…10,000 lives at risk
…GGR: More cases of unsafe abortion imminent in Nigeria
By Sola Ogundipe
Women in developing countries were the first casualties as soon as President Donald Trump assumed office in January 2017.
With a stroke of his pen, Trump declared war on women’s health by reinstating and expanding the Mexico City Policy, an executive order also known as the Global Gag Rule (GGR).
First introduced in 1984 by President Ronald Reagan, a Republican, the Mexico City Policy had earlier been suspended by former President Barack Obama, a Democrat, in 2009.
Similar reinstement and suspension of the controversial policy had occurred earlier between George Bush and Bill Clinton. Obama’s suspension of the policy and the latest restoration by Trump, are in continuation of a long standing differentiation of political position between the Democrats and the Republicans.
Traditionally, the Mexico City Policy required foreign NGOs particularly those working in developing countries, to pledge that they would not perform or actively promote abortion as a method of family planning even with non-US funds as a condition for receiving US global family planning assistance.
While the GGR policy formerly applied only to cutting family planning assistance provided through the State Department and the US Administration for International Development, USAID, Trump adopted a more stringent version of the rule and expanded it to other US global health assistance under which NGOs that refuse to sign up are denied all categories of health assistance.
One year after the reinstatement of the policy, access to contraceptive commodities and services, including provision of voluntary family planning information, education and services around sexual and gender-based violence like rape, Female Genital Mutilation, FGM, early and forced marriage amongst others, are adversely affected.
But experts say this burden may further increase as a result of the GGR. “The result will be catastrophic,” notes Dr. Stella Aniston, a privately practising family planning counsellor. “Maternal death will increase, unintended pregnancy will increase and the number of unsafe abortions will rise. Huge cuts in family planning financing of up to $600 million a year are being recorded.”
Nigerian experts generally describe the GGR as a restrictive, anti-choice policy. They agree that by blocking funding to the world’s largest NGO providers of modern contraception, the gag rule is worsening an already bad global contraceptive funding gap and undermining women’s ability to prevent unwanted pregnancy.
They say by restricting access to vital reproductive care services, the GGR is fuelling increases in unintended/unwanted pregnancies, unsafe abortions, maternal and newborn deaths etc.
Findings by Good Health Weekly show that in Nigeria, contraceptives are generally underfunded and significantly covered by individuals through out of pocket expenses.
Many states have no appreciably dedicated family planning or reproductive health financing, rather, they depend on major partners including USAID; the Department For International Development, DFID; United Nations Population Fund, UNFPA, among others.
It was also gathered that huge funding shortfalls are characteristic of the heavily donor-dependent National Family Planning and commodities procurement programme.
For instance, in 2017, the UNFPA earmarked $12 million annually to be spent on contraceptives in Nigeria. Between 2011 and 2017, the Federal Government spent $2 million on family planning commodities and in January 2018, released $1 million for procurement of contraceptives – a far cry from the estimated $15 million to $20 million required annually.
According to the Guttmacher Institute, among sexually active unmarried women in Nigeria, 22 per cent have an unmet need for family planning even as records show that 19 per cent of over 3.8 million married and sexually active adolescents (15-19) have an unmet need for contraception.
At the 2017 London Family Planning Summit, Nigeria committed to increasing its annual allocation for contraceptives from $3 million to $4 million while expecting to take advantage of the Global Financing Facility and international development assistance loans.
With access to reproductive health services to all women still hampered by financial gaps, pointers on ground indicate that with the expanded gag rule, the targeted 36 per cent Contraceptive Prevalence Rate, CPR, for 2018 set by the National Family Planning Blueprint may not be achieved.
According to the Family Health Department of the Federal Ministry of Health, $603 million is required to enable 7.3 million women have access to contraceptive methods of their choice.
Indicators show that the GGR is not just cutting support to reproductive health and increasing stigma around induced abortion but further causing a rollback on women’s rights.
“The GGR does not reduce abortion, on the contrary, it fuels abortion. Implementation of the GGR under previous Republican administrations did not in any way, reduce unsafe abortions,” noted Dr Ejike Oji, chairman of the Association for the Advancement of Family Planning, AAFP, and the President/CEO, Dr Ejike Oji Community Development Foundation. “By eliminating access to contraception, the gag rule inadvertently caused more unintended pregnancies and more unsafe abortions,” Oji noted.
According to Guttmacher Institute, there are around 40,000 deaths from unsafe abortions in Nigeria every year.
Marie Stopes International, MSI, a global organisation providing personalised contraception and safe abortion services, predicts additional 660,000 abortions in the country from now up to 2021 as a result of which about 10,000 women are estimated to die.
In 2016, MSI said it administered at least one family planning method for 785,000 Nigerian women. Without restriction of the GGR policy, the NGO expects that it would have prevented about 1.8 million unintended pregnancies and more than half a million abortions and avoided more than 10,000 maternal deaths between 2017 and 2020.
In a statement, Country Head of MSI, Effiom Effiom, described the US decision to pull funding on reproductive health as ill conceived.
“They’ve been key in strengthening healthcare. It’s their funding that allowed us to reach 500,000 women in the past three years. Who will bridge that gap?”
Giving a graphic picture of the economic burden of unsafe abortion in Nigeria, Oji related findings of a study showing the cost of treating life-threatening complications due to unsafe abortion was six times higher than the cost of all attempts to end the pregnancy.
“Women spent on average N12,586 in all attempts to end the pregnancy while the average cost of treating the severe unsafe abortion complications was N74,407.
“Boyfriends (six out of 11), and to a lesser extent, family members, were most commonly responsible for paying the cost of the abortion procedure. About half of the women did not know who bore the cost of treatment.”
Findings by Good Health Weekly show that induced abortion is illegal in Nigeria except when performed to save a woman’s life, yet pregnancy terminations are quite common, and because most are performed clandestinely or by unskilled providers, many are unsafe.
Despite legal restrictions, unsafe abortion is already a major contributor to the country’s high levels of maternal death, ill health and disability.
According to the Guttmacher Institute, unsafe abortion is dangerous and costly, and places serious burden on the nation’s health system as well as on the health and well-being of women and their families.
In the view of the Country Director, Ipas Nigeria, Barrister Hauwa Shekarau, the expanded gag rule is a harmful US policy that would slow and even reverse efforts and progress of governments around the world toward ensuring every woman can exercise her right to her own body.
Shekarau asserted that lack of access to contraception and safe abortion is a major public health crisis for women in the world’s poorest countries. She said legally restricting reproductive health services such as abortion, do not affect the number of abortions that happen.
“Legal restrictions on abortion make abortion unsafe, especially for poor women. Where abortion is legal and safe services are available, deaths and disabilities from abortion are greatly reduced. Currently, there are millions of women who want to avoid pregnancy but lack access to modern contraception.
“Women are at risk of unsafe abortion because they lack access to safe, high-quality abortion care,” she argued.
Presenting an update on maternal health and abortion in Nigeria, Shekarau recalled that the first national study to examine the incidence of abortion in Nigeria, conducted by the Guttmacher Institute estimated that in 1996, about 610,000 abortions, or 25 per 1,000 women aged 15–44, occurred.
Another study by the Institute in 2012 conducted in collaboration with the University of Ibadan and released November 2015, found that an estimated 1.25 million induced abortions were performed in the country with an annual abortion rate of 33 per 1,000 women aged 15–49. The abortion ratio was 19 abortions per 100 live births, according to the study.
Guttmacher also found that in 2005, Post Abortion Care, PAC, in Nigerian hospitals cost $132 per patient, of which $95 was paid by families.
In her contribution, Dr Abiola Akinyode-Afolabi, Executive Director, Women Advocates Research and Documentation Center, WARDC, Lagos, stated that: “Under the new gag rule, organisations well suited to provide comprehensive reproductive health care services, including abortion in countries where it is legal, will lose their funding or be frozen out of seeking US aid.”
Akinyode-Afolabi warned that cuts in family planning funding mean higher rates of unintended pregnancy and abortion.
“By reducing funding to such providers in under-served areas, the global gag rule will decrease women’s ability to access pregnancy-related care, family planning, and services for HIV/AIDS and other sexually transmissible infections.”
She explained that the gag rule also undermines the international consensus on reproductive rights by compromising access to reproductive health-care services—including legal and safe abortion.
Observers urge that the Federal Government needs to invest more in family planning services and contraceptive supplies. Family planning experts say most abortions result from unintended pregnancy, and in order to protect the most vulnerable women – the poor and underprivileged – levels of both unintended pregnancy and unsafe abortion need to be reduced through expanded family planning programming as well as sexuality and family life education.
“Without contraceptives, there are no programmes. And without contraceptives, the Sustainable Development Goals (SDGs) and ambition of Universal Health Coverage will not be achieved as women and girls are denied access to the means to prevent unwanted pregnancy,” the International Planned Parenthood Federation, IPPF, remarked.