Global Gag Rule Two Years In: What Are We Seeing?


The global gag rule, also known as the ‘Mexico City Policy,’ is a U.S. foreign policy that prohibits non-U.S., non-governmental organizations from using their own private funds to provide comprehensive abortion care, counseling for abortion, referral for abortion, or organizing/lobbying/conducting public campaigns in support of abortion on the condition of receiving global health funding. The rule has appeared under previous Republican administrations, but under the current administration it has been vastly expanded. Two years in to the expanded global gag rule, there are a plethora of negative effects. Vanessa Rios from the International Women’s Health Coalition (IWHC) and Jade Maina from TICAH talk to us about IWHC’s new report and why the global gag rule must go.

The global gag rule doesn’t only impact funding for sexual and reproductive health, but 9 billion U.S. dollars of global health funding as a whole. This means that funding for malaria, tuberculosis, HIV/AIDS, and maternal and child health are streams of funding that are being negatively affected by this policy. IWHC’s report during the first year of the expanded global gag rule focused on unanswered questions and concerns during the primary roll-out of the rule. Organizations impacted by the rule experienced a ‘chilling effect’ and stopped offering services out of uncertainty. Now in the second year, those fears, unanswered questions, and concerns are becoming a reality.

The policy has clearly affected access to reproductive health services by fragmenting the care that clinics can provide, and is leading to the deaths of women and girls. In Kenya, research shows that 35 women die from unsafe abortions every month, and unsafe abortions are completely preventable through the use of contraception and implementation of comprehensive sex education. When access to safe abortion care is out of reach, many turn to clandestine options. The policy also continues to marginalize those that are on the fringe of health services, and puts a lot of pressure on services that are low-cost or free.

IWHC’s documentation project takes place on Nepal, Nigeria, Kenya, and South Africa. The data presented comes from more than 170 interviews with civil society organizations over the two years of the implementation of the expanded global gag rule. IWHC has found that the policy is extremely harmful to women and girls and marginalized populations, depriving them of essential health services and information on a whole array of health services.

Photo by Jonathan Torgovnik


Jennie Wetter: Welcome to rePROs Fight Back a podcast on all things repro. I'm your host Jenny Wetter. In each episode, I'll be taking you to the front lines of the escalating fight over our sexual and reproductive health and rights at home and abroad. Each episode, I will be speaking with leaders who are fighting to protect our reproductive health and rights to ensure that no one's reproductive health depends on where they live. It's time for repros to fight back.

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Jennie Wetter: Hi everybody and welcome to a special bonus episode of rePROs Fight Back. I'm your host, Jenny Wetter and today we're going to continue our ongoing series of special episodes I recorded while I was at Women Deliver, a global maternal and reproductive health conference. While I was there, I was lucky enough to talk to advocates from around the world about issues they're working on every day. In today's episode you're going to hear a wonderful conversation I had with Vanessa Rios with the International Women's Health Coalition and Jade Maina with TICAH in Kenya. Um, I talked to Vanessa and Jade about the global gag rule and the report that the International Women's health coalition released recently about what we're seeing two years in with the global gag rule, what kind of impacts we are seeing on the ground and how it's being implemented. Um, it's a really important conversation to make sure that we are grounding our talk about this terrible policy and then the impacts that people are seeing on the ground and what we will be seeing for years to come. Um, so I hope you enjoyed this conversation.

Jennie Wetter: So since I have two people here, I'm going to let them introduce themselves so everybody can hear who's talking when. So first of all, thank you both for being here. So I'm going to throw it to Vanessa first.

Vanessa Rios: Hi, this is Vanessa. I am a program officer for learning, monitoring and evaluation with the International Women's health coalition.

Jade Maina: And I'm Jade Maina with TICAH that's based in Nairobi, Kenya. Okay. So today we're going to talk about, um, IWHC's new report, um, A Crisis in Care which talks about two years in what we are seeing are the effects of the global gag rule. So, but before we can get there, I think maybe we should just do a little basic scene setting, which is what is the global gag rule?

Vanessa Rios: So the global gag girl also known as the Mexico City policy is a US foreign policy that prohibits non-US nongovernmental organizations from using their own private non-US funds to provide comprehensive abortion care. In most instances, these organizations are prohibited from providing counseling for patients on their available options. They can't refer them to other abortion services and they also cannot organize or lobby to liberalize abortion laws in their countries or conducted public campaigns to educate people on abortion and all of that as a condition of global health assistance. It's important to note that there are several things that are excluded from the policy. So, um, abortion due to rape, incest or where the life of the pregnant person is at risk, those instances are excluded from the policy. It also does not include, um, post abortion care services and those are explicitly exempt from the policy.

Jennie Wetter: Okay. And I think also just worth noting, one if you want, um, a fuller explanation on the global gag rule, we have an episode that we released earlier that you can go back and listen to. Um, I'll make sure to tag it in our show notes so people can listen to that as well. Um, but also just worth noting that it has been a political football that goes back and forth and has been around, um, since under Reagan. Um, but right now it is under a vast expansion from what it used to be. Um, in previous iterations.

Vanessa Rios: Yes. Previously it only applied to family planning funding, um, and a much smaller number of organizations. And now it applies to all global health assistance. So that encompasses not only family planning, but HIV services, which is the biggest pot of global health assistance funding, malaria, TB, maternal child health. All of those streams of funding are being affected by this policy and that's almost 9 billion US dollars.

Jennie Wetter: And to give you a sense of scale, but it went from effecting about $600 million to $9 billion. So that's just huge. Okay. So last year IWHC it did a report looking at what, what we were seeing under the first year of the global gag rule. Do you want to talk a little bit about what that report said?

Vanessa Rios: Um, in the first year of our report that policy was just starting to roll out. The way the policy is implemented is through a contract provision. And what that means is that it didn't all just apply to all of the organizations at once. It was really contract by contract as organizations were signing the contract or receiving a new disbursement of funds. So there was um, kind of, there's a lot of confusion around the policy. A lot of organizations were being affected for the first time since this was much more expansive than previous versions of the policy. And so there was a lot of kind of grappling with what does this mean? What kind of changes are we going to have to make? Will this really affect the work that I'm doing. Where are the boundaries of the, um, and a lot of concerns because what we know from previous implementations is that this is a really harmful policy that caused increases in unsafe abortion and really, particularly in Sub-Saharan Africa and in Latin America. And it limited the availability of contraceptives and a lot of places. So we already knew it was bad. Um, when it was being brought back, uh, people just had a lot of fears and concerns around it. It was also starting to, uh, create fissures in, in civil society as you had some organizations that really prioritized abortion and were very vocal about not signing from the onset. Um, and organizations that were more focused on other issues such as HIV with abortion being a smaller portion of their work. And therefore we're still kind of trying to figure it out, trying to weigh the costs and benefits, which is a really difficult position to be in. Um, and now in the second year, we're really starting to see all of those fears and concerns coming to light. Um, they're becoming a reality. Um, and I can talk a little bit more about that later. Okay.

Jennie Wetter: Jade, did you want to talk a little bit about some of the things that you saw in Kenya in the first year?

Jade Maina: Um, so what we saw in the first year, was definitely the fear and the chilling effect of the global gag rule. What this meant was that, um, organizations that knew that they had US government funding and did, did not see themselves having the option to not sign onto the rule, started censoring themselves way earlier than they should have and they stopped providing services immediately, almost immediately, which definitely means that there is misinformation of when a rule like this starts to take effect. And there's also over implementation of the rule itself because we find that, um, organizations that are now gagged failed to understand that there are exceptions and when they stop providing services, they stopped providing all abortion related services including services for post abortion care, and referrals for post abortion care and life saving services, which are an exemption of the global gag rule. Um, the other thing that we have, uh, we are now, uh, continuously seeing, especially in the second year is the fragmentation of um, coalitions, uh, coalitions that did work together for a long time starting to fall apart because organizations that are gagged feel that they are not able to come into meetings where other organization might probably have strategies on working on abortion, which they could jeopardize their funding and for them to feel that they are being safe, they stop engaging in all coalitions that have the possibility of having this kind of programming, which is a shame because a lot of strong work was happening because of the strength of coalitions.

Vanessa Rios: What jade said, um, helping me remember a few specific examples of that kind of fear and over interpretation that was happening even very early on. Um, in South Africa there had been a very strong kind of sexual and reproductive health movement in the 90's that was able to get the, uh, CTOP act passed. Um, and a lot of the kind of activists that we spoke to in the first year of the project were remembering that. And then remembering when, um, the last version of the gag rule was in place. Um, and how it really kind of stalled the progress that was being made in South Africa during that time. And so they were fearful that the same thing would happen, that it would really kind of sideline the conversations that are happening now around abortion access and sexual and reproductive health and rights. Um, and really caused the focus to go back just to HIV, which we know it's really important for all of these services to be integrated. Um, people need to have access to a full spectrum of services. So that was something that really came out there. And then also in Kenya, there were examples very early on of clinics even putting up signs outside in their window saying abortion is not offered here. Um, so just really over applying the policy, um, and doing things that could really exacerbate the stigma that already exist around abortion. Um, and there was also just add to what Jade was saying, a lot of um, confusion around whether post abortion care was included in the policy or not a real low levels of knowledge about the exemptions or exceptions for rape and incest and to protect the life of the mother. And so we were just getting a lot of questions about, you know, what am I supposed to do with when happens that am I supposed to do if someone is coming to me because they were raped, am I no longer even able to engage in a conversation? Um, because they may need an abortion?

Jennie Wetter: Definitely. When I looked at the first year report, it definitely seemed like misinformation or lack of understanding and not having anywhere to go because the lack of understanding wasn't just in the organizations. It was for new parts of, um, the US government that were implementing the program that I hadn't had to implement the global gag rule before. And so they didn't have anywhere to go to get answers because the people that the programs were going to didn't have the answers either.

Vanessa Rios: Yes, we saw that at all levels. So there were some of the uh, sub grantee organizations that were asking their primes, the organizations that directly receive the funding from the US government, you know, what does this mean or are things going to change? And they were not able to really get straight answers a lot of times or they were in the process of developing a proposal for a new project and asked questions like if we got this grant, does that mean that we're going to have to sign this policy and therefore not being able to do the work that we do on abortion and receive just no response and therefore didn't want to go through with the process even though they probably would have been able to get that funding. There were, yeah, a lot of questions but also fear about asking questions. Yeah. Because if they were to say, you know, need more clarification on where they can and can't do around abortion, they were scared even just asking that question would put their funding in jeopardy. So I think there, there was just a lack of information. A lot of confusion, but also fear about asking questions around it.

Jade Maina: I think also to just understand that, for example, you know, in our context we realize that even the government, the Ministry of Health had very little understanding about the rule itself or were in denial about what the rule meant for services in Kenya. Um, when we did have an interview with the Ministry of Health, their take was that because governments are exempt from this rule that it will not affect health services. But we know that this is not true because a lot of the services that are provided in Kenya, most of them are provided by faith based organizations and civil society organizations, which means that once civil society organizations ability to provide services is affected, the general health sector is affected in Kenya. Um, so we found that either the lack of understanding of what this meant for health services or the complete denial that this was going to affect women.

Jennie Wetter: Yeah, that's a lot. And we know that with year two we saw even more, um, problems. So do you want to talk about what the new report and we will make sure to include links to the report so listeners can read it in the show notes and um, online. Um, so you'd want to talk a little bit about what we've seen in year two now.

Jade Maina: Um, so what we have seen in year two is that uh, policy definitely has affected access to reproductive health services and it has, it is actually leading to deaths of women and girls. Um, one of the organizations that was interviewed in the report is a sex worker organization that has worked for a long time, um, referring women for services when they have needed safe abortion services. But because they had to sign onto the gag rule, what it has meant is that they now cannot refer women to services and um, they are seeing that numbers of sex workers who are dying of unsafe abortions is on the rise. A report that has just been completed by another sex worker organization in Kenya is showing that unsafe abortion is the leading cause of deaths of sex workers. They in their report show that 35 women every month die out of unsafe abortions. And as we know, unsafe abortions are completely preventable, um, especially through use of contraception and um, safe abortion when safe abortions are needed. So we see that the defragmentation of services has meant that when a facility provides comprehensive services and now has to shut down clinics or has to cut down number of staff, puts a lot of burden on the few remaining staff or makes it impossible for some women to reach a health care facility near them. Therefore, the broadening the gap on unmet need for contraception taking higher and higher the numbers of unwanted pregnancies with the shutdown of safe services available for abortion, most women are being pushed to the back street, meaning that unsafe abortions that are on the rise. And this is definitely leading to higher deaths of women from unsafe abortion.

Vanessa Rios: Yeah. And it's just tragic that we're seeing it being the most vulnerable and the most marginalized. I mean you are talking about seeing this among sex workers and there are already very marginalized in the community, so it's going to affect the most marginalized the most.

Jade Maina: Yes. The sad bit is that for women who have means or are able to pay for services will continue to affect to receive and access, uh, safe services. So this, um, policy, what we are seeing is that it's continuing to marginalize those who are on the fringe of health services. This includes also, um, young women. Um, a good example is one of the organizations that provided free services to women and girls under the age of 18 now can no longer provide free services. They have had to even shut down some of their facilities. Um, so there is a lot of pressure on services that are either highly subsidized or even free, and these are being shut down. What this means is that women who have been marginalized continue to be further marginalized. So we see that this is also a reproductive justice issue.

Vanessa Rios: So I just want to give a little context about our project before diving into the findings. So, um, IWHC's documentation project is not only in Kenya but also in Nepal, Nigeria and South Africa. As I started talking about those a little bit earlier, um, in the first year of the project we did about almost 60 interviews and then the second year we did 118. So the data and presenting is coming from, um, more than 170 interviews that we did with civil society organizations. Um, those working on comprehensive sexual and reproductive health, but also some that are doing HIV or other global health focused work, um, with government agencies in these countries. Um, and multilateral organizations. We even did our best to reach out to some, um, organizations that are kind of on the other side of things, um, and are kind of anti-women’s rights or against abortion, um, to get a holistic perspective on what's going on and then diving into our findings in, in the second year. It's exactly what you're saying. Um, this policy is really harmful to, to girls, to women and to marginalized populations. It's depriving them of essential health services and information. And it's not just about abortion, it's really affecting a whole array of services. Uh, for example, when you force a clinic to close, it is not just one type of service that's affected. Um, especially in rural and remote areas. People might have to travel really far to access any kind of health service. Um, and therefore, you know, all services need to be integrated. There's really only one place that people can go, um, or one doctor in that region that can provide, um, health care. And so it's the HIV services that go, it's the pregnancy services that go antenatal care services are no longer supported. And so that's why it creates a really difficult choice because even if doctors or providers know that access to information and referrals about abortion services is lifesaving and that women in their communities need access to that, the choices between continuing to provide that. So the choices between continuing to provide that very needed service or continuing to have funding to provide all of the above services. Um, and it's really heartbreaking to have to make that choice. Um, we did focus groups with community health workers in Kenya, um, where FHOK the IPPF affiliate had some clinics that were forced to close as a result of the policy. And they provided HIV testing and treatment, nutrition information, um, prenatal counseling, all types of services to their communities. But after the clinics closed, they had nowhere to refer patients that needed help. Um, and they shared how they were still being approached by people in their community asking them questions like where could they go? Um, and they, they had, you know, it, they were really limited in what they were able to do. So it's, it's really affecting people. It's really affecting communities and it's always the poor and most marginalized communities, those that already have a lot of barriers to accessing services that are affected the most.

Jennie Wetter: Yeah. And I think it's, um, you know, important you're talking about groups having to weigh the benefits of losing all of the services because they having to close because they are, except not going to accept gagged funds or making a really hard decision to stay open and provide the other services. And that have to stop doing one that they believe in. So I think it's also really important to say just because groups except gagged funds does not mean they're in support of this policy. They're having to weigh lives against lives and nobody should have to make that decision.

Vanessa Rios: This policy is so harmful because it's just based in ideology and not in evidence. So, um, we spoke with organization or it was representatives from faith based organizations that said, I'm against abortion. I don't believe that people should have abortion, but I also am against this policy because I know that it's going to lead to unwanted pregnancies and to people seeking abortion using unsafe methods and it's going to kill people. So it's just not based in evidence. It's doing the opposite of what it claims to, to be doing. Um, and it's really harmful and dangerous.

Jade Maina: I just wanted to add, um, the fact that we are also seeing other than the, the effects on the services that this gag rule is contributing towards. It's also contributing towards a really toxic environment because it's leading to a heightened, um, opposition. There's definitely an emboldened opposition. Right now. In the last one and a half years we have seen, um, a petition to shut down Marie Stopes services on abortion including services that save lives, including post abortion care. And what this has meant is that these definitely much more stigma on an already stigmatized topic. Um, earlier on this year we saw billboards with messages like abortion is murder ,making women who have needed abortions or who will continue to need abortions feel more stigmatized about a service that women do need almost every day. We are also seeing a shift in funding because the funds that are you from the US for health are not being cut down. They are just moving from organizations that provide comprehensive services that are more progressive to organizations that are more faith based and maybe not providing as comprehensive services as before. Organizations that also have provide, have comprehensive services have taken a long time to build capacity for them to even get to the point where they can access, um, US government funding. So to shut that down and to represented with much young organizations that probably don't have the capacity to meet the gap that is there of the services that are there. There's definitely a gap between when those organizations will, even when they are progressive, will be able to provide services to the extent that the ones that are shutting down were. And this gap we all know is women's and all communities health that is being affected. And it's really sad that no one, um, that there is very little being done to document that. So we are hoping that the documentation project right now does highlight those kinds of changes. And hopefully in future there is no point where we will have a policy that affects life and causes gaps in health provision because of such harmful policies that are put in place.

Jennie Wetter: Yeah, I think, you know, you're definitely seeing this report starts to outline some of the health problems we are saying none more serious than pregnant people dying. I mean, bottom line and as I think, um, I'm gonna steal from, I think Beirne said at a panel, Beirne at the Center for Health and Gender Equity, said at a panel I was at earlier: Nobody on the other side is writing reports, talking about the health benefits of the global gag rule because there aren't any.

Vanessa Rios: I wanted to add to what jade was saying because we're seeing the, that beyond these harms to health, um, this policy is really emboldening wrangling actors and increasing their influence on health, not only in Kenya but also in South Africa and Nigeria in particular. Uh, we've seen examples of funding going to regressive and anti LGBTQI, anti-sexual and reproductive health and rights groups in these places. And we know that the US government is also conducting trainings and helping them build that capacity to be able to access these funds more easily. The policy is amplifying the voices of these actors while at the same time silencing advocates for, um, comprehensive SRHR, um, and advocates even just for evidence-based care. Um, so it's really leaving a void where those voices can be heard even louder. Um, and this was a concern that we heard not only from civil society organizations, but also from some of the government representatives that we spoke to. It's important for government to hear from a vibrant civil society that can really speak to the needs of their communities and, and their people. Um, and this policy is making it so that they're prevented from talking about some issues that are critical.

Jennie Wetter: Okay. So we're talking a lot about, um, impacts we're seeing on the providers. Are we seeing any impacts on the governments?

Vanessa Rios: I think that this is one of the most surprising findings from, from this documentation that we've done. The policy is really undermining government's abilities to drive its own health priorities, um, and to set health policies for their people. This is one of the more kind of indirect and insidious results that is happening from this policy in South Africa. The curriculum for life skills based education is under development. Um, and this involves different government agencies and also a group of civil society organizations that are providing their expertise on, um, sexual and reproductive health. Because a lot of these organizations that are actually doing the writing of the policy receive their money from USAID. It's all but guaranteed that abortion will be excluded from the curriculum. And this is in a country where the constitution guarantees a right to health and specifically includes reproductive health. And also South Africa has one of the most progressive abortion laws. And if the result of this gag rule is that you can't even mention the national law that's incredibly problematic and can affect a whole generation of young people that are going to receive this education,

Jennie Wetter: That would be devastated to see a country that has taken steps purposely to make sure that there is access to safe abortion care. Um, to see people then not be educated that it's an option would be terrible. Okay. So with all of this depressing and horribleness that we've talked about today, I think it's even more important to ask what can people do. So what can people listening do to fight back against the global gag rule?

Jade Maina: I think people who live in countries where the global gag rule applies need to, um, consolidate the efforts and work together to create strategies that mitigate the harm they need to continue to collect evidence. Because before we haven't had tangible evidence of the effects of the gag rule. And use this evidence to advocate with their governments, um, especially for their governments to increase, uh, budgetary allocation to health services and slowly by slowly move away from being so much donor dependent that then affects women in these kinds of ways when policies are passed in other countries. So a sort of get their own governmental autonomy on the aspects of health that they want to and they feel is important for their citizens. I feel that that this also provides a space for activists to create awareness about safe abortion and uh, to build a critical mass and the movement towards reproductive health rights and build a strong movement of women that know what their rights are and are demanding for their rights under accessing their rights under the provisions of their law, but also in ways that are accessible in their countries. I'd say organizations that do know what the global gag rule means. Create awareness about that with the media, raise voices. Um, that also just helps build capacity for organizations that either have been gagged and need to navigate this difficult times so that we can ensure that we are seeing less and less lives lost. Even while the gag rule is, um, being implemented, but also looking into the future. How we don't find ourselves in this space again.

Vanessa Rios: From the U S perspective, um, I think there's just one solution which is to add this policy. So there is a by partisan legislation that's on the table called the Global HER act. And what that would do is immediately put an end to this policy and also prevent future presidents from being able to, um, with the stroke of pen, make it come back. So I think it's critical that we continue to build the evidence, um, and build the support to educate, um, each other and to educate, educate our legislators, um, that it's critically important for them to prioritize passing this legislation.

Jennie Wetter: And I think that means reaching out to our friends who are already on and saying thank you. And even reaching out to those who you know won't support, but we can't let them off the hook. We have to make sure you are telling your representatives, maybe, especially if they're vehemently in favor of the global gag rule that you're not, that they, that it's not okay and they need to feel the pressure from their constituents for supporting this terrible policy. All right. Well, Jade, Vanessa, thank you so much for doing this. I think this was a great conversation.

Vanessa Rios: Thank you so much, Jenny.

Jade Maina: Thank you for having us.

Jennie Wetter: For more information, including show notes from this episode and previous episodes, please visit our website You can also find us on Facebook and Twitter at rePROs Fight back. If you like our show, please help others find it by sharing it with your friends and subscribing, rating and reviewing us on iTunes. Thanks for listening.