The Mexico City Rule and Maternal Death

By Clíodhna Ní Chéileachair

The ‘Mexico City Rule’ is a Reagan-era regulation which bars US funding to worldwide NGOs which provide counselling relating to abortion, or referrals for abortion services, or which advocate for the expansion of abortion access. The regulation is a sticking point for the two-party reality of US politics, and has been rescinded by every Democratic president since Reagan, and reinstated by each Republican president. Trump is no exception, and his administration’s approach to the policy has been exceedingly expansionist; where the policy traditionally only applied to aid tied to family planning projects, the policy now extends to all international health care aid provided by the US government, amounting to almost $9 billion every year, and covering US aid policies in the areas of family planning and reproductive health, infectious diseases, TB treatment, children’s health, nutrition, HIV/AIDS prevention, water and sanitation programs, and tropical diseases.

The effect of the policy extends past the years in which it is actively in place. Population Action International reports on a reluctance on the part of US governmental officials and non-governmental partners to enter into agreements with organizations that may be ineligible for funding in the future based on the putative reinstatement of the policy, in effect operationalizing the policy beyond the times in which it is in active effect. Beyond the expanded remit given to the policy by the Trump administration, and the temporal expansion based on likely reinstatement, the wording of the policy itself goes some way to expanding the scope of the policy beyond what might be necessary in a vacuum. The structural effect of the policy is to prevent the funding of abortion access with US aid money (an outcome which is illegal regardless through the Helms Amendment) and abortion advocacy. The policy contemplates a neat categorization of organizations such that it is possible to carve out the aspects of a healthcare organization that deal with abortion care as an aspect of reproductive health and justice.

The reality is very different, as reproductive health is commonly folded into other aspects of an organization’s advocacy and is difficult to extricate without abandoning the provision of abortion care, or advocacy for abortion care altogether. Given the integration of reproductive health, the aim of the policy is plainly to restrict the provision of these services and not simply to prevent the use of US funds in these areas. Perverse to this aim, a Stanford study in 2011 found that the Mexico City Policy was associated with increases in abortion rates in sub-Saharan African countries, and while no definitive conclusion is drawn about the reason for this, the study authors conclude that a reduction in contraception advocacy by organizations that also perform abortion advocacy may have an impact on the later need for abortion services by women for family planning purposes.

The impact is difficult to overstate. In Cambodia, for example, the Centre for Reproductive Health have commented that many women are unaware that abortion is legal in the country and as a result will attend unqualified practitioners for abortions, risking their lives in the process in a setting where 30% of maternal deaths arise from unsafe abortion practices. The advocacy provided by groups whose funding is cut under the Mexico City Rule are denied the ability to provide lifesaving counseling to women in a country where they are entitled to access abortion services, but unaware that they may do so. It’s important to bear in mind that these are the effects that occur even when it is possible to isolate out the abortion access and information providers from organizations that provide abortion counseling and support alongside a myriad of other health-based treatment and advocacy, and is the most narrowly tailored effect of the policy. In broader cases, where abortion access and advocacy is provided by a health centre alongside other medical treatment, the effects are far greater; curtailing access to an unlimited range of medical treatments by virtue of the fact that the organization may provide information on abortion. Even more disturbingly, often the reason that clinics are originally selected for US aid funds is in recognition of their unique place in providing healthcare in contexts where other providers do not exist. The policy cuts to the core of reproductive rights in some of the most under-resourced regions of the world.

The aid guidelines are notoriously unclear, chilling NGO action because it’s difficult to ascertain what the carve-outs to the policy are. Human Rights Watch have repeatedly referred to a lack of clarity on the implementation of the expanded policy by USAID, despite representations that new training would be provided by US grant administrators. Data also indicates that the operation of the policy is consistent with an increase in maternal death rates in areas typically reliant on US healthcare aid, frequently as a result of unsafe abortion practices. Nearly 20 million unsafe abortions are practiced every year globally, almost entirely in developing countries, and over 70,000 women die every year as a result of abortion complications.

There is an exception in the policy for abortion services, counselling and referrals in cases of rape, or incest, for post-abortion care and in cases where the continuation of the pregnancy will risk the life of the pregnant woman. The rule engages some of the most prominent and intractable debates over issues that centrally define abortion rights, most notably perhaps when the ‘risk to life’ exception in the rule is engaged. This is an issue that has plagued legal regimes which allow abortion in cases where the pregnant individual’s life is at risk from the continuance of the pregnancy, but not where the health of the pregnant individual will be compromised. The complexity at the center of the issue is that health and life exist as an extension of one another, and not in discrete categories, and no clear boundary delineates the distinction between risking health on the one hand, and risking life on the other. No clear definition of ‘risk to life’ exists either, and the two categories, which distinguish between permissible action under the Mexico City Rule and impermissible activity which will lead to a termination of financial support blur into one another.

Beyond the conceptual definitional issue, in reality, the way in which these distinctions operate is to incentivize delaying the provision of therapeutic abortion until a medical practitioner is entirely certain that a risk to life has materialized, compounding the fact that the Mexico City rule already scaffolds a reality in which individuals die of diseases where the cures are under-funded, or where health centers and organizations cannot pursue a health mandate while receiving funds. A Kaiser Family Foundation study in May found that 40 of the countries which receive US health aid allow abortion in at least one instance that the Mexico City policy does not, most commonly therapeutic cases to protect the health of the woman, or in cases where fetal abnormalities exist that are incompatible with life.

A political strategy on the part of the State Department has been to promise a review in six months from last May of the effects of the policy, “which could include identifying implementation issues” While preferable to no review, the problem with a six-month review is that it’s nearly impossible to track significant changes in that space of time given that many organizations have not yet needed to renew their grant funding, and as such have not had to implement changes to their practices. Perhaps more heartening is the flurry of activity by government and non-governmental who have guaranteed to provide the work and research to make that review meaningful in addition to stepping up to bridge the gap between the world’s largest provider of healthcare funds and some of the most vulnerable people on the planet.

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