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The Global Cost of the American Anti-Abortion Movement

by Jodi Enda March 17, 2024

Co-published with The New Republic


Audio: Listen to the article here.

Because Editar Ochieng knew the three young men, she didn’t think twice when they beckoned her into a house in an isolated area near the Nairobi River. One was like a brother; the other two were her neighbors in the sprawling Kenyan slum of Kibera.

Ochieng did not know the woman who performed her abortion. She and a friend scoured Nairobi until they found her, an untrained practitioner who worked in the secrecy of her home and charged a fraction of what a medical professional would. Mostly, what Ochieng remembers is the agony when this stranger inserted something into her vagina and “pierced” her womb. “It was really very painful. Really, really, really painful,” she told me. Afterward, Ochieng said, she cut up her mattress to use in place of sanitary pads, which she could not afford. She was 16 years old.

As traumatic as her experience was, Ochieng was more fortunate than many women in Kenya, which bans most abortions. She, at least, survived.

Like Ochieng, most Kenyan women facing unwanted pregnancies have no good choices. They live in a culture that gives women little agency over their bodies; they experience high levels of poverty—two-thirds of residents live on less than $3.20 a day—and they must contend with conflicts between abortion laws codified in the country’s 2010 constitution and an older, harsher penal code that remains on the books. Because the penal code criminalizes abortion, relatively few women are able to obtain the procedure legally, and then only if a health professional determines that their life or health is in danger or, technically, if their pregnancy was the result of rape. That final exception dates only to 2019—13 years after Ochieng’s three acquaintances raped her—and is rarely applied.

Despite the prohibitions, more than half a million Kenyan women have abortions every year. The small percentage with means might find a trained professional willing to perform a clandestine, but safe, abortion. All too often, women gamble on risky methods reminiscent of the coat-hanger days of pre–Roe v. Wade America. They insert knitting needles into their vaginas and ingest dangerous chemicals, abortion rights advocates in the country say. They turn to unskilled providers, who scrape their uteruses with wires, give them concoctions intended for animals, or tell them to ingest concentrated soap, said Nelly Munyasia, executive director of Reproductive Health Network Kenya, which represents nearly 600 private health care providers. The national hospital in Nairobi, Kenya’s capital and largest city, has an entire ward dedicated primarily to women suffering from the complications of botched abortions, the advocates said. (Post-abortion care is legal.)

If they can’t access abortion, some women resort to killing healthy newborns, tossing them in rivers or poisoning them with Coca-Cola. Ochieng told me that the dead infants and aborted fetuses pulled from Kibera’s drainage systems and pit latrines were an indication of women’s desperation. “They know when you do a safe abortion, you don’t come with the fetus. You only carry your fetus because you’re doing it at the backstreet,” she said. “And it is happening because of … the condition of the women who are living in poverty, and they don’t have an option.”

When performed properly, abortion is considered extremely safe. But nearly half—45 percent—of the 73 million abortions performed worldwide each year are unsafe, the World Health Organization reported. Others suggest the proportion is even higher; in sub-Saharan Africa, three-fourths of abortions are considered unsafe. Globally, unsafe abortions cause 39,000 maternal deaths and millions of complications a year, a preventable scourge that almost entirely afflicts women in developing countries, the WHO confirmed. “There are a huge number of lives being lost,” said Elizabeth Sully, principal research scientist at the Guttmacher Institute, a research organization that supports sexual and reproductive health and rights.

One big reason: American anti-abortion policies.

For half a century, the United States has used the power of the purse to force poorer nations to abide by the anti-abortion values of American conservatives or forgo aid for family planning and, more recently, other health care. Of the several policies adopted over the years, two have been particularly onerous, according to several studies and more than 20 interviews with researchers and reproductive rights advocates in the United States and abroad. Touted to reduce abortions, the policies actually have driven up their numbers sharply and led to tens of thousands of unnecessary maternal deaths. “Anything that happens in the U.S. has a huge impact on the rest of the world,” said Giselle Carino, director of Fòs Feminista, an international alliance that promotes sexual and reproductive health and justice. When Washington places restrictions on abortion, “we have a lot of evidence how it hurts, particularly the women who need the most care and services.”

That anti-abortion policies would lead to more abortions seems counterintuitive, except when you consider that the organizations that perform, counsel, and educate people about abortion are often those that provide condoms, pills, IUDs, and other forms of birth control. If health care providers so much as mention abortion, they can lose money for broader health care services, including contraceptives. Fewer contraceptives equal more unwanted pregnancies. More unwanted pregnancies equal more abortions. More abortions in countries that greatly restrict them equal more unsafe abortions. And more unsafe abortions equal more maternal deaths.

The United States is not to blame for all the internal political and cultural strife in other countries. But as the largest funder of health care in the world, what it does matters. Essentially, this nation has given women around the globe no alternative but to seek backstreet abortions that send some to emergency rooms and others to their graves.

This November, Americans will vote in the biggest election since the Supreme Court, in 2022, overturned the constitutional right to abortion, giving states the authority to decide whether and when people could terminate pregnancies. Millions of women now live in states that severely restrict access or ban abortion altogether, spawning great hardships as they are compelled to travel to get abortions, forced to carry nonviable pregnancies to term, or turned away from hospitals for fear their miscarriages will be construed to be abortions. Such suffering, relatively new to young women in the United States, is commonplace in countries that must abide by the abortion restrictions Washington places on them. Commonplace there, and commonly ignored here. Candidates rarely mention how U.S. foreign policies harm women or campaign on the torment caused by Congress and presidents.

This year, one candidate is singularly responsible for imposing the tightest restrictions affecting overseas abortion access to date. His name: Donald Trump.

The women who bear the brunt of U.S. abortion-related restrictions are predominantly Black and brown. They live, most of them, in Africa, Latin America, and parts of Asia. They are also the people who, in the middle of the last century, U.S. policymakers were uncommonly worried about—worried not about their well-being, but about their birth rates. Indeed, the government’s current involvement in funding family planning worldwide can be traced back to midcentury consternation about how a population explosion could deplete dwindling natural resources, said Yana Rodgers, faculty director of the Center for Women and Work at Rutgers University. “Family planning was seen as a method by which to limit the growth of biologically and socially inferior races,” Rodgers wrote in her 2018 book, The Global Gag Rule and Women’s Reproductive Health.

For reasons both racist and environmental, Democrats and Republicans alike supported population control programs internationally and domestically, Rodgers wrote. In 1965, President Lyndon B. Johnson, a Democrat, issued a call to action. Three years later, the U.S. Agency for International Development, or USAID, started distributing birth control in developing countries. President Richard Nixon, a Republican, and his ambassador to the United Nations, George H.W. Bush, successfully pushed to establish the U.N. Fund for Population Activities, or UNFPA, which grew to be the world’s largest provider of donated contraceptives. As a Congress member in the 1960s, Bush was such a strong advocate for birth control that his colleagues called him “Rubbers.”

Soon, however, the politics of abortion overtook the politics of population growth in the power centers of Washington. Once the Supreme Court legalized abortion in 1973, religious conservatives pressed politicians on both sides of the aisle to limit the procedure wherever they could.

Abortion opponents in Congress could do little about the ruling on the home front, where the women’s rights movement was in full swing. But they could appease conservative activists and the Roman Catholic Church by imposing anti-abortion policies on countries that relied on the United States for family planning money. Starting in December of that year, lawmakers adopted the first of several policies that attached ever-tightening restrictions to U.S. assistance—and that, ultimately, would outlive Roe v. Wade.

The first strike was the Helms Amendment, which prohibits foreign governments and nongovernmental organizations from using U.S. money “as a method of family planning” or to “motivate or coerce any person to practice abortions,” even in countries where abortion is legal. The law was adopted by a bipartisan group of Congress members, as were subsequent abortion-related rules that dictate what recipients of U.S. funds can and, more often, cannot do in foreign countries. There’s even a law called the Biden Amendment, a 1981 provision that prevents foreign assistance from being used for biomedical research related to abortion or involuntary sterilization. (The president, now a supporter of abortion rights, has acknowledged that his views on the subject have shifted.)

But Congress didn’t go far enough for many on the Christian right, which emerged as a powerful force during the presidency of Ronald Reagan. In 1984, during a conference on population control in Mexico, the Reagan administration announced it would double down on foreign aid restrictions. Under the Mexico City Policy, foreign organizations that accept U.S. family planning assistance cannot perform abortions, provide abortion counseling, or advocate for abortion rights—even with non-U.S. money.

“If they counsel on abortion, if they say the word ‘abortion,’ it’s like a trigger, a switch,” said Bethany Van Kampen Saravia, senior legal and policy adviser for Ipas, an international organization that supports access to contraception and abortion. “If you flip the switch, you lose your U.S. funds.” Detractors dubbed the policy the “global gag rule.”

Before Reagan left office, the University of Michigan School of Public Health estimated that in just three years, the Mexico City Policy resulted in 380,000 unwanted pregnancies, 311,000 births, 69,000 abortions, and 1,200 maternal deaths. Nonetheless, every Republican president since Reagan has invoked the policy. Every Democrat has rescinded it. So while the Helms Amendment is always in effect, the Mexico City Policy ping-pongs back and forth depending on which party controls the White House.

Starting with Reagan, Republican presidents also stopped paying America’s annual bill to the UNFPA, now called the U.N. Population Fund.

Even “Rubbers” went along with that.

“I’m very pro-choice,” Donald Trump declared on NBC’s Meet the Press in 1999. “I hate the concept of abortion. I hate it. I hate everything it stands for. I cringe when I listen to people debating the subject. But you still—I just believe in choice.” That was not a winning position in a Republican Party that had been moving rightward since the election of 1980, when the Reverend Jerry Falwell and his newly minted Moral Majority helped propel Reagan to victory. And it was not the stance Trump took when he sought the party’s presidential nomination in 2016. Instead, he aggressively courted religious conservatives, first pledging to nominate Supreme Court justices who opposed abortion rights, then suggesting they would “automatically” overturn Roe—which they ultimately did. What’s more, Trump—a coarse, thrice-married TV celebrity who was not conversant with the language of the church—chose as his running mate Mike Pence, an evangelical Christian with strong ties to the political right and an unyielding position on abortion. As a Congress member, Pence threatened to shut down the government if it didn’t defund Planned Parenthood; as Indiana’s governor, he signed what at the time was one of the strictest anti-abortion laws in the country.

Three days after his inauguration in 2017, Trump reinstated the Mexico City Policy, which had been rescinded by Barack Obama. That wasn’t all. With Pence’s help, Trump greatly expanded the policy’s reach and renamed it Protecting Life in Global Health Assistance. Rather than impose constraints solely on family planning money, as Reagan and both Bushes had done, Trump applied them to all U.S. global health care assistance. Instead of affecting $560 million in aid, the abortion restrictions now would apply to about $12 billion in fiscal 2018 alone, the U.S. Government Accountability Office reported. About two-thirds of that money went to the President’s Emergency Plan for AIDS Relief, America’s largest and perhaps most successful foreign health program. The bipartisan program, known as PEPFAR, is widely considered to be one of George W. Bush’s greatest legacies.

A doctor specializing in reproductive health attends a patient at a clinic in Nairobi’s Kayole neighborhood. The clinic provides services to victims of sexual violence. (Photo by TONY KARUMBA/AFP via Getty Images)

Trump didn’t stop there: He extended the restrictions to subcontractors of organizations receiving U.S. aid. In 2019, Secretary of State Mike Pompeo announced that the Trump administration would prohibit contractors from paying any money (including their own) to subcontractors that provided abortion-related services—even if what they were paying for had nothing to do with abortion. “There’s this notion that if you take U.S. money, you have to abide by the rules. This is different,” said Bergen Cooper, chief operating officer of the Torchlight Collective, an international human rights consulting group that opposes the restrictions. “This is if you don’t take U.S. money”—but contract with an organization that does—“you have to abide.”

Never was the fallout so severe. Between 2017 and 2021, Trump’s expanded restrictions “resulted in approximately 108,000 maternal and child deaths and 360,000 new HIV infections,” according to estimates of Proceedings of the National Academy of Sciences. Trump broadened the restrictions so markedly that they impaired testing and treatment for HIV/AIDS, cancer, malaria, and tuberculosis, according to multiple reports. “The fear was immediate,” said Jedidah Maina, executive director of Trust for Indigenous Culture and Health, which supports sexual and reproductive health and rights in Kenya.

The Trump administration reasoned that it was tightening the rules to prevent U.S. money from trickling down through organizations that didn’t provide abortion-related services to those that did. “We will enforce a strict prohibition on backdoor funding schemes and end runs around our policy,” Pompeo said. “American taxpayer dollars will not be used to underwrite abortions.” Never mind that the Helms Amendment had made it illegal to use U.S. money to directly pay for abortions overseas for decades.

Pompeo, who, like Pence, is an evangelical Christian, dismissed assertions that the tough rules were hurting women and leading to unwanted pregnancies and abortions. “They’re just wrong about that,” he told reporters. “The theory that somehow not protecting every human life is destroying human life is perverse on its face.”

Marjorie Dannenfelser, president of Susan B. Anthony Pro-Life America, also rejected arguments that the Trump restrictions were injurious. His beefed-up Mexico City Policy “has never reduced family planning funding or any other global health funding amounts by even a penny,” she said in an emailed statement. “It simply ensures that U.S. taxpayer dollars fund foreign non-governmental organizations that offer real support without promoting abortion in countries that embrace a culture of life.”

Pompeo’s State Department issued a report defending the new policies by noting that all but eight of more than 1,300 direct recipients of U.S. funding had accepted the restrictions. This stood to reason, because the United States underwrote the biggest chunk of many organizations’ budgets. The 2019 report also said the United States was able to find other organizations to do the work of the eight groups that declined, though it acknowledged that there was “some impact on the delivery of health care, including for HIV/AIDS, voluntary family planning/reproductive health, tuberculosis, and nutrition programming.”

Just weeks before the 2020 election, Trump joined a group of largely repressive countries in co-sponsoring a nonbinding directive called the Geneva Consensus Declaration on Promoting Women’s Health and Strengthening the Family, which supported human rights for women while decrying abortion access. After Trump lost, his administration told the United Nations that “there is no international right to an abortion.”

President Joe Biden withdrew from the Geneva Consensus Declaration, saying it undermined U.N. efforts to advance gender equality and global health. Valerie Huber, president of the Institute for Women’s Health and an architect of the declaration, has urged 2024 presidential candidates to pledge that, if elected, they would rejoin the coalition of countries that signed it. Trump was the first to agree.

There is a common theme among the countless studies that have examined the effects of the Helms Amendment and the Mexico City Policy over the years: The rules have backfired. One of the most widely quoted studies, which came out of Stanford University and was published by The Lancet in 2019, found that during the eight years of the George W. Bush administration, abortions increased a whopping 40 percent in countries that were “highly exposed” to the Mexico City Policy. The same study reported that use of modern contraceptives declined by 14 percent and pregnancies rose 12 percent.

“It’s one of these classic unintended consequences of policies that policymakers don’t consider or anticipate,” said Rutgers University’s Rodgers. She analyzed data from 51 countries from 2001 to 2008 and found that women in Latin America were three times more likely to have an abortion during the Bush administration than during the Clinton administration before it. The difference: Bush invoked the Mexico City Policy, and Clinton did not.

“If the rule’s objective is to prevent abortions, it fails miserably,” said Carino, of Fòs Feminista. “What has happened is that abortions happen anyway, the rule just makes it unsafe, and particularly unsafe for those women who are already in the most difficult circumstances in life.”

Repealing Helms alone and using U.S. aid to ensure that abortions are safe would reduce abortion-related maternal deaths by a colossal 98 percent, saving the lives of 17,000 women a year in 33 countries, according to a study by the Guttmacher Institute. It would prevent 19 million unsafe abortions annually.

Abortion is no longer the bipartisan issue it was 50 years ago. Now, Democratic politicians almost uniformly support abortion rights, just as their Republican counterparts oppose them. The GOP presidents and Congress members who champion the abortion restrictions don’t talk about the deadly repercussions. But they have been made aware of them by researchers and reproductive rights advocates, not to mention all those studies. Still, they have blocked attempts to reverse course.

“We certainly are out there talking about the serious and wide-ranging harms” of U.S. policies, said Caitlin Ryan Horrigan, senior director of global advocacy for the Planned Parenthood Federation of America. Horrigan and others are particularly enraged by the Mexico City Policy because, when imposed, it is layered on top of the Helms Amendment, making the effect that much more intense. “All the research that exists on the global gag rule points to harm,” she said. “That is clear; whether they choose to admit it or act on it is another thing.”

Not one of the Republican officials or other abortion rights opponents contacted for this story agreed to an interview. Most failed to respond to repeated messages. That includes spokespeople for Trump’s presidential campaign; Pence; Bush; Representative Chris Smith of New Jersey, who for decades has been Congress’s de facto leading abortion opponent; and Senator Cindy Hyde-Smith of Mississippi, who chairs the Senate Pro-Life Caucus.

Two anti-abortion leaders—Dannenfelser, of Susan B. Anthony Pro-Life America, and Huber, of the Institute for Women’s Health—emailed me, confirming their continued support for the abortion restrictions. Neither responded to my questions about the many studies that found the policies increase abortions and maternal mortality. Nor did they provide research that came to different conclusions, as I invited them to do.

“We hold that U.S. taxpayer dollars should never be used to provide or promote abortion in the United States or abroad,” wrote Huber, who held high-ranking positions on women’s health in the Trump administration and, previously, was an advocate of abstinence-only education. “With regard to the Helms Amendment, it is worth highlighting that a recent poll revealed the majority of Americans oppose their tax dollars being used to fund abortions globally, including those who identify as ‘pro-choice.’”

In that 2023 poll, conducted by the Marist Poll for the Catholic fraternal organization Knights of Columbus, 78 percent of respondents said they opposed using taxpayer money to pay for “abortion services” overseas. That runs counter to a 2019 poll by Hart Research Associates on behalf of Ipas, which found that 54 percent of respondents favored overturning Helms, while 33 percent opposed doing so. Likewise, polls conducted in 2018 and 2020 for abortion rights advocates found that nearly 60 percent of respondents opposed the Mexico City Policy; one poll found that 70 percent wanted to end it altogether.

Meanwhile, Republicans in Congress, led by New Jersey’s Smith, have been trying to impose the Mexico City Policy on PEPFAR, the HIV/AIDS program credited with saving 25 million lives.

Women dying from botched abortions is hardly a new development. They die whether the Mexico City Policy is on or off, whether a Republican or a Democrat is in the White House. But sometimes the ramifications are more profound, and Trump’s four-year term was one of those times. Some health care facilities ran out of contraceptives, some began charging for birth control that they formerly distributed for free, and more women became unintentionally pregnant, Columbia University found. Clinics that provided safe abortions or abortion-related counseling and referrals had to decide whether to continue doing so, and lose money from the United States, or whether to stop, and lose money from other governments or organizations. Some had to choose between providing abortion-related care or HIV services. And many organizations feared that their mere affiliations with groups that provided abortion-related services would cost them their lifeblood—U.S. dollars.

Advocates for women’s health say the fallout was far greater than the Trump administration let on, a position supported by outside research. “The gag rule tore apart health systems,” said Terry McGovern, senior associate dean for academic and student affairs at the City University of New York Graduate School of Public Health and Health Policy. Most organizations couldn’t afford to say no to the Goliath of health care funding. But some did. Some survived by accepting fewer patients, advocates said, but a number closed altogether.

Nelly Munyasia experienced firsthand the pain of losing U.S. assistance at the organization she runs, Reproductive Health Network Kenya, which is supported in part by Planned Parenthood Global. The network includes clinics that perform legal abortion (under the rare circumstances when it’s allowed) and provide post-abortion care, contraceptives, HIV treatment, cancer screening, and other medical care. Munyasia said the network never accepted U.S. money for abortion-related care, but it did receive about $1 million a year, approximately half its budget, for other services. Under Trump, the network lost that money and had to stop serving 200,000 women and men a year—two-thirds of its clientele. One-third of those were HIV patients. It had to shutter some 25 clinics, most of which were “one-stop shops” that provided comprehensive health care in remote areas reachable only by unpaved roads. Often, Munyasia said, the closures left entire communities without medical care. “People have to walk half a day before they access a health care facility,” she told me.

Even the largest organizations reported taking big financial hits. The London-based family planning organization MSI Reproductive Choices, which works in 37 countries, received about 17 percent of its annual budget from the United States before the Trump presidency, said Bethan Cobley, director of external relations. When it refused to agree to his rules, it lost $30 million in 2017 alone. During the four years Trump was in office, MSI estimated that the money it lost could have prevented six million unintended pregnancies, 1.8 million unsafe abortions, and 20,000 maternal deaths.

Because Trump’s severe restrictions cast a wide net, they endangered people who needed all kinds of health care. Advocates said that, though there are few statistics to date, there is anecdotal evidence that the rate of HIV infections rose among women and men because the restrictions applied to PEPFAR.

Even sanitary napkins were on the chopping block. When the Kenya Legal and Ethical Issues Network on HIV and AIDS lost about half its $900,000 U.S. grant, it could no longer provide free menstrual pads, said Nerima Were, a former official there who is now the legal director at the Initiative for Strategic Litigation in Africa. This exacerbated a “phenomenon” commonly called “sex for pads,” in which young women and girls have sex with older men who give them money to buy the products, Were said. The women and girls “weren’t able to negotiate safe sex,” she explained, “and that’s why there was an increase in the incidence in HIV amongst our population.”

In other countries, too, the HIV/AIDS population was hit especially hard, said Beirne Roose-Snyder, a senior policy fellow for the Council for Global Equality, a coalition that advocates for LGBTQI rights around the world. “In many communities, there is one safe clinic, there’s one clinic that isn’t going to out you, who isn’t going to make you feel terrible,” she said. “That is also likely to be the place that is providing abortion care, or, in restrictive environments, at least counseling, referrals, and information.”

In Eswatini, formerly known as Swaziland, a local nonprofit lost so much money that it had to stop performing voluntary male medical circumcision, a technique PEPFAR funded to prevent HIV infections, said Jennifer Sherwood, director of research, public policy, at amfAR, the Foundation for AIDS Research. For heterosexual men, circumcision reduces the risk of HIV by up to 60 percent, according to several studies. “A large portion of the population is living with HIV. And so we really need every tool that we have to prevent HIV,” Sherwood told me. The Family Life Association of Eswatini provided services for women, and when their male partners accompanied them to appointments, they were offered circumcisions, she said, “and many men were taking this up.” When the association quit offering the procedure, another group tried to step into the void. But “they were starting from scratch, trying to go out and convince men to get this service,” Sherwood said. “And they were really unsuccessful.”

Eight days after taking the oath of office, Biden revoked Trump’s version of the Mexico City Policy. “It is the policy of my Administration,” he declared, “to support women’s and girls’ sexual and reproductive health and rights in the United States, as well as globally.”

On the ground, though, progress has been slow. “When you shut down facilities, when the gag rule is lifted, they don’t magically reappear,” said Maina, the head of Trust for Indigenous Culture and Health in Kenya. “They are gone for good.” Munyasia said that her network has reopened some mobile health facilities to reach remote villages, but the health care system remains hobbled. “Every day, we hear of women that died even trying to deliver because they were not able to access services,” she said.

A 19-year-old with an unwanted pregnancy in Nairobi’s Kibera slum. (Photo by Donwilson Odhiambo/SOPA Images/LightRocket via Getty Images)

After Trump left office, foreign health organizations funded by the U.S. struggled to resume the family-planning services they had been forced to cut. But problems lingered, in part because communications from Washington were unclear, and for most of 2021 some women were unable to access legal abortions, Fòs Feminista reported. To this day, the stigma of abortion has remained, as has a chilling effect on medical providers who know all too well that the next GOP president is likely to reinstate restrictions, advocates told me. It is not lost on them that that president could be Trump.

“If there’s a Republican president, we’re screwed,” said Elisa Slattery, a human rights researcher who specializes in reproductive health, rights, and justice. Slattery pointed to Project 2025, a road map for the next Republican administration drafted by the conservative Heritage Foundation, which recommends expanding the Mexico City Policy to all foreign assistance, going far beyond the restrictions imposed by Trump.

It doesn’t help that, for 13 years, Congress has failed to increase the amount the United States contributes to international family planning, which has stagnated at about $600 million a year, said Craig Lasher, a senior fellow at Population Action International, an advocacy and research organization that supports reproductive health and rights. “We feel like the one sibling who comes down on Christmas morning and finds coal in the stocking,” he told me. Biden proposed a $70 million increase for family planning assistance and UNFPA in fiscal 2024. But his administration ran headfirst into House Republican proposals to slash the family planning budget by nearly one-quarter, codify Trump’s Mexico City restrictions, and block any payment to UNFPA. Given that possibility, a fourteenth year of stagnation “might qualify as a victory right now,” Lasher said. (As of this writing, Congress has not finalized a budget for the current year.)

Abortion rights advocates argue that spending on family planning saves lives and reduces costly post-abortion care following unsafe procedures. The Guttmacher Institute reported in January that, currently, U.S. assistance prevents about 14,000 maternal deaths a year. If the United States nearly tripled its investment, Guttmacher figured it could save an additional 35,000 lives a year. 

That kind of budget increase is a pipe dream in the current political environment. Another likely pipe dream in 2024: convincing Congress to repeal the Helms Amendment and block future presidents from ever implementing the Mexico City Policy again. Congress members didn’t even attempt to repeal Helms until 2020, 47 years after it was adopted. The House, then led by Democrats, stripped the amendment from foreign assistance legislation, but it crept back in during negotiations with the Republican-controlled Senate. Last year, Democrats in both chambers reintroduced the bill. One lone Republican—Senator Lisa Murkowski of Alaska—joined Democrats in co-sponsoring legislation to ban future presidents from enacting the Mexico City Policy. Murkowski declined to comment for this article, and spokespeople for Biden would not say whether he supports the two bills.

Representative Barbara Lee, one of Congress’s leading women’s rights advocates, has been working for years to permanently abolish the Mexico City Policy. The policy “kills women in many ways around the world, and we should not be party to that,” the California Democrat told me. “What you see is the Republicans using American foreign assistance to be weaponized as a tool of oppression and a tool to turn the clock back on women’s rights.”

With the House controlled by Republicans, the Senate by Democrats, and an election looming, there is virtually no chance either bill will become law.

Editar Ochieng didn’t tell her parents about her rape and pregnancy and didn’t go to a hospital. The stigma of abortion was too great, she told me, noting that even songs characterized the procedure as a crime. As a high school student, Ochieng couldn’t afford the 20,000 Kenyan shillings—roughly $280 in 2006—to pay for a safe abortion, or even the 3,000 shillings—less than $43 at the time—for an unsafe abortion. She borrowed money from a close friend, who took it from her college fund.

Now 35, Ochieng is no longer secretive. She’s a social justice advocate and feminist leader who strives to improve the lives of women and girls who are victims of poverty, violence, and inequality. In 2016, she founded Feminist for Peace, Rights and Justice Centre, which works to empower young women by developing their leadership skills. She shares her personal story in an attempt to change how Kenyans perceive abortion and to prevent others—including her two daughters—from going through the trauma she endured.

If she doesn’t, she believes, “the violence will be a circle every day, and it will make all of us vulnerable.” So she turned her life into “a public school.” “When I decided to share my story with the women around me, it has really shifted the way they think about abortion, and they don’t judge people.… I get calls like every week from women who want to abort, and I have a number that I will give them so that they can access a safe abortion.” She tells the women to say that Editar sent them so that the cost will be subsidized.

Her activism has elicited enemies—often men who instruct their wives or partners not to associate with her—but Ochieng remains steadfast. To this day, she said, she knows “so many” women who have died from unsafe abortions. But because of the patriarchal culture, strict prohibitions, and very real fear of punishment, she said, families often conceal the cause of death and strain, or even decline, to eulogize their loved ones.

Things could be different, Ochieng and other abortion rights advocates said, if Washington would end the restrictive policies that placate American conservatives but jeopardize the health and lives of women outside U.S. borders. The effect would be most pronounced in countries with broad abortion rights. Even in places like Kenya, it would shrink the number of unsafe abortions and maternal deaths and, potentially, begin to change the oppressive culture, women there said. “When the U.S. is making any decision, the reality is it affects directly a woman who is on the ground and a woman who is very, very poor,” Ochieng said. “We cannot wait for so many women to die to have change.”

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