Exportable Righteousness, Expendable Women


What Does Abortion Have to do with Family Planning?

Family planning providers may offer a wide range of services, including sex education, maternal health care, and programs designed to stop the spread of sexually transmitted diseases. But the basic goal of family planning is simple: to give people the means to control their fertility. Family planning focuses on contraception to prevent pregnancy, rather than abortion. This focus is consistent with the Program of Action negotiated at the 1994 International Conference on Population and Development in Cairo. The program explicitly condemns the use of abortion for family planning.

By preventing unwanted pregnancies, family planning can decrease the incidence of abortion. Research has confirmed the obvious: in country after country, as contraceptive use has increased, abortion rates have declined. But the need for abortion never completely vanishes. No contraceptive method works perfectly; rape and incest occur in every society.

A woman may want an abortion for any of a number of reasons. She may worry about the impact of a pregnancy on her health, or about her ability to support a child. She may fear social disapproval or punishment, the loss of educational opportunities, or the loss of a job. Without access to safe and legal abortion, a woman in such straits may try to self-abort, or she may turn to a practitioner who employs dangerous methods. Around the world, the equivalent of the coat hanger—representative of so much needless suffering before abortion was legalized in the United States—includes everything from twigs to crochet hooks. In Zambia, women have even been known to drink gasoline to end an unwanted pregnancy.

The consequences are often fatal. Worldwide, an estimated one of every eight maternal deaths is due to unsafe abortion. Many more women are injured. In large, urban public hospitals in developing countries, women with abortion complications account for as many as two out of every three maternity beds, according to the Alan Guttmacher Institute, an NGO that studies reproductive health. Romania made itself into a tragic social experiment with this form of misery when it virtually banned abortion from 1967 to 1989. Abortion-related maternal deaths soared from less than 25 per 100,000 births in 1965 to 142 per 100,000 by the end of that era.

The real tragedy behind such statistics is that virtually all these deaths are avoidable. When performed properly, abortion is a very low-risk procedure. In industrialized countries, the risk of dying from abortion is roughly one-ninth the risk of carrying a pregnancy to term. In developing countries, where death rates from pregnancy and childbirth are several times higher, this ratio is even more lopsided.

According to the Alan Guttmacher Institute, one-quarter of the world’s women live in countries where abortion is prohibited altogether or allowed only to save a woman’s life. (See map, pages 28–29.) Some 15 percent live in countries that permit abortion to protect women’s physical health and in some cases, their mental health as well. Another 20 percent live in countries that recognize socio-economic concerns, in addition to health concerns, as grounds for the procedure. The remaining 40 percent live in countries where abortion is legal, regardless of the reason that it is sought, although it may be subject to gestational limits, consent requirements, mandatory counseling, or waiting periods. Women in developing countries are more likely to face restrictive abortion laws than are their counterparts in the industrialized world.

Between 1985 and 1997, 9 developing and 10 industrialized countries reduced restrictions on abortion. In many countries where the laws remain restrictive, public debate about abortion is growing—in part, presumably, because more and more women are aware that the status quo is not inevitable. As the Peruvian activist Susana Galdos Silva puts it, "We support reform of Peru’s abortion laws so that women need not fear for their lives when they face an unwanted pregnancy."



The "global gag rule" is stifling a debate about reproductive health. It’s going to force a lot of poor women in developing countries to bear children they don’t want. It’s likely to increase (not decrease) the number of "coat hanger" abortions. And it’s probably going to get a lot of women killed, which will in turn boost death rates among the children they leave behind. So why exactly is it U.S. policy?

The desire to control fertility may be nearly as ancient and universal as sexual desire itself. Every culture, it seems, has had its contraceptives, although their efficacy has varied greatly. To prevent pregnancy, the Petrie Papyrus, an Egyptian medical text from 1850 BC, recommended vaginal suppositories made of crocodile dung. In the 4th century BC, Aristotle described women coating their cervixes with olive oil before intercourse. Women on Easter Island made suppositories from seaweed. And from the 1930s to the 1960s, Lysol, now a popular household cleaner, was marketed coyly to American women as a "certain...yet safe" disinfectant douche.

In the developing world today, nearly two-thirds of all women in their reproductive years—about 525 million of them—rely on some form of birth control, according to the United Nations Population Fund (UNFPA). But there is still a great deal of unmet demand for contraceptives. More than 100 million women in these countries say they want to delay the birth of their next child or stop having children altogether, but are not currently using contraception.
Family planning has been recognized by the international community as a fundamental human right. Under the program of action adopted at the International Conference on Population and Development in Cairo in 1994, "All couples and individuals have the basic right to decide freely and responsibly the number and spacing of their children [that is, the length of time between births] and to have the information, education, and means to do so." But efforts to secure this right were dealt a serious setback last year. On his first working day and the 28th anniversary of the U.S. Supreme Court decision that legalized abortion in the United States, President George W. Bush issued an executive order that resurrected a measure known informally as the "global gag rule."

Essentially, the gag rule prohibits foreign family planning organizations from receiving U.S. government aid if they provide abortions (except in cases of rape, incest, or danger to a woman’s life), or if they counsel women about abortion as an option for dealing with an unwanted pregnancy, or if they advocate less restrictive abortion laws in their own countries. The restrictions apply even if no U.S. funding is being used for the activities in question: any such activities, no matter how they are funded, render an organization ineligible for U.S. support. The gag rule, which obviously gets its common name from its sanctions against free speech, had first been imposed by Ronald Reagan in 1984. Bill Clinton lifted the policy during his first week in office. Its reinstatement by Bush has put the United States in a peculiar diplomatic position: while formally committed to the Cairo program of action, the United States is in effect using its economic power to undermine the human rights principle upon which the program is built.

The U.S. government is the largest international donor to family planning programs. U.S. contributions flow through the country’s foreign aid agency, the U.S. Agency for International Development (USAID), which has budgeted $425 million for family planning for the 2002 fiscal year. About half of this money will go to foreign governments and to multilateral agencies like UNFPA, to whom the gag rule does not apply. The other half will be channeled to non-governmental organizations (NGOs), which are subject to the rule. The rule applies on a rolling basis: when a project is due for renewal, the managing organization must decide whether to comply or forgo funding.

USAID supports medical training and research on family planning, but it also funds the direct provision of services to millions of couples in over 60 countries, including many of the poorest and most densely populated on Earth. In comparison to other major international donors, USAID relies heavily on NGOs to carry out its family planning activities. And that makes U.S. programs highly vulnerable to the gag rule.

The effects of the rule are already being felt. The compliance option has been rejected by two of the largest international providers of reproductive health services, the International Planned Parenthood Federation (IPPF) and Marie Stopes International (MSI, named after the activist who in 1921 founded the first British family planning clinic). These organizations argue that as a matter of principle, they cannot exclude access to safe abortion from the set of reproductive health goals that they are trying to advance. As a result, IPPF will lose approximately $8 million from 2001 to 2003, or 8 percent of its budget; MSI has thus far lost over $2 million. To date, at least a half dozen other NGOs—some international and some local—have lost funding by refusing to comply with the gag rule.

The potential consequences led Anthony Browne, health editor of the British newspaper, the Observer, to label the gag rule "the Bush edict that kills women." Clinic closures have already been reported from Nepal to Peru to Kenya. Marie Stopes-Kenya, for example, has closed two centers serving the slums of Nairobi and Kisumi. In Kenya as a whole, only one in four married women uses a modern method of contraception, according to UNFPA. In the poor areas served by these clinics, the proportion is likely to be even lower. The country also has a high maternal mortality rate: for every 100,000 births, 650 women die as a consequence of pregnancy or childbirth. One-third of those deaths are caused by botched abortions, even though Kenya has restrictive abortion laws.

The pervasiveness of abortion, even where it is illegal or cannot be safely performed, is perhaps the clearest indication of the gag rule’s medical absurdity. (See sidebar, below.) The rule’s ostensible objective is to reduce the number of abortions, but by obstructing the delivery of family planning services as a whole, it is likely to have just the opposite effect. As Sue Newport, MSI’s Africa Regional Director, explains, "In depriving access to contraception and basic reproductive health choices through these unavoidable clinic closures, Mr. Bush has condemned more women to face crisis pregnancies and resort to desperate, life-threatening methods to abort."

The rule is a legal absurdity as well. In the first place, it’s discriminatory because it applies to pro-choice activities only: anti-abortion lobbying does not render an organization ineligible for funding. The rule also sends a strong signal to developing countries that the United States disapproves of abortion; that will likely set back efforts to increase access to safe abortion, despite the fact that in the United States, abortion is legal. In developing countries that permit abortion, the rule has the bizarre effect of preventing counselors from discussing a procedure allowed by law, with the very people most likely to need it. More generally, the rule’s suppression of debate is hardly a proud reflection of the U.S. constitution, which is supposed to guarantee the right of free speech. Susana Galdos Silva, an activist for the Movimiento Manuela Ramos, a Peruvian women’s rights NGO that accepts USAID money and has consequently been gagged, testified on this matter at a U.S. Senate hearing last July. "The gag rule," she said, "has taken away my freedom to speak about an important issue in my country—a serious issue that is about the life and death of women in Peru." Had it been delivered in Peru, her testimony would itself have been sufficient to disqualify her organization for U.S. aid. Some critics of the rule regard such de facto censorship as a kind of ideological hegemony. Malcolm Potts, Bixby professor of population and family planning at the University of California, Berkeley, School of Public Health, puts it this way: "You can’t run a world on a few people’s political and religious assertions."

No family planning, no security

Family planning provides a higher return on investment than almost any other type of development assistance. "A development success story" is the phrase the World Bank used in its 1994 survey of the field. Its most obvious successes appear, not in demographic trends, but in the lives of the women it reaches. In the developing world, pregnancy and childbirth are the leading cause of death and disability for women of reproductive age. Worldwide, UNFPA estimates that over 500,000 women die in pregnancy or childbirth each year and several million more suffer injury or infection. Ninety-eight percent of these women live in developing countries. In Africa, the continent with the highest rates of maternal death, a woman has a one in sixteen chance of dying in childbirth over her lifetime. Before giving birth, African mothers sometimes bid their older children farewell. In Tanzania, a common formula is: "I am going to the sea to fetch a new baby but the journey is long and dangerous."

The World Health Organization estimates that 100,000 maternal deaths could be avoided each year if all women who said they wanted to stop bearing children were able to do so. Reducing maternal mortality would also confer enormous benefits on large numbers of children, as is apparent in a negative way from current child mortality statistics: in some developing countries, the loss of a mother increases the death rate by 50 percent for children under the age of five.

For most couples, family planning might best be characterized not as a way of preventing pregnancy outright, but as a way of better managing its frequency. Spacing births at least two years apart leaves time for a mother’s body to recover, allows more attention to be given to the newborn, and tends to improve nutrition for both mother and child. The result is a 50 percent increase in infant survival.

The benefits of family planning extend well beyond the health effects. There is a strong correlation between lower fertility rates and the educational and financial advancement of women. This correlation was borne out, for example, by an 11-year study of working women in Cebu city in the Philippines. Researchers found that the fewer children a woman had, the greater the increase in her earnings over that period. Although it is difficult to distinguish cause from effect in such situations, few if any experts doubt that family planning improves the social position of women.

At the national level, reducing population growth can promote economic development. Some economists argue that families with fewer children save more money, a phenomenon called the "demographic bonus." Higher savings rates may in turn reduce a country’s dependence on foreign capital. Decreasing population growth can also ease the strain on over-taxed natural resources, particularly those associated with subsistence agriculture. Today, an estimated 420 million people live in countries where the amount of cropland per capita has dropped below 0.07 hectares—the amount generally deemed necessary to sustain a bare minimum vegetarian diet. By 2025, the number of people living in such countries will probably have reached between 550 million and 1 billion. But the most important limit is not likely to be access to land; it’s likely to be access to water. Already, half a billion people are living in areas prone to severe water shortages. In 25 years, that number will probably have risen to between 2.4 and 3.2 billion.

Such figures suggest the importance of family planning as a global enterprise. By 2050, the world’s population is likely to approach 9 billion—almost a 50 percent increase from its current level of 6.1 billion. Nearly all of that increase will come in the developing world and at this point, most of it is probably inevitable. That’s because record numbers of young people are now coming into their peak reproductive years (between the ages of 15 and 24). Even if the global fertility rate (the average number of children per woman) were to fall overnight from its current level of 2.8 to the longterm "replacement level" of 2.1, more than three-quarters of the growth projected for the next half century would still occur, because of the enormous demographic bulge of young adults.

This population expansion will create profound challenges to development in many ways—political, technical, and moral. Family planning is going to be essential for managing those challenges. On this broad demographic level, family planning could be said to serve two purposes: incremental reduction of population growth over the relatively near term, and over the long term, insuring that the growth actually stops somewhere around that 9 billion mark.

The decency gap

The gag rule is a product of American neoconservatism. Hostility to family planning was not a standard element in the conservative outlook before the Reagan era. In 1969, with the United States firmly committed to providing family planning assistance overseas, it did not seem incongruous to hear President Richard Nixon identify population growth as "one of the most serious challenges to human destiny in the last third of this century."
But the election of Ronald Reagan in 1980 inaugurated a marked shift in both conservative ideology and the electoral mechanics of the Republican Party. During Reagan’s presidency, conservative Christianity became an increasingly influential force within the party. And of course, the issue that conservative Christian groups care most about—then and now—is abortion, which they want to outlaw. Their position on family planning proper (which is built around the provision of contraceptives, not abortion) varies somewhat but is generally unfavorable. This constituency scored a major coup at the 1984 population conference in Mexico City, when the Reagan administration announced that it had adopted the initial version of the gag rule as U.S. policy. (The rule is still sometimes called the Mexico City policy.)

Opposition to family planning picked up additional momentum from serious abuses within several national programs. Coercive government policies have sometimes created a lasting suspicion of family planning in the countries concerned; this happened in parts of India, for example, after the forced sterilization programs in the mid-1970s under the Indira Gandhi administration. In Washington, such cases of coercion have tended to strengthen the neoconservative agenda. In 1985, the Reagan administration expressed its displeasure with China’s one-child policy, which has been associated with forced sterilizations and forced abortions, by ordering a $10 million cut in U.S. contributions to UNFPA. The cut was equal to the amount that UNFPA was spending on Chinese family planning programs. (Despite its involvement in China, UNFPA does not endorse any form of compulsion.) In the following year, U.S. support for UNFPA was eliminated altogether. (It was not restored until 1993 and even today, the United States continues to deduct from its contribution an amount equal to UNFPA’s China expenditures.) In 1998, accounts of forced sterilization in Peru triggered U.S. legislation withholding monetary and food aid to that country until the sterilization program was stopped.
The Reagan era gag rule set off a series of reactions that substantially undercut family planning efforts in the developing world. Two of the field’s biggest "umbrella organizations," IPPF and the affiliated Family Planning International Assistance, decided that they couldn’t comply, and consequently lost funding. IPPF lost a full quarter of its operating budget. Out in the field, the efforts of many little NGOs—the "subgrantees" under these umbrellas—were disrupted by the cuts. In the schools, educational curricula were purged of references to abortion; medical textbooks mentioning the subject were withdrawn. And although post-abortion services were not explicitly prohibited, the rule reportedly had a chilling effect on both the providers and seekers of this type of care. Meanwhile in Washington, the gag rule’s supporters were looking beyond the rule itself. In 1985, USAID granted funds to the Family of the Americas Foundation, an organization opposed to all artificial methods of birth control. This grant violated USAID’s own informed consent policy, which requires family planning programs to supply information on all contraceptive methods.

Even after Bill Clinton repealed the gag rule, Congress continued to use its power over the budget to chip away at family planning expenditures. (See graph, page 26.) From its peak of $542 million in fiscal year 1995, Congress cut USAID funding for family planning by 35 percent for the next fiscal year—a substantially greater loss than the 20 percent cut inflicted on foreign aid as a whole. The family planning budget regained some ground in the following year but in 1999, Clinton struck a deal with congressional conservatives: in exchange for an agreement to pay back dues owed to the United Nations, Clinton signed a more lenient version of the gag rule, which cut USAID funding by $12.5 million. Late in his presidency, Clinton negotiated a 2001 budget with ostensibly more favorable terms. Family planning funding would be increased to $425 million and the gag rule withdrawn—but conservatives insisted on one important condition: no funds could be disbursed until after February 15, 2001. Thus the fate of the rule hinged on what turned out to be one of the most unusual presidential elections in American history.

Bush lost no time in reinstating the rule with all its Reagan-era restrictions, but the intervening 17 years had altered the field. In the first place, there are more NGOs than there used to be, particularly in the advocacy sector. NGOs are also generally better organized and more sophisticated—and USAID is much more dependent upon them to drive its family planning programs. Abortion laws have changed too: in many countries, restrictions have eased, so compliance with the gag rule will probably be more onerous than it once was. Overall, these changes are liable to make the effects of the rule more complex than in the 1980s. More complex means less predictable, but it’s safe to say that in many developing countries, civil society is much less likely simply to accept the gag.

In the short term, at least, the rule’s effects will probably be mitigated somewhat by funding increases from elsewhere. Poul Nielson, the European commissioner for development, announced his commitment to fill the immediate funding shortfall, which he called "the decency gap." In June, both the Danish and the Finnish governments increased their IPPF contributions. And Los Angeles Times columnist Patt Morrison sparked an informal fundraising campaign in the United States, when she told readers she was planning to make a donation to Planned Parenthood in George W. Bush’s name as a President’s Day "gift." Her idea, circulated over the internet, brought in tens of thousands of contributions.

In the United States, several legal challenges to the rule have also been mounted. Last February, a bipartisan bill to overturn the rule was introduced into Congress. In the House, it survived a committee vote but was defeated on the floor. In the Senate, it won the support of the Foreign Relations Committee—a major political accomplishment, since that committee is chaired by arch-conservative Jesse Helms (a Republican from North Carolina), and since Bush had already threatened to veto the bill if it got to his desk. (At the time of writing, the bill had not yet been scheduled for debate on the Senate floor.) In the courts, the Center for Reproductive Law and Policy has sued for the rule’s withdrawal, on the grounds that it violates the right to free speech. "President Bush is holding free speech hostage to a viewpoint he doesn’t like," says Janet Benshoof, the organization’s president. "As a result, many foreign organizations can no longer work in partnership with my organization, cannot attend events at the United Nations at which we are speaking, cannot meet with us and provide information about the situation in their own country." The case was dismissed by a U.S. district judge in New York but the Center has promised to appeal.

Does the gag rule have momentum?

The resurrection of the gag rule suggests that attacks on family planning may escalate. Although Bush insists that he supports family planning itself, conservative policy appears to be singling the field out for unfavorable treatment. This is apparent, in the first place, from the way the rule itself works. The rule does not restrict USAID funding for HIV prevention, safe motherhood, or child survival programs, even though these activities overlap significantly with family planning—for example, in the distribution of condoms—and even though many of the same NGOs are involved. Only family planning comes in for the gag rule’s restrictions. As development policy, such contradictions don’t seem to make much sense. But as a U.S. domestic political strategy, unfortunately, they do: to many conservative political activists, family planning is suspect; safe motherhood and other such programs are not.
There is also a kind of financial double standard at work in the administration’s policy. The use of federal funds to support abortion abroad was banned in 1973—long before the Mexico City conference. But supporters of the rule argue that it closes a loophole by preventing indirect funding of abortion: the argument is that an NGO could use U.S. funds to cover its nonabortion family planning activities, thereby freeing up funds from other sources for its abortion services. Yet the administration has been careful to deny the same line of argument when it comes to one of Bush’s pet projects: the "faith-based" initiative, which would provide government funding for social programs run by churches and other religious organizations. The administration argues that the initiative would not violate the constitutional ban on state support of religion, because churches can keep their social services funding separate from their religious funding.

The months following Bush’s inauguration saw the emergence of several other initiatives that took aim at abortion in the United States. Tommy Thompson, Bush’s Secretary of Health and Human Services, suggested that he might reconsider federal approval of the abortion pill, RU-486. (He later withdrew this suggestion because "Nobody has written to me asking me to review it on any safety concerns.") And the House passed an "Unborn Victims of Violence Act," which would make it a federal crime to harm a fetus, or even an embryo, in an attack on a pregnant woman. Supporters of the bill claim that it demonstrates that "all life is precious." At present, the bill has little chance of getting through the Senate, where Democrats now have the upper hand, but if it actually were to become law, it might establish a legal precedent for regarding even a fertilized egg as a person. Such a precedent could be used to argue that abortion providers are guilty of a federal crime.

Conservatives have also been targeting family planning proper. Bush’s proposed budget for 2001 eliminated coverage of contraceptives from the federal employee health insurance plan. Congress overruled him on this point, but Congress itself may be undermining contraception in a less controversial way. For the 2001 fiscal year, Congress approved a $20 million increase in funding for abstinence-only sex education programs, and a $30 million increase for 2002. But no increase has been approved for family planning. The goal, say officials, is to spend as much money on abstinence-only programs as on family planning, despite the fact that the latter provides medical services and supplies, while abstinence-only programs consist mostly of classes and workshops. Nor is there any evidence that abstinence-only programs actually work.

Attacks on domestic family planning are bad news for the international programs, which are likely to be even more vulnerable to politicians out to prove their commitment to some "pro-life" constituency. That vulnerability is probably in part the result of ignorance: most Americans appear to know little about population issues. A recent survey by the RAND Corporation, a nonprofit policy think tank, found that only 14 percent of the U.S. population had even a rough sense of what the global population is. They estimated it at about 5 to 6 billion—but a similar proportion of the people surveyed thought it was greater than 30 billion! Yet despite their fuzziness on the reasons why it is needed, Americans seem to have little problem with family planning per se. The RAND survey found that 80 percent of Americans favor support of voluntary family planning programs in developing countries. Apparently, then, the gag rule is not taking U.S. policy in a direction that most Americans would want it go. And it is certainly not taking it in the direction envisioned by the Cairo conference—towards a world with fewer abortions, healthier mothers, and healthier babies.

Ann Hwang is a medical student at the University of California, San Francisco, and a former intern at the Worldwatch Institute. The author would like to thank the following people, who provided valuable guidance in researching this article: Felicia Stewart and Tracy Weitz, at the UCSF Center for Reproductive Health Research and Policy; Barbara Crane at Ipas; and Susan Cohen at the Alan Guttmacher Institute. This article was originally published by the Worldwatch Institute.

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