In Kenya, homeland of President Obama’s father and paternal grandparents, abortion is illegal except in very limited circumstances. More than 40 percent of births are unplanned according to the Guttmacher Institute, and one-fourth of all married women want to space or limit births but have no access to contraceptives.

Lack of control over sex and reproduction costs Kenya’s women dearly.  The United States Agency for International Development (USAID) estimates that 15,000 Kenyan women die of complications of pregnancy and unsafe abortion each year, and that an additional 294,000 to 441,000 women suffer disabilities from the same causes. Despite the risks to their lives and health, some 300,000 women in Kenya seek out abortions each year, desperate to end pregnancies that they cannot, for whatever their own personal reasons, carry to term.

Yet Kenya is not a worst-case scenario.  In many countries, maternal mortality rates — maternal deaths per 100,000 lives births — are far higher.  A 2007 UN multi-agency report notes that 13 nations have maternal mortality rates that exceed 1,000 deaths of women per 100,00 live births. All but Afghanistan are in sub-Saharan Africa.  Despite many international agreements, we’ve made negligible progress in reducing maternal deaths over the past 20 years and today more than 500,000 women worldwide die each year of pregnancy-related causes.

I don’t know whether President Obama will be thinking of women in Kenya—or in any one specific country—when he signs the executive order lifting the “global gag rule” as he is expected to do.  It is a much anticipated and welcome step toward reversing eight years of Bush Administration policies aimed at driving international reproductive health programs into the ground.

I do know that this action is nonetheless a critical and necessary but not sufficient condition for promoting women’s reproductive and sexual health and rights now and in the future.

The  global gag rule has been extensively covered on Rewire and
researched by many in the advocacy community.   “Officially termed the
Mexico City Policy," according to Population Action International:

"[T]hese restrictions mandate that no U.S. family planning
assistance can be provided to foreign NGOs that use funding from any
other source to: perform abortions in cases other than a threat to the
woman’s life, rape or incest; provide counseling and referral for
abortion; or lobby to make abortion legal or more available in their
country.

Called the "gag" rule because it stifles free speech and public debate
on abortion-related issues, the policy forces a cruel choice on foreign
NGOs: accept U.S. assistance to provide essential health services – but
with restrictions that may jeopardize the health of many patients – or
reject the policy and lose vital U.S. funds, contraceptive supplies and
technical assistance.

In countries like Kenya, Tanzania, and Uganda, imposition of the
global gag rule has meant the loss of critical funds for the
contraceptive supplies and services needed to prevent unintended
pregnancies in the first place.  In virtually every country with high fertility rates, lack of access to contraceptives means women have more children than they want or can afford.  And in every one of these countries, women die at high rates from complications of unsafe abortion.

If as expected President Obama rescinds the global gag rule, he will deserve great praise for acting on behalf of women.  Doing so will send  a clear signal to providers of the most basic health care to women in the poorest countries of the world that the US government is no longer their enemy. And it will send a clear signal to women everywhere that we care about their lives, their health, and their rights…and that we trust them to make the decisions that are right for themselves and their families.

“Rescinding the global gag rule sends a very important symbolic and political signal," states Adrienne Germain, President of the International Women’s Health Coalition:

"Symbolic in the fact that we remain constrained in both domestic policy and foreign policy, unable to spend U.S. government funds on safe abortion services for women who cannot pay for them themselves.  Political in the sense that it’s a very powerful statement following eight years in the desert, eight years in which women have been consigned to death or lasting injury unnecessarily because they couldn’t gain access to safe services.  As importantly, they couldn’t be referred to these services, and nobody could speak out on their behalf."

Likewise, the advocacy community deserves to rejoice.  Many organizations have worked long and hard to get rid of the global gag rule, and there is due cause for celebrating its demise.

Having fought this policy for so long, it may seem like getting rid of it brings us to the end of a long road.  However, we cannot stop here.  The types and magnitude of unmet needs for basic sexual and reproductive health services are growing every day.  Even without the gag rule, our policies are ill-equipped to deal with either the changes of the past decade or with current and future needs.  U.S. international health policy needs a complete overhaul, and
reproductive and sexual health has to be at the top of the list for a
makeover.

As Obama stated in his inaugural address:

“The world has changed, and we must change with it.”

The HIV epidemic is but one example of the changes to which we must better respond.

Today, women make up
the majority of those infected with HIV worldwide and comprise nearly
two-thirds of those infected in sub-Saharan Africa.  HIV infections are
driving the rate of maternal deaths ever higher, and AIDS-related complications are leading causes of death in women ages 15 to 49 in many sub-Saharan countries.  A study of maternal
mortality in two slums in Nairobi, conducted by a team led by Abdhalah K. Ziraba, of the African Population and Health Research Center (APHRC), found that deaths due to HIV infections in pregnant women
represented a large share of overall maternal deaths yet HIV was not being adequately considered as a causal factor in maternal deaths (and never mind deaths due to AIDS-related causes among non-pregnant women).

In many countries, lack of access to education and economic opportunities, denial of basic legal rights such as the right to inherit property, and high rates of violence and coercion together with lack of access to basic services make a deadly combination.  Uganda, once lauded by the Bush Administration as an HIV "success story" and the first country hung with a "mission accomplished" banner by PEFPAR may represent one of the starkest examples of the failure of both the gag rule and of US global AIDS policy over the past eight years.  The Museveni government worked in close alliance with the Bush
Administration in promoting abstinence-only programs for HIV prevention
and in denying funding for basic contraceptive supplies.  Uganda now has one of the highest rates of maternal mortality in sub-Saharan Africa, and is experiencing an uptick in HIV infections, shortages of contraceptives, and high rates of cervical and breast cancer.  Unintended pregnancies also have risen, resulting in a fertility rate of 7 percent and rapid population growth, all of which taken together indicated the Uganda "success story" may be turning into a nightmare.

Bush Administration policies have undoubtedly made a bad situation worse, but returning to where we were before Bush simply is no longer enough.  For a long time, our policies, programs, and funding streams have treated sexual and reproductive health as a series of easily compartmentalized medical problems to be addressed in isolation.

Women, however, don’t experience sex and reproduction as separate compartments in
separate spheres of their lives.  Instead, they may be at risk of
unintended pregnancy and HIV infection in any single act of unprotected
sex and at various times in their lives.  They may have been married at
an early age against their will or for lack of education and economic
alternatives outside of marriage.  They may be experiencing violence
and coercion as a routine part of their daily lives at the hands of intimate partners.  A World Health Organization multi-country study of violence against women found that:

The proportion of ever-partnered women who had ever experienced physical or sexual violence, or both, by an intimate partner in their lifetime, ranged from 15% to 71%, with most
sites falling between 29% and 62%.

A report on gender violence by the Carnegie Council for Ethics in International Affairs underscores the need for coherence in and deepening of our strategies in addressing simultaneous risks, stating that:

The correlation between domestic violence and women’s vulnerability to
HIV infection adds considerable impetus to the need for all governments
to address seriously and meaningfully domestic violence against women.
Otherwise, in a continent devastated by HIV/AIDS, any strategy to
combat the pandemic will be compromised. Programs that attempt to
prevent the spread of HIV/AIDS by encouraging abstinence from sex,
fidelity, and consistent condom use are a start, but they do not
address women’s unequal decision-making power and status within their
intimate relationships.

Despite these realities, US policies and funding streams remain too linear and do not respond to the indivisible risks faced by women of unprotected sex.  Family planning funds are in one account, maternal and child health in another, and HIV and sexually transmitted infections in a series of yet other accounts, oftentimes guided by policies that have more to do with the political aspirations of policymakers than the needs of the people they are ostensibly tended to serve.  Channeling money to the field in this way is in part the product of historical precedent left over from the era of "population control," and in part the result of pressure from the far-right which has successfully linked contraception with abortion.

This politicization of sex and reproduction has fostered a climate in which Congresspeople often will not speak unequivocally in support of family planning or contraception; in which maternal/child health and HIV advocates often are reluctant to speak about integration of services because of fear it might trigger controvery around abortion; and in which family planning advocates often fear the loss of funding for basic contraceptive services anytime suggestions are made of broader approaches to sex and reproduction.

The existence of separate streams of funding and sometimes dueling policies often means we are doing a little bit of everything everywhere, without focusing on consolidating and strengthening truly comprehensive services in a sustainable way anywhere.  It is not uncommon in US missions abroad for maternal and child health,
family planning and HIV program managers to be unaware of what their
counterparts are doing. As a result, we often undermine our own stated goals.  While conducting field research on US global AIDS programs in Kenya in 2006, for example, I was told that the rapid influx of US funding for AIDS treatment was actually drawing community health workers away from family planning and maternal and child health care services. Why? Because "reproductive health" organizations were losing US funding, while "HIV" organizations were recieving huge amounts of money and could outbid their counterparts for workers, deeply undermining the goal of building sustainable health systems, and once again reinforcing the notion that a sexually-driven HIV epidemic is unrelated to high instances of unintended pregnancy, unsafe abortion, and sexual violence and coercion. 

Not.

Bush Administration policies have left a blanket of restrictions across these disaggregated programs that go well beyond the gag rule.  Current PEPFAR guidance for prevention of sexual transmission focuses heavily on "abstinence and faithfulness" in an epidemic in which the majority of women at risk are married and in their twenties and thirties.  Restrictions on the purchase of contraceptive supplies with and through PEPFAR programs reinforces the notion that sexual risks are divisble, and denies women their rights to protect themselves simultaneously from both infection and from unintended pregnancy.

Moreover, our need to "measure success" in yearly increments forces us to use indicators, such as the numbers of condoms distributed or the number of abstinence messages delivered, that tell us virtually nothing about the longstanding success of our efforts.  The focus on achieveing short-term outcomes over longer-term gains may look good in an annual report, but in the end causes us to miss opportunities to create a stronger platform for social change and a sustainable foundation for health care systems.  Moreover, with short-term vision, we neglect more intractable issues that continue to drive the poor outcomes about which we are concerned.  For example, while gender-based violence is a huge factor contributing to the spread of HIV infections and to high rates of unintended pregnancy and consequently unsafe abortion, there is relatively little funding available for integrated efforts to respond to the epidemic of violence against women.  We may be funding family planning programs without a gender-based violence strategy in one country and gender violence programs without reproductive health strategies in another.  This makes no sense.

In his inaugural speech, Obama underscored a desire to look for programs and strategies that work, and to find creative new solutions to the longstanding and in many cases growing problems we face.  Revamping the way we address sex and reproduction is one place to start.  Once we’ve gotten rid of the global gag rule, we need to move on to building truly integrated strategies for meeting people’s needs, ensuring access to basic reproductive and sexual health services, including methods of contraception and access to safe abortion services, while addressing the economic, social, and cultural factors that drive unintended pregnancy, unsafe abortion, and the spread of HIV in the first place.  Doing so will require our own community to look beyond the categories and boundaries we ourselves have fostered to come up with new approaches to sexual and reproductive health programs in a changing world.

These issues require vigorous debate in our community and we invite you to start that process here.  And in the coming weeks, we will continue to suggest new approaches and encourage debate on these issues at Rewire.