In contemporary political debate, there is no surer way to discredit and delegitimize a policy than to establish that it injures women and children. Over the past year, a chorus of critics have lodged just this accusation at the Bush administration’s foreign aid policy. According to their charges, cutting off U.S. funding to groups that perform or promote abortions will raise the death toll for women and children in the Third World.
The restrictions in question on U.S. international population assistance--known as the “Mexico City policy,” or by its critics as the “global gag rule”--were originally implemented under President Reagan. President Clinton rescinded the policy for the entirety of his two terms. Then, on his first day in office, President George W. Bush reinstated the Mexico City policy. Detractors assert that move was not only unsound, but positively lethal. The Atlanta Journal-Constitution editorialized at the time that, through the new policy, “the President sentenced some of the world’s poorest women to death.” Similarly, California Senator Barbara Boxer argued that “no matter how [Bush] executes the policy,” it “will lead to an increase in the number of deaths due to unsafe abortions.”
Last fall, at the urging of Boxer and others, the Senate passed a foreign aid bill that would have revoked the Mexico City strictures. Under threat of a White House veto, the Senate-House aid bill ultimately excised Boxer’s provision. But in the eyes of its critics, the global gag rule issue is by no means settled. As post-September 11 politics returns more nearly to pre-terror norms, Congress can be expected to revisit the Mexico City policy--possibly quite soon. And a return to the issue will mean a full airing of the critics’ worst apprehensions about restrictions on U.S. population funding: namely, that these will cause higher rates of maternal and infant mortality, higher levels of unwanted pregnancy, and perhaps even higher overall levels of abortion as well. Happily, a closer examination of the evidence shows those fears to be unwarranted.
Determining the health consequences of the Mexico City policy is no simple exercise. In much of the developing world, vital registration systems are still rudimentary. Typically, a low-income country’s statistical system is not capable of providing accurate annual tallies even of births and deaths. Consequently, for most countries that receive U.S. population assistance, one cannot trace the health effects of particular funding decisions with a great deal of precision. Nonetheless, we can be confident that the ultimate impact on maternal and children’s health of the Mexico City policy is slight.
Why do I say this? We can begin by checking the record of the recent past. Over the past two decades, the United States government has already run a sort of “controlled experiment” with restrictions on its international population assistance funding. From 1984 to 1993, Washington enforced the Mexico City policy. For the following eight years, the policy was suspended. In addition, there have been substantial increases and decreases in U.S. international population assistance in recent years: Funding rose from $322 million to $576 million between 1992 and 1995, then fell to $384 million between 1995 and 2000.
At the time, those quite substantial changes in U.S. population assistance occasioned predictions of striking--indeed devastating--repercussions on the health and well-being of vulnerable, low-income populations. In 1996, for example, Dr. Nafis Sadik, then executive director of the United Nations Population Fund, had this to say about impending cuts in U.S. population funding:
“The way U.S. funding is going, 17 to 18 million unwanted pregnancies are going to take place, a couple of million abortions will take place, and I’m sure that 60,000 to 80,000 women are going to die of those abortions--just because the funding has been reduced overnight.”
Similarly, in June 1997 the Planned Parenthood Federation of America warned that the 35 percent reduction in funding for U.S. population assistance that year would translate into:
“Four million more women [with] unintended pregnancies that will lead to 1.6 million more abortions, 8,000 more women dying in pregnancy and childbirth, and 134,000 more infant deaths.”
Those dire forecasts turned out to be very bad forecasts indeed. International demographic and health experts did not detect any upsurge in global birth rates, abortion rates, maternal mortality rates, or infant mortality rates after the 1996 cuts in U.S. funding. To the contrary: The Census Bureau depicts continuous and uninterrupted declines in both fertility levels and infant mortality rates for “less developed countries” for the years 1995-2000. Nor, incidentally, has evidence been adduced that a prophesied shutdown of medical clinics and cutback in health services actually came to pass.
Conversely, no acceleration in health progress for women and children in developing regions has been detected or even claimed for the period in the early 1990s when U.S. international population funding was rapidly increasing, and the Clinton administration was undoing the global gag rule strictures of the previous two administrations.
Put simply, the evidence suggests that the world is a more complicated place than those critics of restrictions on U.S. population funding assumed. In the vast and complex dynamic that shapes family formation and family health trends in low-income areas, the role of U.S. foreign aid in determining outcomes may be far less important than many in the “population community” assume.
But what of the health implications of the Mexico City policy itself? There are three reasons to expect the reimposition by the Bush administration of abortion restrictions on U.S. population assistance to have a limited demographic and health impact.
First, the restrictions themselves are not nearly so effective or far-reaching as both critics and supporters seem to imagine. According to a March 2001 report by the Congressional Research Service, the newly implemented regulations contain the following important exceptions:
- abortions may be performed [by organizations receiving U.S. funding] if the life of the mother would be endangered if the fetus were carried to term or [if the abortions follow] rape or incest.
- health care facilities may treat injuries or illnesses caused by legal or illegal abortions (post-abortion care).
- “passive” responses by family planning counselors to questions about abortion from pregnant women who have already decided to have a legal abortion [are] not considered an act of promoting abortion.
- referrals for abortion as a result of rape, incest, or where the mother’s life would be endangered, or for post-abortion care are permitted.
- USAID will further be able to continue support, either directly or through a grantee, to foreign governments, even in cases where the government includes abortion in its family planning program. Money provided to such governments, however, must be placed in a segregated account and none of the funds may be drawn to finance abortion activities.
Given the rather broad leeway allowed by these regulations, and the fact that the Bush administration has committed itself to maintaining and even increasing the overall level of U.S. international population funding, any impact from the changes in U.S. family planning policies would seem likely to be distinctly less noticeable than the impact of funding cuts in the late 1990s, which, as noted above, were not detectable in standard reference demographic accounts.
Second, U.S. population assistance is only one component of the total resources used in family planning in low-income regions--and while the United States may be a major international funder, it is by no means the dominant funder. If U.N. estimates are correct, U.S. funding today (around $450 million per year) accounts for less than a quarter of all Western population aid--almost four-fifths comes from other Western sources. And a still greater pool of family planning funds--some $7.5 billion--is raised by low-income countries themselves. By that reckoning, U.S. population assistance amounts in aggregate to only 6 percent of the resources for population programs that developing countries are already mobilizing.
Third, and most important, the correspondence between public health spending and personal health outcomes, far from being precise and mechanistic, is in reality rather diffuse. This is true for family planning expenditures and family planning outcomes as well. There are many reasons for this, but one of them is that the parents in question are independent actors in this drama. They take actions to safeguard and improve the health of their families irrespective of government programs and resources. Third World women, Third World adults, do not behave as passive, helpless agents in matters of central importance to their families--nor do they believe that babies are born under cabbages.
There is both good news and bad news, then, about the expected health and demographic consequences of the reinstituted Mexico City policy.
On the one hand, these restrictions are unlikely to have any significant impact on the global level of abortion. And it is most unlikely that these restrictions will tangibly reduce the rate of abortions in the regions affected by the new restrictions--as proponents of the Mexico City policy intended and hoped.
At the same time, the fear that these restrictions will lead to palpably higher levels of maternal and infant mortality is unwarranted. Claims of dramatic adverse health consequences from the Mexico City policy are undocumentable and unsupportable. Until evidence to support such claims becomes available, those charges should be regarded as political theater.
Nicholas Eberstadt is the Henry Wendt Scholar in Political Economy at AEI.