A Historic Moment
On 24 June 2022, the United States Supreme Court eliminated federal protection of reproductive care, overturning almost fifty years of legal precedent. While advocates in the United States now focus attention on legislation at the state level, the decision begs the question: what are the global implications? Some experts believe the Dobbs decision is unlikely to have a large international impact, arguing U.S. court influence on international judicial decisions is overestimated. Others, however, argue the U.S. Supreme Court ruling will undermine America’s credibility as a leader on women’s rights and legal authority, especially in sub-Saharan Africa where maternal mortality threatens the lives of millions. Nelly Munyasia, the executive director of Reproductive Health Network Kenya noted that anti-abortion groups may begin lobbying the Kenyan government and, she argues, “they’ll want to cite the Roe v. Wade decision.”
Various policies in the United States, including the Global Gag Rule and the Helms Amendment, restrict funding and aid for reproductive care abroad, including sexually transmitted disease testing and treatment, family planning services, and antenatal care. First enacted in 1984, the Global Gag Rule denies organizations that receive U.S. assistance from using additional, non-US funds to provide information, referrals, or services for legal abortions. Depending on the presidential administration in power, the rule is reinstated and rescinded frequently (through executive order). Unstable implementation leads to inadequate aid flows and confusion surrounding the legality of utilizing U.S. funds for contraceptive care, and the ruling specifically impacts sub-Saharan Africa. Initially, the Global Gag Rule applied only to family planning and reproductive health assistance provided by the United States Administration for International Development (USAID). However, the Trump Administration expanded the rule to include all health-related grants from any federal department or agency, impacting $9.5 billion in foreign aid.
Gender Parity, Women’s Empowerment, and Contraceptive Access
Gender equality–goal five of the UN’s Sustainable Development Goals–is imperative for sustainable growth, reducing poverty, and promoting good governance. Gender inequality, especially in education, leads to higher rates of adolescent pregnancy, increased risks of maternal and infant mortality, and higher prevalence of diseases such as HIV and AIDS. Women’s empowerment–measured by decision-making power and autonomy–is directly related to contraceptive use, maternal care service access, and fetal and neonatal death prevention. However, in sub-Saharan Africa, women lack reproductive autonomy threatening their health and wellbeing.
At the turn of the millennium, international treaties, including the International Conference on Population and Development Programme of Action (1994), declared reproductive rights a human right. In the landmark case, Mellet v. Ireland (2013), the United Nations Human Rights Committee found prohibition and criminalization of safe abortion contradictory to international human rights law. The African Charter on Human and Peoples’ Rights on the Rights of Women in Africa (Maputo Protocol), however, recognizes the right to safe abortion only in cases of sexual assault, rape, incest, or when pregnancy endangers the health of the mother.
State of Care in Sub-Saharan Africa: Rwanda, Kenya, and Zambia
Sub-Saharan Africa has the world’s lowest rates of contraceptive use and the highest rates of infant, child, and maternal mortality. Globally, 8 percent of maternal deaths relate to abortion and 44 percent occur in Africa amounting to 34,000 deaths annually on the continent. Regionally, condoms and injectables are the most widely used form of modern contraception. Studies demonstrate access to media and education are likely to increase contraceptive use, however, social norms and limited access hamper widespread use and awareness. In sub-Saharan Africa, Rwanda, Kenya, and Zambia are considered to have liberal reproductive care laws and adequate access to contraceptives in comparison to other countries in the region, but socio-economic, cultural, and political barriers persist and limit access to care.
Rwanda
In 2012, Rwanda aligned national legislation with the Maputo Protocol, allowing for abortion in cases of rape, incest, preservation of the mother’s health, or forced marriage. The same year, the Rwandan government spent $17 million to treat complications from unsafe abortions. Social stigma and bureaucratic barriers persist, stalling legislation implementation. The law stipulates women are required to seek approval from a judge and two doctors to receive a legal abortion. In Rwanda, however, only one doctor exists for every 17,000 people. Access to one doctor–let alone two–is virtually impossible for many seeking care. In addition, women, judges, and health care professionals, especially those in remote regions, are often unaware of the law, creating uncertainty over the legality of reproductive care.
Prosecution for illegal abortions in Rwanda is not uncommon. Individuals convicted face punishment of up to three years in prison or a hefty fine. Women who experience complications from self-induced abortions are often reported to the police by neighbors and healthcare professionals, contributing to further stigma and distrust. Between 2008 and 2013, more than 500 of the 7,800 women in Rwandan prisons were convicted of abortion or infanticide, many claiming they were wrongfully prosecuted. Unique to Rwanda, many women cite a lack of parental support–due to familial casualties during the Genocide–deterred them from carrying their pregnancies to term.
While the statistics remain stark, progress in Rwanda is notable. Since 1990, unintended pregnancies have steadily declined. Some of this success is attributed to restructuring the healthcare system following the Genocide, which resulted in a 60 percent increase in contraception use. In 2019, President Paul Kagame released and pardoned 367 women from prison convicted for abortion. Still, Rwandan women report having an average of 1.5 more children than they desire and 40 percent of complications from unsafe abortions will require medical attention.
Kenya
In 2010, under a new constitution, reproductive rights were expanded to include emergency concerns. Kenya’s Ministry of Health deemed post-abortion care essential to ensure the wellbeing of the mother. In 2019, the High Court of Kenya granted victims of sexual assault the right to an abortion. In 2022, the High Court deemed abortion a fundamental right, citing precedent from Roe v Wade.
However, as in Rwanda, the penal code has not been updated to reflect the stipulations in the constitution or the recent court decisions. Confusion and potential legal consequences deter medical providers from performing life-saving abortions. Imprisonment for illegal abortions ranges from 7 years (for self-induced abortion) to 14 years (for aiding in an illegal abortion). Insufficient access to health care and a lack of education and awareness result in women resorting to extreme measures such as using knitting needles and drinking bleach to terminate their pregnancies. As a result, approximately 28 women and girls die every week in Kenya from complications of unsafely terminating a pregnancy.
A lack of access to contraceptives and reproductive counseling constrict family planning practices. Modern contraceptive use among Kenya’s poorest and least educated married women is as low as 12 percent. Currently, the government provides more than half of the country’s contraceptive supplies free of charge; however, demand is higher than the available supply resulting in inconsistent–and ineffective–use. Following the Trump’s Administration’s iteration of the Global Gag Rule, $600 million in aid to health care organizations in Kenya was cut, resulting in the closure of five clinics, including one in the slums of Nairobi that provided contraceptive services, antenatal care, HIV testing and treatment, and cancer screening to vulnerable populations. Although fewer married women use contraceptives in Kenya than in Rwanda, the unmet demand for modern methods is lower, and unintended pregnancies have continued to decline since 1990.
Zambia
Praised by the international community for its liberal laws, the language of Zambia’s Termination of Pregnancy Bill (1972) permits abortion for broad socio-economic reasons. However, as in Rwanda, institutional barriers exist for those seeking care. Three medical doctors, including a specialist, must give their approval for legal abortion to take place in Zambia. With a population of 16.2 million people, there are 1514 medical doctors in Zambia, making it one of 25 countries on the continent with less than one doctor per 10,000 people. Additionally, more than 60 percent of the population lives in rural areas that lack adequate health services. Complications constitute 30 percent of maternal deaths in Zambia.
Recent changes to the law allow one medical doctor to approve an abortion in emergency situations; however, very few healthcare workers are aware of the changes nor reproductive legislation more broadly. As in Kenya, Zambian women are largely unaware of their rights. As a result of the updated Global Gag Rule, family planning organizations in Zambia lost 24 percent of their funding. Clinics that provided contraceptive care in underserved areas were forced to close. Compared to Kenya and Rwanda, Zambia has the lowest rate of contraceptive use (perhaps due to greater social stigma) among married women (only half). Unintended pregnancies have not changed significantly since 1990.
Improvements and Next Steps
The situation in Africa–and its unique challenges to reproductive and maternal health–is not homogenous. However, reproductive care remains a crisis of resources, as well as structural and cultural barriers. The 2020 Family Planning Report found that between 2012 and 2020, the number of women in Africa using modern contraception increased by 66 percent. Across the continent, governments are moving to expand access to care to address the maternal mortality crisis. In the past five years, Benin, the Democratic Republic of Congo, and Liberia all made efforts to align legislation with the Maputo Protocol and update national penal codes. In July 2022, Sierra Leone’s Cabinet unanimously approved a bill enshrining the right to abortion and reducing barriers to accessing family planning services. In response, Sierra Leone’s President, Julius Bio, said, “at a time when sexual and reproductive health rights for women are either being overturned or threatened, we are proud that Sierra Leone can once again lead with progressive reforms.”
The continent’s broad success is attributed to expanding supply chains, broadening contraception methods, and focusing on disadvantaged communities. Continued support is necessary to decrease maternal mortality, improve child health, and increase the autonomy of women. Local initiatives, like Kasha, a text service in Kenya and Rwanda that delivers condoms to rural villages by moped, are imperative to reaching rural communities. Entrepreneurial opportunities and community based initiatives are both feasible and economically beneficial interventions to increase contraceptive use and improve maternal health. Access to sexual health media and education campaigns–like a voucher program implemented in Madagascar or activist Nana Akosua Hanson’s use of Ghanian radio–can increase awareness and demand for contraceptives, as well as improve the understanding of reproductive rights laws and reduce social stigma.
International organizations have stepped in to help offset the fluctuation in U.S. funding. However, there is simply not enough philanthropic support to address the need. In response to Trump's instatement of the expanded rule, Bill Gates declared, “the U.S. is the No. 1 donor in the work that we do. Government aid can’t be replaced by philanthropy. When government leaves an area like that, it can’t be offset, there isn’t a real alternative. This expansion of this policy, depending on how it’s implemented, could create a void that even a foundation like ours can’t fill.”
To address the structural barriers for women and doctors throughout the region, sustained international funding to educate health care professionals and provide aid and equipment is essential. The Global HER Act, proposed in January 2021 by the House Committee on Foreign Affairs, would permanently repeal the Global Gag Rule, shielding it from the whims of politicians, providing consistent funding for health care centers, and decreasing international confusion about receiving US aid. Global HER would ensure organizations remain indefinitely eligible for US assistance, even if they provide abortion services with non-US funds.
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