraceptive stockouts, staff layoffs and salary cuts. It also led to the curtailment of community-based activities, such as community health volunteers referring women for services. </p>
<p>In addition, NGOs that provided comprehensive integrated sexual and reproductive health services – such as HIV, child health and maternal health – reported closure of some components of their service delivery when they were forced to choose between US funding and funding for these other services. This meant that women encountered more difficulties obtaining these services.</p>
<h2>Ambiguous</h2>
<p>We also found that the Global Gag Rule is ambiguous (and confusing) (we believe purposefully so), leaving ample room for over-interpretation. This led to organisations reducing or ending services not restricted by the rule, such as post-abortion care, out of fear of violating the policy. </p>
<p>The policy also emboldened opponents of sexual and reproductive health and rights and safe abortion. This stifled the efforts of those advocating for safe and quality care. It also compounded existing legal, policy and cultural barriers in the delivery of these services.</p>
<h2>Partnership disruption</h2>
<p>The Global Gag Rule created divisions between NGOs that chose to comply with the policy and those that declined to do so. This led to the disruption of existing coalitions and partnerships. In addition, some compliant NGOs no longer referred clients for permitted services to non-compliant NGOs.</p>
<p>As one interviewee from a non-US NGO said:</p>
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<p>It’s impossible to partner with a US-funded organisation…We are working in silos…we cannot work in the same space. Even in terms of being invited in meetings, you would feel like you are being stigmatised, in fact not invited in those places, yeah, because you do not believe in the Global Gag Rule, and you are pro-choice.</p>
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<p>What does this mean for Kenya?</p>
<p>The US <a href="https://stats.oecd.org/">provides</a> 55% of Kenya’s development aid for health and 95% of sexual and reproductive health aid. </p>
<p>In light of evidence of the effects of this policy, the US government should reconsider how it affects people living in different contexts. And the Kenyan government must figure out how to lessen the impact of the global gag rule on its health system.</p>
<p>It is critical for the Kenyan government to look to its own policies and increase budgetary allocation for sexual and reproductive health services so that they cushion the impact of the global gag rule.</p>
<p>In addition, policymakers in the US should work to permanently repeal the policy in light of ample evidence demonstrating its adverse impact.</p><img src="https://counter.theconversation.com/content/145777/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Global Gag Rule transcends abortion and exacerbates weaknesses and vulnerabilities of the Kenyan health system.Boniface Ushie, Research Scientist, African Population and Health Research CenterSara E Casey, Assistant Professor, Heilbrunn Department of Population and Family Health, Columbia UniversityTerry McGovern, Chair, Heilbrunn Department of Population and Family Health, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1124912019-03-04T11:39:23Z2019-03-04T11:39:23ZAbortions rise worldwide when US cuts funding to women’s health clinics, study finds<figure><img src="https://images.theconversation.com/files/261709/original/file-20190301-110123-wpcogy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A billboard built by sex education advocates outside Mexico's National Population Council office, in Mexico City, warns that 'being a mother is not child's play.' (May 29, 2014)
</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Mexico-Teen-Pregnancy/4c057493e7914cbd831308d25ce1701b/32/0">AP Photo/Rebecca Blackwell</a></span></figcaption></figure><p>Advancing Republican efforts to <a href="https://www.nytimes.com/2019/02/22/health/trump-defunds-planned-parenthood.html">reduce access to abortion</a>, Secretary of State Mike Pompeo <a href="https://www.nytimes.com/2019/03/26/us/politics/state-department-abortion-funding.html">announced</a> on March 26 that the Trump administration will further restrict federal funding to health providers abroad that perform, promote or even talk about abortions.</p>
<p>The move expands the “<a href="https://theconversation.com/trumps-global-gag-order-5-questions-answered-77838">global gag rule</a>” Trump imposed in 2017. It substantially expands the number of <a href="https://pai.org/newsletters/absolutely-deplorable-trump-administrations-ggr-interpretation-represents-massive-overreach/">groups affected</a> by cutting funding to any organization with a foreign partner that provides abortions – even if those overseas groups are not, themselves, U.S. government-funded. </p>
<p>First implemented under Ronald Reagan in 1984, the global gag rule has been <a href="https://www.amfar.org/articles/on-the-hill/older/president-obama-reverses-%E2%80%9Cglobal-gag-rule%E2%80%9D/">rescinded by every Democrat</a> and reinstated by every Republican to occupy the Oval Office, reflecting the partisan nature of abortion.</p>
<p>Supporters of the global gag rule say defunding abortion providers will <a href="https://lifedefender.org/2017/06/5-reasons-why-defunding-planned-parenthood-is-crucial/">reduce abortions</a>. However, <a href="https://www.scielosp.org/scielo.php?pid=S0042-96862011001200010&script=sci_arttext&tlng=en">researchers from Stanford University</a> in 2011 found that this U.S. policy actually made women in sub-Saharan Africa twice as likely to have an abortion.</p>
<h2>Gag rule increases abortions in Latin America and Africa</h2>
<p>My <a href="https://smlr.rutgers.edu/news/study-global-gag-rule-increased-abortion-rates-some-regions">recent study</a>, published in November 2018, confirms those findings in Africa and shows that the global gag rule had an even greater effect in Latin America. </p>
<p>Analyzing abortion data from 51 developing countries between 2001 and 2008 – which encompassed the reproductive decisions of about 6.3 million women – I found that women in Latin America were three times more likely to have an abortion while the global gag rule was in effect. </p>
<p>Reflecting this impact, the percentage of pregnancies in Latin America that <a href="https://www.sciencedirect.com/science/article/pii/S0140673616303804">ended in abortion</a> rose from 23 percent in 1994, under the Clinton administration, to 32 percent by 2010, after two terms of the Bush administration.</p>
<p>In the United States, where abortion is legal nationwide, about <a href="https://www.cdc.gov/reproductivehealth/data_stats/abortion.htm">18 to 23 percent of pregnancies</a> end in abortion.</p>
<h2>How a US law hurts women abroad</h2>
<p>Funding cuts under the global gag rule cause health care staff reductions, clinic closures and contraceptive shortages. Without family planning counseling and birth control, there are more unintended pregnancies – and, consequently, more abortions. </p>
<p>Numerous <a href="https://www.guttmacher.org/infographic/2016/restrictive-laws-do-not-stop-women-having-abortions">studies</a> confirm that making abortions harder to get doesn’t stop them from happening. It just makes them less safe, because the procedure is not necessarily performed in sterile facilities by qualified doctors. </p>
<p><iframe id="t73Yb" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/t73Yb/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Latin America, a heavily Catholic region, has the <a href="https://theconversation.com/in-latin-america-is-there-a-link-between-abortion-rights-and-democracy-85444">world’s most restrictive abortion laws</a>. Six countries, including Honduras, Nicaragua and El Salvador, <a href="http://derechosdelamujer.org/wp-content/uploads/2017/07/CRR-Mapa-Aborto-AL-2016.pdf">completely ban abortion</a>. Others permit it only in extreme cases like rape, incest or maternal health. </p>
<p>Latin America also has the world’s highest rate of illicit abortions, according to a <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31794-4/fulltext">2017 study</a> in The Lancet. Seventy-five percent of all abortions in Latin America are performed illegally.</p>
<p>Since Trump reinstated the global gag rule in 2017, health workers <a href="https://www.amfar.org/Issue-Brief-The-Effect-of-the-Expanded-Mexico-City-Policy/">in developing countries</a> have reported drastic <a href="http://www.genderhealth.org/files/uploads/change/publications/Prescribing_Chaos_in_Global_Health_full_report.pdf">reductions</a> in the availability of contraception, teen sex education and family planning services.</p><img src="https://counter.theconversation.com/content/112491/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yana Rodgers does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The White House will expand a law that cuts funding to abortion providers abroad. When the Bush-era ‘global gag rule’ was last in effect, abortion rates tripled in Latin America and doubled in Africa.Yana Rodgers, Professor of Labor Studies, Rutgers UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/778382017-05-19T01:00:45Z2017-05-19T01:00:45ZTrump’s global gag order: 5 questions answered<figure><img src="https://images.theconversation.com/files/169611/original/file-20170516-11920-18ugjes.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Community health workers like these visit patients’ homes in Malawi to help prevent mother-to-child transmission of HIV. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/usaid_images/14929179975/in/photolist-fpbMUp-aQMAYZ-dCxeUD-aSur7V-b3R1Rt-b3R2oX-dEVMyy-b3R27a-dRQPAZ-6ZtchW-hgsjEG-5bwcvw-9Ew4ZB-9Ui5Dt-dAYLds-oKeX3F-dU2Dh3-qFoYn-dw9Hnp-dEBboS-fgvYov-aQMAZ6-bEyXDR-aMxvhD-fgLeJY-qbViAL-cni9zU-hHrpg9-hHqXKb-c2XNWA-aRwNcx-oERaPx-u7rF96-hHrKFM-945Zp6-fokQm2-oFmDXh-9W2YA2-4v8yRi-cE9xzJ-oKeX5K-fEQHxX-9VxEus-hHqCbR-dw9fng-cE9bkd-bmCsUq-9VuPrz-dEQncT-kXqimY/">Baylor College of Medicine Children's Foundation–Malawi/Chris Cox</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><p><em>Editor’s note: President Donald Trump recently signed an executive order that media reports say could obstruct nearly US$8.8 billion the U.S. spends annually to <a href="http://khn.org/morning-breakout/trumps-abortion-gag-rule-will-block-8-8b-in-aid-to-fight-malaria-aids-and-other-diseases/">fight deadly diseases abroad</a>. Here, Maureen Miller, a Columbia University Medical Center professor and infectious disease epidemiologist with training in medical anthropology, answers five questions about this move, including what it has to do with abortion.</em></p>
<h2>1. What’s at stake?</h2>
<p>Three of the biggest killers in the developing world are AIDS, tuberculosis and malaria. Currently 36.7 million people are <a href="http://www.unaids.org/sites/default/files/media_asset/global-AIDS-update-2016_en.pdf">living with HIV/AIDS</a>, a third of the world’s population is <a href="https://www.cdc.gov/tb/statistics/">infected with tuberculosis</a> and more than one million people <a href="https://www.unicef.org/health/files/health_africamalaria.pdf">die from malaria</a> each year.</p>
<p>Trump’s executive order endangers $6.8 billion in annual funding for the <a href="https://www.pepfar.gov/funding/budget/index.htm">President’s Emergency Plan for AIDS Relief</a>. Former President George W. Bush created this initiative, known as PEPFAR, to help save the lives of people suffering from HIV/AIDS. </p>
<p>The U.S. put <a href="http://kff.org/global-health-policy/fact-sheet/u-s-federal-funding-for-hivaids-trends-over-time/">$1.35 billion</a> of that money into the the Global Fund to Fight AIDS, Tuberculosis and Malaria last year. This independent organization is the largest entity dedicated to preventing and treating these diseases. The U.S., its top donor, covers half <a href="http://kff.org/global-health-policy/fact-sheet/the-u-s-the-global-fund-to-fight-aids-tuberculosis-and-malaria/">the Global Fund’s operating costs</a>, but that represents only a quarter of what our nation spends to fight these diseases internationally. Some $600 million in family planning aid is affected, as is <a href="https://theconversation.com/will-trumps-global-family-planning-cuts-cause-side-effects-75813">other spending</a> slated for global health. </p>
<p>Although I follow these issues closely, I have been unable to find a complete breakdown of the widely reported <a href="http://khn.org/morning-breakout/trumps-abortion-gag-rule-will-block-8-8b-in-aid-to-fight-malaria-aids-and-other-diseases/">$8.8 billion affected</a>.</p>
<p>Women compose <a href="http://Aidsinfo.unaids.org">51 percent of the people living with HIV/AIDS</a> worldwide. Since 60 percent of the people with the virus in sub-Saharan Africa are women, they may bear the brunt of this move. </p>
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<img alt="" src="https://images.theconversation.com/files/169610/original/file-20170516-11945-en0mnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/169610/original/file-20170516-11945-en0mnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/169610/original/file-20170516-11945-en0mnh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/169610/original/file-20170516-11945-en0mnh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/169610/original/file-20170516-11945-en0mnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/169610/original/file-20170516-11945-en0mnh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/169610/original/file-20170516-11945-en0mnh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Eunice Adhiambo, an HIV-positive Kenyan woman, and her HIV-negative daughter Jyll.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/usaidafrica/9451379699/in/photolist-fpbMUp-aQMAYZ-dCxeUD-aSur7V-b3R1Rt-b3R2oX-dEVMyy-b3R27a-dRQPAZ-6ZtchW-hgsjEG-5bwcvw-9Ew4ZB-9Ui5Dt-dAYLds-oKeX3F-dU2Dh3-qFoYn-dw9Hnp-dEBboS-fgvYov-aQMAZ6-bEyXDR-aMxvhD-fgLeJY-qbViAL-cni9zU-hHrpg9-hHqXKb-c2XNWA-aRwNcx-oERaPx-u7rF96-hHrKFM-945Zp6-fokQm2-oFmDXh-9W2YA2-4v8yRi-cE9xzJ-oKeX5K-fEQHxX-9VxEus-hHqCbR-dw9fng-cE9bkd-bmCsUq-9VuPrz-dEQncT-kXqimY">Riccardo Gangale/USAID Kenya</a></span>
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<h2>2. How does the US support global efforts to fight and treat HIV/AIDS?</h2>
<p>PEPFAR, primarily implemented through USAID, the National Institutes of Health and the Centers for Disease Control and Prevention, emphasizes improving the health of women, newborns and children. Among its biggest achievements has been integrating AIDS relief and reproductive health services, since HIV is transmitted primarily through unprotected sex. </p>
<p>Until now, PEPFAR has commanded broad bipartisan support, perhaps due to its well-documented success. For the first time since the HIV/AIDS epidemic began in the 1980s, new HIV infections in sub-Saharan Africa – which accounts for <a href="http://aidsinfo.unaids.org/">almost two-thirds</a> of all people living with HIV/AIDS – <a href="http://www.unaids.org/sites/default/files/media_asset/global-AIDS-update-2016_en.pdf">are decreasing</a>. Former President Bush, who <a href="http://www.reuters.com/article/us-africa-bush-idUSKBN1761LJ">traveled to Botswana and Namibia</a> in April, still champions the program.</p>
<h2>3. How is global health aid connected to abortion?</h2>
<p>An estimated <a href="http://kff.org/global-health-policy/fact-sheet/the-u-s-government-and-international-family-planning-reproductive-health-efforts/">303,000 women</a>, primarily in developing countries, die yearly from complications due to pregnancy, childbirth and abortion, and those are the <a href="http://www.who.int/mediacentre/news/releases/2017/yearly-adolescent-deaths/en/">leading causes of death</a> among adolescent girls globally. Approximately one-third of maternal deaths could be prevented if all women had access to effective contraception.</p>
<p>The U.S. is the <a href="http://kff.org/global-health-policy/fact-sheet/the-u-s-government-and-international-family-planning-reproductive-health-efforts/">world’s largest supporter</a> of family planning and reproductive health services. It is also one of the largest purchasers and distributors of contraceptives. <a href="http://kff.org/global-health-policy/fact-sheet/the-u-s-government-and-international-family-planning-reproductive-health-efforts/">No federal funds have paid for abortions</a>, however, since 1973 – either internationally or at home. All nongovernmental organizations receiving U.S. support must agree to this policy.</p>
<p>In 1984, the Reagan administration expanded those restrictions by denying U.S. family-planning money to entities that performed abortions or promoted the practice. Subsequent Democratic presidents lifted this restriction, known either as the “<a href="http://kff.org/global-health-policy/fact-sheet/mexico-city-policy-explainer/">Mexico City policy</a>” or the “global gag rule,” while Republican presidents reinstated it.</p>
<p>Trump framed his new order as “<a href="https://www.state.gov/r/pa/prs/ps/2017/05/270866.htm">Protecting Life in Global Health Assistance</a>,” but it’s unlikely to reduce the number of abortions performed in poor countries. A <a href="http://www.who.int/bulletin/volumes/89/12/11-091660/en/">2011 study by Stanford University researchers</a> found that abortion rates in sub-Saharan African countries rose when the standard restrictions were in force from 2001 to 2008. </p>
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<h2>4. How does Trump’s action stray from Republican precedents?</h2>
<p>The Trump administration has expanded the policy’s reach, broadening it to encompass all foreign health care providers that receive U.S. funding rather than only those that get family planning dollars. For example, any group that does sexual health education to prevent the spread of HIV and also informs women that abortion is legal where they live will <a href="https://www.statnews.com/2017/05/16/mexico-city-policy-global-health-funding/">lose their U.S. support</a>. They would have remained eligible for that money had Trump followed the pattern set by the past three Republican administrations.</p>
<p>The exact repercussions are unknown. The <a href="https://www.state.gov/r/pa/prs/ps/2017/05/270879.htm">State Department</a>, under Rex Tillerson’s leadership, plans to review the impact within six months.</p>
<h2>5. Can other donors bridge the gaps?</h2>
<p>It’s unclear which organizations will agree to these new restrictive terms or what will happen to spending. The administration says it <a href="https://www.state.gov/r/pa/prs/ps/2017/05/270879.htm">will redistribute funds</a> from organizations that refuse to comply to those that will. </p>
<p>But those other groups may not exist. As Johnathan Rucks of the <a href="https://www.nytimes.com/2017/05/15/us/politics/trump-gag-rule-abortion.html?rref=collection%2Fbyline%2Fgardiner-harris&action=click&contentCollection=undefined&region=stream&module=stream_unit&version=latest&contentPlacement=2&pgtype=collection">global health group PAI</a> told The New York Times: “It’s not like we have an influx of providers in places like West Africa.” </p>
<p>Given the limited alternatives, the number of unmet health needs will surely rise, particularly for women and children. In March, other governments and private funders announced they had raised <a href="http://www.npr.org/sections/goatsandsoda/2017/03/02/517959453/-190-million-raised-to-fill-aid-gap-left-by-trumps-abortion-rule">$190 million for international family planning</a> to narrow the anticipated gap caused by the Trump administration’s policies. Now, that’s probably just a drop in the bucket of what will be needed.</p>
<p><a href="https://www.theguardian.com/global-development/2017/feb/14/bill-and-melinda-gates-trumps-global-gag-rule-endangers-millions-women-girls-us-funding">Bill Gates</a>, a philanthropist who with his wife Melinda gives more than <a href="http://www.gatesfoundation.org/Who-We-Are/General-Information/Foundation-Factsheet">$4 billion</a> away every year, mostly to improve global health and fight poverty, told The Guardian that Trump’s expansion of the policy could “create a void that even a foundation like ours can’t fill.”</p><img src="https://counter.theconversation.com/content/77838/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maureen Miller does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>All recent Republican presidents have cut off foreign aid tied to abortion. Trump’s expansive version of those restrictions endangers billions slated for HIV/AIDS, malaria and other diseases.Maureen Miller, Adjunct Associate Professor of Epidemiology, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/759222017-04-19T06:49:59Z2017-04-19T06:49:59ZAs the US stops funding reproductive health services, China should step in<p>On April 4 2017, US President Donald Trump decided to <a href="https://www.washingtonpost.com/world/national-security/trump-administration-to-eliminate-its-funding-for-un-population-fund-over-abortion/2017/04/04/d8014bc0-1936-11e7-bcc2-7d1a0973e7b2_story.html?utm_term=.272ee1417072">not fund the United Nations Population Fund</a> (UNFPA) in 2018 because of the body’s alleged support for coercive abortions and forced sterilisation in China. </p>
<p>The US is the largest donor to the agency, which <a href="http://www.unfpa.org/frequently-asked-questions#goal">mandates access</a> to high-quality sexual and reproductive health services and voluntary family planning. It allows people to make informed and voluntary choices about their sexual and reproductive lives.</p>
<p><a href="http://www.guttmacher.org/media/inthenews/2015/04/10/index.html">US funding</a> totalling US$610 million (including US$35 million for UNFPA) for family planning programs and reproductive health helped prevent 2.4 million abortions in 2015, by averting six million unintended pregnancies. </p>
<p>In 2016, the total amount, which again includes funding for UNFPA, was <a href="http://kff.org/global-health-policy/fact-sheet/the-u-s-government-and-international-family-planning-reproductive-health-efforts.">US$608 million</a>. The US Agency for International Development (US AID) alone has requested <a href="http://foreignpolicy.com/2017/03/20/the-global-gag-rule-americas-deadly-export-trump-africa-women-reproductive-rights/">US$544 million for family planning and reproductive health for 2017</a>, and the funds cut from UNFPA are expected to be redirected to it.</p>
<h2>Hurting the poor</h2>
<p>Some of the <a href="http://www.guttmacher.org/media/inthenews/2015/04/10/index.html">key areas</a> disrupted by Trump’s extraction of funding include addressing gender-based violence, biomedical and contraceptive research and development, contraceptive supplies and distribution, family planning programs that link HIV/AIDS and sexually transmitted diseases (STD) information and services, post-abortion care, sexual and reproductive health education and the training of health workers. </p>
<p>Without these programs, thousands of infants <a href="http://www.who.int/mediacentre/factsheets/fs364/en/">could have their health compromised</a> as a result of increased high-risk births, especially babies born to adolescent mothers. And couples will lose access to modern contraceptives, which could result in unwanted pregnancies. </p>
<p>A substantial fraction of these unwanted pregnancies <a href="http://www.who.int/whr/2005/chapter3/en/index3.html">could result in illegal, unsafe abortions</a>. What is equally worrying is what the effects of a lack of education and availability of contraceptives might do to efforts toward containing HIV/AIDS and other STDs. </p>
<p>And then there’s the potential stresses on future family and national health budgets because of the lack of information and services for safe termination of pregnancies in the case of Zika babies.</p>
<p>Undermining access to family planning education and services will deny women in poorer countries the tools they need to establish some form of health security within social systems that fail to meet their needs to reproductive and sexual health. The absence of such programs has driven women towards <a href="http://foreignpolicy.com/2017/03/20/the-global-gag-rule-americas-deadly-export-trump-africa-women-reproductive-rights/">unsafe and illegal abortions</a>, jeopardising their health and resulting in many deaths.</p>
<h2>Women’s health in Southeast Asia</h2>
<p>In Southeast Asia, the UNFPA and US AID s<a href="https://explorer.usaid.gov/aid-dashboard.html">ustain the reproductive and sexual health</a> of women and girls and <a href="http://asiapacific.unfpa.org/">manage population policies and programs across countries</a> such as Cambodia, Myanmar, Laos, Indonesia, the Philippines and Timor-Leste. </p>
<p>Health budgets in some Southeast Asian countries <a href="https://www.futurereadysingapore.com/2015/the-health-of-southeast-asias-healthcare-systems.html">are extremely strained</a>, as they have to contend with several health challenges. The withdrawal of funding can result in women’s reproductive and sexual health budgets being curtailed, as they might not be priority areas.</p>
<p>The removal of women’s choice in terminating pregnancies is bound to severely strain family incomes in the future (if they have Zika babies, for example). And it can also translate to severely stressed future health expenditures of these countries. </p>
<p>In addition, <a href="http://www.vox.com/identities/2017/1/23/14356582/trump-global-gag-rule-abortion">abortion numbers are unlikely to drop</a>. Rather, we will see the rise of unsafe abortions, one of the <a href="http://www.who.int/reproductivehealth/topics/unsafe_abortion/magnitude/en/">leading causes of maternal mortality</a> in the region. So we are in danger of compromising the economic security of families and by extension of these poorer nations because we think it will reduce abortions.</p>
<p>Pregnant adolescent girls, both as a result of early marriage or rape, drop out of school and later, can only gain low-skill jobs. Their income earning potential will be much lower than a young woman who has a minimum ten years of basic numeracy and literacy. </p>
<h2>Development goals and human rights</h2>
<p>This is a human rights issue and can have great impact on global health security and women’s health. The global community needs to step up to take action to address this deficiency.</p>
<p>The alternative would be to have this failing affect global stability and peace especially in terms of achieving the <a href="http://www.un.org/sustainabledevelopment/sustainable-development-goals/">sustainable development goals</a> – our shared objectives for humanity. All 17 of these require the equal and effective participation of women. </p>
<p>The cuts could make Goal 5 for Gender Equality almost impossible to achieve. Target 5.6, for instance, spells out objectives to attain sexual and reproductive health and reproductive rights. </p>
<p>Within this context we need like-minded countries to address this <a href="https://www.washingtonpost.com/world/national-security/trump-administration-to-eliminate-its-funding-for-un-population-fund-over-abortion/2017/04/04/d8014bc0-1936-11e7-bcc2-7d1a0973e7b2_story.html?utm_term=.d51e3dc41481">shortfall of US$32.5 million</a> for the UNFPA in the upcoming budget year.</p>
<p>On January 23, <a href="https://www.theguardian.com/world/2017/jan/23/trump-abortion-gag-rule-international-ngo-funding">Donald Trump signed an executive order</a> reinstating the “global gag rule”, which disallows NGOs from offering abortion services or information about pregnancy termination. It prompted countries such as
<a href="http://www.reuters.com/article/us-usa-trump-norway-abortion-idUSKBN15Z1KL">Norway</a> and the <a href="https://www.globalcitizen.org/en/content/netherlands-fund-global-gag-rule-abortion/">Netherlands</a> to pledge financial assistance to make up for the shortfall so that access to birth control and safe abortions could continue in poorer countries. </p>
<p>Unfortunately, the crisis is too large and the resources too few to have the gap easily filled, especially in light of the recent cuts to UNFPA funds. </p>
<p>But this might be an opportunity for China to help address the global shortage, especially in regions it has close historical and contemporary ties.</p>
<p>Despite continuing human rights problems both domestically and internationally, China has been trying to step up as a responsible global citizen. Consider its commitment to the Paris Agreement and its recent emphasis of renewable energy; its plans to build a <a href="http://news.xinhuanet.com/english/2017-03/02/c_13607346.htm">national park 60% larger</a> than Yellow Stone National Park to protect the highly endangered Siberian tigers and Amur leopards; and its plan to completely <a href="https://www.theguardian.com/environment/2016/dec/30/china-ban-ivory-trade-2017-elephants-wwf">ban the ivory trade</a> by the end of 2017.</p>
<p>Perhaps the rising superpower can help establish equal access for health and well-being in some of the poorer regions in the world: African states where it has vested interests, and Southeast Asia, where it has economic interests and historical ties as well.</p>
<p>China seems to be weaving the narrative of a soft power, as opposed to the hard stance of the US. Whether intentional or otherwise, it is fast gaining kudos and international respect. Adding the feather of global health security to its good international citizen hat would certainly help garner more respect in the international community</p><img src="https://counter.theconversation.com/content/75922/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tamara Nair does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The US is the largest donor to the United Nations Population Fund, which mandates access to high-quality sexual and reproductive health services and voluntary family planning.Tamara Nair, Research Fellow in Non-Traditional Security Studies at RSIS, Nanyang Technological UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/758132017-04-17T22:57:35Z2017-04-17T22:57:35ZWill Trump’s global family planning cuts cause side effects?<figure><img src="https://images.theconversation.com/files/165138/original/image-20170412-25875-nkcuv9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Actress and U.N. Population Fund Goodwill Ambassador Ashley Judd visited a refugee camp in Mafraq, Jordan in 2016. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Mideast-Jordan/693454dd4a3841a5bc0b031a443fa2e8/3/0">AP Photo/Raad Adayleh</a></span></figcaption></figure><p>President Donald Trump is leading an assault on family planning around the world.</p>
<p>Most recently, his administration <a href="https://www.devex.com/news/trump-administration-cuts-all-future-us-funding-to-unfpa-89986">cut off U.S. contributions</a> to the <a href="http://www.unfpa.org/">United Nations Population Fund</a>, which provides and funds reproductive health services in poor countries. That follows his reinstatement of what’s known as the “<a href="https://theconversation.com/trumps-global-gag-rule-will-cause-more-abortions-not-fewer-71881">global gag rule</a>,” the executive order enacted by all Republican presidents since Ronald Reagan barring foreign <a href="https://theconversation.com/us-foreign-aid-explained-74810">nongovernmental organizations (NGOs)</a> that receive U.S. funding from even mentioning abortion. </p>
<p>But Trump wants to go even further than his GOP predecessors by slashing spending on global health efforts funded through the <a href="https://www.usaid.gov/">United States Agency for International Development</a> (USAID). Deeper family planning retrenchment would, however, put millions of lives at risk.</p>
<h2>US family planning assistance</h2>
<p>Trump’s proposed <a href="http://www.reuters.com/article/us-usa-trump-budget-state-idUSKBN16N0DQ">28 percent cut to the foreign aid and diplomacy</a> budget could translate into a US$175 million reduction in USAID’s family planning spending from 2015 levels. </p>
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<p>The magnitude of these cuts pales in comparison with the nation’s $4 trillion budget and the administration’s overall plan to <a href="https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/budget/fy2018/2018_blueprint.pdf">reduce non-military spending by $54 billion</a>. But the potential impact on the lives of women, children and men in developing countries outweighs their monetary value.</p>
<p>Rolling back U.S. support for family planning in developing countries is dangerous for two main reasons. First, contraception saves lives by limiting the total number of pregnancies, including those endangering mothers’ lives. Second, as I explain in my book, “<a href="http://www.cambridge.org/us/academic/subjects/politics-international-relations/african-government-politics-and-policy/intimate-interventions-global-health-family-planning-and-hiv-prevention-sub-saharan-africa?format=HB">Intimate Interventions in Global Health</a>,” past U.S. funding for family planning had an unintended upside: it helped form the backbone of many countries’ early HIV-prevention efforts and created organizations that remain central to the response to HIV. </p>
<p>The U.S. government has identified <a href="https://www.usaid.gov/what-we-do/global-health/family-planning">24 priority countries for family planning assistance</a>, including 16 in sub-Saharan Africa. In these countries, on average only half of women who wish to avoid pregnancy are <a href="https://www.usaid.gov/what-we-do/global-health/family-planning">using modern contraception</a>. That means U.S. funding can go a long way toward helping these women have the number of children they desire.</p>
<h2>Contraception saves lives and strengthens health systems</h2>
<p>Contraception lets women and men exercise reproductive freedom and averts maternal and infant deaths. According to the <a href="https://www.guttmacher.org/article/2016/05/just-numbers-impact-us-international-family-planning-assistance">Guttmacher Institute</a>, which researches sexual and reproductive health, U.S. foreign assistance for family planning in 2016 funded contraceptive services for 27 million girls, women and couples, helping avert 6 million pregnancies and 11,000 maternal deaths.</p>
<p>Fewer unintended pregnancies also means fewer maternal deaths due to unsafe abortion. Sub-Saharan Africa has both the world’s highest fertility rate and the <a href="http://worldabortionlaws.com/">least access to safe abortion</a>. U.S. family planning assistance in 2016 helped <a href="https://www.guttmacher.org/article/2016/05/just-numbers-impact-us-international-family-planning-assistance">prevent 2 million unsafe abortions</a> resulting from unplanned pregnancies.</p>
<p>For the 22 priority nations with good data, the fertility rates average 4.5 children per woman, ranging from 2.3 in Bangladesh and India to 6.6 in the Democratic Republic of the Congo. In comparison, the <a href="http://www.prb.org/DataFinder/Geography/Data.aspx?loc=312">U.S. total fertility rate</a> is 1.9 children per woman.</p>
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<p>Designed to slow global population growth and encourage socioeconomic development, U.S. spending on family planning in sub-Saharan Africa in the 1980s also yielded benefits beyond family planning.</p>
<p>Specifically, U.S.-supported family planning organizations became the first responders when the HIV epidemic emerged. For example, to promote contraception, a group of Nigerian medical professionals founded the <a href="http://www.sfhnigeria.org/">Society for Family Health in Nigeria</a> in 1985 <a href="http://www.psi.org/country/nigeria/#about">in partnership with PSI</a>, a U.S. nonprofit previously known as Population Services International that gets government funding. </p>
<p>In the 1990s, the HIV epidemic took off in Nigeria amid political chaos and government denial of the disease. As one of the main sources for condoms, the Society for Family Health helped prevent the spread of the as-yet untreatable virus. It remains both a key player in the response to HIV and a major recipient of <a href="http://files.kff.org/attachment/report-foreign-ngo-engagement-in-u-s-global-health-efforts">U.S. global health funding</a>. Similar results <a href="http://www.jiasociety.org/index.php/jias/article/view/17511">were echoed across Africa</a>.</p>
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<a href="https://images.theconversation.com/files/165053/original/image-20170412-25882-2935n9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/165053/original/image-20170412-25882-2935n9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/165053/original/image-20170412-25882-2935n9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=337&fit=crop&dpr=1 600w, https://images.theconversation.com/files/165053/original/image-20170412-25882-2935n9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=337&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/165053/original/image-20170412-25882-2935n9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=337&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/165053/original/image-20170412-25882-2935n9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=423&fit=crop&dpr=1 754w, https://images.theconversation.com/files/165053/original/image-20170412-25882-2935n9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=423&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/165053/original/image-20170412-25882-2935n9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=423&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The United Nations Population Fund provides family planning and health services in India, where it also seeks to improve maternal health.</span>
<span class="attribution"><a class="source" href="http://india.unfpa.org/en/news/10-new-year%E2%80%99s-resolutions-help-change-world">UNFPA</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>In “Intimate Interventions in Global Health,” I also detail how U.S. family planning helped build infrastructure for women’s health research in Senegal that became useful for the fight to stop HIV’s spread. Key researchers working at the Social Hygiene Institute, including Senegalese doctors Soulemayne Mboup and Ibrahim Ndoye, argued in the 1980s that effectively running family planning programs required comprehensive knowledge of sexually transmitted infections among women. USAID agreed and invested in laboratory capacity, which ultimately supported Senegal’s successful response to the epidemic.</p>
<h2>What to expect once the US cuts global health spending</h2>
<p>For sure, the impact of the U.S. government’s cessation of United Nations Population Fund support will be largely symbolic. In 2015, Washington’s <a href="http://www.unfpa.org/donor-contributions">$76 million contribution</a> amounted to about 7.5 percent of <a href="http://www.unfpa.org/sites/default/files/pub-pdf/UNFPA_2015_Annual_Report.pdf">the global agency’s $993 million budget</a>. </p>
<p>Previously, when the U.S. has refused to support the global agency, other countries stepped in to <a href="https://www.cgdev.org/doc/Resources-at-UNFPA.pdf">fill the gap</a>. It’s unclear whether other countries or additional funders, like the Bill and Melinda Gates Foundation, would be willing to do so if Congress embraces Trump’s broader proposed cuts to global health assistance. (The Gates Foundation spent <a href="http://www.gatesfoundation.org/Who-We-Are/Resources-and-Media/Annual-Reports/Annual-Report-2015">$144 million on family planning in 2015</a>, slightly less than a quarter of what USAID spent on family planning that year.)</p>
<p>Family planning funding alone could not stop HIV from infecting <a href="https://www.aids.gov/hiv-aids-basics/hiv-aids-101/statistics/">the 1.2 million Americans living with the virus</a> that causes AIDS, but it did help slow the virus’s spread in sub-Saharan Africa, particularly when <a href="http://kff.org/global-health-policy/timeline/global-hivaids-timeline/">governments widely denied</a> the need to make treatment and prevention high priorities.</p>
<p>Cutting U.S. funding for global health efforts, including family planning, would leave the poorest countries <a href="https://theconversation.com/how-the-trump-budget-undercuts-security-risks-posed-by-pandemics-75281">ill-prepared for epidemics, pandemics</a> and other emerging health threats – including the kinds that <a href="http://www.vox.com/2017/3/4/14803596/trump-pandemic-response-global-health-cdc">easily cross borders</a>. This negligible budgetary savings will ultimately cost rich and poor nations in the future.</p><img src="https://counter.theconversation.com/content/75813/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachel Sullivan Robinson does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Contraception saves lives, and U.S. spending on it abroad had an unintended upside when it formed the backbone of early HIV prevention efforts.Rachel Sullivan Robinson, Associate Professor, American University School of International ServiceLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/719492017-02-01T12:54:02Z2017-02-01T12:54:02ZCeaușescu’s orphans: what a regressive abortion law does to a country<figure><img src="https://images.theconversation.com/files/155208/original/image-20170201-29896-1tzbcq2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> <span class="attribution"><span class="source">Photo: Penny Kibble / Flickr</span>, <span class="license">Author provided</span></span></figcaption></figure><p>Donald Trump’s announcement of the reinstatement and reinforcement of the “<a href="https://www.engenderhealth.org/media/info/definition-global-gag-rule.php">global gag</a>” – which means the US will no longer fund any non-governmental health organisations working outside the US that give information about abortion – will have a devastating impact in some countries. I know because I have witnessed it happen before. </p>
<p>In 1990, as a young reporter specialising in women’s issues, I travelled to Romania a few weeks after the revolution that deposed the dictator, Nicolae Ceaușescu. While I was there, I spent time with Francu – a mother of two. In my mind’s eye, we are in a bare Bucharest hospital corridor which doubles up as recovery room. Francu is relaxed and smiling although she’s about to have an abortion. But that’s because this one is going to be performed by doctors. </p>
<p>She’d performed the last one herself using dirty rubber piping and had been in near-death agony afterwards. But the ban on abortion at the time – and the ban on even receiving information about abortion – meant she’d had to deal with the blood, pain and risk of death in secret.</p>
<p>The reason she’d got to this point was hidden in another ward. There, I encountered hundreds of Romania’s “orphans”. They lay under once white blankets, in little glass boxes like museum exhibits behind glass. The room was as quiet as a provincial museum. At the time, having little experience of babies, I did not realise that the lack of crying was a sign of emotional deprivation. The nurses were kind but they were few and the babies many. The nurses could not attend to them when they cried so the babies had given up crying. It saved energy. These “orphans” probably had parents – but they’d been given away because their parents could not feed the children they already had.</p>
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<a href="https://images.theconversation.com/files/155170/original/image-20170201-12656-17p1t8v.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/155170/original/image-20170201-12656-17p1t8v.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/155170/original/image-20170201-12656-17p1t8v.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=942&fit=crop&dpr=1 600w, https://images.theconversation.com/files/155170/original/image-20170201-12656-17p1t8v.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=942&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/155170/original/image-20170201-12656-17p1t8v.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=942&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/155170/original/image-20170201-12656-17p1t8v.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1184&fit=crop&dpr=1 754w, https://images.theconversation.com/files/155170/original/image-20170201-12656-17p1t8v.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1184&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/155170/original/image-20170201-12656-17p1t8v.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1184&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Codruta, a Romanian orphan, at 13 years of age in 1990.</span>
<span class="attribution"><span class="source">Angela Catlin</span></span>
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<p>The reason for “<a href="http://news.bbc.co.uk/1/hi/world/europe/4629589.stm">Romania’s orphans</a>” was Ceaușescu’s fixation on achieving a larger workforce. Measures to grow the birth rate included a near-complete ban on abortion – and information about it – combined with extremely limited access to contraception (though some was smuggled in). There was workplace pregnancy-testing to ensure women didn’t arrange abortions themselves.</p>
<p>It was a policy which gifted Romania the <a href="https://www.ncbi.nlm.nih.gov/pubmed/1949105">highest maternal mortality rates in Europe</a>, the highest number of deaths from abortion, and a generation of emotionally afflicted, malnourished “orphans” raised in miserable conditions until, after the revolution, charities (and philanthropists <a href="http://www.childrights.ro/media_articles.htm">such as JK Rowling</a>) supplied help and funds.</p>
<p>In Romania before the revolution it was illegal to have an abortion, it was illegal to talk about abortion, it was illegal to give anyone information about abortion. Yet as my experience shows – and works such as Gail Kligman’s <a href="http://www.ucpress.edu/book.php?isbn=9780520210752">The Politics of Duplicity, Controlling Reproduction in Ceaucescu’s Romania</a> confirm – women still had abortions. Some of the women I interviewed had friends who died from illegal abortions, but that didn’t stop them having one that was equally dangerous. </p>
<h2>Backwards step</h2>
<p>This is why Trump’s reinstatement of <a href="http://www.independent.co.uk/news/world/americas/mexico-city-policy-donald-trump-abortion-funding-ban-federal-money-global-gag-rule-a7542311.html">the “Mexico City” policy</a> on abortion and aid is so retrograde. All that will happen, as <a href="http://www.ippf.org/global-gag-rule">activists have pointed out</a>, is that in developing countries such as Nepal and in Sub-Saharan Africa life chances will be diminished and the abortion rate may even go up. </p>
<p>This result was observed in a <a href="http://www.who.int/bulletin/11-091660.pdf">World Health Organisation study</a> of a previous iteration of this policy which was brought in by George W Bush in 2001 and was rescinded in 2009 by Barack Obama. </p>
<p>The death rate of women in these countries will also climb. In the first year after abortion was legalised in Romania, <a href="https://www.ncbi.nlm.nih.gov/pubmed/1949105">the maternal death rate fell by 50%.</a></p>
<p>This “gag” could have been offset if it had been matched by a vast increase in federal funds for contraception in those countries which are going to be affected. But – no surprises here – that hasn’t happened.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"825638392251695104"}"></div></p>
<p>This year is the 50th anniversary of the <a href="http://www.legislation.gov.uk/ukpga/1967/87/contents">Abortion Act</a> in the UK. The figures for death from illegal abortion prior to that year are hard to confirm but the <a href="https://www.rcog.org.uk/en/news/campaigns-and-opinions/human-fertilisation-and-embryology-bill/rcog-opinion-the-abortion-act-40-years-on/">Royal College of Obstetricians and Gynaecologists</a> states they were the leading cause of maternal death in the 12 years before the Act. </p>
<p>If women in a rich country died then through a lack of information and access to legal abortion, how much worse the plight of women in developing countries today. What this means globally is hungrier babies, reduced life chances and the needless death of young women in countries which are already struggling.</p><img src="https://counter.theconversation.com/content/71949/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sharon Maxwell Magnus won the Rosemary Goodchild Award for her coverage of women’s health in the aftermath of the Romanian revolution.</span></em></p>The ‘global gag’ will not lower the rate of abortions, but it will increase misery and suffering.Sharon Maxwell Magnus, Principal Lecturer in Journalism, University of HertfordshireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/718812017-01-26T07:51:05Z2017-01-26T07:51:05ZTrump’s ‘global gag rule’ will cause more abortions, not fewer<p>Two days after large numbers of <a href="https://theconversation.com/women-marching-worldwide-revive-a-long-sought-dream-global-feminism-71777">people across the globe joined Woman’s Marches</a>, US President Donald Trump <a href="http://www.newyorker.com/news/daily-comment/trump-makes-the-global-gag-rule-on-abortion-even-worse">reinstated the “global gag rule”</a>, which cuts off all US funding to international NGOs whose work includes abortion services or advocacy.</p>
<p>Fortunately, <a href="http://www.abc.net.au/news/2017-01-26/netherlands-government-launches-global-abortion-fund/8213744?WT.mc_id=newsmail&WT.tsrc=Newsmail">the Dutch government has announced a plan to compensate NGOs</a> for the funding shortfall of US$600 million over four years. Several countries within and outside the EU have indicated their support, as have private companies and foundations. </p>
<p>But it remains to be seen whether this ambitious target will be reached and what other needs will be left unmet as a result of any redirected funds. </p>
<p>Dutch Minister for International Development Co-operation, Lilianne Ploumen, who <a href="https://www.theguardian.com/global-development/2017/jan/25/netherlands-trump-gag-rule-international-safe-abortion-fund?utm_source=esp&utm_medium=Email&utm_campaign=Australia+Morning+mail+new+030615&utm_term=210232&subid=2689150&CMP=ema_1731">announced the initiative, said</a>, “I’m pro-choice and pro-women’s rights. It’s important to stand your ground.”</p>
<p>But as welcome as efforts towards replacing the funding lost to the global gag rule is, it’s important to realise that this is not a pro-life debate. It’s a global health issue that has serious implications for the most vulnerable populations – millions of men, women and children in developing countries.</p>
<h2>Threat to services</h2>
<p>Also known as the Mexico City policy, the global gag rule requires all NGOs operating abroad to refrain from advising, endorsing or performing abortions as a method of family planning. However, some NGOs operate in contexts where abortion – safe or unsafe – is the only accessible form of contraception.</p>
<p>Many international NGOs are working hard to increase access to both short-term and long-term contraception. But such a transition takes time and money.</p>
<p>NGOs that may be forced to reduce or close health services as a result of the policy are often a woman’s only source of reproductive health care. They may, in fact, be her family’s only point of medical contact for other primary health-care services, such as cervical screening, HIV prevention, testing and counselling, STI prevention and treatment, pre and post-natal care and even newborn health care.</p>
<p>Services threatened by the policy also train health professionals, including midwives and traditional birth attendants, in countries that are desperately short of qualified health personnel.</p>
<p>Most developed countries have <a href="http://www.who.int/whr/2006/06_chap1_en.pdf">33 health professionals per 10,000 people</a>; most developing countries have two health professionals for the same number of people. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4249206/">Research also shows</a> that unattended births have much higher rates of maternal and newborn death.</p>
<h2>Unintended consequences</h2>
<p>The rule was first put into place by former <a href="http://kff.org/global-health-policy/fact-sheet/mexico-city-policy-explainer/">US president Ronald Reagan in August 1984</a>. Since then, it has been lifted by Democratic presidents and reinstated by Republican presidents. </p>
<p>Unlike when Reagan implemented the policy, we now have ample evidence of its unintended health consequences. <a href="http://www.who.int/bulletin/volumes/89/12/11-091660/en/">A 2011 study showed</a>, that women were 2.73 times more likely to have an abortion under the rule. So while its intention may be to reduce the rate of abortion, the policy actually increases it.</p>
<p>Reducing access to family planning services leads to more unplanned pregnancies, more unsafe abortions and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2709326/">more maternal death</a>. </p>
<p>The sexual and reproductive health research organisation, the Guttmacher Institute, quantified this in 2016. <a href="https://www.guttmacher.org/article/2016/05/just-numbers-impact-us-international-family-planning-assistance">It showed that when US$607.5 million is cut</a> from family planning and reproductive health services, 27 million women and couples are prevented from receiving family planning services and supplies. This leads to six million more unplanned pregnancies and 2.3 million more abortions, two million of which will be unsafe.</p>
<p>This may not mean much in a developed country, where deaths resulting from pregnancy and childbirth are 12 women per 100,000 live births. But it will have a huge impact on women in developing countries, where the maternal mortality rate is <a href="http://www.who.int/mediacentre/factsheets/fs348/en/">239 women per 100,000 live births</a>, and where 99% of total global maternal deaths occur.</p>
<p>In 2000, 189 countries including the United States, committed to the <a href="http://www.un.org/millenniumgoals/mdgmomentum.shtml">Millennium Development Goals</a>. These included a <a href="http://www.un.org/millenniumgoals/maternal.shtml">commitment to improving maternal health</a> by reducing maternal mortality and providing access to reproductive health services by 2015. This was one of the least successful Millennium Development Goals, <a href="http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20%28July%201%29.pdf">falling short by half</a>.</p>
<h2>Falling short</h2>
<p>While the <a href="https://www.theguardian.com/global-development/2015/apr/08/foreign-aid-spending-2014-least-developed-countries">US ranks 19th</a> worldwide as an international aid donor in terms of percentage of gross national income, USAID is the largest humanitarian donor in dollar terms. It <a href="http://humanitarianadvisorygroup.org/trump-and-humanitarianism/">allocated in excess of $USD6.42 billion</a> to humanitarian aid in 2015. </p>
<p>This means the global gag rule seriously threatens the UN Sustainable Development Goal of <a href="http://www.unwomen.org/en/news/in-focus/women-and-the-sdgs/sdg-3-good-health-well-being">reducing maternal mortality</a> to less than 70 per 100,000 live births by 2030. It also threatens the goal of ensuring access to sexual and reproductive health-care services, including family planning, information and education.</p>
<p>The rule targets family planning, which is essentially about spacing out childbirth. The health and economic benefits of child spacing are well documented and include <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3785173/">reduced pregnancy-related deaths and better child survival</a>. Then, <a href="http://apps.who.int/iris/bitstream/10665/69855/1/WHO_RHR_07.1_eng.pdf">there’s reduced rates of HIV/AIDS</a>, and sexually transmitted infections, empowerment of women, enhanced education and a reduction in adolescent pregnancy.</p>
<p>These benefits lead to more advantages, including slowed population growth, natural resource conservation, climate change mitigation and economic growth, which reduces conflict and migration.</p>
<h2>The wrong debate</h2>
<p>Forcing impoverished women – in places where they have no access to health care or contraception – to have more babies has a <a href="https://www.adb.org/sites/default/files/publication/157217/adbi-rp68.pdf">detrimental impact on the entire family</a>. It places demands on scarce resources, reduces access to education, limits employment options, reduces family income and ultimately reinforces the poverty cycle.</p>
<p>The regions predicted to experience the largest population growth in the coming decades (<a href="http://www.mbctimes.com/english/india-and-nigeria-countries-with-the-fastest-growing-populations">South Asia and Africa</a>) are also the most impoverished. They have the weakest health-care systems and rely on foreign aid to provide essential services. </p>
<p>Their only hope for economic development and poverty eradication is to <a href="https://www.populationeducation.org/content/what-demographic-transition-model">undergo the demographic transition</a>, which high-income countries have already experienced. And this starts with a reduction in family size. Anyone who has worked in reproductive health in developing countries will tell you that this is what impoverished women with large families want.</p>
<p>So let’s get it right: this is not a high-income country, religiously charged pro-life debate. The global gag rule actually increases abortion demand and has consequences for a range of other health issues such as HIV/AIDS, cervical cancer and child health and well-being. </p>
<p>This misinformed, short-sighted policy is as far removed from scientific evidence as denying climate change. As a global community, we have a duty to expand access to family planning for people worldwide, particularly to the most vulnerable.</p><img src="https://counter.theconversation.com/content/71881/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patricia Schwerdtle is an association member of MSF-Australia. </span></em></p>Also known as the Mexico City policy, the rule increases abortion demand and has consequences for a range of other health matters such as HIV/AIDS, cervical cancer and child health and well-being.Patricia Nayna Schwerdtle, Academic, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.