Unintended Consequences of an International Abortion Policy
Each year more than 280,000 women die from pregnancy- and childbirth-related complications. Ninety-nine percent of these deaths occur in developing countries, where childbearing is the leading cause of mortality among women of reproductive age. In these countries early and frequent pregnancies undermine the health and education of young women, perpetuating a cycle of poverty and marginalization that has become a target of development efforts worldwide. Family planning programs play an important role in U.S. foreign aid, alongside programs for maternal and child health and the empowerment of women and girls.
But, a political back-and-forth on a policy regarding abortion may be impacting some of those key international development efforts. In 1984 President Reagan issued the Mexico City Policy (MCP), which prevents foreign non-governmental organizations who receive U.S. family-planning funds from promoting abortion as a family-planning option. The MCP has sparked intense ideological responses along abortion-policy lines in the U.S. The policy has been re-implemented by all Republican presidents since Reagan and rescinded by all Democratic presidents, each side exploiting its greater maneuverability on foreign policy than in the domestic abortion-rights arena. Policy analysts have meantime analyzed the impact of the MCP on the ground, emphasizing unintended consequences that may have swamped the policy’s stated objectives. As one of his first official acts, President Trump reinstated the MCP and broadened its scope to cover all forms of global health assistance from the United States Government.
In Sub-Saharan Africa, the policy appears to have increased the rate of induced abortions in countries dependent on U.S. family-planning assistance.
- The use of U.S. funds to pay for abortions has been illegal since the 1973 Helms Amendment, but the Mexico City Policy went beyond this by preventing foreign non-governmental organization (NGOs) that deliver U.S.-funded family-planning assistance from providing even information about abortion to those who receive their services. Organizations that choose not to comply with the MCP lose U.S. funding. And, this de-funding effect may have reduced the availability of family-planning services in affected countries.
- The Mexico City Policy is intended to reduce the prevalence of abortions. However, a study of 20 countries in Sub-Saharan Africa finds that the opposite happened when the rule was re-imposed in 2001 after it had been rescinded by the Clinton Administration. Abortion rates increased in Sub-Saharan Africa, with the increase focused in the countries that had been the most dependent on U.S. family-planning assistance during the late 1990s.
- The policy’s unintended impact on abortion rates is consistent with an increase in unwanted pregnancies due to reduced availability of family-planning services. Experts view the large unmet demand for contraception as a crucial constraint on women’s ability to achieve the reduced fertility levels they desire. Trends in contraceptive prevalence suggest that the Mexico City Policy may have sharply reduced the availability of contraception and associated reproductive health services in countries heavily reliant on U.S. family planning assistance. Among the 20 Sub-Saharan African countries, those that received higher levels of U.S. family planning assistance in the 1990s saw slower increases in contraceptive prevalence after the MCP was reinstated in 2001 compared to countries that were less reliant on the U.S. funds for family-planning (see chart). Contraceptive prevalence had been rising faster in the countries that received higher family planning assistance during the Clinton Administration, but after a brief delay, consistent with funding lags and temporary compliance efforts by affected NGOs, the rate of increase in the these countries fell both in absolute terms and by comparison with countries less exposed to the MCP. This divergence continued throughout the George W. Bush Administration, stabilizing only after the Obama Administration rescinded the policy in 2009.
- Changes in funding that impact the availability of contraceptives can affect women differently depending on their relative income levels. A recent study finds, for example, that contraceptive supplies in Ghana fell 10 to 16 percent following the George W. Bush administration’s re-issue of the policy in 2001. The reduction in contraceptive prevalence was associated with increased pregnancy rates among women of all income levels. But, among higher-income women the increase in pregnancies led to an increase in abortions. Among lower-income women, the increase in pregnancies led to more births. For both groups of women, the policy appears to have operated with greater force through the disruption it caused in the availability of essential reproductive health resources than through its impact on knowledge about abortion. The reduction in contraceptive prevalence exposed women of all income levels to greater pregnancy and childbearing risks as well as to elevated exposure to HIV transmission.
- The scope of the Mexico City Policy has been gradually widening across successive cycles of repeal and reinstatement. The original 1984 Mexico City Policy was restricted to family-planning programs run by the United States Agency for International Development (USAID). President George W. Bush, Jr. widened the policy to all U.S. sources of family-planning funding but carved out explicit exemptions for the President’s Emergency Plan for AIDS Relief (PEPFAR), assistance programs devoted to strengthening maternal and child health systems, and funding provided to inter-governmental organizations like the United Nations. The Bush Administration directive therefore applied to less than 10 percent of U.S. global health assistance. By contrast, President Trump’s version widens the scope of the MCP to cover “global health assistance furnished by all departments or agencies.” However, the practical scope of President Trump's extension may not be clarified for some months and is still subject to change – President Bush’s January 2001 memorandum reinstating the MCP was fleshed out in detailed Presidential directives that appeared in March 2001 and later.
What this Means:
The Mexico City Policy has high symbolic value for both Democratic and Republican administrations. Evidence from the re-implementation in 2001, however, suggests that the unintended consequences of the policy have been severe. In Sub-Saharan Africa, the policy appears to have increased rather than decreased the rate of induced abortions in countries dependent on U.S. family-planning assistance. This failure, in turn, appears to be driven by a reduction in the access of poor-country populations to reproductive and maternal health services, including contraception. This impact generates a wide range of additional costs associated with increases in unprotected sex and higher rates of unwanted pregnancy. According to leading accounts of long-run economic development, these costs perpetuate poverty by reducing educational attainment and lifetime earning potential among both women and children. By reinstating the rule and broadening its scope, therefore, the Trump Administration is putting in motion a set of potential side effects the American people are largely unaware of and would be unlikely to support. These impacts may now go beyond the crucial domain of reproductive health to endanger progress in priority areas that include HIV/AIDS, malaria, child well-being, and health-system strengthening in low-income countries. This is a sharp departure from previous Republican administrations, which have been faithful to the achievements of these programs and the broad bi-partisan support they command by explicitly exempting them from the policy.