US antiabortion gag rule hits women hard: What we found in Kenya and Madagascar

US President Joe Biden has reversed a Trump administration policy that prohibited US funding for nongovernmental groups that provide or refer patients for abortions.

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 Since its introduction, the policy has been instated by each Republican president and rescinded by each Democrat president.

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.

The Global Gag Rule requires non-governmental organizations (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 liberalization of a country's abortion law. It also applies to non-US based NGO sub-grantees of organizations getting money—even if they don't receive US global health assistance. The policy applies to US government and non-US government funds alike.

The policy allows for limited exceptions. 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, our research shows that these exceptions are not always understood or followed in practice.

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 in Kenya and Madagascar. 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.

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 legislation.

What we found

Research participants in Kenya described increased difficulties referring women for contraception, legal abortion, and post-abortion care. This is because some organizations chose to end sexual and reproductive health programs that included abortion in order to receive US government funding.

Additionally, we found that some organizations 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.

In Madagascar, we found evidence of negative effects on women's access to family planning services. This was true even though abortion is illegal there.

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.

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.

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."

Some women ended up with an unintended pregnancy because they could not obtain their contraceptive method.

Expansion under Trump

Under former Republican presidents the Gag Rule applied only to US government family planning assistance. This stood at $575 million in 2016.

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 US$9.5 billion.

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.

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 58% of HIV funding to Kenya.

As a result, we found that the delivery of the country's HIV and sexual and reproductive health services has been fractured.

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 USAID's own promotion of integrated services.

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 are wary of rebuilding or reinvesting in abortion-related work, for fear of its reinstatement.

What now?

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.

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.

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.