Each year, 19 million women risk their lives to undergo unsafe abortions because the procedure is illegal, severely restricted, or difficult to access. Of women who undergo unsafe abortions, as many as 80 percent face illness, injury, or disability. Globally, unsafe abortions account for approximately 68,000 deaths annually and 13 percent of all pregnancy-related deaths. As alarming as these global statistics are, the situation for refugees and internally displaced women is especially dire due to lack of access to proper facilities and services. Since refugees and internally displaced persons are in similar positions with regard to reproductive health and unsafe abortions, this paper will refer to both populations as “refugees.” A 1999 report by the United Nations Population Fund (UNFPA) estimates that “25 to 50 per-cent of maternal deaths in refugee settings are due to complications resulting from unsafe abortions.” In addition, many who survive live with the effects of severe complications, including incomplete abortion, sepsis, hemorrhage, and intra-abdominal injury or long-term health problems such as chronic pelvic inflammatory disease, tubal blockage, or secondary infertility.
Many refugees are left with few alternatives to unsafe abortions. Refugee women are often subjected to forced sex and have limited access to reproductive health services, including contraceptives. This can cause a high rate of unwanted pregnancy and increases the need for safe and accessible abortion services. However, the staggering number of maternal deaths caused by unsafe abortions each year among refugees demonstrates that their reproductive health needs are not being met. As with many refugee services, reproductive health programs suffer from a lack of resources and accessibility.
Over the last two-and-a-half decades the issue has been further complicated by the Mexico City Policy. Since the U.S. policy was first instituted in 1985, it has been rescinded and reinstated several times by successive presidents of different parties. Most recently, President Barack Obama rescinded the policy on January 13, 2009. The Mexico City Policy banned U.S. funding from going to any organization that performs or promotes abortions, “provides advice, counseling, referrals or information regarding abortion, or [lobbies] a foreign government to legalize or make abortion available,” even if the money used for those services are private funds. Critics dubbed the policy the “global gag rule” because it restricts these humanitarian organizations from discussing abortion as an option for pregnant women. Since President George W. Bush reinstated the policy in 2001, many family planning and reproductive health organizations that serve refugee populations lost funding. This, in turn, has impeded access to all forms of reproductive health services, including safe abortions.
President Obama’s removal of the policy is an excellent start to undoing the damage done by the policy over the last eight years. However, much more remains to be done to ensure that refugees have access to safe abortion services. Additionally, there is no guarantee that this policy will not be reinstated in the future after the current administration leaves office. It is important to understand the consequences of this policy for refugees when considering its possible reinstatement by a future administration. The inconsistency of U.S. policy puts organizations that provide reproductive health services at a disadvantage because they face continual uncertainty about their funding.
This study will first examine the unique situation of refugee women and their need for access to safe abortions. It will then look at the history of the Mexico City Policy and some of the objections critics have raised. After a discussion of the Mexico City Policy in general, the specific impact the policy has had on refugees and the humanitarian organizations that serve them will be explored. An overview of international law regarding refugees, reproductive health, and abortion rights will be followed by an examination of how various organizations have coped with the policy. Lastly, this study will look ahead to the impact President Obama’s reversal of the policy may have and additional recommendations for the United States and the international community. These recommendations include not reinstating the policy in the future, increasing funding for all reproductive health services, and more fully recognizing the special importance of providing safe abortion services to refugees.
Refugee Women at Risk
The issue of access to safe abortions is particularly relevant for refugee women. Refugees often find themselves temporarily or permanently lacking traditional community or family structures. Refugee camps do not always provide a safe environment for women and leaving the camps to farm or collect firewood or water can expose them to even more dangerous circumstances. Rape is increasingly documented as a weapon of war and sexual violence has been committed against refugee women by other refugees, military troops, police, border guards, and aid workers.
Additionally, refugee women are cut off from their normal means of subsistence. Faced with these difficult circumstances, some refugee women turn to prostitution as a means of survival or are coerced into sex in exchange for basic resources such as food, water, or protection. The social repercussions of having a baby as the result of rape or prostitution can carry severe consequences for refugee women. In some countries, such as Sudan and Chad, women can be faced with divorce, shame, and ostracism from their families and communities. They may even be deemed unfit for future marriage. For reasons that may include shame, social stigma, and economic difficulties, aid workers report that many babies are abandoned. For example, CNN reported in June 2008 that up to twenty babies a month were being abandoned in just one of the camps in Darfur housing 22,000 people.
Reproductive health care is sometimes overshadowed by other services that are seen as more essential, such as food, shelter, and basic health care. As a result, refugee women may have limited or no access to condoms, contraceptives, or emergency contraceptives, which increases the likelihood of unwanted pregnancies and the need for safe abortion services. Yet access to safe abortions is restricted by many factors, including the laws of host countries; cultural, traditional, and religious beliefs; lack of financial means; no access to transportation; and family opposition to visiting abortion referral centers. Finally, refugee women and health care providers are too often uneducated about the framework in which abortions can be legally performed.
Unsafe abortion is one of the leading causes of maternal death in refugee settings; however, research indicates that it can be easily prevented. Access to safe abortions, in conjunction with a comprehensive package of reproductive health and family planning services, can reduce maternal mortality rates in vulnerable refugee populations. International Planned Parenthood Federation writes: “Evidence from many countries—from the United States to Nepal—clearly demonstrates that the legalization of abortion and the provision of family planning services dramatically reduce abortion-related deaths.” However, legalization is not enough. Refugee populations must be able to easily access these facilities and organizations providing these services must be properly funded. Despite this very serious situation for refugee women, the United States has spent the past eight years neglecting their needs. The Mexico City Policy made it even more difficult for women—specifically refugee women—to obtain safe abortions abroad. The United States should continue with policy changes, such as the removal of the Mexico City Policy, that support reproductive health rights and services for women.
The Mexico City Policy and the Helms Amendment
U.S. foreign policy regarding the use of U.S. funds for abortions and its promotion date back to 1973 when the Helms Amendment was added to the 1961 Foreign Assistance Act. This amendment prohibits U.S. foreign assistance funds from being used to pro-mote or fund abortions. In 1985, President Reagan enacted the Mexico City Policy, which was first announced at a population conference in Mexico City in 1984. This regulation “prohibits non-U.S., nongovernmental organizations receiving USAID [United States Agency for International Development] family planning assistance funding (either directly or through sub-awards) from using their own or other non-USAID funds to provide or promote abortion as a family planning method.”
In 1993, President Clinton rescinded the Mexico City Policy, returning to the previous policy under the Helms Amendment that allows USAID to fund organizations so long as that money is not directly used to promote or perform abortions. Yet on January 22, 2001, President George W. Bush reinstated the Mexico City Policy. President Bush said: “It is my conviction that taxpayer funds should not be used to pay for abortions or advocate or actively promote abortion, either here or abroad. It is therefore my belief that the Mexico City Policy should be restored.” The policy also prohibits health care providers from discussing abortion with patients or referring them to abortion services except in the case of rape, incest, or risk to the mother’s life. Additionally, it prohibits organizations from advocating for abortion practices.
The policy was significantly more restrictive than the Helms Amendment because organizations could no longer receive funding if they promote or perform abortions at all, even if these activities are financed through non-USAID money. However, the policy did not restrict organizations from providing post-abortion care or from treating injuries or illnesses caused by legal or illegal abortions. Additionally, President George W. Bush committed to maintaining the $425 million funding level for family planning provided for in FY 2001 after the implementation of the policy.
On January 23, 2009, President Obama followed in President Clinton’s footsteps and rescinded the policy. President Obama released a statement saying: “It is clear that the provisions of the Mexico City Policy are unnecessarily broad and unwarranted under current law, and for the past eight years, they have undermined efforts to promote safe and effective voluntary family planning in developing countries.” The statement goes on to direct the secretary of state and the administrator of USAID to waive the conditions of the policy in any current grants, to notify current grantees that the conditions have been waived, and to no longer impose the conditions of the policy on any future grants.
However, for the eight years the Mexico City Policy was in place, it negatively affected refugee populations because many of the organizations that provide services for them are funded by USAID. When the policy was reinstated, organizations that work with refugees faced the choice between altering their policies and losing funding. The result was that many organizations, such as Marie Stopes International, lost funding that was essential to the provision of an array of reproductive services—not just abortions—to refugee populations. Refugee women have little recourse to turn to alternative services other than what is available to them in the refugee camps, such as non-USAID funded organizations. Due to a lack of options, many refugee women choose to undergo unsafe abortions each year.
Objections to U.S. Policy
Some policymakers objected to the Mexico City Policy on the grounds that U.S. law already prohibits taxpayer funds from directly promoting or performing abortions. For example, Senator Patrick Leahy issued the following statement to President George W. Bush on January 23, 2001:
The Mexico City policy goes much farther, which is why it is often called the “global gag rule.” It prohibits taxpayer funds from being used to support private family planning organizations, like the International Planned Parenthood Federation, that use a small portion of their own private funds—not tax-payer funds—to provide advice, counseling, and information about abortions, and to advocate for safe abortion practices in countries where tens of thousands of women suffer injuries or die from complications from unsafe abortions.
Others argued that abortions are performed more safely where it is legal and NGOs should be allowed to lobby for abor-tion rights in other countries. On October 31, 2007, in the opening statement of a House Committee on Foreign Affairs hearing on the Mexico City Policy, former Chairman Thomas Lantos cited a study published in The Lancet, a leading British medical journal, conducted jointly by the UN’s World Health Organization and New York’s Guttmacher Institute on worldwide abortion rates. The study found that abortion rates are relatively equal in countries where abortion is legal and countries where it is illegal. However, where it is legal the study found that abortions are performed in a safe manner. On the other hand, where it is illegal abortions are often performed under unsafe conditions by poorly trained providers. Lantos argued that given these results “the United States should be actively supporting NGOs which are fighting to get rid of unjust laws banning or severely limiting abortion, not shunning them.”
However, legalization is not sufficient to ensure the safe per-formance of abortions for refugees. Safe abortion services must also be properly funded and accessible. The U.S. government should not only maintain the repeal of the Mexico City Policy but should reconsider the conditions required under the Helms Amendment. Under the Helms Amendment, no taxpayer funds can go directly toward providing abortions. Organizations that receive USAID funding must use separate money to perform abortion services. Given the high number of maternal deaths among refugees attributed to unsafe abortions, the United States should consider funding safe abortion services for refugees.
Consequences of the Policy for Refugees and Organizations
Funding levels from the United States for family planning, as promised by President George W. Bush, did not decrease during the eight years the Mexico City Policy was in place. In fact, the government’s budget for global family planning programs was $436 million in 2006, up from $425 million in 2001. However, a 2006 United Nations Population Fund (UNFPA) report points out that global funding for family planning programs has been steadily decreasing and was below the suggested target of $11.5 billion in 2005. Although the Mexico City Policy did not cut U.S. funding specifically, it may have impeded organizations from getting additional funds from USAID that could have helped make up for the global deficit in family planning resources.
Also, while overall U.S. funding levels did not decrease, the Mexico City Policy did result in funding cuts for organizations with extensive experience and credibility in the field. For example, in Kenya, several well-established reproductive health and family planning organizations lost funding and USAID contracts due to the Mexico City Policy. Two such organizations are The Family Planning Association of Kenya, an affiliate of the International Planned Parenthood Federation, and Marie Stopes Kenya. The Family Planning Association of Kenya closed three clinics due to loss of funding. Marie Stopes Kenya had to close two clinics and terminated a $1.6 million, three-year agreement with USAID.
Additionally, Marie Stopes Kenya lost eligibility to participate in the Amkeni Project, a five-year family planning and reproductive health project. The project was not able to include Marie Stopes as planned because the organization refused to alter its policies in order to receive USAID funding. Dr. Albert Henn, the director of the project, said of the restriction: “We are depending upon [Marie Stopes Kenya]. . . . We will be hard pressed to find another partner that could play this important role as effectively as Marie Stopes.” As a result, USAID-funded projects such as Amkeni are forced to turn to less experienced partner organizations, leading to a less effective use of U.S. funds.
Although these programs were not focused directly on refu-gees, it may have hindered Kenya’s ability to strengthen its overall reproductive health care structure, having an indirect affect on refugees’ ability to access services. Kenya is a country with a large and growing refugee population. Due to ongoing conflict in Somalia, Kenya has seen a large influx of refugees crossing its borders. Human Rights Watch reports that more than 65,000 refugees entered Kenya in 2008, significantly up from the 19,000 the previous year.
Overall, at least twenty organizations globally, including the Family Planning Association of Kenya, the Family Guidance Association of Ethiopia, the Planned Parenthood Association of Ghana, Marie Stopes Kenya, and the International Planned Parenthood Federation, have lost funding due to the Mexico City Policy. Steven W. Sinding, who ran the International Planned Parenthood Federation from 2002 to 2006, said this policy cost the organization and its national member associations alone at least $116 million in federal funding in recent years.
Additionally, the Mexico City Policy prevented organizations that do receive USAID funding to inform refugee women of their full range of choices. Dr. Ann C. Hwang and Dr. Felicia H. Stewart explained in a study titled, “Family Planning in the Balance” the effect that the Mexico City Policy has had on health care providers and the level of care they can give their patients:
In the case of physicians and other health care providers, the [Mexico City] policy creates a particularly vexing conundrum: by not allowing physicians to discuss abortion with patients (except in instances of rape, incest, and threat to the life of the mother), it may preclude physicians from providing ethically sound care.
The American Medical Association Code of Ethics lays out several fundamental elements of the patient-physician relationship. The first of these elements is the patients’ right to receive information from physicians about treatment alternatives. In the United States, a physician is required to explain to a patient with an unwanted pregnancy the options of continuing with the pregnancy, adoption, and abortion. However, USAID-funded physicians cannot meet this same ethical obligation to provide patients with information to make informed decisions because they are banned from discussing abortion, even in countries where it is legal.
Additionally, in cases of rape, incest, or threat to the mother’s life—when the health care provider could discuss abortion with the patient under the Mexico City Policy—lack of funding to organizations that perform abortions makes it difficult to find an appropriate health care facility to which they can refer these women. In refugee settings, rape results in many unwanted pregnancies that women may choose to abort. Under many countries’ laws this would be legally permissible. However, it does rape victims no good if organizations are not equipped to provide such services even under legal circumstances.
International Law and Abortion Rights
International law has provided a basic outline of some reproductive rights that should be guaranteed for all people, including refugee populations. However, it does not go far enough in order to guarantee that all refugee women have access to the full array of reproductive health services, including abortion. Partially due to the moral and political controversies over abortion services, many in the international community have not yet demanded safe abortion services as a right. Therefore, it is difficult to determine where the Mexico City Policy fits into international law. Although there is a much broader array of international law in regard to reproductive health, this section will focus mainly on aspects of international law that are directly related to refugees, reproductive health rights of refugees, and specifically abortion.
International Human Rights Law
The International Covenant on Economic, Social, and Cultural Rights (signed by 69 countries with 160 parties, it has been signed but not ratified by the United States ), states that everyone has the right to enjoy the “highest attainable standard of physical and mental health.” Although “reproductive health” is not specifically mentioned in the covenant, the committee of experts created to oversee the implementation of the treaty assert that Article 12(2) protects the right to sexual and reproductive health services, facilities, goods, and health education. The Committee also explicitly stated that since refugees are vulnerable and marginalized individuals protected by the treaty’s non-discrimination clause, access to reproductive health services must be guaranteed to them as well.
The 1999 Optional Protocol to the Convention on the Elimi-nation of All Forms of Discrimination against Women, which created the Committee on the Elimination of Discrimination Against Women (CEDAW), has been ratified by 185 countries or 90 percent of UN member states. The United States has signed but not ratified the Optional Protocol. The Convention stipulates in Article 12 that health care includes family planning. The Committee stated in a general recommendation on Article 12 that this right to health care and family planning extends to all women and girls “even if they are not legally resident in the country” and that special attention should be given to the health needs and rights of refugee and internally displaced women. CEDAW also states that “other barriers to women’s access to appropriate health care include laws that criminalize medical procedures only needed by women and that punish women who undergo those procedures” in a clear reference to abortion.
CEDAW goes on to say that “it is discriminatory for a country to refuse to legally provide for the performance of certain reproductive health services for women,” and that if health service providers refuse to perform certain services on the basis of conscientious objection “measures should be introduced to ensure that women are referred to alternative health providers.” The Mexico City Policy clearly went against CEDAW policy to protect a woman’s right to obtain an abortion and offer referrals to alternative services.
International Consensus Documents
The 1994 International Conference on Population and De-velopment (ICPD) Programme of Action and the 1995 Fourth World Conference on Women (the Beijing Platform for Action) have also further defined reproductive rights. The Beijing Platform for Action recognized women’s human right to “decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health.” The ICPD Programme of Action specifically addressed refugees and IDPs and highlights reproductive health as a right that should be protected. Both conference documents call on states to ensure the physical protection of refugees—particularly women and children—and to provide them with appropriate and adequate services. They also both recognize unsafe abortion as a major public health concern and call for the provision of post-abortion care in all cases, and for safe abortion services where these are legal. The Beijing Platform for Action also calls on governments to consider reviewing laws that punish women for obtaining illegal abortions. Paragraph 8.25 from the ICPD Programme of Action outlines its policy on abortion:
In no case should abortion be promoted as a method of family planning. . . . Prevention of unwanted pregnancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should have ready access to reliable information and compassionate counseling. . . . In circumstances where abortion is not against the law, such abortion should be safe.
Although it bans abortion from being promoted as a method of family planning, it clearly states that women should have access to information and counseling and that, where legal, abortions should be performed safely. Though the United States has en-dorsed this provision, the Mexico City Policy did not follow its guidelines. The Mexico City Policy banned “reliable information” from being given to women who have unwanted pregnancies because it forbids the discussion of abortion and opposed abortions even under local laws that permit it.
Response to the Mexico City Policy and Unsafe Abortions
Many organizations and governments created new initiatives in response to the Mexico City Policy to better bridge the gap between availability of, and demand for, abortions. The International Planned Parenthood Federation (IPPF) initiated major new efforts to provide services and advocacy for safe abortions in recent years. In February 2006, the UK government started the Safe Abortion Action Fund and appointed the IPPF to administer its programs. The Safe Abortion Action Fund is a “targeted reserve of resources to enable the implementation of programmes and initiatives to increase access to comprehensive safe abortion services, within a comprehensive package of reproductive health services, with particular regard for the needs of marginalized and vulnerable women.” It aims to disburse resources to non-governmental organizations working on abortion issues and was specifically designed to help organizations that had been denied funds due to the Mexico City Policy. The fund is supported financially by the governments of Denmark, Norway, Sweden, Switzerland, and the United Kingdom. In 2007, the fund awarded $11.1 million in grants to NGOs.
Marie Stopes International, which had been denied USAID funding, has been working on programs that advocate for a full range of sexual and reproductive services specifically for refugees. Marie Stopes International, along with Columbia University, has created the Information and Services in Emergencies (RAISE Initiative) that “aims to ensure that comprehensive [reproductive health care] is considered a standard part of humanitarian strategies.” Additionally, Marie Stopes International held the Global Safe Abortion Conference in October 2007, which aimed to openly discuss the need for safe abortion and to renew a global commitment to provide access to safe abortions for women all over the world. The agenda for the conference featured a session on “Abortion Needs Among Refugees and Displaced People,” a promising sign that general abortion rights groups are beginning to recognize the unique needs of refugees.
The startling statistics regarding the negative effects of unsafe abortions highlight the need to deal with the situation more adequately. It is a positive step that President Obama has rescinded the Mexico City Policy, but that is not enough. All reproductive services need to be more adequately funded and the United States should contribute to this cause by devoting more foreign aid to this area. The United States should also reconsider restrictions under the Helms Amendment that do not allow taxpayer funds to be used for the promotion or performance of abortions. The performance of safe abortions is essential to protect the lives of women globally and should be funded with U.S. money as necessary. Additionally, the United States should ratify and adhere to international treaties and conventions that work toward protecting women’s right—especially in refugee populations—to reproductive services. Lastly, the United States should support efforts to raise awareness among the international community on this issue.
The removal of the Mexico City Policy will help organizations that are well-qualified and highly effective in providing a full range of reproductive health services to receive U.S. funding. It also allows health care providers to present all available options to patients, including abortion. It will make abortion referral services more widely available in cases where abortions are legal because organizations making the referrals will be more properly funded. For these reasons, it is important that the policy not be reinstated in the future.
Additionally, the removal of the Mexico City Policy allows organizations that provide a full range of reproductive services, abortions, and other important services to receive funding. Abortions are not going to become readily available to refugee women if other forms of reproductive health services are not accessible. General reproductive services need to be better funded and more widely available. Additionally, the number of trained personnel able to perform a full spectrum of reproductive health services, including safe abortions, needs to be increased. The availability of reproductive health services for refugees could be enhanced through increased funding from the international community and specifically the United States to reach the levels recommended by UNFPA.
The United States should also ratify and implement interna-tional documents like the CEDAW and the ICPD Programme of Action. However, the international treaties, organizations, doc-uments, and manuals that exist still do not go far enough and fail to advocate for the availability of safe abortions for refugees. For example, the Inter-Agency Field Manual on Reproductive Health in Refugee Situations produced by the UNPF is one of the few documents that directly address guidelines for providing reproductive health services specifically to refugees. It states that:
This Field Manual does not address a number of other issues related to reproductive health, either because they are relatively less significant in terms of public health, or because they may be approached as in normal situations and information on the issue is abundant elsewhere. This is the case for most needs of postmenopausal women, elective abortion, reproductive tract cancers and infertility.
This manual needs to recognize that elective abortion cannot be treated as “relatively less significant” or “may be approached as in normal situations” because of the unique needs and circumstances of refugee women. International literature needs to recognize more fully that elective abortion is a unique need for refugee women and the consequences of not addressing it directly relate to unsafe abortions resulting in 25 to 50 percent of maternal deaths in refugee situations.
Finally, raising awareness within the international community is critical for initiating and funding proper reproductive health services. High profile initiatives such as the Global Safe Abortion Conference can help to disseminate information to the international community. It is promising that this conference featured a session tailored to the specific needs of refugees. More abortion advocacy organizations that work for abortion rights for the greater population need to recognize the unique needs of refugees and push for abortion rights to be extended to them. The United States can contribute by participating in and funding these educational activities. To increase awareness, organizations need to collect more complete and accurate data on the availability (or lack thereof) of abortions for refugees. This information can be an important tool for advocacy and funding for the issue.
The international community is beginning to take steps to recognize the issue of unsafe abortion. Refugee women are particularly susceptible to unplanned pregnancies and the effects of birthing the child may carry severe consequences. Therefore, the need for access to safe abortions is even more imperative for refugees. The Mexico City Policy has only served to complicate the problem by restricting funding for organizations that provide reproductive services to refugee women. President Obama’s decision to rescind the policy is a big step in the right direction. However, the problem can only be solved through increasing the availability of safe abortions as one aspect of a comprehensive reproductive health program. The United States must align its policies with international law that recognizes women’s right to reproductive services, including abortion rights. The United States should also continue to support initiatives such as the 2007 Global Safe Abortion Conference and the Safe Abortion Action Fund that are bringing attention to the issue and encouraging the international community to take action. Through these actions, the United States will assume a leadership role in protecting the lives of refugee women and will assist in the provision of adequate and appropriate reproductive services, which are so direly needed.
A. Elise Letanosky is an MA candidate in international affairs at The George Washington University Elliott School of International Affairs, with a focus on development. She graduated from Rollins College in Winter Park, Florida in May 2007 where she majored in international relations and minored in women’s studies.