In 2016, churches in the small southeastern African country of Malawi did something surprising: They backed a law to expand abortion access.

At the time, Reverend Alex Benson Maulana, chair of the Malawi Council of Churches (MCC), said that abortion was still a sin. But Malawi was also facing a crisis: In a country with one of the highest maternal mortality rates in the world, 18 percent of those deaths were due to unsafe abortions.

Malawi’s Termination of Pregnancy Bill was certainly controversial that year, but it was also picking up steam with religious leaders, doctors and local nonprofits. They supported its expansion of legal abortion to include limited circumstances such as rape or pregnancies that threatened a woman’s health.

Then, in January 2017, newly inaugurated President Trump signed an executive order. As one of his first acts in office, he reinstated and dramatically expanded the “Mexico City policy.” Known by critics as “the global gag rule,” the policy bans foreign organizations that provide abortion services, counseling or referrals from receiving U.S. family planning aid funding. Trump’s version, officially called “Protecting Life in Global Health Assistance,” significantly ramped up restrictions to encompass all U.S. global health funding — from programs for HIV/AIDS support to water and sanitation services.

Trump’s new rule caused Malawi’s abortion bill to grind to a stop. “The government immediately halted the process, fearing that if they proceeded with enacting this law, they may lose aid from the U.S. government,” says Brian Ligomeka, executive director of the Malawian human rights organization Centre for Solutions Journalism. The drafted law had been seen as a solution for deaths caused by unsafe abortions, Ligomeka says: “But because of the funding Malawi gets from the U.S. government, that process has slowed down.”

It’s not just Malawi. Mounting evidence from a number of African countries — including Kenya, Senegal, Uganda, Ethiopia and Zimbabwe — shows that the Trump administration’s policy is playing a direct role in blocking efforts to liberalize or implement abortion laws there.

A report by the advocacy group Center for Health and Gender Equity (CHANGE) is just the latest evidence the rule is quashing efforts by activists and lawmakers to change restrictive abortion laws. While the rule’s impact on clinic closures, reduced advocacy and even increased abortion rates have been well-documented, a growing body of research is showing how it could also impact the national laws of African countries for years to come.

Increased efforts to liberalize abortion laws across the continent are largely in response to the fact that an estimated two-thirds of global maternal deaths occur in sub-Saharan Africa, which also has the highest number of abortion-related deaths in the world.

“Many countries have watched these trends and decided that they have to make access to safe abortion legal,” says Terry McGovern, who is chair of the Department of Population and Family Health at Columbia University and leading a study on the effects of Trump’s policy in Kenya, Madagascar and Nepal. “For the U.S. to then come in and say that foreign NGOs cannot receive aid money if they also work to make legal abortion more accessible, particularly when these countries are highly dependent on that aid, is directly meddling with national sovereignty and the national ability of countries to address their own health problems.”

Contextualizing Trump’s ‘global gag rule’

The Mexico City policy has a long history, having kicked off in 1984 under then-President Ronald Reagan. It has been a political football ever since, rescinded by Democratic presidents and reinstated by Republicans like clockwork. Consequently, it has left foreign nonprofit organizations with decades-long whiplash.

The policy is actually responsible for increasing abortion around the world by 40 percent, according to a study published in the Lancet last year: When it is in place, it reduces women’s access to contraception, which is associated with increased abortions. This tracks with research suggesting the United States’ own abortion rate dropped to an all-time low last year in part due to the growing use of contraceptives.

Preceded by the 1973 Helms Amendment, passed in the wake of Roe v. Wade to prohibit the use of foreign aid for abortions, and the 1981 Siljander Amendment, which bans using U.S. funds for abortion-related lobbying, 1984’s Mexico City policy is part of a web of legislation meant to restrict abortion in foreign countries.

Beirne Roose-Snyder, director of public policy at CHANGE, describes Helms and Siljander as the basis for abortion-related foreign policy. The Mexico City policy became a blanket intermittently thrown on top of them. “It isn’t quite as dramatically partisan as it seems,” says Roose-Snyder. “The U.S. is a very negative actor even during the best of times. Ever since 1973, we’ve been pulling countries backwards.”

But Trump’s expansion was significantly broader than its predecessors. It increased the affected aid by 15 times that of the original Mexico City policy, ultimately restricting nearly $9 billion in foreign health assistance. Organizations that counseled or provided referrals about abortion were forced to either refuse U.S. global health funding or dramatically reduce their services in response.

U.S. officials have said they don’t think the policy will reduce health-care services. “We are not changing funding amounts by one dollar,” Alma Golden, a deputy assistant administrator for USAID, the government’s foreign-aid agency, told The Washington Post in 2018. Other officials told The Post that funds denied to some organizations would be redirected to others that promise to follow the new policy.

Theoretically, the policy shouldn’t affect the passage of other nations’ legislation. But activists say one of its more pernicious effects is that it whips up fear and confusion in countries that rely heavily on U.S. global health funding.

One country’s story

After Trump reinstated the policy, Ligomeka, of Malawi’s Centre for Solutions Journalism, noticed that his regular meetings with senior Ministry of Health officials about the Termination of Pregnancy Bill started being delegated to junior officials. When he pressed these officials about the bill’s progression to law, he says they’d evade his questions or kick him down the line to other people.

“People who had been speaking out about it in the Ministry of Health no longer were. That was when we knew that they had been gagged,” Ligomeka says. According to Ligomeka, some Ministry of Health officials eventually confided in him that if they became “noisy about this, we risk losing funding.”

Officials from the Malawi government have not responded to request for comment.

The Malawian government might be “treading carefully in pushing for law reform,” representatives from Ipas, an international organization working to expand access to safe abortion, told CHANGE researchers in the recent report. “The government also receives a lot of funding from the U.S. government, so it is quite an uncertain environment [for the Malawian government] to navigate when factoring in the gag rule.”

Indeed, foreign aid makes up almost a quarter of Malawi’s gross national income, according to World Bank data. The United States is one of its biggest donors, which researchers say can create an atmosphere where the U.S. government is seen as a “big brother.”

Growth across the continent

The climate of fear and uncertainty among policymakers that Ligomeka describes isn’t limited to Malawi.

McGovern’s team at Columbia says they have heard multiple reports of similar circumstances in Madagascar, where abortion is completely prohibited (making it one of the strictest abortion laws in the world).

And in Senegal, research by the reproductive rights advocacy organization PAI found that efforts by 17 civil society groups to liberalize the country’s abortion law have faltered in the last couple of years. That came after a central organization dropped its advocacy efforts because it risked losing half its funding due to Trump’s policy.

“They were just so scared that things just stopped in their tracks,” says Jamie Vernaelde, a PAI senior research and policy analyst. “What’s really a shame is that break in momentum. There’s a point where civil society is coming together, they’re engaging leaders around safe abortion, they’ve figured out what terms to use, how to talk to people about these issues. And then something like the global gag rule happens, and it just completely pulls the rug out from under them.”

The rule has even affected African countries where abortion laws have already been liberalized, according to activists. Mozambique decriminalized abortion in 2014 with the goal of reducing maternal deaths, but was still in the process of issuing clinical guidelines for providers when Trump expanded the Mexico City policy. The United States is the largest bilateral donor to Mozambique, so many of the organizations expected to help roll out guidelines either lost funding or left providers unsure of the legality of their work. Researchers say this means that although abortion is technically legal, many providers still have not received training on safely performing the procedure; many hospitals don’t offer abortions because they don’t have the guidelines to do so; and health-care professionals are anxious to even mention abortion for fear of violating the policy. In other words, safe abortions by trained providers remain out of reach for many women.

Ethiopia expanded its abortion law even earlier, in 2005, and South Africa did so in 1996. Still, researchers have found the Trump administration’s policy is affecting both countries’ abilities to carry out their laws. Again, that’s related to the reduction in the number of clinics able to offer abortion-related services and an overall atmosphere of fear and confusion, experts say.

For many African activists, the rule underscores how their abortions laws have been at the mercy of powerful Western countries — not only today, but throughout history.

“The abortion law that we are using in Malawi is one that was formed during colonial rule that, up to date, we haven’t changed,” says Likomega, referring to the fact that most abortion laws in Africa date from colonial rule (in Malawi’s case, British rule). “It’s a big disappointment that the policies that one country, in this case the United States of America, is making have a very negative impact on the laws of another country.”

He adds: “It’s a major concern that a policy that has been made by the current U.S. government is going to be responsible for killing women and girls in Africa.”

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