Abstract
Recurrent U.S. government policies restrict the use of U.S. global health assistance for comprehensive sexual and reproductive health services. The Mexico City Policy (MCP) was in force from 1984 to 1993 and from 2001 to 2008. “Protecting Life in Global Health Assistance” (PLGHA) is an expanded version of this policy that was instituted in January 2017. The MCP/PLGHA requires that foreign nongovernmental organizations receiving U.S. assistance certify that they are not using U.S. funds or any other funds to provide or counsel on abortion as a method of family planning. The MCP applied to U.S. family planning funding; PLGHA applies to almost all U.S. global health funding, dramatically increasing the scale and scope of the activities affected. Research reveals three key domains of MCP/PLGHA impact: (1) reduced access to contraception with attendant increases in unintended pregnancy and induced abortion, (2) decreased stakeholder coordination and a general “chilling” of discussion related to sexual and reproductive health and rights, and (3) negative outcomes in nonreproductive health domains. These three domains are known determinants of maternal morbidity and mortality. Public health and human rights actors use several strategies to address the harms associated with the MCP/PLGHA, including advocacy to modify or end PLGHA, producing data on the impacts of the policies, educating stakeholders to prevent overinterpretation, and implementing service delivery programs to mitigate harm. This APHA policy statement calls for urgent and intensified use of these action steps to counter the harms to health and human rights associated with PLGHA.
Relationship to Existing APHA Policy Statements
Problem Statement
The 1984 Mexico City Policy (MCP) was promulgated at the beginning of the Reagan administration as an effort to reduce abortion, a Republican policy objective. Commonly known as the “Global Gag Rule,” the MCP imposed restrictions on the use of family planning assistance by foreign nongovernmental organizations (NGOs). It required that foreign NGOs receiving such U.S. assistance certify that they were not using U.S. funds or any other funds to provide abortion as a method of family planning, counsel and refer women to abortion as a method of family planning (unless women proactively stated that they were seeking an abortion in a context wherein abortions were legal), conduct public information campaigns on the availability of abortion, and advocate for the liberalization of abortion laws or lobby for the continued legality of abortion. Abortion is not considered a family planning method in cases in which the pregnancy arose from rape or incest or carrying the pregnancy to term would endanger the woman’s life. The restriction also did not apply to research activities.[1] The policy has since been rescinded by subsequent Democratic presidents and reinstated by Republican administrations. The rationale provided for the initial MCP was that the “United States does not consider abortion an acceptable element of family planning programs.”[2]
In January 2017, the policy was reinstituted by the Trump administration, renamed “Protecting Life in Global Health Assistance” (PLGHA), and expanded to apply to all “global health assistance furnished by all departments or agencies” rather than only to family planning assistance. Thus, the restrictions apply to many more organizations, projects, and health areas than in the past. U.S. government funding agencies that administer global health assistance require foreign NGO recipients to certify their intent to comply with the policy when a new agreement or modification to an existing agreement is issued. There is no way to track the exact amount of money and number of organizations affected; however, a recent Kaiser Family Foundation report analyzing U.S. global health funding obligated by the U.S. Agency for International Development (USAID) in fiscal years 2013–2015 showed that, had PLGHA been in place during that time, at least 1,275 foreign NGOs working in 91 countries would have faced restrictions.[3] The total amount of global health assistance that might be affected by PLGHA (to the extent that such funding is granted or subgranted to foreign NGOs) is approximately $9 billion annually, as compared with the approximately $625 million a year in family planning funding that was subject to the MCP from 2001 to 2009.[3]
In March 2019, U.S. Secretary of State Mike Pompeo announced an expansion of PLGHA. Foreign NGOs that receive U.S. government global health assistance as prime awardees or sub-awardees are prohibited from providing any (including non–U.S. government) financial support to any foreign NGOs that engage in activities prohibited by the policy. This expansion limits what foreign NGOs that do not receive U.S. global health assistance can do with their own money. Secretary Pompeo’s office stated that the expansion will ensure that the policy is “enforced to the broadest extent possible,” with the recognition that “money is fungible.”[4]
PLGHA does not apply to funding provided to intergovernmental organizations (e.g., the World Health Organization [WHO]), foreign governments, or U.S.-based NGOs. Humanitarian assistance is also excluded. However, U.S.-based NGOs implementing global health assistance-funded projects must include the policy in their grant agreements with foreign NGO subrecipients, which are then required to certify compliance. The policy applies irrespective of the legal status of abortion in a given country.
Finally, it is important to note that, for the first time, there is also a “domestic gag rule.” In August 2019, all grantees of the U.S. government’s Title X family planning program were required to certify their “good faith” attempt to comply with new rules that are similar to PLGHA. These rules prohibit abortion referrals, impose counseling standards for pregnant patients, and impose requirements for the separation of Title X–funded activities from a range of abortion-related activities. As is the case with PLGHA, some organizations—most notably Planned Parenthood—have forgone funding rather than comply.[5]
International human rights law upholds the right of all people to “the enjoyment of the highest attainable standard of physical and mental health.”[6] In 2000, the United Nations (UN) Committee on Economic, Social, and Cultural Rights specifically affirmed “the right to control one’s health and body, including sexual and reproductive freedom, and the right to be free from interference,” as well as the requirement that sexual and reproductive health services, education, and information be accessible.[7] UN declarations, UN treaty monitoring committees, and regional human rights mechanisms recognize unsafe abortion and barriers to safe abortion access as a violation of human rights.[8] Importantly, General Comment 22 of the International Covenant on Economic, Social and Cultural Rights calls on states to “liberalize restrictive abortion laws, guarantee women and girls access to safe abortion services…and respect women’s right to make autonomous decisions about their sexual and reproductive health.” Researchers have found that the MCP and PLGHA compromise these rights and limit interrelated rights, including the right to information and to the benefits of scientific progress.[8] Finally, it is important to note that PLGHA can conflict with the decisions made by legislatures and policymakers in countries that receive U.S. global health assistance, undermining their sovereignty. PLGHA applies to more than 60 countries that have their own informed consent, medical ethics, and abortion laws and frameworks. Depending on the country and its policies, PLGHA may violate any of these laws or frameworks.
Quantitative and qualitative research on the MCP and PLGHA have revealed three key domains of public health impact: (1) reduced access to contraception and an increased number of unintended pregnancies and induced, unsafe abortions; (2) decreased stakeholder coordination related to contraception and a general “chilling” of discussion related to contraception and abortion in policy forums; and (3) negative outcomes in domains of health other than reproductive health, including deterioration of broader health system functioning. Each of these domains of impact is outlined in detail below. These changes often disproportionately affect the most vulnerable; foreign NGOs undertake significant health outreach activities, and when funding for these activities is curtailed or ended, women in rural areas or highly stigmatized groups may have fewer options for health care.[9]
Reduced access to contraception and increased unintended pregnancies and induced abortions: Women of reproductive age who have access to family planning are less likely to experience unintended pregnancy, unsafe abortion, infant mortality, HIV/AIDS (when using condoms), and maternal mortality.[10]
Impacts on organizations that opt not to comply with the MCP/PLGHA: Foreign NGO providers of family planning services that decline to certify their compliance with the policy forfeit their access to U.S. government funding to provide health services under PLGHA. Notably, Marie Stopes International (MSI) and International Planned Parenthood Federation (IPPF) affiliates have chosen not to comply, as have many other foreign NGOs. As a result, MSI, the IPPF, and other foreign NGOs may close clinics providing services and/or impose (increased) fees for services. According to the IPPF, it “stand[s] to lose up to $100 million over the course of the policy,” and MSI stated in June 2019 that it faced a “funding gap of $50 million through to 2020.”[11,12] Client referrals between compliant and noncompliant organizations may be precluded. Referral disruptions may disproportionately affect rural areas, where clients rely on NGO-funded extension workers and have few if any other options for obtaining contraception or other health services.[9] USAID may eventually identify an NGO that is willing to comply and offer health care previously provided by the NGO that decided not to comply, but the new recipient may lack the client load capacity, management skills, local knowledge, and client familiarity of the previous grantee.[9]
Impacts on organizations that comply with the MCP/PLGHA: Organizations that opt to receive U.S. global health assistance and that work in domains related to reproductive health might deny their clients evidence-based medicine insofar as they cannot counsel or refer a woman for abortion unless she explicitly states that she has decided to have an abortion or unless national policy requires appropriate counseling and referral by providers.
Documented health outcomes of the MCP: Four quantitative studies indicate that access to modern contraception decreased and induced abortions increased in three world regions after implementation of the MCP.[13–16] One of the studies showed that these trends were reversed when the MCP was not in effect (from 2009–2014), providing further evidence that the policy was the cause of the trends.[16] The countries most affected by unsafe abortions, which result in 4.7% to 13.2% of maternal mortality annually, often rely heavily on USAID for family planning funding.[17–19] Due to the sizable proportion of USAID funding for these countries, NGOs serving women have few choices to replace this funding should they want to offer services that educate women on the diverse array of family planning options. This leads women to seek alternatives such as unsafe abortions when they are not ready to raise a child. These decisions can lead to unintended long-term morbidity or mortality, including hemorrhage, infection, injury to the genital tract and internal organs, and death.[17]
Documented health impacts of PLGHA: Several organizations have collected data from countries in sub-Saharan Africa and Asia regarding the early impacts of PLGHA. Early results suggest that the MCP and PLGHA produce the same chain of consequences: reducing access to contraception and increasing unintended pregnancies, unsafe abortions, and poor birth spacing. In addition, the findings revealed negative effects on organizational resources, including family planning program budget cuts, staff terminations, clinic closures, increased costs passed to patients for contraceptive services, reduced availability of contraceptives, and cessation of rural outreach activities.[9,20]
Decreased stakeholder coordination related to contraception and a general “chilling” of services and discussion related to abortion: Some compliant organizations have overinterpreted the MCP—and now PLGHA—such that they refrain from engaging in allowable activities (e.g., stakeholder discussions about the health impacts of current laws in a given country). Such overinterpretation can stem from incomplete or incorrect information received from USAID missions and/or fear of jeopardizing an important source of funding. As a result, compliant grantees may withdraw from coordinating bodies or platforms related to reproductive health, depriving these bodies of important expertise.[21] For example, studies in Uganda, Ethiopia, Kenya, Peru, and Nepal undertaken during the course of the MCP revealed that, as a result of this “chilling effect,” fewer stakeholders were involved in discussions about abortion law reform and lawmakers lacked access to critical information. This chilling effect can extend to services, such that organizations that opted to certify the MCP stopped providing permitted reproductive health services such as postabortion care and emergency contraception.[22–24]
These dynamics may be exacerbated by the recurrent nature of the policy. NGOs may choose to avoid the risks of working in the domain of abortion. They are constantly confused about what is and what is not allowed and assume the most restrictive interpretation, and they are bogged down by the significant transaction costs of repeatedly changing internal policies to ensure compliance as the policy cycles through being in force and not being in force.[25]
Negative outcomes in nonreproductive health domains, including deterioration of broader health system functioning: U.S. foreign assistance is essential to the health system infrastructure in many low- and middle-income countries. The United States is the largest bilateral source of global health assistance, contributing more than a third of all official health development assistance and 45% of total bilateral funding for family planning.[26] It is not feasible for another donor to provide a comparable level of replacement funding. Moreover, the global health community has invested significant human and financial resources to integrate health services, an approach that, if implemented well, can improve cost effectiveness and better serve patients.[27] Research shows that the MCP and PLGHA fragment health systems, as the policies result in broken relationships between organizations that do and do not comply and disrupt coordination and referral networks between contraception and related services.[13] In addition, clinics providing contraceptive services often provide other services, particularly HIV prevention. When these clinics are shuttered, community members lose access to contraception as well as to other HIV prevention services, potentially contributing to the spread of HIV.[13] An electronic survey of 286 prime President’s Emergency Plan for AIDS Relief (PEPFAR) implementing partners showed that 33% of respondents across 31 countries experienced an impact from PLGHA, including reducing their provision of non-abortion-related information such as information about HIV.[28]
One quantitative, peer-reviewed study has assessed the impact of the MCP on other health domains. Jones et al. found that weight and height for age were negatively associated with having been born in a period when the MCP was in effect, likely due to shorter birth intervals negatively impacting the health of pregnant women and their children.[29]
Given the expanded nature of PLGHA and the fact that many health systems have become further integrated since the previous version of the MCP was in force, it is widely expected that PLGHA will have an impact on health systems well beyond sexual and reproductive health.[30] For example, WaterAid, a large water, sanitation, and hygiene organization operating in 34 countries, has decided not to certify PLGHA because it refers women who experience sexual assault while fetching water to the closest appropriate clinic, which may be run by a noncompliant organization. As a result, USAID-funded programs and partnerships have ended, depriving long-term partners and beneficiary communities of WaterAid’s work.[31] Moreover, groups similar to WaterAid that do choose to comply can no longer cooperate with organizations providing comprehensive sexual and reproductive health and rights services. Along similar lines, a “risk index” for the harm of PLGHA in PEPFAR-supported countries, developed with data from governments and bilateral donors, suggests that countries with generalized HIV epidemics, high reliance on U.S. bilateral assistance, and a high degree of service integration could face significant disruptions to referrals and HIV and contraceptive service provision.[32]
Early evidence regarding the effect of PLGHA on health systems includes cessation of referral links,[20] termination of community health workers providing contraception and other services,[33] and closure of sites providing antiretroviral treatment, including those specifically tailored for sex workers and men who have sex with men.[20] Evidence suggests that these already marginalized populations with whom community partners have developed relationships over time may face stigma and other barriers that prevent them from seeking services elsewhere.[34]
Evidence-Based Strategies to Address the Problem
As is the case with all complex advocacy and efforts to mitigate harms associated with a policy, evaluating the impact of strategies to address the problem is extremely challenging. Insofar as possible, documenting the impact of the five main strategies described below would be an important contribution to the evidence base around PLGHA.
Advocating to policymakers in the executive and legislative branches of the U.S. government to modify or end PLGHA: Reproductive health advocates have advocated that U.S. legislators rescind the MCP and PLGHA since each was imposed. Legislators have introduced a bill to the U.S. House of Representatives that would end PLGHA by prohibiting the eligibility requirements for foreign NGOs that receive foreign assistance. In other words, foreign NGOs would not be ineligible for foreign assistance if they counseled on abortion and made referrals for abortion services in countries where this is legal. They have also tried to end the rule through appropriations.
Producing and sharing data on the public health and other impacts of the MCP/PLGHA with the U.S. government, global health stakeholders, and the public at large: Research related to PLGHA is ongoing. Such research has been discussed in peer-reviewed articles, gray literature publications, conferences, and the media. Donors, implementers, and others have held roundtables and other events to discuss research findings.
Educating and providing legal support on the policy to stakeholders in countries receiving global health assistance to prevent overinterpretation: Some U.S.-based NGOs provide help to foreign NGOs receiving U.S. funds with respect to complying with PLGHA and diminishing overinterpretation. This assistance includes a pro bono legal clearinghouse,[35] guidance in multiple languages for global health assistance grantees,[36] in-country and online training sessions, and ongoing technical assistance to staff, subgrantees, and partners. These strategies aim to ensure that foreign NGOs receiving U.S. global health assistance participate in coordination forums that are permitted and continue to work in reproductive health domains that are permitted, such as postabortion care and emergency contraception.
Identifying and promoting bilateral donor-, global-, and country-level policies that may mitigate harm: WHO, the United Nations Population Fund, and other leading global health organizations may have policies or programs—such as stop-gap contraceptive supplies—that mitigate the harm of PLGHA. In addition, some non-U.S. bilateral donors attempt to temper the impact of PLGHA as part of their assistance programs. The government of the Netherlands launched the “She Decides” initiative, a political movement that supports “the fundamental rights of girls and women to decide freely and for themselves about their sexual lives.” One goal of the initiative is to advocate that governments, foundations, and businesses invest more in sexual and reproductive health services.[37] These funds can be used to support activities that the U.S. government will not support, although the amount will undoubtedly be dwarfed by U.S. global health assistance. The Swedish International Development Agency issued guidance in response to PLGHA stating that it would review partnerships with foreign NGOs that may not be able to fulfill the scope of their agreements because they comply with PLGHA. There has not been any research to assess the opportunity costs of these efforts; some are concerned that additional conditionality will further erode NGOs’ space and ability to decide what issues to address and how to address them.
National-level policies can also mitigate harm. For example, national law regarding provider scope of practice and duty to counsel and refer for abortion may conflict with the prescriptions of PLGHA. In these cases, PLGHA stipulates that national law holds sway. Some U.S.-based reproductive rights organizations seek to maximize the impact of local laws by using non–U.S. government funding to educate country-level stakeholders as well as by supporting improvements in domestic laws, regulations, and medical guidelines on abortion.
Implementing service delivery programs to mitigate harm: We did not find examples of direct service provision activities explicitly intended to counteract the MCP/PLGHA. However, it is important to note that public health actors increasingly advocate expanding the availability of medication abortion and women’s awareness of this option, particularly in locations where safe abortion care is otherwise inaccessible or inadequate. Evidence shows that programs providing support for medication abortion with misoprostol in these settings can be feasible, safe, and effective.[38] According to WHO, mortality and morbidity attributed to unsafe abortion could largely be prevented through comprehensive sexuality education, use of modern contraceptive methods, legal abortion services, and rapid treatment of complications.[19] Thus, implementing these strategies could mitigate harm.
Opposing Arguments/Evidence
There are five key types of opposing arguments to this proposed policy statement. First, there are assertions about the harms of abortion to the fetus. These arguments are on the belief that fetuses should have the same moral status as born persons. Based on firmly held religious or philosophical convictions about when human life deserving of full protection begins, these arguments oppose abortion generally.[39] The absence of PLGHA does not compel anyone who believes that a fetus is a living being deserving protection to obtain an abortion or to act in any way against personal conscience. The metaphysical views underlying this opposing argument do not reflect existing APHA policy statements, which recognize women’s rights to bodily autonomy.[40] Moreover, as documented elsewhere in this statement, the effect of PLGHA on the distribution of contraception increases the abortion rates in many affected countries.[13,16] The presumption of many supporters of PLGHA, that it will reduce abortion rates in areas served directly or indirectly by U.S. international aid, is false.
Second, many argue that abortion causes physical and mental harm to the pregnant woman. As described in APHA Policy Statement 20152, medically provided abortion is one of the most common and safest surgical gynecological procedures.
Third, some assert that the MCP and PLGHA ensure that U.S. taxpayer money is not used to fund abortion. However, the 1973 Helms Amendment to the Foreign Assistance Act (still in effect) prohibits the use of U.S. development assistance for the provision or promotion of abortion as a method of family planning. It remains in force and is scrupulously applied by USAID in its health programs.
Fourth, some disagree that the MCP and PLGHA have deleterious effects. They note that the MCP and PLGHA do not imply a reduction in U.S. assistance to family planning and that money previously given to organizations that chose not to comply can be given to organizations that do. A formal 6-month review of PLGHA undertaken by the U.S. State Department noted that only three prime grantees have declined to comply with the policy.[41] However, subrecipients, which are more numerous and often foreign NGOs, were not included in the review. Moreover, as described above, evidence from many countries suggests that the MCP/PLGHA has deleterious effects. It contributes to a rise in induced abortions—the opposite of its intended effect. The studies indicating increased odds ratios for abortion included “exposure to the policy” as an independent variable, with exposure to the policy being defined by amount of U.S. assistance for family planning per capita.[13,15,16] Thus, the studies accounted for the fact that U.S. government family planning assistance was likely “reprogrammed” to organizations willing to comply with the MCP.
Finally, some argue that the U.S. government should not be funding family planning programs overseas at all. However, the contribution that family planning makes to reductions in unwanted pregnancies, unsafe abortion, and maternal morbidity and mortality, as well as to birth spacing and improved birth outcomes, is well documented in the peer-reviewed literature and is promulgated by APHA Policy Statements 201113 (Call to Action to Reduce Global Maternal Neonatal and Child Morbidity and Mortality) and 20153 (Universal Access to Contraception).[41] Moreover, investments in family planning are cost effective; contraception saves families and health systems money, as they are less likely to deal with morbidity and other challenges that can arise from inadequate birth spacing.[42]
Action Steps
APHA promotes evidence-based policies over ideology. The organization has an irreplaceable voice on PLGHA. The following action steps are organized according to the categories of evidence-based strategies described above.
Advocacy
Research
Education
Harm Mitigation
References
1. United States Agency for International Development. Standard provisions for non-U.S. nongovernmental organizations. Available at: https://www.usaid.gov. Accessed November 27, 2019.
2. United States of America. Policy Statement of the United States of America at the United Nations International Conference on Population (Second Session), Mexico City, Mexico, August 6–14, 1984. Undated document.
3. Henry J. Kaiser Family Foundation. The Mexico City Policy: an explainer. Available at: http://files.kff.org. Accessed November 27, 2019.
4. Global
