by Priyanjana Pramanik.
Abortion remains a controversial issue in many parts of the world, with many governments attempting to limit access to services through domestic policies. In studies comparing countries with restrictive abortion laws to those without, researchers find that the former have more abortions than the latter (37 abortions per 1,000 women to 34 abortions per 1,000 women). This is because countries with more restrictive abortion policies are also more likely to suffer from unmet contraceptive needs, theoretically increasing the incidence of unwanted pregnancy and unsafe abortion there. The World Health Organization estimates that 553 million dollars are spent each year on treating complications caused by unsafe abortions.
Unfortunately, it is not just domestic policies related to abortion that are a cause for concern in developing countries. In 1973, shortly after the landmark Roe v. Wade decision by the Supreme Court, the U.S. Congress passed the Helms Amendment to the Foreign Assistance Act, stating that “no foreign assistance funds may be used to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortions.” In 1984, it was followed by the introduction of the Mexico City Policy, which has come to be known scornfully as the Global Gag Rule.
The terms of the original policy are simple: an NGO in a developing country that receives family planning aid from USAID should not “perform or actively promote” abortions or conduct research to improve abortion methods. They should not lobby for the liberalization or legalization of abortion, conduct campaigns to educate women about the benefits or availability of abortion, or refer women to abortion providers in countries where abortion is legal for reasons other than rape, incest, or life-threatening conditions. They cannot do any of these things even with funding received from non-US sources. If they refuse to agree to these conditions, they lose any family planning assistance (FPA) they receive from USAID. This is no small matter, as FPA from the US to NGOs is greater than the combined FPA from the remaining 21 countries on the Development Assistance Committee or DAC, which provides the bulk of international development aid. A 1984 press release from the International Planned Parenthood Federation states that the organization lost 25% of its budget when it refused to give up its support for abortion-related activities.
Other than the fact that it is an intrusive, restrictive policy, the Mexico City Policy has one fascinating characteristic. Whether it is in place or not is entirely dependent on which party controls the White House. Republican President Reagan introduced it, and Republican President George H.W. Bush kept it in place. Democratic Presidents Clinton and Obama rescinded it within their first weeks in office, while Republican Presidents Bush (Jr.) and most recently Trump reinstituted it within days of entering the White House. Furthermore, both Bush and Trump changed the terms of the policies slightly: Bush by exempting organizations that provided HIV/AIDS services, and Trump by extending the policy to apply to all global health assistance.
For those who follow the pro-life vs. pro-choice debate, the political interplay around the policy comes as no surprise, and nor should it be shocking that pro-lifers hail each reintroduction of the policy as a victory. But this leads to two pertinent questions. Is the approval of the pro-lifers justified? Similarly, should the pro-choice community, or those concerned with family planning and development, be concerned about the policy? In essence, what, if any, is the effect of the Global Gag Rule?
Theories abound, but empirical evidence, unfortunately, is limited. This is for a variety of reasons, including the fact that data on abortion in developing countries (especially in a form conducive to statistical analysis) is scarce. In fact, most of what we know about the effect of the policy on abortion comes from two papers, one by Kelly M. Jones (2011) and the other by Eran Bendavid, Patrick Avila and Grant Miller (2011). They make use of Demographic Health Survey or DHS data, a collection of cross-sectional surveys conducted in developing nations around the world to show that the effect of the policy has been to increase abortion rates, not lower them.
Usually, DHS surveys base the fertility section of their survey around births, and not pregnancies. For example, they might ask when the date of birth for a pregnancy was, as opposed to asking when that pregnancy ended. While there are often questions regarding whether a woman has ever had an abortion, this makes it extremely difficult to identify which pregnancies may have been ended by choice, and when. In the absence of that information, abortion under policy versus non-policy periods cannot be compared, leading to the need to use innovative identification strategies to tease out results. Jones was able to make use of a special DHS survey conducted in Ghana in 2008, which was pregnancy-focused instead of birth-focused. It enabled her to construct an extremely detailed woman-month panel dataset, and to calculate detailed probabilities of becoming pregnant and of having an abortion in a policy versus a non-policy period. She found that the policy increased a woman’s chances of getting pregnant by 12%. She also found that the policy did not reduce the probability that woman would have an abortion. Studying urban and rural women separately, she once again found no effect for urban women. For rural women, however, she found that the probability of having an abortion went up dramatically.
Bendavid, Avila and Miller found similar results. Compiling data from 30 different DHS surveys in 20 different Sub-Saharan countries, they found that induced abortion rates went up during a policy period as compared to a non-policy period. They did not know exactly which pregnancies ended in abortions due to the shortcoming of DHS surveys mentioned earlier, but instead predicted probabilities for induced abortions based on a number of factors, including whether the woman reported wanting a particular pregnancy and contraceptive use. These effects were driven by countries were more exposed to the policy (by virtue of being more dependent on family planning aid from the US).
We can hypothesize why this would be happening. The NGOs that provide family planning services in developing countries and are affected by the policy are often the sole providers of contraception in low access areas. This means that when they lose funding, need for contraceptives in those areas is less likely to be met, and consequently the probability of a woman there having an unwanted pregnancy increases. Since rural areas tend to be more low access, compared to urban centres, this explains Jones’s result. The evidence, then, is against the policy being an effective means of reducing the incidence of abortions; it appears to do the exact opposite. Furthermore, since the policy restricts access to abortions while not changing demand, women are more likely to get unsafe abortions.
But the effects of the policy go even beyond that, as evidenced by another disturbing finding from Jones. Since the policy increases the risk of unintended pregnancies, and not all of these pregnancies end in abortion, there are more unplanned and arguably “unwanted” children being born. Jones finds that children born in policy periods are shorter and weigh less on average than their siblings who were born in non-policy periods, both sobering signs of malnutrition.
The effects of the policy as studied up till now are worrisome, and it seems likely that there are others that have not yet been identified. The expansion of the policy under the current administration may lead to other unforeseen impacts on the health of women and children in developing countries around the world. Understanding their extent and how to mitigate them is crucial. Leona Baumgartner, a key figure in the establishment of USAID, once said that family planning assistance is not about population control, but about improving the quality of life and opportunity for low access populations. That has never been truer.
Priyanjana Pramanik is a second-year Master’s student at the Department of Economics, Tufts University. Her areas of interest are development, behavioural economics, gender and social justice. She is currently researching and writing a thesis on the impact of the Mexico City Policy on the health of women and children in low-access areas.