At the Kamazu Central Hospital in Lilongwe, Malawi, Dr. Grace Chiudzu, the head of the maternity ward, ticks off the most common issues her patients face: “One is bleeding, second is infections, third is abortion complications.” Malawi, a country where 60 percent of the population lives in poverty and 1 in 36 women dies while pregnant or during childbirth, has been something of a development darling. This is largely thanks to President Joyce Banda, who puts health high on the national agenda. Malawi’s donors, including the United States, the Gates Foundation and many others, have thrown support behind Banda’s Safe Motherhood Initiative, an intrepid plan to save the lives of the many Malawian women who die or are seriously injured while pregnant or giving birth. Donors highlight their work to fix some of the problems that Chiudzu mentions: using drugs to stop hemorrhaging, training birth attendants to help counteract complications, delivering antibiotics to treat sepsis and other infections. But there’s one word you don’t hear very often from their mouths: “abortion.” At the 1994 International Conference on Population and Development in Cairo, unsafe, illegal abortion was highlighted as a leading cause of maternal death and a driver of gender inequality. Two decades later, maternal mortality is down, but the proportion of maternal death and injury caused by unsafe abortion has not changed. “Since the Cairo conference, we think conservatively that at least 1 million women have died from unsafe abortion,” Liz Maguire, the president and CEO of the reproductive health advocacy group Ipas, told me. “More than 100 million have been injured. All of these deaths and injuries are entirely preventable.” Chiudzu’s description of the complications landing her patients in the hospital dovetails neatly with international statistics: Unsafe abortion is the third leading cause of maternal mortality worldwide. The World Health Organization identifies safe abortion care as one of seven necessary interventions to ensure quality reproductive, maternal and child health care. Ending death and injury from unsafe abortion is also one of the easiest goals to achieve — early-term abortion is a simple procedure and, when done by a trained provider, remarkably safe. The rate of death from unsafe abortion could conceivably get very close to zero. But that takes political will and funding. Many groups that focus specifically on maternal health will barely utter the word “abortion,” let alone advocate for it to be legal, accessible and safe. Even progressive leaders working in women’s health can be hesitant to touch the problem of unsafe abortion and often deny it’s an issue at all.

A maternity ward in Lilongwe, Malawi, in 2008. Toby Binder / Anzenberger / Redux Chief Inkosi Kwataine is a traditional leader in Malawi whose work to decrease child marriage and ensure no woman dies in childbirth has been highlighted in The New York Times and at major international conferences. In December, I asked him about unsafe abortion. “Abortions are not very common,” he told me. Yet in 2009, an estimated 29,500 women in Malawi were treated for complications from unsafe abortion, and unsafe procedures were the cause of almost 1 maternal death in 5. That’s far from “not very common.” What is less understood is that U.S. foreign policy exacerbates this global public health crisis, perpetuating a culture of stigma, silence and inaction around a leading killer of women.

A big chill

The Helms Amendment, passed 40 years ago in the wake of backlash against Roe v. Wade, prevents U.S. funds from paying for abortions overseas “as a method of family planning” or to “motivate or coerce any person to practice abortions.” But it has been interpreted conservatively, and in practice, abortion is often not even discussed, let alone provided, even for women facing life-threatening complications and rape and incest survivors who, even under the Helms Amendment, should be allowed access to abortion care. Because of Helms, Maguire told me, in countries receiving U.S. Agency for International Development (USAID) assistance, “there’s just a big chill.”

Agencies that receive money from USAID are often not allowed to attend meetings where abortion is discussed. There’s censorship in training materials. It’s unconscionable. Liz Maguire CEO, Ipas

The Mexico City Policy, also known as the Global Gag Rule, implemented under the Reagan administration went far beyond Helms, blocking not only USAID funding from paying for abortion, but also pulling any U.S. funds from other organizations that provided abortion with their own non-U.S. dollars, advocated for abortion rights or provided any information about abortion at all — even counseling, information about legal abortion or referrals to legal providers. That policy was kept in place until the Clinton administration. George W. Bush reinstated it and Barack Obama again removed it. Although it isn’t in place now, many organizations that receive U.S. dollars remain wary of abortion care, knowing the political tides may change. While the Mexico City Policy was in place, it had devastating effects. By 2002, shipments of USAID-funded contraception to 16 countries were halted; many NGOs cut HIV/AIDS services; and clinics that were often the only providers of family planning tools, STI testing and treatment, HIV treatment and prenatal and well-baby care were shuttered. In 1994, the Leahy Amendment sought to clarify U.S. funding policies under Helms, stating that the Helms provision against motivating abortion “shall not be construed to prohibit the provision, consistent with local law, of information or counseling about all pregnancy options.” In other words, USAID-funded groups are permitted to inform women of all their legal reproductive options — including abortion. Unfortunately, the Leahy Amendment is largely ignored. Ipas and other organizations have been pressing the Obama administration to correctly implement Helms, to little avail. That leads to perverse and confusing outcomes. In Ethiopia, Maguire said, a woman living in an area where health facilities receive USAID support will be denied the abortion care that is legal in her own country, whereas a woman living in a different district funded by another donor will have access to safe care. “It’s an imposition of U.S. abortion politics on women in developing countries who are the least able to advocate for their own needs," Maguire said. And that can lead to censorship. “Agencies that receive money from USAID are often not allowed to attend meetings where abortion is discussed. There’s censorship in publications that accept USAID funds; there’s censorship in training materials. It’s unconscionable.”

Different funding streams

Funding for global health increasingly comes from foundations, nongovernmental donors and the private sector. Some of those groups and individuals recognize the need for safe, legal abortion. But many others don’t — including many affiliated with for-profit companies, which bill themselves as more efficient and less beholden to political interests than traditional NGOs and governments.

Malawian midwife Rustica Banda, attending to a newborn baby in need of resuscitation at Mitundu Community Hospital near Lilongwe in 2005. This under-resourced rural hospital delivers 10 to 13 babies a day. Gideon Mendel / Corbis At a conference in mid-March on “best buys” in global health, James Cunningham, the director of product innovation from Merck for Mothers, discussed Merck’s 10-year, $500 million initiative to reduce maternal mortality. “Because of the multifaceted nature of this problem,” Cunningham said, “taking a portfolio approach is important.” Merck’s approach includes a range of partners who offer a multiplicity of solutions, but it doesn’t include safe abortion. Merck for Mothers focuses largely on two causes of maternal death: hemorrhaging and preeclampsia. It emphasizes that a woman dies every two minutes from complications related to pregnancy and childbirth. “That’s 800 women a day,” its website points out. What it doesn’t say is that 1 out of every 8 of those women dies of an unsafe abortion. Five million more women seek care for complications from unsafe procedures. Even more are injured but don’t go to a hospital or clinic. That’s a women’s health crisis — a public health crisis. Cunningham wouldn’t admit that, though. Asked about unsafe abortion, he sidestepped, saying Merck for Mothers talks to women, for example in Zambia, “about what would help them.” In Zambia, abortion is legal but widely inaccessible. A six-year survey (PDF) of five major hospitals showed that 85 times more women were treated for complications from unsafe abortion than actually received safe, legal terminations.

Ignoring unsafe abortion doesn’t end it. While other maternal health challenges are slowly abating, unsafe abortion stubbornly remains a foremost cause of death. Why is that?

Merck is not the only organization advocating for women’s health while steering clear of abortion. The Bill and Melinda Gates Foundation is a major funder of family planning tools worldwide — but Melinda Gates publicly insists that “we’re not talking about abortion.” “From the very beginning,” she told Newsweek, “we said that as a foundation we will not support abortion, because we don’t believe in funding it.” The Gates Foundation, though initially responsive to an email about family planning, would not discuss inquiries about abortion. Ignoring unsafe abortion doesn’t end it. While other maternal health challenges are slowly abating, unsafe abortion stubbornly remains a foremost cause of death. Why is that? “Stigma is the key barrier,” Ellen Israel, a senior technical adviser for women's health and rights at Pathfinder International, a global leader in sexual and reproductive health, told me. “It’s why women hide. It’s why they don’t come. It’s why they come late. It’s why, even if misoprostol is available in the market, women don’t have information on how to take it so it will work.”

Equal players