A U.S. foreign policy that cuts money to nongovernmental organizations performing or promoting abortions abroad has actually led to an increase in abortions, according to Stanford researchers who have conducted the most comprehensive academic study of the policy’s impact.

Eran Bendavid, MD, and Grant Miller, PhD — both associate professors of medicine at the School of Medicine — and graduate student Nina Brooks found that abortions increased among women in African countries where NGOs, such as the International Planned Parenthood Federation, were particularly vulnerable to the policy’s requirements.

The policy, widely known as the Mexico City Policy, explicitly prohibits U.S. foreign aid from flowing to any NGO that does not agree to abide by the policy’s main condition: no performing or discussing abortion as a method of family planning, even if just in the form of education or counseling.

The policy has been a political hot potato since its inception. Enacted under Ronald Reagan in 1984, it’s been enforced by subsequent Republican administrations, whereas Democrats in the White House have revoked the policy within days of taking office.

The study, published June 27 in The Lancet Global Health, looked at the policy’s effects in more than two-dozen African countries over a span of 20 years under three presidents: Bill Clinton, George W. Bush and Barack Obama. It found that, when the policy was in place during the Bush years, abortions were 40 percent higher relative to the Clinton and Obama administrations.

When the policy was suspended during Obama’s two terms, the Stanford researchers found that the upward trend in abortion rates reversed.

“Our research suggests that a policy that is supported by taxpayers ostensibly wishing to drive down abortion rates worldwide does the opposite,” Bendavid said.

A key reason for the uptick in abortions is that many NGOs affected by the policy also provide contraceptives — and funding cuts means birth control is harder to get, Brooks said.

“By undercutting the ability to supply modern contraceptives, the unintended consequence is that abortion rates increase,” she said.

The policy’s scope has expanded under the Trump administration. While it originally restricted aid directed only toward organizations providing family planning and reproductive health services, President Trump has extended the policy to cover any group engaged in global health, including organizations providing services for HIV or child health — not just family planning.

Groundbreaking research

The stakes are high. America is the world’s largest provider of development assistance: It spent about $7 billion on international health aid in 2017. Many women in sub-Saharan Africa depend on this aid for contraceptives.

In sub-Saharan Africa, NGOs are often primary providers of family planning services. Two of the world’s largest family planning organizations, International Planned Parenthood Federation and Marie Stopes International, have forfeited large sums from the U.S. government for refusing to comply with the policy, according to news reports.

Our research suggests that a policy that is supported by taxpayers ostensibly wishing to drive down abortion rates worldwide does the opposite.

The research findings were based on records of nearly 750,000 women in 26 sub-Saharan African countries from 1995 to 2014. When the policy was in effect under George W. Bush, contraceptive use fell by 14 percent, pregnancies rose by 12 percent and abortions rose by 40 percent relative to the Clinton and subsequent Obama years — an impact sharply timed with the policy and in proportion to the importance of foreign assistance across sub-Saharan Africa.

The paper is the second study of the rule’s impact by Bendavid and Miller, and is also one of the few evidence-based analyses of the policy.

Their earlier research was the first quantitative, large-scale effort to examine the policy’s impacts. It looked at a smaller set of African countries during the Clinton and Bush administrations and also found an increase in abortion rates when the policy was enacted in 2001.

“Our latest study strengthened our earlier findings because we were able to look at what happens when the rule was turned off, then on, and then off again,” said Bendavid, referring to the policy’s whipsawing under Clinton, Bush and then Obama.

Miller said the team’s research reveals a deeply flawed policy.

“We set out to provide the best and most rigorous evidence on the consequences of this policy,” he said. “What we found is a clear-cut case of government action that everyone on all sides of the abortion debate should agree is not desirable.”

Signs of global pushback

Brooks noted that the findings may underestimate the rule’s full impact.

“The excess abortions performed due to the policy are more likely to be performed unsafely, potentially harming women beyond pregnancy terminations,” she said.

Norway, Canada and several other countries have pledged to increase funding of international NGOs affected by the policy — though not by enough to cover the expected shortfall, Miller said.

“This shows us,” he said, “that despite the intense partisanship in the U.S. over the rule and its implementation, there are ways that policymakers around the world can offset its effects — by ensuring higher levels of family planning funding, for example.”

Miller is the director of the Stanford King Center on Global Developmentand a senior fellow at the Stanford Institute for Economic Policy Research. Bendavid is a faculty affiliate of the King Center. Miller and Bendavid are faculty members of Stanford Health Policy

The research was funded by the William and Flora Hewlett Foundation, the Doris Duke Charitable Foundation, the David and Lucile Packard Foundation and a Stanford Earth Dean’s Fellowship.

Stanford’s Department of Medicine also supported the work.