Annie Hylton | Longreads | October 2017 | 12 minutes (3,250 words)

It was a Tuesday in the district of Merhabete, in central Ethiopia, and the smell of burning spices infused the air. Hundreds of people — men and boys herding donkeys and goats, and women cloaked in white cloth with baskets atop their heads — lined the gravel roads leading to the government-run health clinic; some had walked for hours to trade and sell goods at the weekly market.

Yeshi estimates she is 37, based on the age of the eldest of her six children. She and her husband left home around 7 a.m. that morning. For a few months, Yeshi had been unable to perform basic tasks. She was too weak to visit the neighbors and bled profusely, like she was menstruating, every time she drank coffee or water. She had lost weight and was concerned she was dying. But on this Tuesday, the day her husband would make the hour-long walk to sell bananas at the market to earn the $7 USD that would sustain their family of eight for the week, Yeshi would accompany him to the village. If she were able to make the trek, she would visit a doctor and nurse from Marie Stopes International, a non-governmental organization that provides sexual and reproductive health services around the world. One of Marie Stopes International’s 12 mobile outreach teams in Ethiopia, funded by the U.S. Agency for International Development (USAID), would be at the village’s health clinic. They would offer family planning consultations and perform what they call the “permanent method” — vasectomies and tubal ligations.

Those teams reach thousands of women and men in rural and hard-to-reach places across Ethiopia, providing life-saving maternal health and family planning services that would otherwise not be accessible. But while President Donald Trump’s federal funding cuts to women’s health care have received much attention, human rights groups claim that Trump’s war on women also extends to some of the poorest countries in the world, including the Horn of Africa.

This war began in earnest within Trump’s first week in office, when he reinstated a Reagan-era policy banning U.S. funding to overseas health groups performing abortions, known as the Mexico City policy, or, “Global Gag Rule.” In May, Trump announced a vastly expanded version of the rule, one Katja Iversen, the President and CEO of Women Deliver called, “the Global Gag Rule on steroids.” Under the expanded rule, no non-U.S. international organizations that receive U.S. funding can perform or “actively promote” abortion.

According to Marie Stopes International, this means that NGOs forfeit all U.S. aid if they tell a woman abortion is a legal option in her country, refer her to another provider, or advocate for abortion rights with funding from non-U.S. sources. Although Marie Stopes does not perform abortions with U.S. funding due to the Helms Amendment — a 1973 amendment to the Foreign Assistance Act that limits the use of U.S. foreign assistance for abortion — they must forfeit funding for all of their outreach programs, which reach women like Yeshi, if they choose to continue providing access to safe abortions. The organization has estimated that during Trump’s first term, re-enacting the Mexico City Policy in Ethiopia alone would result in service stoppages that could lead to over 67,000 unintended pregnancies, 62 maternal deaths, nearly 12,000 unsafe abortions, and nearly $6 million USD in lost funding.

According to Aram Shvey, Senior Policy Counsel and Manager of Special Projects for the Center for Reproductive Rights, the injustices and international cost of the policy’s expanded version will be immeasurable. “Here [in the U.S.] it would almost certainly be unconstitutional,” said Shvey.

“This is not just about sex, abortion, and contraception,” said Katja Iversen. “A woman’s ability to decide on her own fertility is the bedrock of gender equality and economic empowerment.”

The previous iteration of the rule under George W. Bush applied exclusively to international family planning organizations and $0.6 billion in funding. Trump’s version has a pool of nearly $9 billion and cuts across all global health assistance; it will touch not only organizations that provide contraception, but also those that provide services for HIV and AIDS, the Zika virus, and malaria, among others. Jason Cone, the Executive Director of Doctors Without Borders (MSF), told me the new version of the rule “essentially eliminated one of the best weapons of eliminating maternal mortality… If you want to talk about a sweeping policy that risks eliminating progress on health, you couldn’t have found a better match.”

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Yeshi grew up in the Amhara region of central Ethiopia, historically one of the country’s poorest regions. According to the World Bank, agricultural growth has now reduced poverty; the majority of people subsist on farming, and women participate in agricultural work. Yeshi’s family farms teff and barley, while others in the region farm wheat, sorghum, and corn.

At 14, Yeshi said she was required to lead her family, doing most of the farm labor, when she married her husband, who is 13 years her senior. When I asked her whether it was an arranged or love marriage, she replied, “I have no knowledge of that; it was an arranged marriage.” Yeshi explained that she suffered physical abuse at the hands of her husband, and was desperate to run away to her mother, who told her: “No!”

Although some regions in Ethiopia have seen a significant decline in child marriage, other areas are plagued by it: In 2013 the Council on Foreign Relations reported that 52% of girls in the Amhara region marry before age 15, and 25% give birth before 18. Yeshi had her first child at 15, and her second child at 16; she lost both of those children (she also lost a third child). Ethiopia has a law against child marriage, but it is challenging to implement in rural areas: When I was in Enewari, in Amhara, a government health worker told me a 14-year-old girl had recently died from childbirth in a nearby community.

This is not just about sex, abortion, and contraception,” said Katja Iversen. “A woman’s ability to decide on her own fertility is the bedrock of gender equality and economic empowerment.

According to Risha Hess, Country Director of Marie Stopes Ethiopia, four factors lead to high-risk pregnancies: mothers under 18; pregnancies less than two years apart; mothers with more than five births; and pregnancy in mothers over 35. For mothers over 35, this risk is exacerbated for women who had teen pregnancies. Early marriage is linked to three of those factors, and Yeshi fulfills all four high-risk factors.

Access to family planning is directly correlated with maternal mortality and morbidity rates, according to Asfawossen Mengistie, a health officer with Marie Stopes in the Awassa region, and it can reduce rates of abortion — which, ironically, is the Mexico City Policy’s intended goal. For some women, access to family planning and safe abortion services is a matter of life and death. In Ethiopia, women who cannot obtain safe abortions still seek unsafe, back-alley abortions, putting their lives at risk; The use of herbs, coat hangers, spoons, knitting needles, and drugs is common. Women will also go to a wadaja, where a local religious man provides herbs for abortions, according to a 2003 report by the Center for Reproductive Rights called Breaking the Silence, which studied the impact of the Global Gag Rule on unsafe abortions.

But in recent years, Ethiopia has made significant progress reducing maternal mortality rates and offering legal abortion in particular circumstances. In 2005, Ethiopia decriminalized abortion. Women can now terminate pregnancies resulting from rape or incest; when the fetus has severe abnormalities; when a girl is under 18, and cannot care for the baby herself; or if the pregnancy endangers the life of the woman or fetus. According to a 2014 report by IRIN news, women’s health in Ethiopia improved drastically with access to contraceptives, family planning services, and education. The minister of health in Ethiopia told IRIN that six percent of women used birth control before the amendment, and by 2014 that number had gone up to 40 percent.

The Mexico City Policy will almost certainly threaten Ethiopia’s progress. The last time the Gag Rule was implemented, in 2001 until 2009, Ethiopia was hard hit. The 2003 Center for Reproductive Rights report argued that the Bush Administration’s Gag Rule contributed to the global unsafe abortion crisis. The rule compels healthcare providers to withhold vital medical information from indigent women patients (including those who are victims of rape, incest, or are pregnant after being abducted to become a bride). Women may be forced to induce abortion, which can inevitably lead to complications and potential death. “Contrary to its stated intentions, the Global Gag Rule results in more unwanted pregnancies, more unsafe abortions, and more deaths of women and girls. We who have seen those effects first-hand can no longer tolerate silence about the Gag Rule’s tragic effects.” Dr. Eunice Brookman-Amissah said in the report.

Contrary to its stated intentions, the Global Gag Rule results in more unwanted pregnancies, more unsafe abortions, and more deaths of women and girls.

According to Banchi Dessalegn, director of Marie Stopes International’s operations in Ethiopia, the primary goal of the outreach teams is to prevent maternal death. In some cases, it’s imminent, she said, “People say ‘if I get pregnant again, I’ll die.’” The Mexico City Policy can also affect families, who rely on the support of the woman as the caregiver and for agricultural labor. According to Hess, a maternal death can lead to family separation, and children becoming displaced. “There are huge ramifications for the future if there are six, seven children without a mother.”

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In Enewari, a short distance from where Yeshi lives, colorful storefronts checker the streets and families live in round, thatched roof huts made of grass, wood sticks, and mud. There, a group of around 70 women met. They wore colorful embroidered scarfs and held umbrellas to ward off the sun. Despite the sweltering heat, they had gathered outside for a community meeting, to share concerns about sanitation, and to learn about family planning from Marie Stopes workers. Rich, decadent coffee — jebena — was brewed in a traditional clay coffee pot, and passed around while an elder cut the bread baked for a coffee ceremony.

The goal of such gatherings, a joint effort between the Ethiopian government and Marie Stopes, is to break taboos and misconceptions about vasectomies and tubal ligations, and, as Marie Stopes sees it, it’s essential to engage both men and women, in separate ceremonies. Men may believe that receiving a vasectomy is the equivalent of castration; women may understand tubal ligation as a flipping of the uterus. Such misconceptions may be a barrier to care, and so women and men from the community who have received the procedures are asked to give testimonies.

The woman in charge of brewing the coffee stood up, mid-meeting, and told the group that she had four living children, and one dead. Every time she gave birth she had severe postpartum hemorrhage (a leading cause of maternal mortality) and believed it was life-threatening. “So, I decided to do it,” she said, referring to a tubal ligation. “I saved my life.”

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I approached four women at a nearby Marie Stopes health clinic, all in their thirties, who had received the procedure after giving birth to five children each. Two of them told me that the most significant change in their lives had been the opportunity to educate themselves, alongside their children. One woman had just reached a grade nine-level education and was continuing to learn. At that moment, the women asked me how old I was. I told them I was 33 and married, but did not have children. They squealed in disbelief — one of the women handed me her round-cheeked baby named China, who was wearing a ballet tutu, and told me: “take this one.”

* * *

Ethiopians have dealt with a turbulent political climate for decades. When I visited earlier in 2017, journalists and human rights advocates wanted to meet in inconspicuous locations and sometimes called from anonymous numbers. Ethiopians still speak of the period from 1974 to 1991 when a military junta, the Derg — composed of a committee of nearly 120 military officers — overthrew the ruling Emperor and imposed a socialist state. In 1977, a man named Mengistu Haile Marian (who was tried in absentia and found guilty of genocide in 2006) took leadership of the Derg and unleashed a brutal campaign known as the Red Terror, or Qey Shibir, during which anyone suspected of “counterrevolutionary activities” was targeted. Over a two-year period, up to half a million people were executed and tens of thousands arbitrarily detained and tortured, while many more became refugees.

According to an academic paper written by Gemma Burgess, A Hidden History: Women’s Activism in Ethiopia, the Derg “at least to a degree put women on the agenda, in the Constitution, and in jobs within its institutions.” But, while women were involved in the armed struggle — 10,000 were part of the Derg army, while some 40,000 women served in the Tigrean People’s Liberation Front, an opposition group that eventually helped overthrow the Derg in 1991 — the benefit to women’s equality was limited, the author argued.

Human rights groups have also argued that the Global Gag Rule, and the U.S. (under conservative administrations) imposing an anti-abortion agenda in countries with fragile democracies, has a chilling effect and infringes on state sovereignty, which, in turn, impacts gender equality. This is “politicizing women’s bodies and women’s right to choose,” said Saba Kidanemariam, country leader for IPAS Ethiopia. “They [the U.S.] use their power to impose their ideas on governments,” she said. “That is the most powerful arm of the Gag Rule.”

But the U.S. has a history of meddling in other countries’ domestic affairs when it comes to reproductive rights. According to a 2010 report by the Leitner Center for International Law and Justice at Fordham Law School, Exporting Confusion, when the Ethiopian government had the political will, in 2003, to fully liberalize the country’s abortion law, many anti-choice religious groups opposed the action. Chris Smith, a U.S. Congressman, sent a letter to the Ethiopian Embassy in Washington denouncing Ethiopia’s constitutional amendment. In a 2007 speech on Ethiopia and Human Rights, he said, “I also expressed my deepest disappointment and sorrow over… recent legalization of abortion on demand and argued that Ethiopia’s women and children have suffered enough death. Abortion is violence against children — it dismembers and chemically poisons babies — and it hurts women physically and psychologically.”

* * *

When Yeshi was in her mid-30s, she had a set of twins and then decided she was done bearing children. The most available contraceptive to women in rural areas in Ethiopia is an injectable that they must receive every three months, and an implant, four centimeters long, which is inserted into a woman’s upper arm (other women also receive IUDs). “What the government has done really well is to de-medicalize family planning,” said Hess, Marie Stopes International’s Country Director in Ethiopia. “It has really contributed to the success of IUDs and implants. But it stops at that level.” While government health workers have been trained to insert implants, only hospitals or private clinics perform tubal ligations, where the procedure can cost more than $150 USD, which is out of reach for most Ethiopians. (According to the World Bank, the average per capita income of Ethiopia in 2016 was $511.20, compared with $52,194.90 in the U.S.)

Yeshi opted for the implant. After a government health worker inserted it into her arm a year and a half ago, Yeshi said she began experiencing side effects, like excessive bleeding and weight loss. (Marie Stopes staff said they weren’t certain it was the implant that caused Yeshi’s side effects, and that it could have also been obstetric fistula or another health problem that had gone unattended.) According to Catrin Schulte-Hillen, a midwife and member of MSF’s Working Group on Reproductive Health and Sexual Violence, this is a known side effect of the implant, and when women don’t report the side effects there can be severe consequences.

After Yeshi learned about the possibility of receiving a tubal ligation, she asked the government health worker to connect her with Marie Stopes. She discussed the procedure with her husband, who agreed, because, Yeshi said, “he wanted me alive.”

That Tuesday, Yeshi — with her husband’s support — journeyed to the clinic, when Marie Stopes was in a nearby village. She and her husband passed crops and huts, and eventually reached a nearby village, after two hours. Then, they waved down a public taxi, which took 30 minutes to reach a road leading to the government-run health clinic.

Two rooms in the dilapidated facility are devoted to Marie Stopes’ family planning services: one for counseling, and the other for performing procedures. Arriving at the clinic around 11 a.m., Yeshi, the first woman to request the procedure that day, was taken into the counseling room. She passed elderly women lining the hallway, draped in traditional white shawls called netela, praying and crying, as a woman from their community went through labor. Children in Ethiopia are highly valued, and it is not unusual for women in rural areas to have nine or more children.

When Yeshi walked into the counseling room, she looked frail and tired and said she’d been unable to eat. A black scarf covered her shaved head, and a loose brown floral dress clothed her skinny body. But she had come a long way and knew what she wanted. She sat across from the doctor and nurse, and argued: “I know all of the methods; don’t tell me the others.” Within minutes, Yeshi was taken into the procedure room, where she would receive a tubal ligation, and the nurse would cut into her left arm to remove two implants.

In that room, Yeshi was placed on a table surrounded by USAID stickers plastered on equipment and walls. She received only local anesthetic and held hands with the nurse who spoke softly to her as the doctor made an insertion in her lower abdomen. Her toes pointed, and she moaned as the doctor prodded deeper to locate her fallopian tubes. Her body began to jerk. I cannot recount the events that succeeded, in detail, as I soon felt the room spin and my lunch slowly climb up into my throat. But when I gathered myself and went back into the room, Yeshi’s implants were being removed, and the doctor had successfully sealed her tubes. She was faintly smiling.

After a few moments, Yeshi was given a bottle of soda and taken outside to sit down, where a woman who was next in line waited to receive the procedure. That woman explained that a doctor advised that if she got pregnant again, because of severe postpartum bleeding with previous pregnancies, she might die. (The vast majority of women in Ethiopia, most of whom live in rural areas, do not give birth in health institutions, but rather have their babies at home, far away from any hospital if a complication arises.)

When Yeshi finished her soda, we hopped into a Marie Stopes vehicle. Before we could leave, her husband began to knock on the door, as his banana basket was empty and he had finished his sales at the market. From there, we would drive them to the point where they would begin making the two-hour walk home. “You saved her life,” her husband told the driver, vigorously shaking his hand, “now I can buy my wife lunch.”

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Annie Hylton is an international investigative journalist with a background in human rights law. Through long-form narrative writing, she seeks to create empathy and illustrate the human stakes behind key policy debates. She writes about gender, immigration, human rights, and conflict, and has worked in the Middle East, Central America, Asia, and Europe. She reported this story on a fellowship from the International Reporting Project (IRP).

Editor: Krista Stevens | Copy editor: Michelle Weber | Fact checker: Ethan Chiel