When it comes to sending U.S. aid to poor countries, every Republican president from Ronald Reagan through Donald Trump has imposed a rule: Foreign aid groups are prohibited from getting U.S. assistance for family planning unless they promise not to "perform or actively promote abortion as a method of family planning." That includes providing patients with referrals or information about the procedure, even if those activities are funded by non-U.S. government sources. (Trump's version of the funding ban has gone even further — applying to aid for virtually all global health services, not just family planning.)
Opponents of abortion rights have long advocated for the ban — known as the Mexico City policy after the city where it was first announced in 1984 — on the grounds that it ensures that U.S. taxpayer dollars are not used even indirectly to fund abortions overseas.
But a new study in the medical journal The Lancet suggests that the Mexico City policy has actually increased the rate of abortions by about 40% in the countries studied — likely because the funding ban caused a reduction in access to contraception and a consequent rise in unwanted pregnancies.
How do the study's authors come to that conclusion?
First, they make use of the fact that the two most recent Democratic presidents, Bill Clinton and Barack Obama, each lifted the funding ban while they were in office. This means that over the 20 years from 1995 to 2014, there were three distinct periods: From 1995 through 2000 (during which Clinton was president), the funding ban was not in place. From 2001 through 2008 — George W. Bush's years as president — the funding ban was in place. And then from 2009 through 2014, under Obama, the ban was again lifted. The researchers looked at what happened to abortion rates in 26 sub-Saharan African countries over those years.
Of course, abortion rates could have changed during those two decades for reasons wholly unrelated to U.S. funding policy. But in an effort to factor out that possibility, the researchers divided the 26 countries into two groups: In the first were countries that received the highest amount per person of U.S. family planning aid. In the second group were the countries that received the lowest amount.
The idea is that countries receiving a large amount of aid per person would likely be more vulnerable to changes in the policies governing U.S. aid. So by comparing what happened to the abortion rates in those more aid-dependent countries with the abortion rates of countries that were otherwise similar but less dependent on U.S. money for family planning, the researchers believed they could better isolate the impact of the funding ban on abortion rates.
In addition to finding that the ban produced a 40% increase in a country's typical abortion rate during the period when the Mexico City policy was in place, the authors found a 14% decrease in the use of contraception and a 12% increase in pregnancies.
Co-author Nina Brooks of Stanford University says it seems likely that aid groups unable or unwilling to comply with the abortion restrictions on U.S. funding ended up losing U.S. aid dollars and therefore cut back on their activities, which included distributing contraception.
"So we speculate the mechanism that drove the increase in abortions was the reduction in supply of contraception," says Brooks. "If you lower the contraceptive supply, then there are more unintended pregnancies and then more abortions."
The study offers some of the most "compelling" evidence to date of the impact of the Mexico City policy, says Jennifer Kates, director of global health and HIV policy at the Kaiser Family Foundation, which has been tracking the worldwide effects of Trump's version of the funding ban.
Previous studies on the impact of the policy have been limited to shorter periods of time and smaller numbers of countries. And most of these reports essentially amount to anecdotal accounts of how much money particular aid groups have lost as a result of the ban and to what extent this caused them to cut back on family planning activities.
"This is the largest empirical study of the Mexico City policy to date," says Kates.
But Connor Semelsberger, legislative assistant at the Family Research Council, which has long supported the Mexico City policy, says he finds the study unconvincing because it did not delve into what he argues are key data points — such as which aid groups were operating in the affected countries and how much the amount of U.S. aid changed during the years studied. "I was really wanting more information," he says.
Study co-author Grant Miller of Stanford University and the National Bureau of Economic Research says the larger takeaway should matter to people on all sides of the abortion debate. "Regardless of what people personally believe about abortion, our evidence is consistent with what aid organizations [on the ground] have been saying, which is that this [Mexico City policy] leads to a pretty big increase in abortions."
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