Student Perspective

Global Gag Rule: How Local Research and Advocacy is the Key to Mitigation

Jennifer Britton, MPH is a 2019 graduate of the Heilbrun Department of Population and Family Health. Since 2017, she has worked as a research assistant on the department's multi-country, mixed methods study of the Global Gag Rule's impact on access to and provision of sexual and reproductive health services. 

In Homabay, Kenya, an increasing number of young, vulnerable women are turning to unsafe and clandestine abortions. This is following the recent closure of the local Family Health Options Kenya (FHOK) clinic, a branch of Kenya’s oldest provider of sexual and reproductive health (SRH) services. The impact is being felt throughout the community.

“With the closure of FHOK clinic, unsafe termination of pregnancies by the teens in Homabay slums is now getting out of hand. We are worried this practice could lead to more deaths if nothing is done,” says John Ogweno, a nurse at the Homabay Omega Foundation, a community health and development NGO.

Like many communities around the world, Homabay has been impacted by the Global Gag Rule (GGR; sometimes referred to as the Mexico City Policy), a US foreign assistance policy that restricts the family planning activities of foreign non-governmental organizations (NGOs) that accept U.S. government (USG) global health assistance.

Foreign NGOs subjected to the GGR are given a choice: sign a pledge to refrain from counseling, providing, or advocating for abortion as a method of family planning, even with the support of non-USG funds, or forgo all USG global health assistance.

The Global Gag Rule, explained

Earlier iterations of the policy, implemented by Presidents Ronald Regan, George H.W. Bush, and George W. Bush, applied solely to U.S. foreign assistance for family planning—approximately $400 million in 2001. President Trump expanded the scope of funding and activities subject to the policy; the majority of global health assistance going to foreign NGOs – not just family planning – now faces the GGR. Approximately 9 billion dollars in funding may be affected.

Research has demonstrated that past iterations of the GGR had significant impacts on sexual and reproductive health by reducing access to family planning services, weakening HIV/AIDS prevention, and even increasing abortion rates in impacted areas – and there is no reason to think that the impact of this expanded policy will be any less harmful. These and other findings from the George W. Bush era GGR define a clear causal pathway from the GGR to poorer health outcomes for women: as the policy forces SRH programs to shut down or silo themselves from each other, access to family planning decreases, particularly for the most vulnerable populations – leading to more unintended pregnancies and fewer accessible resources to address them.

So why would any organization certify this policy? For many foreign NGOs, they are left with little choice. While refusing to sign the GGR means maintaining organizational autonomy, it also means forgoing financial support from a significant global health donor. For some, this means losing over 50% of their family planning budget.

As the largest provider of global health assistance, the U.S. government has the power to cause immense damage to health programs worldwide by withholding and dictating the use of these funds.

Different abortion laws, persistent impact

National context is particularly relevant to gauging the impact the GGR will have in a particular country. Abortion laws vary widely around the world, from highly liberalized to extremely restricted. Nepal, Kenya, and Madagascar provide an example of this variation. While Nepal’s law is the most liberal of the three, with abortion available on demand up to 12 weeks’ gestation, Kenya allows abortion in a broadly interpreted law that only makes exceptions for the life or health of the mother, and in Madagascar, abortion is illegal.

The GGR includes exemptions in the cases of rape, incest, or to save the life of the pregnant woman.  Post-abortion care is also allowed, as are counseling and referrals in certain limited situations. One might assume that a country with highly restrictive abortion laws – one that does not even allow for these exemptions under its own statutes – would not feel an impact from the GGR. In other words, if abortion is illegal in a particular country, shouldn’t that country be immune to a policy that is meant to restrict funding for organizations that provide abortion-related services?

Madagascar is particularly dependent on US government funds, which account for 88% of their Official Development Assistance in reproductive health. Marie Stopes International (MSI) is the leading NGO provider of women’s SRH services, including family planning counseling and methods and STI services. MSI abides by the laws and policies of Madagascar and does not provide abortion. However, MSI—which operates in 37 countries – has chosen not to certify the GGR, given its organizational mission to support SRH, including safe abortion where it is legal.

As a result, the organization as a whole faces a funding gap of $50 million, the effects of which ripple throughout all the countries they serve. In Madagascar, this has already resulted in the discontinuation of a voucher program that provided contraceptive counseling and services to women and girls living in poverty, the termination of 20 outreach teams, and the closure of 66 private sector clinics.

Although Nepal and Kenya have more liberalized abortion laws compared to Madagascar, women still face many barriers to accessing the procedure – issues that are compounded by the GGR. In Nepal, there is an extreme lack of awareness surrounding abortion, with 59% of women of reproductive age remaining unaware that abortion is even a legal option for them. In Kenya, requirements such as securing physician and court approval for abortion prevent many women from accessing safe services. This includes a teenage rape victim who died from complications after being unable to access post-abortion care (PAC) for a clandestine abortion. The GGR exacerbates these issues by reducing the reach of services to women who already have the most difficulty accessing them.

Global Gag Research

In trying to fully understand the nuanced impacts of this policy, national context really matters. The Heilbrunn Department of Population and Family Health is conducting mixed-methods research to demonstrate the repercussions of the GGR on health outcomes in Kenya, Nepal, and Madagascar. These countries were selected for the varying legal, socio-political, and geographic contexts they represent.

Leading the study implementation are local research and service-delivery partners who provide the most nuanced insight into the dynamics and needs of each country. Quantitative data on service provision by public and private women’s health clinics in both rural and urban areas are being triangulated with interviews with key stakeholders including government, NGO, and donor staff, urban and rural health providers, clinic managers, and individual clients. By collecting these data at multiple time points, including prior to implementation of the GGR, researchers hope to create a rich picture of an extremely complex situation, demonstrating how the GGR impacts different actors and health sectors over time.

From Research to Impact

For people living in the shadow of the GGR, its effects are real and imminent, as Wilfred Owuor, the CEO of the Omega Foundation in Kenya describes:

“Reinstatement of Global Gag Rule by US administration has impacted negatively on diversified funding streams Omega Foundation enjoyed in the past seven years. The long term effect of this is that hundreds of thousands of these women and girls have not been able to make informed decisions about their health care options when pregnant, thus putting their lives at risk and rolling back the gains Omega Foundation has made at county and community levels towards improving the general health of women and girls.”

With no end to the GGR in sight, it is important to focus on how to mitigate the impacts that real people are facing, here and now. Strong advocacy movements in the United States have mobilized against the GGR, but in-country advocacy is also key for change to take place. National and other local efforts involve supporting the liberalization of abortion laws, strengthening health systems, and increasing access to sexual and reproductive health services.

Women and families need providers like the Omega Foundation for SRH services that are essential to their life, health, and wellbeing. The key to combatting the detrimental effects of the GGR and keeping these services alive is supporting the efforts of local healthcare providers and public health advocates. As researchers, it is our job to find and amplify the voices of those who are most deeply affected by this policy, and to bolster those who can defend against it.