How Trump’s abortion policies could be felt around the world

As the U.S. presidential election approaches, Lalaina Razafinirinasoa cannot shake a frightening thought. If Donald Trump wins, he will likely impose policies that could lead to the deaths of women she knows. 

After all, it has happened before.

One of Mr. Trump’s first acts when he became president in 2017 was to sign an executive order cutting off all American health aid to organizations that “perform [or] actively promote abortion.”

The ban was not intended to stop U.S. money from being used on abortions; that has been forbidden for 50 years. Rather, it was meant to keep American aid dollars out of the hands of pro-abortion-rights groups more generally. That’s whether they planned to use the money to fund birth control, give HIV tests, or treat malaria – a vastly expanded version of a policy enacted by every Republican administration since Ronald Reagan.

Ms. Razafinirinasoa runs the Madagascar branch of MSI Reproductive Choices (formerly Marie Stopes International), a family planning charity that chose to give up $30 million a year in U.S. funding rather than accept the new conditions.

That forced Ms. Razafinirinasoa’s team to cut outreach programs that brought birth control to the island’s poorest and most remote corners, a decision that still haunts her.

“We’ll never know exactly how many women we lost,” Ms. Razafinirinasoa says. Globally, one peer-reviewed study estimated the U.S. policy led to the deaths of more than 10,000 women and nearly 100,000 children, primarily as a result of decreases in the quality of their medical care.

So now, as Ms. Razafinirinasoa and other global family planning advocates watch the election approach from thousands of miles away, it feels close and urgent.

“We are trying not to panic, because what can we do?” says Jedidah Maina, the executive director of the Trust for Indigenous Culture and Health, a Kenyan health nonprofit. “It could change our lives, but we don’t even have a vote.”

The luxury of choice

When Ms. Razafinirinasoa became the director of Marie Stopes Madagascar in 2015, she often found herself brushing up against the lives she could have lived.

Visiting remote, rural villages like the ones where her parents grew up, she met pregnant 11-year-olds and hungry women struggling to feed a half-dozen emaciated children, all of them far too small for their age. “I’m just tired of giving birth,” she remembers one mother of seven quietly confessing.

Ms. Razafinirinasoa knew that only a razor-thin line separated her life from theirs. In Madagascar, whose international image is of white sand beaches and wide-eyed lemurs, the average woman is a mother of five, and a third of girls give birth before the age of 19. Nearly half the population is chronically hungry.

“Not many people have the luck I did,” she says. Her parents moved to a city and sent her to school. But another fundamental part of that “luck” was also that she got to decide if and when she had children. Everyone “should at least be able to make their own choice on their reproductive life,” she says.

The World Health Organization agrees. When women control their fertility, it concludes, they are healthier, more educated, and more economically independent. And so are their children.

Over the past four decades, the number of women worldwide using modern contraceptives has doubled. In many places, American aid has played a major role in this story. But the help comes with strings attached.

Since the 1980s, American funding for family planning has been deeply politicized. Each time a Republican becomes president, they instate the Mexico City Policy, an executive order barring American funding for foreign organizations that do abortion-related work. Each time a Democrat takes office, they repeal it.

Historically, the Mexico City Policy, which critics call the “gag rule,” applied only to funding earmarked for family planning. But in 2017, Mr. Trump announced he was expanding it to all American global health aid, then around $9 billion annually.

Suddenly, recipients had to choose between providing legal abortions and getting funding for things like malaria tests, HIV medications, and child nutrition. “When we design programs” for these services, “we don’t intend to fund the abortion industry,” explained the White House in a statement to The Washington Post at the time.

Meanwhile, in countries like Madagascar, where abortions are not allowed even when they are needed to save the mother’s life, groups still lost funding if their parent organization supported or provided them elsewhere.

“I don’t know that people are always aware that this policy has enormous impact even where abortion is highly restricted,” says Sara Casey, an assistant professor of population and family health at Columbia University.

Counterintuitive consequences

At the end of Mr. Trump’s presidency, Dr. Casey led a study of the policy’s impact in Kenya, Madagascar, and Nepal. In all three countries, her research concluded that the policy made it harder for women and girls to access family planning. Organizations receiving American funding also often aggressively self-policed, overapplying the policy out of worry that they might accidentally overstep an unseen line.

In Madagascar, the researchers found the policy’s effects were especially far-reaching, in part because the United States provided nearly 90% of all family planning aid. That meant that when MSI Reproductive Choices and other organizations cut their programs, many women lost their only access to free birth control.

One woman described scrambling to find ways to pay $0.65 for an injectable contraceptive at a private pharmacy, until one day she couldn’t anymore. “And now I’m pregnant when I didn’t want to be,” she said.

Globally, experts estimate that despite the policy’s purported aims, it actually increased the number of abortions being performed in many countries. A study published in the journal Lancet estimated that abortions increased by 40% during the Trump and Bush administrations in counties that relied heavily on U.S. family planning aid, including Madagascar. Although the study did not analyze the causes of this increase, the authors posited it could be because the policy restricts access to contraceptives, leading to more unwanted pregnancies.

Ms. Razafinirinasoa says the effects of those years still reverberate. Though Marie Stopes Madagascar eventually made up some of its lost funding, the scope of its work remains narrower than in 2016. Another Trump administration would likely mean more cuts, with a possible further extension of the Mexico City Policy to include emergency humanitarian aid.

Ms. Razafinirinasoa knows who would suffer most from those policies. “This is about equity,” she says. When aid goes away, “The poorest people are always the first ones who will die.”