Kate Hodal, Jonathan Watts, Michael Safi and Murithi Mutiga
As affected groups worldwide take in news of Donald Trump’s renewal of a policy that has dire implications for family planning, Médecins Sans Frontières has aimed a broadside at the US president’s stance
Médecins Sans Frontières has told the Trump administration to stop “playing politics” with women’s rights and other global health efforts after the new US president reintroduced a policy likely to affect millions of women and girls around the world.
The “global gag rule”, which was reinstated by Donald Trump on Monday, withholds USAid funding from any overseas family planning organisation that offers or provides information about abortions.
The rule also affects civil society programmes, such as contraception provision, and campaigns for LGBT communities and teenage girls. Work to combat HIV and Aids, cervical cancer and Zika will likewise suffer.
MSF is not directly affected by the gag rule since it relies on donations rather than US government funds to provide its services. Nonetheless, the organisation pointed out that it treats women and girls with abortion-related complications daily.
Unsafe abortion is one of the five main causes of maternal mortality worldwide. The World Health Organisation has said that rates are even higher in certain regions – not least Latin America – and in contexts such as refugee camps and areas affected by conflict.
“The medical consequences of unsafe abortion are dire and should be treated as such,” said Jason Cone, executive director for MSF in the US.
“Governments should not play politics with the lives of women and girls. No matter what the risk or barrier, women will continue to seek ways to end pregnancies and they will continue to needlessly die if safe abortion care is not accessible. The Trump administration needs to face these facts and end policies that endanger the lives of women and girls.”
Below we look at groups likely to be particularly hampered by the gag rule around the world.
Teenage girls
Globally, roughly 16 million girls aged 15-19 – and an additional 1 million girls under 15 – give birth each year, according to the World Health Organization. The majority of these girls live in low- and middle-income countries, and many of them lack access to sex education and contraception. Roughly three million unsafe abortions among 15- to 19-year-old girls take place each year, the WHO estimates, which can lead to lasting health problems and in some cases maternal death.
Bernard Washiaka, programme manager for Family Health Options Kenya, one of the country’s main providers of sexual and reproductive health services, says an end to its programmes would have a major effect on many women and young girls.
“We live in a patriarchal, male-dominated society and the advice and information we offer helps to empower girls,” he says. “They can enjoy their sexuality while avoiding unintended pregnancy and sexually transmitted diseases. The services are entirely voluntary and based on the decisions of the girls, but we have seen the impact they have … Girls are able to stay in school for longer, which opens up a world of opportunity.”
In Uganda, where 78% of the population is under 30 and fertility rates are among the world’s highest, access to much-needed contraceptives will be severely restricted, particularly in rural communities, said Jackson Chekweko, executive director of Reproductive Health Uganda. A successful pilot initiative that distributes Sayana Press, a three-month injectable contraceptive combining the drug and needle in one unit, would likely come to an end because of lack of funding.
“As well as reaching more people with family planning services, we need to give women more choices about the form of contraception they want. Sayana Press does that,” he says.
LGBT communities
The global gag rule will also severely impact global LGBT communities, many of which already face severe marginalisation. Lesbian and bisexual women are between two and 10 times likelier to get pregnant – and are also at higher risk of sexual assault – than their heterosexual peers, according to the US National Centre for Lesbian Rights.
In countries where some people believe rape can “reverse” homosexuality, LGBT communities are particularly threatened as sexual assault can lead to unwanted pregnancy. In India, for example, where it is illegal to be gay, health groups have become increasingly reliant on US funding, often discreetly delivered, for programmes aimed at promoting LGBT rights and safety.
Rupsa Mallik, a director at the feminist human rights organisation Crea, said these groups would now have to make “a tough call” on whether to continue such work, if it meant also dropping any abortion services they provided.
HIV and Aids communities
Young women and teenage girls are at a disproportionately higher risk of contracting HIV and Aids: those aged 15 to 24 accounted for 60% of all new HIV infections among young people in 2013, while a UN report found that 80% of young women with HIV live in sub-Saharan Africa.
The gag rule is likely to prevent them from accessing contraceptives and counselling services, as well as limiting family planning programmes that could prevent future mother-to-child transmissions.
Kalpana Apte, secretary general of the Family Planning Association of India, said programmes that address HIV and Aids, maternal and child health, cervical cancer screening [and] gender-based violence would be affected by Trump’s ruling.
The US invests roughly $20m (£16m) annually in Indian health programmes in areas that include family planning but also target tuberculosis, and improved nutrition and sanitation. Funding for all of these is now subject to the gag.
“We stand to face significant reduction in our core grants [and] expect that in times to come, we may have to close our outreach services, satellite centres and reduce the staff strength,” Apte said. “It will hit the programme very hard.”
Victims of rape, and Zika-affected populations
In predominantly Catholic Latin America and the Caribbean, anti-abortion laws have come under stricter interpretation in recent years – a trend that is likely to be bolstered by Monday’s ruling. Terminating pregnancies is already a minefield: more than 97% of women of child-bearing age in the region live in countries where abortion is restricted or illegal. Even in countries where it is legal, the gag rule is likely to wipe out any assistance to women who require abortion – say in cases of rape – campaigners claim. In Peru, it is estimated that 13% of all maternal deaths are the result of back-street abortions gone wrong.
For women and girls in Zika-affected areas, being able to terminate an unwanted pregnancy is likely to become even more difficult because of the ruling. In Haiti, only 34% of women have access to contraception, while in El Salvador, almost 90% of pregnancies are unplanned. In Guatemala, Honduras and Nicaragua as well, groups that work on Zika prevention and family planning could lose funding if their US partners are deemed to fall foul of the gag rule in any way.
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