Under attack, global sexual health 'can't rely on US'

Religious campaigns and political interference could threaten hard-won reproductive health rights in the global South in the wake of the U.S. Supreme Court decision on abortion, health advocates fear.

Cross-border solidarity and coordination will be needed to face down the growing global threat to reproductive rights, health and policy experts have told SciDev.Net.

Unsafe abortion is a leading cause of maternal death worldwide. Around ten percent of abortion-related maternal deaths occur in Latin America and Sub-Saharan Africa, where abortion access is most restricted. Yet, evidence shows that legal restrictions do not reduce abortions—they occur most often where abortions are legally restricted.

Health advocates fear the U.S. Supreme Court decision to eliminate the federal standard that protected the right to abortion, enshrined in Roe v. Wade, will have a cooling effect on funding and political support for sexual and reproductive health services in the global South.

But abortion should not be treated as a foreign funding policy issue, says Rasha Khoury, an assistant professor of obstetrics and gynecology at Boston University. "[Abortion] is a medical provision and everyone should be entitled to it," Khoury says.

For almost 40 years, the controversial U.S. "global gag rule" has been used by Republican presidents to block federal funding to non-U.S. organizations that provide abortion counseling, referrals, and related services, or those that advocate for greater legal rights to abortion.

While President Joe Biden overturned the Trump administration's gag rule in January 2021, there are constant efforts by members of Congress to permanently introduce the policy, according to Rebecca Dennis, associate director of U.S. policy and advocacy at PAI (formerly Population Action International). Some opponents are working to have it permanently removed, she says.

The expanded reach of the global gag rule under the Trump administration meant that public health services were broadly affected, resulting in some clinics closing down if they refused to be gagged, says Dennis. "This policy really had the effect of weakening many health systems around the world right before we went into a massive global health crisis," says Dennis.

Foreign expansion

Abortion opponents are taking their message to the world—and focusing their sights on the global South. Marleen Temmerman, an obstetrics and gynecology professor and former Belgian senator, says nationalistic and religious groups are mobilizing, leading some European governments to reverse reproductive health rights.

"The fight for legalization or decriminalization of abortion has been going on in many, many countries," says Temmerman, now head of the Center of Excellence in Women and Child Health at Aga Khan University, East Africa. "What we currently see here, at least in Kenya and African countries, is the evangelistic churches are getting more and more powerful."

Religious opponents from the U.S. are emboldening European groups to take their fight to Africa, says Martin Onyango, associate director of legal strategies for Africa at the Center for Reproductive Rights. "Opposition groups that operate across the continent—and particularly Sub-Saharan Africa—are led by church groups, they are transnational, traversing the U.S. to Europe, Europe to Africa," Onyango says.

"The same tactics you see being deployed in the US and Europe are the same tactics being deployed in Sub-Saharan Africa, they work with the same groups—largely the evangelical church groups. They have morphed from just being a religious focus group, [there are] also professional groups within those religious groups that then use tactics like litigation to further restrict access to reproductive health care."

South Africa's Choice on Termination of Pregnancy Act states that counseling of pregnant women must be "non-directive." When the government proposed amendments to the act in 2004, the U.S.-based Catholic anti-abortion organization Human Life International (HLI) campaigned to overturn this provision.

HLI says it has branches in more than 100 countries, funds pregnancy care centers in 25 countries and carries out anti-abortion activities around the world, including increasing efforts to "keep Latin America pro-life." The abortion advocacy group Equity Forward has reported that HLI has spent millions of dollars in developing countries to counter legal abortion campaigns, including in Rwanda, the Philippines, Mexico and El Salvador.

In Sub-Saharan Africa, anti-contraception messages are now being pushed on to teenagers, Onyango says, to disrupt their access to information and services.

Colonial hangover

Onyango points out that abortion bans have a colonial legacy. In North Africa and the Middle East, abortion is heavily restricted in more than 55 percent of countries, says Khoury, a board member of Médecins Sans Frontières U.S. who has carried out surgical assignments in Iraq, Lebanon and Afghanistan.

"Those are laws that are based in penal code that often was instated by colonial entities," says Khoury. "You can't divorce the history of coloniality from the current restrictions on abortion and contraception access in these spaces. It is not an indigenous problem of trying to restrict women's access to this very necessary health service, it's really a vestige of coloniality."

The systemic vulnerabilities in global reproductive health services have been 100 years in the making, says Sarah Hawkes, director of the Center for Gender and Global Health at University College London.

Trump's expansion of the reach of the global gag rule led to an estimated US$8-12 billion being withheld from health services around the world—up from $600 million under previous administrations, says Dennis. The UK, meanwhile, has slashed its support for family planning services via swinging cuts to foreign aid.

"This is a situation that we've got ourselves into because we have relied on an incredibly old model that was developed back in the 1920s, of how population control programs … were financed," Hawkes says. "What we haven't done is shared the responsibility, particularly within the countries that people live, operate, work within."

Global solidarity

Hawkes says it is time for states to take control of funding and to support reproductive rights in their communities. "The entire structure of who we are—as individuals, as families, as communities, as societies—is at stake," says Hawkes, who is also co-director of the non-profit Global Health 50/50.

Temmerman agrees: "We have to think how to organize ourselves better not to be dependent that much on the U.S. With the necessary efforts, we can have this debate at the level of the [Inter-Parliamentary Union], which we did for HIV. We could look to work toward parliament and having that structure revitalized for family planning and reproductive health."

Advocates say a coordinated global response and allyship between rights movements could protect hard-won abortion rights.

Latin America and Caribbean campaigner Catalina de la Mar Calderón says that while there are political and social nuances between countries and regions, the U.S. Supreme Court decision highlighted the need for more interaction between regional movements.

"We are under threat… the Dobbs decision is the best example of things going backwards instead of moving forward," says Calderón, a member of the Women's Equality Center, referring to the Supreme Court case known as Dobbs v. Jackson Women's Health Organization. "We need to be holding together: regardless of latitude, country, or which community this is happening in, it will affect the whole world.

"We're here to share whatever we have learnt … but we also need to learn a lot from other countries. We've been conquering legal changes, but access—we're far from it. And in countries where regulation is still needed, we've been fighting [in Latin America] for 20, 30 years, so we can also share what has and hasn't worked, so you don't have to go through that."