The US Supreme Court’s decision to overturn the longstanding Roe v Wade abortion ruling will have a ripple effect on reproductive healthcare provision in low and middle income countries, report Geetanjali Krishna and Sally Howard in The British Medical Journal (BMJ).
In 2018, a reproductive health organisation in Kenya found that anti-abortion advocates had put the address of its reproductive rights helpline on social media.
“It was a veiled threat,” its programme manager, Mina Mwangi, told The BMJ. “They wanted us to know that they knew how to get us.”
On 24 June, the US Supreme Court overturned Roe v Wade, the landmark 1973 decision that protected women’s liberty to choose to have an abortion without excessive government restriction. Sexual and reproductive health rights organisations across the world, including Mwangi’s, feared the effects of the overturning in terms of funding and potential attacks.
“We are heightening our security because of how emboldened the opposition is,” Mwangi says, adding that she dreads a potential withdrawal of funds from US NGOs: her organisation receives more than 50% of its funding from US donors.
Her fears are well founded. Regressive US policy moves on abortion have historically had a profound ripple effect worldwide, particularly in countries where sexual and reproductive healthcare is partly or fully funded by overseas donors.
In the decades since Roe v Wade, 55 countries, including Spain, Ireland, Argentina, Kenya, Romania, Nepal and South Korea, have brought in legislation and policies that have improved access to abortion. Liberia, Sierra Leone and the Democratic Republic of Congo are in the process of legally expanding access, as are several Latin American countries in a “green wave” of liberalisation led by Mexico.
The Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa – the first treaty to recognise abortion (under certain conditions) as women’s human right – has expanded availability in the 15 member nations of the African Union.
In sub-Saharan Africa, which has the world’s highest abortion related deaths in the world, Roe v Wade has been an oft-invoked precedent for advocates of more liberal abortion laws. During the same period only four nations, most recently the US, have imposed further curbs.
Gains at risk of reversal
“We’ve seen amazing progress,” says Sarah Shaw, head of advocacy at Marie Stopes International, an NGO providing contraception and safe abortion services in 37 countries. “Malawi and Sierra Leone are in advanced stages of discussions around law reform for abortion, as are many countries in Latin America, which could lead, remarkably, to the spectre of women from US states crossing the border for safe abortions in Mexico.”
Kenneth Juma of the African Population and Health Research Centre in Kenya points to the sexual and reproductive health Bill currently at the East African Legislative Assembly, the legislative arm of the seven country East African Community, and to liberalising legislation in Liberia as causes for hope. But he fears what the US decision might bring.
“I was in Liberia last week, where lawmakers are preparing a Bill to expand access to abortion, and (the US Supreme Court decision) has come at the very worst time as it has awoken anti-abortion rights activists and given them a seat at the table,” says Juma, who has researched access to safe abortion in Kenya, Nepal and Madagascar.
Shaw fears that Sierra Leone’s safe motherhood and reproductive health Bill, which expands access to abortion in a country where terminations are permitted only when a mother’s life is at risk, will also “run into trouble”. The country has one of the world’s highest rates of maternal mortality and unsafe abortion, and the Bill, though approved by Cabinet Ministers on 7 July, has not yet been enacted.
“The US ruling sends (lawmakers) the message that it’s completely acceptable to disregard the reproductive healthcare needs of half of your population,” says Shaw.
“There is great concern that the dismantling of Roe may catalyse efforts towards similar retrogression in other countries,” Payal Shah, director of Physicians for Human Rights’ programme on sexual violence in conflict zones, told The BMJ.
Health impacts of unsafe abortion
Evidence is clear that restricting abortion does not reduce its incidence but instead makes it less safe. Women and girls (and trans men and non-binary people) who are denied access to safe abortion are forced to use unsafe methods and providers; it is estimated that nearly 25m unsafe abortions take place each year.
The World Health Organisation estimates that at least 7.9% of maternal deaths are due to unsafe abortion, with a greater proportion occurring in Latin America, the Caribbean, and sub-Saharan Africa.
The complications of unsafe abortions include infection, haemorrhaging and injury to internal organs.
“Our staff witness first hand the maternal death and suffering resulting from unwanted pregnancies and unsafe abortions,” says Maura Daly, a sexual and reproductive health adviser at Médecins Sans Frontières (Doctors Without Borders). In 2019, MSF treated more than 25 000 women and girls with abortion-related complications, many of which resulted from unsafe attempts to end a pregnancy.
Daly lists various factors involved, including access to abortion drugs, outdated or harmful information on abortion, and the restrictiveness of the country’s legal framework.
Aisha Awan is a GP in Salford who has seen the effects of unsafe abortion in her voluntary work at a community clinic in Tanzania, where abortion is highly restricted and maternal morbidity and mortality remain high. “Women were at the mercy of cheaper untrained providers, where in some instances ‘instruments’ from twigs to cleaning products were used,” says Awan. “They were plagued by chronic pain and in some cases suffered torn or highly damaged cervixes (for years after the abortion), leaving them at risk of miscarriages or future preterm births.”
Poor and marginalised people bear the heaviest burden from restrictive laws, Juma adds. “Poor people die in greater numbers due to unsafe abortions, are forced to have more children than they can afford, and are at greater risk of poverty due to being forced to carry an unwanted child to term,” he says.
Antonia Mulvey of Legal Action Worldwide, which provides legal aid to victims and survivors of human rights violations and abuses, says any further restriction of abortion provision would be “catastrophic” for victims of sexual violence in conflict.
“Where medical services are available to survivors, they often do not include emergency contraception, meaning that access to free and safe abortions is life saving,” she says.
Encouraging the incorrigible
Reproductive rights activists say the US about-turn is also encouraging anti-abortion factions in poor countries funded by US far right groups, which conduct ugly pressure campaigns through social media and misinformation.
“When Trump strengthened the global gag rule we saw rising social media attacks against MPs who support sexual and reproductive health in Kenya,” says Shaw. “It has also been reported in Nigeria that we (Marie Stopes International) are part of a neocolonial effort to control the population of Nigeria through abortion.”
In Kenya, CitizenGO, a community group using social media to “defend and promote life, family, and liberty” was partly responsible for the sinking of the 2020 Reproductive Healthcare Bill that sought to expand access to safe medical abortion and other reproductive health services. Its tweets labelled the Bill as an “abortion Bill”, despite several researchers and rights observers arguing that it was in keeping with the rules of Kenya’s existing constitution.
The non-profit internet software company, Mozilla Foundation, found that about 15 people, mostly Kenyan, were being paid $10 to $15 per campaign to manipulate the online conversation about abortion.
“In the coming months we will see more and more from these actors,” says Phonsina Archane, programme adviser at the Safe Abortion Action Fund in Kenya.
The road ahead
Some NGOs retain hope that the US’ reversal of Roe v Wade will instead galvanise progressive groups and lawmakers to take positive action to protect abortion rights from further attack.
Marie Stopes International is increasingly focusing on advocacy to protect gains in abortion service provision from being affected by US policy fluctuations, Shaw told The BMJ. When, in 2019, an abortion provider in Kenya was falsely accused of providing abortions outside the national legal framework, Marie Stopes and local organisations successfully countered this misinformation through petitions and co-ordinated opinion pieces in the media, she says.
Shaw also welcomes the arrival of national legal guidelines like Nigeria’s Legal Framework on Abortion, which clearly states what reproductive healthcare providers can and can’t offer to patients to protect such providers from legal consequences.
Juma thinks resilience will come only when nations significantly reduce their reliance on outside aid. He would like to see Kenya’s rights advocates being “proactive rather than reactive” and making the data on abortion clear: “That restrictions increase abortions, unsafe abortions, and mortalities.”
He would also like to see the United Nations Refugee Agency (UNHCR) institute a slush fund allowing it to step in and supply supplies and equipment, such as the chemical abortion drugs mifepristone and misoprostol, anaesthetics, and speculums and tenaculums. This would mitigate the effects when NGOs are forced to withdraw assistance because of external government policies.
Societies need to start treating abortion as a medical issue rather than a political one, says MSF’s Daly. “The heavy burden on people seeking abortion, and their communities, is lost in all the political justifications for not providing this care, rather than seeing it for what it is: a medical decision,” she says.
In June this year, the first African head of the President’s Emergency Plan for Aids Relief, PEPFAR, was sworn in. John Nkengasong, a virologist from Cameroon and the former head of the Africa Centres for Disease Control, told Bhekisisa: “PEPFAR is governed by the laws of the United States, and we have to follow the rules and regulations by which we are governed. We will be looking at (reproductive rights) closely in partnership with the countries in which we work.”
PEPFAR has invested more than $100bn in fighting HIV in more than 50 countries and was created in 2003 during the administration of former president George W Bush. In 2021, the fund spent R7.5bn in South Africa; the programme is the largest contributor to the Global Fund to fight Aids, tuberculosis and malaria.
Reproductive rights, such as access to contraception and safe abortion, are connected to women’s vulnerability to contracting HIV.
Regarding the overturning of the Roe v Wade ruling, and how this would affect the PEPFAR programme, he said: “If there are things we cannot do with our programming (such as funding abortion services), then countries can also lead in that direction or look for additional partners who can leverage the limits and work with us to complete the areas for which PEPFAR cannot provide funding.”
Nkengasong’s appointment comes at a challenging time when the “ongoing COVID-19 pandemic has overshadowed HIV” and current PEPFAR legislation is ending in 2023, according to the PEPFAR Extension Act of 2018.
The organisation has also not been run without contention.
The fund was initially controversial because of Bush’s Republican Government’s strong support for conservative, non-evidence-based approaches to curb the HIV/Aids pandemic, such as provisions that prevented organisations from receiving funding if they supported the decriminalisation of sex work and favouring projects and governments who supported abstinence from sex before marriage as opposed to condom use.
But PEPFAR’S policies have since evolved and today the fund is widely credited with having played a meaningful role in making antiretroviral treatment available in Africa and a consequent decline in HIV-related deaths.
Because the programme also invests in the upskilling of health workers and improvement of health systems, its impact stretches far beyond HIV: studies have found that, compared with countries who don’t receive PEPFAR funding, PEPFAR-supported countries showed significant drops in deaths among children below five years of age, pregnant people and those who give birth between 2004 and 2018.
Such countries also showed a decline in general mortality rates (so also deaths not specifically related to HIV) and increases in the proportion of children getting vaccinated against childhood diseases.
The organisation, however, becomes controversial each time there’s a Republican administration, as the party doesn’t endorse self-initiated abortion and then implements the regulation commonly referred to as the “gag rule”, which requires funded organisations to disassociate themselves from pregnancy terminations as well.
President Joe Biden’s Democratic Government revoked the rule in January 2021, but the US Supreme Court’s overturning of the Roe v Wade ruling in June now complicates matters, as PEPFAR has to follow US laws, Nkengasong told Bhekisisa’s Mia Malan.
However, he added, “The recent changes in the US are very new. We are still discussing these and still need to ask questions for clarity where the need exists.”
The BMJ article – Roe v Wade: How its scrapping will affect women worldwide (Open access)
See more from MedicalBrief archives:
Roe vs Wade: US abortion rights’ ruling could hurt women worldwide
Kenyan High Court declares abortion-related arrests illegal
End of ‘Global Gag Rule’ improves Uganda’s abortion policy prospects
Biden order eases access to abortion, protects clinics and physicians
Political, not legal, threat from US abortion row
Sierra Leone President backs legalising abortion