Every time a Republican is in the White House, women across the world face the devastating impact of the US's ban on discussing abortion in exchange for aid.

Beeju Maharjan Ramba Devi and her sister-in-law, Dusha Saud.

KATHMANDU, Nepal — On Wednesdays and Fridays, Shikha Sharma was banned from saying the word “abortion” out loud. This makes things pretty tricky for her, because Sharma is the go-to person for everything young Nepalis want to know about sex but are too afraid to ask. As the host of a popular late-night radio show, Sharma, 33, takes questions from across the country about consent, queerness, safe sex, sexual taboos, and social mores. Listeners of her show, Khuldulee.com — Curiosity.com in English — can call for free or send her questions via the show’s Facebook page. Sometimes they even track down her personal number for questions or to write messages that simply say, “thank you for your advice :)” “The most common type of distress calls I get are from young people who’ve had unprotected sex,” said Sharma, who has hosted the show for 12 years. “They’re scared about getting pregnant but stop short of asking where and how to get an abortion, because most of them aren’t aware that there are free abortion clinics in Nepal.” Sharma’s job became particularly difficult in 2017, when her station bosses first told her that, for two days a week, she wasn’t allowed to say the word, let alone discuss, abortion. The reason? Donald Trump — and the Republican Party. That’s because, shortly after Trump was elected, he activated the “global gag rule” (GGR), banning US funding of foreign NGOs that provide abortion counseling or referrals. For a country like Nepal, where the health care sector relies heavily on US aid, the effects were always going to be catastrophic for women’s health, but no one was quite sure just how bad things would get. Trump didn’t come up with the GGR, but he has made it worse. The origins of the GGR date back to the administration of Ronald Reagan, who opposed abortions in almost all circumstances, and refused to fund it around the world. In 1984 Reagan brought in what was then known as the Mexico City policy, named after the host city of a UN conference where it was announced, which required NGOs to certify they would not perform or actively promote abortion as a method of family planning if they wanted to receive US government aid. The GGR was eventually rescinded by Bill Clinton in 1993, and now it only comes into effect whenever there’s a Republican in the White House. When the president is a Democrat, it’s taken off the books. Back and forth, back and forth. It leaves the lives of many women around the world, almost exclusively poor, at the mercy of the Oval Office. In one of his first acts in office, Trump sat triumphant — in a room full of men — and signed the executive order that reinstated the policy, marking a break from the Obama years. Two years later, having renamed the Mexico City policy to the friendlier-sounding Protecting Life in Global Health Assistance, he went further than any Republican president before him. Under Trump’s expanded policy, which NGOs scrambled to understand the implications of, foreign NGOs that receive aid from the US could no longer even use their own, non-US funds to refer patients to places that provide safe abortions. In fact, if they even mention abortion as part of their counseling or education programs, they and any other local health care organizations they might support could lose their funds too. The expanded rule has closed off entire networks of grassroots health workers — who need aid money the most — from doing abortion-related counseling, effectively choking off smaller civil society efforts that wish to help women but lack the resources and funds to do so.

Beeju Maharjan Shikha Sharma, host of the late-night radio show Khuldulee.com.

In 2017, no one was completely sure how exactly Trump’s expanded GGR would translate across the world, in countries that relied on the US Agency for International Development (USAID) for health care. For Sharma, it led to a literal gag: She had to either stop using the word “abortion” on air for a year, while the show was supported by USAID, or risk losing funding for her radio show — because for two days a week, Khuldulee was partly funded by US money. This was how Trump ensured that on Nepal’s most popular show about sex and sexuality, abortion became the Thing That Could Not Be Named. “I started taking questions about safe sex on Tuesdays, and then answering them on Thursdays, hoping the caller was still listening and was safe,” Sharma said. “One time, a health expert I was interviewing used the word ‘abortion’ while taping a show that would be aired on a Wednesday. I had to send the transcript to my bosses, and was advised to cut the word out of the final version that aired. Otherwise, I was warned, it would make things difficult for us.” Since 2017, experts fearing the worst issued warnings about the repercussions of Trump’s expanded policy, but had no way to assess the impact on the ground. Now, a collaboration between BuzzFeed News and the Kathmandu Post has found that everything rights groups feared as a result of the expanded GGR is unfolding in real time. In Nepal, where one-third of the country’s GDP comes from remittances, curtailed USAID funding has led to staff reductions and the closure of clinics, and women and men have lost access to conversations about consent, contraception, and HIV. The most common health complaints brought to gynecologists by women — prolapsed uteruses and other abortion-related complications — are directly related to the information vacuum created as a result of the gag. This is the story of how a decision made in Washington, by a man elected to office by US voters, has turned life-threatening for women in one of the poorest countries in the world, where the vast majority cannot access doctors and clinics, where child marriage is still a common practice, and, although maternal mortality has improved, deaths have historically been high.



Beeju Maharjan A nurse counsels a couple about family planning methods at Paropakar Maternity Hospital in Kathmandu.

To reach Doti, a district in the Far-Western Province of Nepal, you have to fly an hour from the capital, Kathmandu, then drive for seven hours up lush and winding hillsides. As the air grows thinner, and snowcapped peaks become more frequent, a short, steep flight of stairs carved into the rocky hillside leads to a single-story clinic, run by the Family Planning Association of Nepal (FPAN), the country’s oldest sexual and reproductive health advocacy organization.



It isn’t much to look at; its sparse rooms are painted white, with strip lighting, plastic furniture, and the occasional diagram of the reproductive system, but the clinic is a lifeline for women in the surrounding villages. Health care is inaccessible to large parts of Nepal’s population — like, really inaccessible: A 2017 study found that there were only a total of seven doctors, nurses, and health care providers for every 10,000 patients, and most of these doctors are concentrated in urban areas. This means that Nepalis living far away from Kathmandu in places like Doti, farming in villages nestled deep in the hills and mountains, frequently have to walk for days just to see the nearest doctor. And in Nepal, as in other countries where there is a deep cultural stigma around sex, women with reproductive health–related problems are already reluctant to seek medical help. Ramba Devi and her sister-in-law, Dusha Saud, are regular visitors to the clinic, even though there’s no such thing as a quick trip to the doctor in these parts. Even for a routine checkup, both women must put their farm work aside for the day, walk three hours up and down a steep hillside, and put up with taunts from neighbors who see their medical trips as an indulgence, a way of avoiding work — or worse, a sign that they are failing their one job as dutiful wives: bearing more children.



But Ramba and Dusha know the cost of too many babies. Ramba’s mother had eight children, and Dusha grew up with 11 siblings. With that many mouths to feed, a woman could never hope to leave the village, or look for a new way of life. As they waited for a nurse at the FPAN clinic, Ramba and Dusha sat on a wooden bench, flushed from their long walk. A few weeks ago, both women had come to the clinic for a “minilap,” or minilaparotomy — a sterilization procedure for permanently obstructing the fallopian tubes.

Beeju Maharjan Clinics across Nepal are dependent on US aid.

“People said we would die because of the operation, and that our bodies would never recover, but I am glad we went ahead with it,” Ramba, 35, said as she held Dusha’s hand. The younger of the two women, Dusha seemed nervous, fiddling with the many strings of glass beads around her neck, swinging her feet back and forth as they dangled off the bench. The memory of their last trip to the clinic was still fresh for Dusha. It had taken a while to recover from both the painful minilap surgery and then the walk home immediately after. The women could have waited at the clinic for a while — the nurse had advised them to — but they wanted to get home before it got dark outside. Despite the lingering pain from that last visit, the women were glad they underwent the procedure. “It’s much easier this way,” Ramba said. “Raising a small family is better. I don’t know how we would get by if we had more children.”



Before the minilap, Ramba used to get a contraceptive injection every three months, walking up and down the steep hill each time she needed a booster. Then, she switched to a five-year implant in her arm. But when her husband left the village to work abroad, she had the implant taken out.



“He wasn’t with me at home, so there was no point having a permanent contraceptive device,” she said. “[The IUD] can cause many problems — it can fall out in the fields when we work, move around the body, anything can happen.”



IUDs can and do get dislodged occasionally, and FPAN’s nurse confirmed this was more likely to happen if a woman is performing heavy manual labor. According to the nurse, Doti was full of women like Ramba, who stopped using contraceptive pills or injections when their husbands migrated outside Nepal for work, sometimes as evidence of fidelity, or because they were genuinely afraid of what an alien implant would do to their reproductive systems — particularly as they labored hard on the hills, farming and walking for hours carrying heavy loads on their heads. Ramba’s husband, who works as a contract laborer between Malaysia and Dubai, usually only comes home for Dashain, one of the most important annual festivals in Nepal. At those times, Ramba too would get some form of semipermanent contraception, only to have it removed again once her husband left. It wasn’t exactly a fail-safe method — she got pregnant three times this way. Many women in the village ended up with unplanned pregnancies as a result of inconsistent contraceptive use. According to the nurse, the most common question she heard when the clinic’s staff conducted health check-ups in the village was “How can we have smaller families?” FPAN’s internal records, seen by BuzzFeed News and the Kathmandu Post, showed that boys as young as 17 had begun asking for vasectomies, just so they wouldn’t be stuck at home with a brood of children, like their parents had been.

Beeju Maharjan A clinical assistant at a Marie Stopes clinic cleans surgical equipment.

Abortion was legalized in Nepal in 2002, after a long campaign by rights advocates, doctors, and organizations like FPAN. But when President George W. Bush was reelected in 2004, FPAN lost 40% of its funds, laid off hundreds of staff, and closed down four projects that taught Nepalis the basics of family planning, according to its director general. Now, under Trump, FPAN has closed down outreach services in 11 districts, along with a family planning project that began when Obama was in office and was supposed to continue until the end of 2019. After Trump’s GGR, it shut down in early 2018. Republicans in the US frequently describe the GGR as protecting unborn children. The evidence suggests otherwise. The policy targets abortion only very narrowly — forcing women to carry unwanted pregnancies has far-ranging effects that go beyond this stated aim. Multiple studies now indicate that abortion bans do not bring down the number of abortions — instead, they endanger the lives of women who need those abortions in the first place, by forcing them to seek dangerous alternatives. The studies show the GGR endangers the lives of newborns and their parents, by denying them lifesaving education about safe sex, maternal care, cancer screenings, and HIV transmission.



Anil Basnet, a former FPAN employee who worked with the organization for over three decades, was supervising the family planning project that began in the Obama years and shut down in 2017.



“I knew the project was doomed when America elected a Republican president,” Basnet said, seated at the FPAN office in Kathmandu, beside a poster with the words “Sexual Rights Are Human Rights.” “People involved with FPAN began to resign and look for new jobs after Trump was elected. I also resigned then,” he added. Basnet, who is in his late fifties, has not found a new job since. For the time being, he has chosen to continue working with FPAN’s remaining clinics as a consultant on a temporary basis. But worse than the loss of equipment, projects, and jobs is the information vacuum the GGR has created around women’s health, by constantly (and absurdly) conflating sexual and reproductive health care with abortions. The Trump administration has even objected to UN resolutions that apply to women, on the grounds that the resolutions were actually promoting abortion by suggesting that women who had survived armed conflicts should receive sexual and reproductive health care.



For women like Ramba and Dusha, every unplanned pregnancy creates a self-perpetuating cycle of poverty and disempowerment that generations will have to bear — longer hours of physical labor, more mouths to feed, less money to send their children to school, young girls who are married off early and sent to their husband’s homes, early pregnancies, and...repeat. Landlocked between India and China in a geologically vulnerable spot, Nepal is a small country prone to flooding, landslides, fires, epidemics, earthquakes, and avalanches. The US has been one of the biggest contributors to Nepal’s development since the mid-20th century, providing more than $1.6 billion in assistance, helping the country lay its first roads, installing its first telephone exchange, and increasing literacy rates. A large part of this aid money has been used for health-related programs. Since women make up 51% of Nepal’s population, and women’s health is directly interlinked with their reproductive health, women need doctors who understand a “rights-based perspective,” which is a fancier way of saying “her body, her choice.” Now that the GGR is policing choice itself, the funding crisis in Nepal has deepened a dangerous gender divide — contributing to a trend of sex-selective abortions that favors male fetuses. According to this flawed logic, common to several South Asian cultures, sons are potential breadwinners and therefore seen as a profitable investment. Daughters, who rarely have the opportunity to go to school, earn significantly less, and are eventually married off — often at great cost to their families — are regarded as an inconvenience. Hundreds of miles away from Doti, closer to the border with India, Rautahat district has always had it bad — the district has among the lowest literacy rates in the country, scoring low on several Human Development Index indicators like gender equity, health, and life expectancy. This year, the annual monsoon floods in July saw over 70,000 homes, including those made of mud and bamboo, completely washed away. A dusty maternity hospital in the district here serves a population of 800,000 people with only 50 beds. Stationed next to the Snakebite Ward, the maternity hospital sees an annual tide of pregnant women seeking abortions in the months immediately following Valentine’s Day.

Beeju Maharjan A health worker talks with patients at Rautahat District Hospital in eastern Nepal.

“What is this, but the result of Western influence?” said Sabita Begum, a nurse who had worked in maternal care for over a decade across Nepal. Begum was joking, and not really blaming the West. While Valentine’s Day is regarded as a Western import that sanctions the public performance of couplehood, Begum realized it was ultimately about sex — and specifically, the very Nepali desperation for sons. This, she said, was the reason she had gained so much experience in carrying out abortions. “Nine times out of 10 when a pregnant woman comes in, it’s her family who wants to know the sex of the child, not her,” Begum said. “It doesn’t matter how educated they are, people will pay thousands of rupees to find out, and then abort the baby if it’s a girl,” she said. Begum was seated in her “office” — on a chair with no back, in front of a steel bedframe. Prenatal sex determination is illegal in Nepal, but Begum said that when she and the attending doctors refused to comply with a family’s request, the woman would invariably be taken somewhere else — to another clinic, or across Nepal’s border to neighboring India — until the family found someone willing to reveal the baby’s sex, and abort the fetus if it were female.



In her career, Begum has worked as a maternity nurse at a United Nations–run health care center, at clinics in the plains (where she works now) and in the mountains, and said she encountered the same crisis everywhere: Girls are married off early so that their families no longer have to worry about keeping them safe from other men. Once married, they start producing children immediately, and keep doing so until they have at least one son, and preferably more. Eventually, after repeated deliveries at a young age, Nepali women become prone to prolapsed uteruses — a condition in which the pelvic floor muscles and ligaments become weak and are no longer able to support the uterus, often leading to the uterus protruding from the vaginal opening. Begum’s eyes flashed in anger as she spoke. “Everybody knows why it happens,” she said. “But what can we do? It’s a health crisis caused by an attitude problem. There is no solution.” One particularly effective — albeit slow-acting — remedy was the relentless campaign for sexual rights led by USAID-funded organizations that worked with Nepal’s government to strengthen the country’s health care system.



Beeju Maharjan Sabina Begum, a nurse at Rautahat District Hospital in eastern Nepal.

For years, nonprofit organizations that were funded by USAID trained entire fleets of doctors, nurses, and government officers in destigmatizing sex, sexuality, and sexually transmitted diseases, handling cases of sexual assault with sensitivity and care, discouraging age-old — and frequently lethal — superstitions about women’s menstrual cycles, educating families about women’s rights to study and work and to have a life beyond making babies.



Now, Trump and his policy have begun to undo all of that work. At a maternity clinic that we are not identifying for fear of endangering the clinic’s funding, BuzzFeed News and the Kathmandu Post spoke to a woman who had undergone multiple abortions so she could ultimately have a son, as Begum had described. The woman spoke on the condition of anonymity because sex-selective abortions are illegal in Nepal.



S. had her first child, a daughter, when she was just 20 and got pregnant with her second a few years later. This time, her family drove her to a town almost seven hours away, close to the border with India, for a sex-determination test. When the test showed that she was carrying a fetus that was female, her family decided she should abort it. Since she was over 9 weeks pregnant, she didn’t have the option of using pills via prescription to induce the abortion and required surgery. Her family took her to a private health clinic where she terminated the pregnancy. “It felt like I was in labor for about an hour, it was much worse than when I had my first child,” she recalled. S. said the pain subsided at around midnight when she started bleeding profusely and saw what she described as “a lump of meat” leave her body. “It was over after that,” she said. S., who is now 33, said she did not regret her decision anymore, but remembered feeling sad at the time she took abortion pills on a separate occasion. “I wondered why I had to throw that baby away,” she said. After a pause, she added, “But then I told myself I already had a daughter and I didn’t want a second one.” After the abortion, S. didn’t want to take any form of contraceptive precautions, because her female relatives had scared her by talking about the side effects. As a result, she got pregnant three times — and had two more abortions when the fetus was determined to be female. Finally, S had a son. It was only last April, after getting yet another abortion, that she decided to get an IUD implant. “People say I am already fat and will put on more weight, but so be it,” she said.

Beeju Maharjan

When Nepalis swap tales of the country’s mountaineering legends, a fond mention is also reserved for the so-called MS Ladies. This is how outreach workers from Marie Stopes International, an organization that provides contraception and safe abortion services around the world, are known. The MS Ladies are Nepali women famed for walking for days across frequently rough terrain to reach isolated villages in the hills and mountains. Dispensing health care, counseling couples and families, addressing sensitive and often taboo subjects around sexuality, violence, and Nepali traditions, MS Ladies also helped women assess whether they needed an abortion, providing guided, nonsurgical abortions when necessary.



As of 2019, disinformation is rife and sources of good information on sexuality — like the MS Ladies and Khuldulee.com — are fast disappearing. Two years ago, when Marie Stopes International refused to sign the GGR, its local branch in Nepal also had to shut down outreach services to 11 districts; when combined with the FPAN closures, that meant there were no outreach services in 22 of Nepal’s 77 districts. In the past, FPAN and Marie Stopes employees trained Nepal’s health care providers to set up mobile clinics, which in turn traveled to remote parts of the country, offering care for people who lived on $1–2 per day, conducting screenings for diseases like cervical cancer, providing free health consultations, teaching new mothers how to care for babies, and distributing contraceptives. The work also included addressing popular myths and the stigma around health care. “There is an old misconception in Nepal that surgeries, particularly those related to family planning like vasectomies and implants, should take place in the winter months, never in summer,” said Tushar Niroula, the head of Marie Stopes Nepal. “People believe that the chances of infection are lower and people heal faster in cold weather — this was true once, but science and medicine have progressed in a way that patients can get help without waiting for the seasons and the weather to change.” At a bustling government-run maternity ward in Kathmandu, Dr. Jageshwor Sharma Gautam said he feared that the women worst affected by funding cuts would be those from the most marginalized sections of society, because they no longer had anyone who could guide them toward making healthier reproductive choices.



“Abortion is just the visible tip of the iceberg of reproductive health,” he said. “It is linked to things like nutrition, immunization, family planning, women’s overall health, including their reproductive health. It affects family planning, so when we discuss contraception, we also talk about how condom use is related to HIV transmission, about HPV and cervical cancer. All of these things fall under the broad category of people’s sexual social behavior.”



Gautam said that if women could not freely discuss safe abortions with licensed doctors, they would resort to other, more dangerous means to terminate their pregnancies.



“These days, people can just buy pills over the counter at every medical shop, without prescriptions. If a woman says she missed her period and asks for the pills, she will be given five tablets, no questions asked,” he said. “But this can lead to severe complications — for instance, if women take these pills when they’ve been pregnant for over 13 or 14 weeks, excessive bleeding can lead to death. We are treating patients like this more and more frequently, and there is no way to stop this from happening without being able to talk about and offer safe abortions to women who need it.” Describing the Bush years of 20012009, Gautam said that his hospital would treat at least two women with abortion-related complications every day.



“There would be several women in the wards, who would come to us after an unsafe abortion with injuries in their intestines [and] uteruses, high fever, and heavy bleeding,” he said. “There were many deaths. It was a terrible time.” In 2019, things appeared to be regressing once more: Gautam said that the GGR actually made it harder to explain reproductive health to women, because it closed off the possibility of talking about several other related subjects. Manuelle Hurwitz, director of institutional delivery at the International Planned Parenthood Federation (IPPF) said it was impossible to put a “human cost” on the impact of losing USAID support. “Not having that support now is going to have a long term impact on people’s health in addition to more immediate impacts such as the closure of health services,” she said in an email. “The Global Gag Rule is really not stopping US funding for abortion because US funds were never utilised for abortion. It has increased stigma around reproductive rights, and hampers basic information such as where to get services from. In a country like Nepal, years of progress can be set back.” Meanwhile, Sharma’s notifications at Khuldulee.com are still blowing up. I’m two weeks late! Why won’t I get my period? Should I have sex with her? Is it safe? Is it normal to feel this way? Am I pregnant? Where do I go? ●

