The United States policy known as the Global Gag Rule has had a devastating impact on women’s access to sexual and reproductive health care since it was reinstated and greatly expanded by the Trump Administration more than three and a half years ago. The policy—which already forces health providers to choose between providing information to patients or receiving US funding—is now set to be expanded even further. To mark International Safe Abortion Day on September 28, Dr. Manisha Kumar, head of the Doctors Without Borders/Médecins Sans Frontières (MSF) task force on safe abortion care, explains the risks facing women and girls.
What is the Global Gag Rule?
The Global Gag Rule (also known as the Mexico City Policy) is a dangerous policy that cuts US government funds to overseas programs that use non-US funds to provide or discuss safe abortion care. The policy acts as a “gag” on health care providers worldwide, prohibiting them from even informing women about their reproductive choices or referring them to other organizations that provide safe abortion care.
Historically, the Global Gag Rule has been enacted in the US via executive order by every Republican president and rescinded by every Democratic president since it was first introduced in 1984. The rule is not about US government funding for abortions. The US already made it illegal to use government funds to provide abortion services internationally with the passage of the Helms Amendment in 1973. Some reproductive rights organizations are advocating for the repeal of the Helms Amendment, as well as the Global Gag Rule.
The Global Gag Rule’s main intent is to censor discussion of abortion in any context, even if funds from other donor countries and institutions are used to support these activities.
The Trump administration took the policy much further. Just a few months after reinstating the policy in January 2017, the administration expanded the restrictions to apply to all US-funded global health assistance, not only organizations involved in family planning.
The massive expansion of the policy shocked the global public health community and has affected frontline health care workers around the world providing a whole range of services—including mother and child health care, nutrition programs, malaria treatment, and tuberculosis and HIV care.
This month the Trump administration proposed a new rule that would expand the reach of the policy even more.
Who will be affected by the proposed expansion of this policy?
The proposed rule would cover all contracts and subcontracts funded partially or wholly with US global health assistance. Essentially, every organization that has a US contract.
For example, if an organization that receives US funding subcontracts some work to another organization, the policy will extend to that other organization. Often these organizations are smaller, local organizations that don’t have the capacity to navigate additional hurdles. It just means more red tape and more restrictions limiting medical care for people in need.
What impact does the Global Gag Rule have?
MSF does not accept US government funding, so our programs are not directly affected by the Global Gag Rule. However, we see the harmful impacts this policy has on limiting women's access to essential health care and restricting the work of other health care providers around the world.
Because of the Global Gag Rule, all health care providers and organizations that accept US funding can’t even talk about abortion or refer their patients to other clinics for abortion services—even if they use funding from other governments or other sources to run these programs. With the proposed expansion, the rule would apply to their contractors and subcontractors as well.
Many organizations face a difficult choice: continue with abortion-related activities and risk losing vital US funding, or stop providing these essential services and comply with the policy’s restrictions. Cutting funds for organizations that provide safe abortion care affects all the other services that they provide—from family planning services to HIV care.
What this policy won’t do is reduce the number of abortions. A study published by The Lancet last year indicated that US policies to restrict funding for abortion services can lead to “more—and probably riskier—abortions in poor countries.” Unsafe abortion is already one of the main causes of maternal deaths worldwide, and it’s the only one that’s almost entirely preventable.
In MSF projects all over the world, our teams treat women for complications from unsafe abortion. In 2019, MSF treated over 25,800 women and girls with abortion-related complications, many of which resulted from unsafe attempts to end a pregnancy. We’ve seen women who have inserted a pen, broken glass, or sticks into their vagina to try to induce an abortion, and we’ve seen other women who drank chlorine or poisons. We have seen women who received pills at a pharmacy, but they weren’t given the right number of pills, or the accurate information they needed in order to undergo the abortion safely. These are examples of what women are forced to do when they don't have access to safe abortion care.
It should not be up to the US government to dictate the health care that is available to people in other countries.
Why does the COVID-19 pandemic make the impact of the Global Gag Rule more dangerous?
The health risks facing women and girls tend to multiply in times of crisis. The awful reality is that more women could die because of the COVID-19 pandemic’s disruption of sexual and reproductive health services than from the coronavirus itself.
Sexual and reproductive health care is essential health care, yet historically it’s neglected. It’s often seen as non-essential or even illegitimate—especially during emergencies. Throughout the COVID-19 pandemic MSF teams have witnessed that contraception and safe abortion care are not made a priority, or they’re just stopped altogether. Our teams have continued providing these important services and are working with local governments and authorities to ensure they are available as essential health services during the pandemic.
Right now, global health needs are surging. We need world leaders to come together to tackle the unprecedented number of humanitarian crises. Instead, the US is using its leverage as the largest funder of global health and humanitarian assistance to block women and girls from receiving the essential health care they need.
The US should be using its wealth and power to expand rather than restrict access to sexual and reproductive health services. Comprehensive sexual and reproductive health care is not only essential to the health of individuals, but to the overall health of families and communities everywhere.
What is MSF doing to address these challenges?
During the COVID-19 pandemic, we’ve been working to adapt the ways we deliver essential health services, such as contraception, safe abortion care, and post-abortion care. We’re trying to limit the time spent in health facilities and move toward more community-based activities, remote support of services, and self-care models. These models of care are not just temporary solutions to the pandemic; they are opportunities to fundamentally change how sexual and reproductive health services are delivered, in order to make them more accessible and support people’s autonomy.
We also use our expertise to speak out publicly against the harmful impacts of policies like the Global Gag Rule and other efforts to limit access to care. In collaboration with an organization called HowToUse, we created an online course on medication abortion for humanitarian aid workers, so people around the world have access to the information that they need. We also conduct research investigating the severity and treatment of complications from unsafe abortion in conflict-affected settings.