“We will just have to forget about the women who will suffer – money is just not enough, we won’t be able to reach the community at all.” This is what a senior staff member at a large health organization in Kenya told me in July this year.
Her organization receives 80 percent of its funding from the United States government – to keep that money, it has had to stop providing information or referrals for abortion or providing abortion services.
At the start of 2017, U.S. President Donald Trump reinstated and dramatically expanded the Mexico City policy, also known as the “Global Gag Rule.” The new rules require foreign nongovernmental groups that receive U.S. global health aid to certify they do not provide abortions except in cases of rape, incest or to save a woman’s life.
Under previous rules, NGOs could not provide these services using U.S.funds, but they could use other funding to do so. Now, if they wish to keep their U.S. funding, groups are banned entirely from offering referrals for abortions – even where abortions are legal – or advocate liberalizing abortion laws.
On paper, governments are exempt from these restrictions. But our research in Kenya suggests the gag rule will also make it more difficult for government clinics to offer access to abortion services.
This is already corroding the scant progress that has been made since the country’s 2010 constitution partly liberalized restrictions on abortion to reduce the high numbers of deaths and injuries from unsafe procedures. Abortion is now permitted in cases of emergency treatment or when the health of the woman is at risk.
The 2010 constitution states that healthcare workers must provide safe abortion care when “the life or health of the mother is in danger.” Health is defined broadly in the country’s 2017 Health Act as “complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
But Kenyans still face major obstacles to getting safe abortion care in government clinics. Many women have no choice but to undergo unsafe procedures, either from back-street quacks or by trying to induce their own abortion with sticks, bleach or other methods.
Some nongovernmental groups provide safe abortion care themselves, but many also play a critical role in helping Kenyan women and girls get safe abortion care at government facilities. They work with government doctors or government clinics by providing training, equipment and other support on abortion care.
The government has made things more difficult with policies that seem to ignore the constitutional changes, leaving nongovernmental groups to inform not just potential patients but also government doctors and other staff of their rights and to support staff who want to provide the services. Now their ability to provide this advice is under threat.
Few Kenyans know about the 2010 reforms. Even health workers have told me that abortion is “illegal in Kenya.” Kenya’s penal code has never been updated, so healthcare workers are still scared of being hauled off to jail for up to seven years for providing abortion care.
In 2013, the health ministry’s director of medical services withdrew government guidelines for reducing injury and death in unsafe abortion, banned the use of abortion drug Medabon, and stopped safe abortion training for healthcare professionals. Now providers are even more confused about when it is legal to provide an abortion.
Representatives of 25 organizations I interviewed said that, in general, government clinics are reluctant to provide safe abortion care, except to save the life of the woman. Nongovernmental groups have been on the front lines of trying to make sure they do, but now that accountability is under threat.
Reproductive Health Network Kenya, for example, supports more than 450 individual doctors, midwives and other health workers – including some government workers – with legal support, training and the equipment they need to perform abortions. The Global Gag Rule has resulted in the loss of two-thirds of their funding.
“No new member has received training,” said Nelly Munyasia, the program director. “We had to lay off two staff.”
I spoke to three Kenyan or regional medical groups that together support about 60 government clinics, including in rural areas with limited healthcare. All said they would have to cut back on safe abortion care because they could not afford to lose their U.S. global health funding.
One of these organizations, whose staff requested anonymity, works with 22 government clinics and has equipped and trained about 70 government healthcare staff members in providing safe abortion care. A representative said they had seen a reduction in injuries and deaths from unsafe abortions over the past years. But, she said, without support from nongovernmental groups, she expects government clinics will probably stop providing abortion care to the full extent of the constitution.
“The doctors are really afraid of the law and were turning women away, [and] the ministry of health does not supply abortion related commodities to their facilities,” she said.
The NGOs see increasing public awareness about the law on abortion as one of their most important jobs. Even when government clinics do provide safe abortion care, their reach will be limited if those NGOs can no longer refer women and girls to their services, or spread information about their rights under Kenya’s Constitution.