Political Perils

Maternal health creates conditions for well-being that echo through the generations. Yet the U.S. government’s foreign policy has alternately supported and impeded women’s health since 1973. The latest chapter starts with the Helms amendment to the Foreign Assistance Act. Passed just months after the Supreme Court struck down domestic anti-abortion laws in Roe v. Wade, the Helms amendment outlaws—to this day—U.S. funding for abortions abroad.

President Ronald Reagan extended the amendment’s reach in 1984 with his Mexico City Policy, also known as the Global Gag Rule. To receive family planning assistance from the U.S., recipient organizations must pledge to neither provide nor promote abortions as a method of family planning—even if they use non-U.S. funding. Easy for the White House to modify—without congressional approval—the policy has been rescinded by Democrats and reinstated by Republicans ever since.

As one of his first acts in office, President Donald Trump reinstated and dramatically expanded the rule. In its latest iteration, the policy applies to all U.S. healthcare assistance of any kind. The move affects fully $8 billion in foreign aid disbursed by the State Department, U.S. Agency for International Development (usaid), and the Department of Defense—a radical expansion from the $600 million previously affected.

The ongoing policy ping-pong has furnished a case study in unintended consequences. The World Health Organization analyzed abortion data across 20 countries, comparing rates during the Clinton and George W. Bush administrations. Their findings, published in 2011, are stark: Where the Mexico City Policy had the greatest impact, the number of abortions—both safe and unsafe—rose, while contraception use fell.

Other studies have shown that where abortion is illegal or highly restricted, the number of unsafe abortions rises, in turn exacerbating maternal and infant mortality rates. WHO estimates that currently there are 21.6 million unsafe abortions a year, which account for about 13 percent of global maternal mortality. The NGO Marie Stopes International, one of the biggest recipients of usaid family planning funds, projects an additional 2.1 million unsafe abortions due to the current version of the policy.

This year, representatives of advocacy organizations and 138 deans of schools of public health—including Mailman School Dean Linda P. Fried, MD, MPH—signed on to a coalition statement opposing the Mexico City Policy because it “seriously hinders the effectiveness of U.S. global health investments and the growing global progress that we, as a global community, have made in expanding access to family planning for couples worldwide and in reducing maternal mortality.”

We asked three Mailman School faculty members to discuss the current policy environment. Professor of Epidemiology and of Population and Family Health Carolyn Westhoff, MD, heads the Division of Family Planning and Preventive Services in the Department of Obstetrics and Gynecology of the College of Physicians & Surgeons. Terry McGovern, JD, chair and professor of Population and Family Health, has served as a senior program officer of both the Women’s Health and Human Rights Advocacy Project and the Gender, Rights, and Equality unit of the Ford Foundation. Lynn Freedman, JD, MPH ’90, professor of Population and Family Health, directs the Mailman School’s Averting Maternal Death and Disability (AMDD) Program.

How does the current political climate affect existing challenges in family planning?

CW: Every dollar spent on contraception saves multiple dollars in direct healthcare costs. What we’re doing has been proven to work extremely well, with excellent health outcomes. Yet people are looking for multiple ways to disrupt it.

What issues are you monitoring in the U.S.?

TM: We’re obviously watching Congress and the Affordable Care Act (ACA). People may lose no-copay birth control. There is uncertainty around ob-gyn care, cancer screening, and pre-existing conditions. If the ACA is curtailed, we’ll see many more women uninsured, disparately impacting African-Americans and Latinas.

CW: The legislative and administrative changes in the works at the federal level are enormous, and so is the resulting uncertainty around how it will all play out. Clinics, many already struggling financially, have very concrete decisions to make around space, staff, supplies. But it’s impossible to do rational planning and budgeting; everyone is focused on contingency planning, which takes away from the real work of providing care. 

Providers are being asked to go to court to defend basic health services, which takes a tremendous amount of preparation. That time and money detracts from budget dollars spent on direct patient care.

The Guttmacher Institute estimates that addressing the global unmet need for contraception would prevent 76,000 maternal deaths and avert 480,000 newborn deaths annually. How do you expect the expanded Mexico City Policy to play out?

TM: The expanded gag rule means that any organization getting usaid—even for working with hungry kids or homeless youth—cannot mention abortion. In the context of violence—sexual and physical—such referrals are quite routine. This means they have to sever long-standing arrangements with Planned Parenthood, Marie Stopes, and the like. Cuts to other types of foreign assistance—like unfpa (the U.N. Population Fund), which helps fund access to contraception in 150 countries—will also be devastating. Our research group has received a major grant to document the effect of these changes on sexual and reproductive health services. We’ll collect baseline data in Kenya, build the capacity of a local research partner there, and convene a coalition of organizations who are also assessing the situation. The goal is to develop a monitoring tool that can be used in other countries as well, while evaluating the immediate impact on people’s health and their lives.

LF: Of great concern to me is the space for civil society within countries around the world. This starts to really clamp down on citizens’ voices in general, and voices for progressive health in particular. For example, in India, several important human rights and legal rights groups have had their registrations canceled and their bank accounts frozen, rendering them inoperative. Other countries, like Vietnam, barely allow NGOs at all. In Egypt, it is now illegal to publish results of a study or survey without government permission. Even if the civil society groups in the crosshairs are not specifically health groups, they are often movements that fight for the rights of marginalized people.

What other policy issues are relevant?

TM: Cuts to foreign assistance—because the numbers are so high—are just devastating. In places where there is either conflict or catastrophic weather events around global climate change, women and girls have a tenuous economic hold. The little ways that they make strides toward controlling their financial destiny are wiped out in the context of these catastrophic events, and we know that economic status is highly correlated with life expectancy and a host of other health outcomes.

CW: There’s been a lot of upheaval and regulatory challenge in healthcare over the last 10–20 years in particular. And the work starts long before some new regulation goes into effect. It consumes everybody trying to figure out what we’re getting ready for and how to cope with it.

LF: It’s very important that our work be aligned with locally based civil society groups, amplifying what they do. They should play the key role.

What can the public health community do to mitigate the damage?

CW: The deep, honorable responsibility of the public health community is to measure what is going on—that is the service we can provide.

TM: We need to answer questions like, What would the public health landscape look like in specific communities with Planned Parenthood gone? And while we have to take this defensive posture now, we need to—as much as possible—continue with our proactive agenda around sexual and reproductive health, like trying to get sexuality education into schools in New York City.

LF: Through AMDD, we’ve been working to combat disrespect and abuse or mistreatment of women during childbirth. If citizens have a real voice, if there’s a social movement, active press, and the ability to engage a health system transparently and openly at both the local and national level, you can do constructive work that improves services for anyone. But if any challenge to authority is understood as a threat and shut down, or if people are scared, you’re forced back into small technical fixes that don’t address the real power dynamics that underlie these big issues in health systems.

What gives you hope in the meantime?

LF: It’s important to remember that along with these negative trends, there are also positive trends. In the maternal mortality field, there has been real progress toward understanding quality of care, and globally, there’s a trend toward promoting universal health coverage, which implies some more serious effort to deal with inequity. And there has been a lot of progress in bringing transparency and social accountability to public health. As a field, we need to find synergies, and complement and expand each other’s efforts.