Review Article
Munzur-E-Murshid1 and Mainul Haque2
1WISH2Action Project, Handicap International, Chamrargola, Kurigram Sadar, Kurigram, Bangladesh
2Unit of Pharmacology, Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kem Perdana Sungai Besi, Kuala Lumpur, Malaysia
The United States of America (USA) is one of the largest bilateral donors in the field of global health assistance. There are beneficiaries in 70 countries around the world. In 2015, the USA released US$638 million for the improvement of global health status by promoting family planning services. Unfortunately, in 2017, Trump administration reinstated Mexico City Policy/Global Gag Rule (GGR). This policy prevents non-US nongovernmental organizations (NGOs) from receiving US health financial assistance if they have any relationship with abortion-related services. This restriction pushed millions of lives into great danger due to the lack of comprehensive family planning services, especially lack of abortion-related services. This article has attempted to let the readers know about the impacts of GGR around the world and how global leaders are trying to overcome the harmful effects of this rule. Finally, it proposes some solutions to the impacts of the extension of Mexico City Policy.
Keywords: GGR, Mexico City Policy, comprehensive, sexual reproductive healthcare, trap, developing countries, low middle-income countries
The United States (US) President Donald J. Trump signed and reinstated the Global Gag Rule (GGR) on January 23, 2017. This administrative directive put back and intensely expanded the earlier “Mexico City Policy” executed under the previous Republican governments since 1984.1 This policy approach confines non-US origin nongovernmental organizations (NGOs) to acquire US family planning financial and other assistance; primarily those NGOs are involved in abortion-related activities (e.g., perform a safe abortion, provide counseling services, and act on advocacy front to legalize the abortion even in their countries).2 The US legislation system does not permit to utilize US international foreign assistance for any kind of abortion-related issues since 1973.3 Globally, the United States of America (USA) is the major bilateral donor of family planning services, as it contributed US$638 million only in 2015. The amount of help made by the USA was almost half of the total bilateral funding.4 Seventy countries in the world are regularly benefitted through different healthcare services funded by the US government.5 The GGR currently is distressing millions of underprivileged and marginalized women of reproductive age around the world because of restriction on the provision of comprehensive sexual and reproductive care services. After that, the GGR intensifies the possibilities of the chance of unplanned pregnancies and dangerous abortions, and indorses maternal morbidity and mortality.6,7 However, at present globally, there is a remarkable accomplishment in minimizing four of the five leading causes of maternal death. Abortion in unskilled hand yet remains as the cause of maternal mortality. Nevertheless, the almost entirely avoidable reason has been largely overlooked. Over 22,000 women are passed away every year because of abortions done by unskilled practitioners and through unsafe way; among these deaths, the majority of cases occur in low- and-middle-income countries (LMICs).8 The objectives of this review work were to inform the readers about the GGR and its detrimental effects on global healthcare services, especially on comprehensive sexual and reproductive care services worldwide and in LMICs.
This review has been based on freely available literature from Google, Google Scholar, and PubMed. Researchers primarily depend on free download manuscripts because this research did not obtain any financial support. The study was conducted basically due to personal interest and out of pocket expenses. The terms used for the search included “global gag rule,” “global gag rule and public health impacts,” and “impacts of extension of Mexico City,” and have implications on comprehensive sexual and reproductive care services. This is a narrative review article that attempted to describe GGR and its impact on global healthcare services, especially on sexual and reproductive care services of LMICs from a historical, political, and contextual point of view, based on the previously published manuscript, reports, and so on.
The GGR was earlier recognized as the Mexico City Policy, which stipulates that any international nongovernmental charitable organization receiving The United States Agency for International Development (USAID) financial assistance must not be involved in any abortion-related activities.10,11 All health professionals, including doctors, midwives, and nurses, working in the organization receiving US public money, are even permitted to use the word “abortion.”12 Yet, abortion is legal according to the country’s law, women herself desired, and utilizes their financial resources.13,14 This rule barred any NGOs involved in abortion, not only the USAID financial assistance but also other essential logistics for family planning, fertility control, and contraceptives.11,15–17 President Ronald Reagan first approved the GGR in 1984. It was later withdrawn by President Bill Clinton, reinstated by President George W. Bush in 2001, and repealed again by President Barack Obama in 2009. President Donald J. Trump restored the GGR in 2017.12 Thereafter, the Guardian wrote, “[w]ith one devastating flourish of the presidential pen, worldwide progress on family planning, population growth, and reproductive rights was swept away. Now some of the world’s poorest women must count the cost.”17
Abortion was legal in the USA before 1840. Women had the right to choose abortion. Americans followed British law in that period.18,19 According to British rule, abortion is a legal procedure before quickening.20 Quickening is the first movement of the baby in the pregnancy felt by the mother. Usually, it happens between 4 and 6 months of pregnancy.18 The British law does not allow abortion after the quickening period, and post-quickening abortion is considered a criminal act.13,18,21,22 In the early 19th century, a group of traditional healers appeared in the American healthcare market. Their target beneficiaries were the abortion-seeking women. In response to the work of conventional healers, modern medical science practitioners’ community had started “Right to Life Movement.”23 The aim of this movement was to promote scientific management of abortion through antiabortion laws and to defend their traditional healer opponents regarding the same market and protecting their financial benefit.18,24
The “Right to Life Movement” gained remarkable success in 1900. Every state of the USA has a law forbidding abortions. Only the physicians were able to decide which case would proceed for abortion.23 The “Right to Life Movement” beliefs again became sharp among Americans until 1960.18,25 In the same epoch, the American women faced the greatest thalidomide tragedy in the 1960s.26,27 Thalidomide causes thousands of childbirths with significant anomalies among the US population.27,28 The grave thalidomide disaster one of top medical error ever happened in human history. This disaster was followed by bouts of German measles which caused thousands of stillbirth and congenital disabilities.18,29 These two (thalidomide disaster and German measles) annoying tragedies among the US population united the American women for abortion law reform movement.13,30 Their extensive campaign with street protest compelled the US government to reform abortion law, and this happened from Colorado to California between 1967 and 1970.18,31 Subsequently, the catholic campaigns supporting the “Right to Life” movement became more organized after 1970.18,32–34 The US procatholic campaigners encouraged the Hyde Amendment (which positively prohibited federal monetary support for abortions through Medicaid) and pushed enormously for a constitutional amendment banning abortion in the 1970s.35,36 Again, in 1980, the antichoice movement in the USA became stronger.37–40 In 1990–2000, this movement of ideology regarding abortion-related issues incorporated with the American political culture. At the same time, the mass street protest became violent too.41,42 There were 153 beating attacks, 383 death intimidations, 3 abductions, 18 attempted assassinations, and 9 killings events among abortion providers in the USA, during the early 1980s and the 2000s.18,43,44
Currently, those NGOs receiving the US Global Health Assistance funding must need to suspend comprehensive sexual and reproductive care activities (especially all abortion-related activities). Another option is that they should secure their alternative source of funding to continue their healthcare services (including abortion-related services or events) for the underprivileged women and girls around the world.18,45–47
In today’s world, about 561 million women of reproductive age are using modern contraceptives, and more than 200 million additional women have an unmet need for family planning services.48–50 On the contrary, USAID is the largest bilateral donor for the family planning fund as well as the largest contraceptive providers. USAID itself provides more than one-third required family planning essential supplies (products) chattels around the world.51,52 In 2004, donors’ contribution to contraceptive supplies support was about US$203 million. In the following year, USAID contributed US$69 million for the purpose to provide contraceptive essential pieces of stuff. In the same year, the USA made available almost 90 million cycles of oral contraceptive pills, 19 million doses of injectable contraceptives, and about 1 million each of IUDs, female condoms, and contraceptive implants, and 444 million male condoms. The US financial assistance was increasing significantly. USAID spent US$150 million in the fiscal year 2007–2008 for contraceptives.48 It is because of the reimplementation of the Mexico City Policy in the form of GGR, the US authorities stopped their contribution towards health and family planning assistance to those international and national NGOs that were involved in abortion-related activities.
As soon as USAID stopped its assistance due to the GGR, then by default, its supply of essential contraceptive also stopped, for example, in Lesotho, Botswana, and Swaziland, where around one-fourth of the ordinary people are infected with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS).53 Lesotho is a country wholly enclaved within South Africa. The average frequency of HIV/AIDS in Lesotho was 27 and 18% in women and men, respectively. All over the country, the higher incidence was observed among women, in urban settings (31% in women; 21% in men) and rural areas (25% in women; 17% in men).53 In South Africa, the prevalence of HIV/AIDS is high, and the adult prevalence rate is 23.2%.54 South Africa has the highest number of HIV-positive inhabitants in the world; HIV infection incidences are eight times higher among teenage girls than among corresponding boys.55 HIV pervasiveness intensifies from 5.6% among young women aged 15–19 years to 17.4% aged 20–24 years, versus 0.7% among young men aged 15–19 years and 5.1% of men aged 20–24 years,55 and the trend persisted comparatively analogous for over 10 years.56 In this scenario, only 426,000 condoms, along with smaller quantities of IUDs and Depo-Provera, were received by the Lesotho Planned Parenthood Association (LPPA) during 1998–2000. USAID donates these essential family planning goods. Currently, LPPA is not receiving any family planning assistance from USAID.57 In addition, the extension of Mexico City Policy created restriction for 16 LMICs in Africa, Asia, and the Middle East region in obtaining USAID family planning essentials, including contraceptive drugs and other kinds of stuff.58 Many countries around the world, especially LMICs, were required to terminate family planning care services, fire their employees, and even need to stop both preventive and curative programs for Sexually transmitted infections (STIs) and HIV/AIDS, mother and child healthcare services, sex–health educational program, and so on. The Gag Rule also directed to terminate all US origin contraceptive supply consignments to family planning NGOs in 29 countries. Then, in the absence of skilled and proper services in these countries, women started relying on unskilled services and thus would undoubtedly suffer from more undesirable pregnancies and dangerous abortions.59 Primarily, adolescent girls are more vulnerable to the consequences of inaccessibility of family planning materials.60 In 2015, 15.2 million adolescents gave child birth.61 This figure is projected to be 19.6 million by 2035(61). Only community awareness, mobilization, public rules and regulation with strict implementation, access to family planning with maternal and child health (MCH), and overall healthcare services can save these teenage mothers from unplanned pregnancies and childbirth-related morbidity and mortality.62–64 Family planning and maternal and child healthcare are inevitably correlated.65–67 In 2008, 47,000 women died due to unsafe abortions. Most of the unsafe abortions are practiced in LMICs,68 and it is one of the leading causes of maternal deaths (13%) globally.6,7 However, adequate, safe contraceptives can prevent these unsafe abortions. Finally, it can be said that USAID is violating the “Contraceptive Protection” by promoting the gag rule.69
Marie Stopes International (MSI), one of the top international NGOs that deals with maternal and child healthcare, failed to manage the alternative source of funding between 2018 and 2020, which caused approximately 2 million marginalized women to suffer from the inaccessibility of family planning services. This deadlock of the service provision projected for 2.5 million inadvertent pregnancies, 870,000 unsafe abortions, and 6,900 avoidable maternal deaths.70 The International Planned Parenthood Federation (IPPF) states that it will lose US$100 million in the next 3 years from 2017 onward due to the restrictions of the GGR. IPPF could provide 70 million condoms, 725,000 HIV tests, and treatment for 525,000 people with STIs and 275,000 women living with HIV. According to IPPF estimation, the loss of US funding could result in 4.8 million unintended pregnancies, 1.7 million unsafe abortions, and 20,000 maternal deaths in the case of IPPF beneficiaries around the world.71 The oldest family planning organization in the whole African continent, the Family Planning Association of Kenya (FPAK), forced to close three clinics after the execution of the GGR.72,73 In 2000, the total number of clients of those clinics was 19,000.73 The clinics provide family planning services, pre- and postnatal obstetric care, and well-baby care for mothers and infants. One of the FPAK clinics was in Nairobi slum, where there are no alternative government healthcare centers available.73 In the Democratic Republic of the Congo, Ethiopia, Ghana, Kenya, Zambia, and Zimbabwe, IPPF needs to close community-based activities greatly hampered due to funding constraints after the expansion of the GGR.15,74 The community health workers (CHWs) of these community clinics are principal performers. They provide several health-related and family planning services in the communities’ hard-to-reach areas.75 The NGOs of this region are compelled to fire or cut new recruitment and training programs because of fund constraints.73 The FPAK was forced to reduce the number of CHWs by 50%. FPAK is facing barriers to obtaining adequate supplies of contraceptives for the remaining staff and family planning products because of the GGR.73 According to a study by Brooks et al.,76 after the extension of Mexico City Policy by Trump administration, 40% abortion increased in sub-Saharan Region. Most of those abortions were conducted by noninstitutional, independent, and inexpert health personnel, thereby increasing the life-threatening hazards due to the lack of adequate expertize, aseptic surgical environment, and other institutional supports necessary for any unforeseen hazards.76
Immediately after President Trump’s expansion of the GGR, Dutch Minister for Foreign Trade and Development Co-operation Ms. Lilianne Ploumen, along with her peers in the public administration departments from Belgium, Denmark, and Sweden, has created a global movement called “She Decides.”77 The aim of this movement is to ensure comprehensive sexual and reproductive healthcare (SRH) access to all marginalized women and girls.78,79 The campaign seeks to overcome barriers of GGR in the implementation of comprehensive SRH services. Rights to access comprehensive sexuality education, modern contraception, safe abortion, and the skills, knowledge, and ability required to avoid HIV, human papillomavirus (HPV), and other diseases, and to resist violence and early and forced marriage, all are included in fundamental sexual and reproductive health rights.80 Almost 40,000 individual friends and over 100 organizations, 35 global champions from all regions and walks of life, and ministers from 10 countries in Europe joined the initiative. Belgium, Denmark, Finland, Norway, Sweden, Nigeria, Senegal, South Africa, Afghanistan, and Canada are with the movement.81 Currently, ministers from Finland and South Africa, and the Executive Director of MexFam (a Mexican civil society organization) are leading the group of champions. The global community is responding significantly to the “She Decides” movement.81
It is estimated that about 214 million women around the world have an unmet need for contraception. They want to delay pregnancy or want to prevent pregnancy. However, they have no scope of contraceptives.82 The maternal mortality ratio is high in Africa and parts of Asia.83–86 The fundamental cause behind the problem is unintended or early pregnancy.87,88 Access to family planning services is vital to continue an academic career for women and girls, especially in LMICs, and the continuation of an academic career is directly proportional to the employment opportunities.89–91
The Women’s Integrated Sexual Health (WISH) Program, UK, funds NGO working throughout the world, with prioritizing the poorest and marginalized women. WISH activities are focused on ensuring comprehensive SRH services for the targeted population.92 It aims to provide equitable comprehensive sexual and reproductive care services for women of reproductive age, especially young women and teenage girls, to provide control over their reproductive physiology. This way, it will prevent unintended and teenage pregnancies and increase the possibility of improving overall health, which, in turn, would strengthen the prospect of their contribution to income-generating activities for the community.92 Overall, its objectives include enhancing individuals’ knowledge, attitude, and practice (KAP), and building and strengthen community involvement to support for sexual reproductive health rights; driving sustainability and national ownership of sexual reproductive health programs through supportive legal, financial, and policy frameworks; improving and ensuring access to and expanding the choice of voluntary family planning and other sexual reproductive health services through evidence-based innovations and best practice.92
The GGR is significantly impacting the accessibility of comprehensive SRH around the world.15 It is creating remarkable negative consequences in the life of adolescents and women who need comprehensive healthcare most. Thereafter, it is clear-cut that the GGR is blowing the whistle to disrupt the health and human rights, especially for peoples of LMICs.93 The International Women’s Health Coalition President Francoise Giard stated that “[t]his deadly policy violates the rights of patients and ties the hands of providers.”94 The GGR is creating barriers to have access to contraceptives and safe abortion care.15 Thus, it increases unwanted pregnancies and causes increased mortality and morbidity.15,17,95
MSI estimates that under the GGR, at least 1.4 million women around the world will go without access to MSI services and care by 2020, which could lead to up to 1.8 million unintended pregnancies, 600,000 unsafe abortions, and 4,600 avoidable maternal deaths.96 The IPPF estimates that in addition to reduced reproductive health services, the loss of funding also prevents them from providing antiretroviral treatment to 275,000 pregnant women living with HIV, and 725,000 HIV tests to enable people to know their HIV status.71,97 This unhumanitarian GGR policy probably pushes human society million miles backward in terms of time. In addition, the GGR policy possibly acts as a driving force to push the marginalized and underprivileged communities around the world toward a most morbid health situation.98,99
The US government claims that it has the most generous administrative culture. Nonetheless, current the US government sponsored promotion and transformation of antiabortion policy and planning into a global program generates future healthcare program vulnerable especially for the peoples of LMICs into a global policy makes it questionable. After the expansion of the GGR, the world community is trying to overcome the barriers of GGR by bilateral or multilateral cooperation. In response to this, cooperative initiatives such as “She Decides” and “WISH-consortium” have been created. These platforms aim to ensure a world where every woman will be empowered over her reproductive physiology through comprehensive sexual and reproductive care services. There is an urgent need for more research for documentation of how the GGR affects overall women’s health, especially reproductive health.
This study proposes the following recommendations:
The authors declare no conflict of interest.
This article has not obtained any financial support.
This is review manuscript based on published manuscripts.
This research work based on published manuscripts around the globe. No human or animal experiments involved. Thereby, ethical approval not required.