On Jan. 23, 2017, President Trump signed a memorandum reinstating a Reagan-era policy that bans U.S. aid to international health groups that promote abortions. At the time, a tweet from NARAL Pro-Choice America caught our eye. It claimed “the global gag rule” (opponents’ name for the policy) ended funding for “ANY health center that even *mentions* abortion.” We determined it was too soon to be sure if this was accurate for Trump’s iteration of this policy, particularly given the administration’s signal that it intended to expand the policy. So we left it as “verdict pending.”
Fast-forward a year. The Trump administration did expand the rule’s reach, appropriators left the expansion in place, and the expanded rules have been in place for over six months. So, given the wealth of new information, does NARAL’s statement hold up? Let’s take another look.
The rule, which supporters call the Mexico City policy, has been rescinded (by Democratic presidents) and then restored (by Republicans) since 1985. Trump’s memo reinstated George W. Bush’s 2001 memorandum that Barack Obama rescinded in 2009.
As we’ve previously explained, under this policy, foreign nongovernmental organizations that receive family-planning assistance from the United States cannot “perform or actively promote abortion as a method of family planning,” even with money that does not come from the United States. The use of U.S. aid to pay for abortions overseas is prohibited, under several laws that were in place even before the Mexico City policy.
Yet those who oppose abortion rights often characterize this policy as a protection not only against taxpayer funds being used to both pay for abortion overseas, but also against actively promoting abortion overseas. That is why NARAL Pro-Choice America and other advocates of abortion rights call it a “myth” that Trump’s policy “bans taxpayer $ for abortion overseas.”
A spokesman at NARAL Pro-Choice America stood by its original tweet: “The broad scope of the Global Gag Rule also creates a severe chilling effect in which providers are afraid to violate the policy out of fear for losing funding.”
So, just what is going on? Per an October revision to USAID guidelines, the Trump administration’s definitions for “performing abortion” and “actively promoting abortion” mirror the Bush administration’s, meaning an organization cannot “commit resources, financial or other, in a substantial or continuing effort to increase the availability or use of abortion as a method of family planning.”
In practice, this means an organization can:
- Respond to a question about where a safe abortion can be performed if the woman has already decided to have a legal abortion and it is legal in the country where the clinic is operating.
- Refer a woman to a legal clinic if the pregnancy is a result of rape or incest, or if the life of the mother would be in endangered if the fetus were carried to term. (This provision, however, does not include fetal abnormalities and the physical or mental health of the mother.)
- Treat injuries or illnesses incurred as a result of a legal or illegal abortion.
However, any attempt to provide information, referrals or services outside listed exceptions is prohibited. In other words, the clinics cannot proactively mention abortion.
Additionally, organizations are not allowed to advocate the legalization of abortion. These rules extend to organizations operating in countries where abortion is legal even if they use non-U. S. funding.
In the past, restrictions put in place by the Mexico City policy applied only to family-planning funds, or about $575 million. The new policy, called the Protecting Life in Global Health Assistance policy (PLGHA), expands the breadth of the policy to any U.S. funding for global health including “international health programs, such as those for HIV/AIDS, maternal and child health, malaria, global health security, family planning and reproductive health.” This means the policy would now be applied to about $8.8 billion in foreign aid across 64 countries, administered by different agencies. In other words, the new policy now covers roughly 15 times the amount of funding previously affected.
The policy does have some exceptions: basic health research and humanitarian assistance programs administered through USAID, the State Department and the Department of Defense; food for peace programs; and American schools and hospitals abroad.
The State Department says the policy is not intended to “reduce the amount of global health assistance the U.S. Government makes available.” To support its case, the administration and antiabortion advocates pointed to the fact that only four primary partners out of 733 that had funding reviews before Sept. 30 declined to sign the updated agreement.
But stated intention and practical application aren’t always the same. As part of capacity-building efforts, many primary USAID partners work with small local organizations that now will have to comply with policy. Moreover, because of the global trend toward co-locating health services, NGOs that house a wide swath of services — including HIV prevention and treatment, immunizations, and safe abortion referrals in the same facility — risk losing U.S. funding for all of their programs.
Marie Stopes International (MSI), a United Kingdom-based family-planning organization, was one of the four entities that declined USAID funding. Its official website said it declined funding because it would force the organization to give up the non-U.S. funding for abortion programs.
In 2017, there were just under 27 million women using a contraceptive method provided by MSI. They estimate 2 million women would lose access to care as a result of the policy change. While this may sound like a small fraction, the organization noted this loss of services tended to be heavily concentrated. For example, in Madagascar, the United States funded a voucher program that delivered more than 170,000 free services to women and girls, which allowed them to receive contraceptive care at Marie Stopes clinics. Because of the funding gap, many of “the world’s poorest women and girls will be denied the contraception they need to prevent an unintended pregnancy,” said Marjorie Newman-Williams, president of MSI-US.
Jonathan Rucks, senior director of advocacy for at PAI, a reproductive health advocacy organization, echoed this, saying, PLGHA “obstructs” health-care organizations’ “fundamental work,” particularly among those in “hard-to-reach communities.” Two case studies from PAI (in Nigeria and Uganda) outlined this impact. In both countries, PAI found organizations already lost “critical implementing partners for service delivery and commodity distribution” and faced more hostile operating environments. Human Rights Watch similarly reported organizations scaling back services, closing programs and canceling educational and training events in Kenya and Uganda.
Reproductive rights groups also say large swaths of the new policy are vague, which has caused confusion among NGOs. They pointed out that USAID has a training program for affected grantees (in part because they have previously implemented an iteration of this policy) but that the Department of Defense, for example, doesn’t have one. Plus, they said, there was little coordination between administering agencies and thus no way to know if the policy was being implemented the same way for every program. The State Department said affected agencies and departments would be developing additional training and compliance tools.
Pitfalls of the new policy have not been lost on the State Department — an Office of Management and Budget review of stakeholders published in February identified several challenges that have arisen. But none of the review’s recommendations have been implemented. It did note the State Department would lead a review of policy implementation by December.
We face a conundrum here. The tweet looks increasingly accurate as the rules are implemented. But it does not quite rise to the level of a Geppetto because of its sweeping assertion.
Does the updated policy restrict funding to any organization that “even *mentions* abortion?” Not entirely, if one believes a reactive response still qualifies as a mention. Does it blanket more organizations than ever before with tightened rules on how grantees and sub-grantees can spend their funds (whether or not those funds are American in origin)? Absolutely.
Every reproductive rights organization, nongovernmental organization and the Department of State pointed out that this type of policy change takes time to play out, and this one has yet to be fully implemented. We still cannot make a definitive ruling on the policy’s effect, so we will leave this unrated. What is clear, however, is that NARAL’s tweet holds more water than we initially thought.
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