Experts and activists across the globe are concerned about the future of abortion services as the United States prepares to go to the polls in November.
A second term for President Donald Trump could mean even further restrictions on how US money can be used in organisations based in countries that are directly and indirectly funded by the US global HIV programme, the President’s Emergency Plan for Aids Relief (Pepfar) — including South Africa and many African countries.
In January 2017, Trump reintroduced the Mexico City Policy, commonly known as the global gag rule.
The policy allows the US government to withdraw its funding from organisations in other countries if they perform or advocate for abortions, regardless of whether US funding is used for this or not.
This includes referring women to facilities and funding organisations that provide abortion services. Trump’s iteration of the gag rule is the first time the policy has expanded to the money allocated for Pepfar.
The UN special rapporteur on the right to health, Dr Tlaleng Mofokeng, recently wrote: “The chilling effect of the global gag rule is such that institutions that receive funds from the United States under the Pepfar continue to be contractually bound to abandon work related to abortion provision, advocacy, law reform and information dissemination … Countries such as South Africa are yet to recover from the fractures made during the George W Bush presidency in the provision for sexual reproductive health rights in public health systems.”
Evelyne Opondo, the regional director for Africa at the legal advocacy organisation Centre for Reproductive Rights, said the reinstatement of the expanded global gag rule in January 2017 is the clearest indication of the Trump administration turning its back on the human rights of women and girls.
“[Trump’s gag rule] has affected the operations of many reproductive health care providers in Kenya. For instance, Kenya’s foremost sexual and reproductive health provider, Family Health Options Kenya, has reported a 60% reduction of its funding due to the expanded global gag rule. As a result, one of its mobile outreach initiatives, which provided 76 000 women each year with free sexual and reproductive health care, has been discontinued.”
Similar situations have occurred around the world, including in South Africa.
A South African partner organisation told the Foundation for Aids Research (Amfar) that they now have to act as if they don’t know about the girls dying because they go to so-called doctors who tell them to drink bleach to end an unwanted pregnancy.
“We are trusted in the community to provide information, but we can’t talk about it [abortion], we have to act like we don’t know about it. It seems like even the department of health has turned a blind eye.”
A recent study in the Global Health Policy journal reported that about a third of the 247 HIV organisations surveyed around the world say they have changed how they operate and the services they provide because of the US anti-abortion policy.
The survey found that the expansion of the policy has not only curtailed termination of pregnancy services, but also other sexual and reproductive health services such as access to contraceptives and HIV treatment for groups of people deemed most at risk of contracting the virus.
Researchers conducted an online survey among 286 organisations that received US funding between April 2016 and March 2018 and 12 one-on-one interviews were held with employees of organisations that
are currently and were formerly funded by the US. Most of the affected countries are in sub-Saharan Africa where the majority of Pepfar funding is allocated, including in South Africa, Kenya, Eswatini and Mozambique.
According to Amfar data analysis, Pepfar funds 95 partners in South Africa, most of which are local nongovernmental organisations.
Survey results showed that 28% of organisations reported stopping or reducing at least one service in response to the gag rule, including not informing patients about sexual and reproductive health and not providing pregnancy counselling, contraceptives as well as HIV testing and counselling. The in-person interviews also revealed that the decrease in these services was because of over-implementing the Mexico City policy, which drastically reduced the number of patients going into these facilities.
Researchers also found that these organisations were over-implementing the expanded policy beyond what is required. Pregnant women, young people and key populations such as sex workers and men who have sex with men were disproportionally affected.
“Reduced delivery of sexual and reproductive health services has the potential to negatively affect many intended beneficiaries of Pepfar funding, especially in areas with high HIV prevalence. Policymakers must respond to disruptions in service delivery and end any implementation that undermines US investment in high-quality HIV and sexual and reproductive health services,” the study researchers argued.
But it’s not just US policies that are curtailing the right to abortion in Africa and elsewhere. Local governments and laws also stand in the way of women’s right to choose. According to the recent publication by human rights law group Section27, which takes a deep dive into abortion services in 10 Eastern and Southern Africa countries, the lack of implementation of sexual and reproductive health policies and laws restricts progressive abortion services.
Although these countries have signed the Protocol to the African Charter on Human and Peoples’ Rights (known as the Maputo Protocol) — which guarantees women’s right to health, including sexual and reproductive health — many continue to criminalise the termination of pregnancy, which “threatens the rights of women to bodily autonomy, their freedom to pursue their goals and in some cases threatens their lives”.
For instance, one of the goals in South Africa’s national strategic plan for HIV is to provide safe abortions to women and sex workers. But there are no guidelines for who should counsel patients seeking abortion or how the counselling should happen. In 2018, the health department said these guidelines were still in the “final review stage” and were slated to be implemented in September that year.
Two years later, the guidelines are yet to be implemented.
Meanwhile, it remains illegal to perform abortions in Eswatini while abortion is legal under strict conditions such as in the cases of rape and incest in Zimbabwe, Namibia and Lesotho.
Trump’s expanded gag rule has shown catastrophic effects on the provision of abortion and other essentials health services for the most marginalised groups, and women are pegged to bear the brunt of its consequences for many years to come.