In global health, abortion bears the scarlet A

At the Kamazu Central Hospital in Lilongwe, Malawi, Dr. Grace Chiudzu, the head of the maternity ward, ticks off the most common issues her patients face: “One is bleeding, second is infections, third is abortion complications.”

Malawi, a country where 60 percent of the population lives in poverty and 1 in 36 women dies while pregnant or during childbirth, has been something of a development darling. This is largely thanks to President Joyce Banda, who puts health high on the national agenda. Malawi’s donors, including the United States, the Gates Foundation and many others, have thrown support behind Banda’s Safe Motherhood Initiative, an intrepid plan to save the lives of the many Malawian women who die or are seriously injured while pregnant or giving birth. Donors highlight their work to fix some of the problems that Chiudzu mentions: using drugs to stop hemorrhaging, training birth attendants to help counteract complications, delivering antibiotics to treat sepsis and other infections.

But there’s one word you don’t hear very often from their mouths: “abortion.”

At the 1994 International Conference on Population and Development in Cairo, unsafe, illegal abortion was highlighted as a leading cause of maternal death and a driver of gender inequality. Two decades later, maternal mortality is down, but the proportion of maternal death and injury caused by unsafe abortion has not changed.

“Since the Cairo conference, we think conservatively that at least 1 million women have died from unsafe abortion,” Liz Maguire, the president and CEO of the reproductive health advocacy group Ipas, told me. “More than 100 million have been injured. All of these deaths and injuries are entirely preventable.”

Chiudzu’s description of the complications landing her patients in the hospital dovetails neatly with international statistics: Unsafe abortion is the third leading cause of maternal mortality worldwide. The World Health Organization identifies safe abortion care as one of seven necessary interventions to ensure quality reproductive, maternal and child health care. Ending death and injury from unsafe abortion is also one of the easiest goals to achieve — early-term abortion is a simple procedure and, when done by a trained provider, remarkably safe. The rate of death from unsafe abortion could conceivably get very close to zero.

But that takes political will and funding. Many groups that focus specifically on maternal health will barely utter the word “abortion,” let alone advocate for it to be legal, accessible and safe. Even progressive leaders working in women’s health can be hesitant to touch the problem of unsafe abortion and often deny it’s an issue at all.

The Helms Amendment, passed 40 years ago in the wake of backlash against Roe v. Wade, prevents U.S. funds from paying for abortions overseas “as a method of family planning” or to “motivate or coerce any person to practice abortions.” But it has been interpreted conservatively, and in practice, abortion is often not even discussed, let alone provided, even for women facing life-threatening complications and rape and incest survivors who, even under the Helms Amendment, should be allowed access to abortion care. Because of Helms, Maguire told me, in countries receiving U.S. Agency for International Development (USAID) assistance, “there’s just a big chill.”

The Mexico City Policy, also known as the Global Gag Rule, implemented under the Reagan administration went far beyond Helms, blocking not only USAID funding from paying for abortion, but also pulling any U.S. funds from other organizations that provided abortion with their own non-U.S. dollars, advocated for abortion rights or provided any information about abortion at all — even counseling, information about legal abortion or referrals to legal providers. That policy was kept in place until the Clinton administration. George W. Bush reinstated it and Barack Obama again removed it. Although it isn’t in place now, many organizations that receive U.S. dollars remain wary of abortion care, knowing the political tides may change.

While the Mexico City Policy was in place, it had devastating effects. By 2002, shipments of USAID-funded contraception to 16 countries were halted; many NGOs cut HIV/AIDS services; and clinics that were often the only providers of family planning tools, STI testing and treatment, HIV treatment and prenatal and well-baby care were shuttered.

In 1994, the Leahy Amendment sought to clarify U.S. funding policies under Helms, stating that the Helms provision against motivating abortion “shall not be construed to prohibit the provision, consistent with local law, of information or counseling about all pregnancy options.” In other words, USAID-funded groups are permitted to inform women of all their legal reproductive options — including abortion.

Unfortunately, the Leahy Amendment is largely ignored. Ipas and other organizations have been pressing the Obama administration to correctly implement Helms, to little avail.

That leads to perverse and confusing outcomes. In Ethiopia, Maguire said, a woman living in an area where health facilities receive USAID support will be denied the abortion care that is legal in her own country, whereas a woman living in a different district funded by another donor will have access to safe care.

“It’s an imposition of U.S. abortion politics on women in developing countries who are the least able to advocate for their own needs," Maguire said. And that can lead to censorship. “Agencies that receive money from USAID are often not allowed to attend meetings where abortion is discussed. There’s censorship in publications that accept USAID funds; there’s censorship in training materials. It’s unconscionable.”

Funding for global health increasingly comes from foundations, nongovernmental donors and the private sector. Some of those groups and individuals recognize the need for safe, legal abortion. But many others don’t — including many affiliated with for-profit companies, which bill themselves as more efficient and less beholden to political interests than traditional NGOs and governments.

Merck is not the only organization advocating for women’s health while steering clear of abortion. The Bill and Melinda Gates Foundation is a major funder of family planning tools worldwide — but Melinda Gates publicly insists that “we’re not talking about abortion.”

“From the very beginning,” she told Newsweek, “we said that as a foundation we will not support abortion, because we don’t believe in funding it.”

The Gates Foundation, though initially responsive to an email about family planning, would not discuss inquiries about abortion.

Ignoring unsafe abortion doesn’t end it. While other maternal health challenges are slowly abating, unsafe abortion stubbornly remains a foremost cause of death. Why is that?

“Stigma is the key barrier,” Ellen Israel, a senior technical adviser for women's health and rights at Pathfinder International, a global leader in sexual and reproductive health, told me. “It’s why women hide. It’s why they don’t come. It’s why they come late. It’s why, even if misoprostol is available in the market, women don’t have information on how to take it so it will work.”

Abortion happens in every corner of the planet, whether it’s funded or unfunded, safe or unsafe. Countries with the lowest abortion rates share a few qualities: access to contraception, good health care, progressive sexual values, comprehensive sexual-health education and a commitment to gender equality. But even in those countries, the number of procedures never reaches zero; the reality is that in every country, women sometimes seek out abortions. While there’s little difference between abortion rates in places where the procedure is legal versus where it’s illegal, there is a big difference in health outcomes. Where it’s legal and accessible, it’s usually very safe. Where it’s not, women die.

At its most basic level, abortion access allows women to be equal players in society. Surviving childbirth is a baseline, not a goal. There is no way for a society to achieve the real objective — full gender equality — without abortion rights.

Development groups increasingly understand that women must be able to plan their families. The returns compound themselves: Girls are able to go to school, women are healthier and able to live independently, and families are more prosperous. Widespread use of contraceptives also helps national economies grow. As the Gates Foundation says, “Every dollar spent on family planning can save governments up to 6 dollars that can be spent on improving health, housing, water, and other public services.”

But abortion — not just contraception — must be a part of that calculus. Women cannot achieve equality without the right to both prevent and end pregnancies.

“It’s not just a question of maternal mortality,” Israel told me. “It’s an issue of women’s rights and of human rights. A commitment to safe abortion is a litmus test of how serious a country is about gender equality.”

There is some hope. In late March, leaders from more than 30 countries called for the decriminalization of abortion and a renewed commitment to the provision of safe abortion services.

In Ghana, Ipas worked with traditional leaders called queen mothers, who, after learning that abortion is allowed under Ghanaian law, are now champions in their own communities, helping women access services, including contraceptives and safe abortion. Pathfinder International partners with nurses and community outreach workers in Ghana to provide care and reduce stigma around the procedure.

Similar efforts in Nepal liberalized abortion laws and placed trained providers in all 75 Nepalese districts. Health facilities put symbols on their buildings to indicate that they offer safe abortions and post-abortion care. Abortion was legalized in 2002; between 1998 and 2009, Nepal’s maternal mortality rate was cut in half. According to one study, the amount of post-abortion complications in the country now hovers around 2 percent. Nepal, Maguire told me, is “a model of how it can be done in a country that is poor and has very challenging social and geographic barriers.”

Much of the opposition to safe and legal abortion originates in the United States — and it is both well organized and well funded. To push for women’s rights, advocacy and health organizations need real attention paid to the high cost of unsafe abortion. They need significant funding, greater resources and stronger political will.

“We feel that ultimately the right thing will be done,” said Maguire. “But it’s a huge task.”