Executive Summary Every year, twenty million—mostly poor—women around the world are driven to unsafe abortion. More than 95% of these abortions occur in low-income countries. And every year, complications from these procedures claim the lives of some 70,000 women. Untold millions more suffer serious injuries and permanent disabilities. Set against this international health crisis is the global gag rule, a U.S. government policy that prevents foreign non-governmental organizations (NGOs) that receive family planning assistance from the U.S. Agency for International Development (USAID) from advocating for or providing abortion-related services, even with their own, non-U.S. government resources. Breaking the Silence: The Global Gag Rule’s Impact on Unsafe Abortion, a report by the Center for Reproductive Rights, gives a voice to advocates in countries where the gag rule has impeded their efforts to slow down spiraling rates of unsafe abortion. Center researchers conducted more than 100 in-depth interviews in four countries—Ethiopia, Kenya, Peru, and Uganda—with a broad cross-section of actors including NGOs that have accepted USAID funding and are therefore “gagged” from advocating for abortion. As far as we know, this research is the most comprehensive survey of the rule’s impact on gagged organizations and exemplifies what is happening in many of the nearly sixty countries receiving USAID funds. Each of the four countries selected for this study depends heavily on U.S. family planning assistance and enforces restrictive abortion laws that prolong the cycle of unsafe and illegal abortion:

• In Ethiopia unsafe abortion is the second leading cause of death for women of reproductive age, accounting for 55% of maternal mortality and causing one-fifth of all hospital admissions.
• One report estimates that more than 40% of Kenya’s maternal mortality rate is due to unsafe abortion, causing more than 5,000 deaths each year. More than half all admissions to gynecological wards across the country result from abortion-related complications
• Approximately 350,000 clandestine abortions are performed annually in Peru, resulting in the hospitalization of one in seven women who have had abortions and one of the highest maternal mortality rates in Latin America.
• In Uganda, 5,000 women and girls are known to be admitted into hospitals for incomplete abortions every year, and unsafe abortions cause approximately one-third of maternal deaths.

Breaking the Silence identifies eight harms that the gag rule inflicts on local advocates struggling to respond to the daily tragedy of unsafe abortion. The report also exposes the U.S. government’s complicity in perpetuating this largely preventable health crisis. The Global Gag Generates a Climate of Censorship Many of the people interviewed for Breaking the Silence said that the gag rule has created a climate of fear, censorship and distrust that forces them to avoid any conversations about unsafe abortion:

We used to hold debates, invited medical doctors, produced research publications. We cannot speak as freely now. No one knows at what point it becomes prohibited speech. USAID told us that we couldn’t lobby for abortion liberalization or decriminalization. That, for example, if we attend a general conference and the issue of abortion comes up we can speak. But we don’t know how much we can talk about it before it crosses over to not being permitted anymore. We, for example, can do research on unsafe abortion. But if we draw conclusions, someone can say “that’s lobbying.” NGO, Peru

The Global Gag Skews the Abortion Debate with Bias and Misinformation Respondents expressed concern, and at times outrage, that the U.S. government was forbidding abortion reform advocates from speaking out while placing no such restrictions on anti-abortion activists. The Global Gag Impedes Abortion Law Reform Historical evidence from the United States and other countries shows that when abortion services are safe, legal and accessible, abortion-related deaths and injuries are greatly reduced. However, the global gag rule has thwarted the efforts of abortion reform advocates to change restrictive laws.

Abortion complications are the easiest to prevent. But we cannot work to prevent them with the global gag rule. Now how can we work to avoid unsafe abortion? It is the issue that contributes to the most mortality. NGO, Kenya

The Global Gag Curtails the Participation of Civil Society in Democracy Strengthening democracy and empowering civil society organizations is one of USAID’s strategic objectives and a U.S. foreign policy goal. Yet the gag rule forbids NGOs from participating in their own country’s democracy and encourages governments to act in an authoritarian manner. The Global Gag Condemns Women to Unsafe Abortion By handicapping advocates for abortion reform, the global gag rule has condemned countless women to unsafe and illegal abortions.

I met with a headmaster of a school where three girls have died from unsafe abortion. When do providers in rural areas say no to girls in need? The clinic is supported with USAID funds—do they turn the girls away because it is related to abortion? What should the school do? Refer the girls to the clinic? How were these kids counseled? The girls were all pregnant by the same man. It is very difficult for the nurse in the situation. What can she counsel about? What about rape and incest? It is a problem if the provider is a member of that community—how can she differentiate about what to say?. . . I could not stand up and take the story to the government. I can’t speak. A person cannot even speak as a community member or a parent. Because how can you differentiate between an individual or NGO employee? Cooperating Agency, Uganda

The Global Gag Reduces Access to Other Reproductive Health Services The gag rule has shut down programs that provide family planning, HIV/AIDS, emergency contraception (EC), and other reproductive health-care services that it is not supposed to affect.

Officially the policy hasn’t affected any programs except for EC. An organization had made a proposal to pilot EC. The Ministry of Health had no objection and we thought there would be no problem. In 2000 they were going to do a promotion and service delivery of EC. Then there was a strong letter from the Cardinal that said the ministry was promoting abortion. The Cardinal later found that it was a USAID-funded project. USAID then did not want to be associated with the project. Government Official, Uganda

The Global Gag Isolates NGOs and Dictates Their Policies Although USAID has emphasized the importance of supporting local NGO networks, the global gag rule has hampered the coalition-building efforts of NGOs that require broad-based support for sensitive issues such as women’s health and rights. The Global Gag Infringes Upon National Sovereignty Government officials feel constrained by the gag rule even though it does not directly apply to them. Many fear that upsetting USAID will result in a loss of funds for the government itself, especially the ministry of health.

When the president of the U.S. comes out with this kind of rule, it will have an impact on other nations. By virtue of him being the president of the U.S., people take note of his opposition to all abortion issues. NGO, Ethiopia

For the sake of women’s health and lives, women’s rights, freedom of speech and the development of democracy, the Center for Reproductive Rights urges the U.S. government to repeal the global gag rule.