By Marisol Escudero Martínez, MARCH centre blog volunteer (MSc Health Policy, Planning and Financing candidate)
Dr Kathryn Church is an Assistant Professor in Sexual and Reproductive Health at LSHTM and is seconded as Senior Scientific Advisor within the Research Monitoring and Evaluation Team at Marie Stopes International (MSI). This role involves support to international and national researchers conducting operational and evaluation studies across MSI reproductive health services delivery programmes. Kathryn provides support to a broad area of projects, such as on post-abortion, family planning, task-sharing for contraceptive and/or abortion provision (including to community health workers and pharmacists), quality of care and promotion of long-acting and permanent methods of contraception
Can you explain what the Mexico City policy is and how the funding restrictions work?
The first thing to state is that the US government has never funded any abortion services delivery since 1973, when they brought up an amendment called the Helms Amendment. This law stated the US government funding could not be used for abortion delivery overseas. So, organisations like Marie Stopes International and International Planned Parenthood Federation (IPPF) have never used this money for abortion. As a consequence, the Mexico policy will not have any impact on stopping abortion because MSI only delivers abortion financed by other donors or by women themselves who pay for abortion services. It only results in increasing recourse to abortion, because its only impact is on international family planning assistance.
The Mexico City Policy is an executive order, it has never been a law, enacted in 1984 by Ronald Reagan who announced it shortly after the UN International Population Conference, held in Mexico City that same year, where ideological concerns first came to really burn on international programming because Reagan was a traditional conservative and antiabortion. This order required that the US foreign assistance could not be spent on any foreign organisation that uses any of its funding, including from other donors, for delivering abortion counselling or services. The order remained until Bill Clinton rescinded it on his first days in the office in 1992, allowing again for US federal funds to be spent on family planning assistance delivered by foreign organisations like IPPF. After that, George W. Bush reinstated the Mexico City Policy once again on his first days as President of USA. It is clear the order is a political instrument and it’s done to appease antiabortion lobby groups and politicians in the US.
Could you summarise why it is important to guarantee women’s access to sexual and reproductive health services, including the provision of safe abortion?
Women die when abortion is made illegal, because when it is illegal it is unsafe. We know that through decades of data. What happens is that unsafe abortion is one of the leading causes of maternal mortality in low-income countries and that is why the estimates of the impact of the Mexico City Policy from MSI include maternal death: in that model if you have many unsafe abortions this is what your outcome is likely to be.
It is very difficult to measure unsafe abortion incidence, but there have been a few good studies done and they do show that abortion happens everywhere whether it is legal, restricted or illegal. Illegality push more women towards having unsafe abortion. In practice, even in countries where it is legal and less restricted, providers often still interpret that law very conservatively and cautiously, so it is not freely available.
How do you think this policy will affect the achievement of the SDG Goal 3 target to ensure universal access to sexual and reproductive health care-services?
This policy will limit access to family planning and abortion services. It will affect many NGOs which are the most effective at providing family planning assistance in a lot of countries and it will limit access to safe abortion because they are the same providers who are often doing it.
There is obviously family planning that is available through the public health sector, even where MSI operates, you can often buy pills over the counter or get them through a public health facility. But what organisations like MSI and IPPF are good at doing is they provide high quality services and also tend to offer long active reversible methods of contraception, so all of our providers are trained to insert implants and IUDs. We also offer sterilisation services, either female sterilisation or vasectomy. When we take that away, women are forced to rely on methods like pills and injectables, where there are lot more issues of access and availability. Contraceptive stock outs are a big problem in many countries and it is one of the reasons that MSI has made the decision to provide long active reversible contraceptives, because they are much more effective and the continuation rate is better so when we take those away some women might still have access to family planning but not the same quality or the same effectiveness. Lower effectiveness means more unintended pregnancy.
In your opinion, is there a mechanism or a strategy that NGOs could use to minimize the effects of losing US funding?
The abortion fund that the Dutch government has proposed sounds like a wonderful idea, I think the global fund of HIV has shown to be effective on doing that so if it can replicate then that’s good. But, I am slightly sceptical because sometimes you get a lot of bureaucracy in the international aid sector and I wonder whether we need another fund, or is it instead that we need donors to invest directly in organisations that are being defunded? If they are fundraising, bringing additional funds to the sector and they gain commitments from the governments to invest in safe abortion and family planning then, great. I think this is a moment when all these affected organizations and institutions can capitalize on the political motivation and political energy that is around the reaction to the policy and try to increase funding and get extra donations.
Certainly, MSI will be looking around to other donors to fund more of its family planning work that won´t be covered. But is such a tragedy because is the poorest women who will be impacted from this cause. If we see cuts, it will likely be our outreach and social franchising services that will be lost – these are service delivery mechanisms that MSI uses to deliver services in rural areas, and which are often currently supported by US funds. In rural outreach, for example, we deliver services once a month or once every three months to provide long term, highly effective contraceptive to women who just wouldn´t be able to access it in any other ways. And that would be lost.
How do you think organizations such as MSI will respond to potential loss of funding because of the Mexico City policy?
Will seek to try to continue our services. Reach the communities where we were, we will look at other donors. However, I am pretty sure services will be cut. MSI says that the impact of the Mexico City policy will be on its services and around 2.2 million abortions would be unsafe because there is no decent safe alternative and because of the result of the lack of access to contraception.
U.S. funds MSI approximately 30 million US dollars a year, around 25 million pounds. There are rural areas where the abortion provision won´t be affected because it is not financed by USAID. Instead family planning provision will be affected. There are places where MSI is the only provider offering highly effective contraception. Everyone lives in a country where you can travel to a town for contraception but who can travel? Who has the funds to get out of that village or town, and how far is the town? So, everyone potentially has access to contraception somehow. But the reality in these locations is that we are the only provider because people can´t get out, they can´t get services, they can´t get the quality.
Do you think MSI is going to invest research time in measuring the impact of the Policy in the services?
We do have the MSI modelling, through our Impact 2 calculator. Impact 2 models have been used by MSI to demonstrate the potential consequence of the Mexico City Policy. Between 2017 and 2020 the loss of USAID funded support will mean 6.5 million unintended pregnancies, 2.2 million abortions, 2.1 million unsafe abortions, 21 700 maternal deaths, so that’s the estimations basically on the assumption that none of that programming is replaced by another donor. We are also having discussions with other research partners to conduct observational research to measure the impact of the Policy on our programmes in countries heavily reliant on US funding.
Do you have any final thoughts?
Abortion services are not going to be affected, family planning services are the ones affected by the policy because abortion services have never been funded by the US government and its institutions. And I think that is very unclear in a lot of the press reporting. The policy is not limiting access to abortion, is limiting access to family planning by punishing NGOs who also provide abortion.
The reinstatement of the Mexico City policy imposes a challenge for international organisations like MSI to continue the provision of high quality family planning services around the world. This also represents an opportunity for the international community to unite efforts in order to support the financial protection of women´s sexual and reproductive health.
I would like to thank Dr Kathryn Church for her time and kindly disposition for this interview.
Image: US Government Publishing Office https://www.gpo.gov/fdsys/pkg/FR-2017-01-25/pdf/2017-01843.pdf