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Ann C. Hwang, MD and Felicia H. Stewart, MD

The authors are with the Center for Reproductive Health Research and Policy, University of California, San Francisco.

Correspondence: Requests for reprints should be sent to Felicia H. Stewart, MD, Center for Reproductive Health Research & Policy, University of California, 2356 Sutter St, Suite 200, San Francisco, CA 94143-1744 (e-mail: fstewar{at}itsa.ucsf.edu).

	ABSTRACT

TOP ABSTRACT INTRODUCTION CUTTING BUDGETS—AND... FREE SPEECH AND MEDICAL... FUNDING IDEOLOGY, NOT EVIDENCE... CONCLUSIONS References

 

Family planning has long been acknowledged as an effective public health intervention. In recent years, however, family planning has come under increased scrutiny from conservative politicians and constituents.

National US policies instituted since 2001 are resulting in cutbacks in family planning programs worldwide. In the long run, these conservative initiatives may set back several decades of progress in reproductive health and reproductive rights.

In promoting an ideologically driven approach to sexual and reproductive health, the recent policy developments threaten to subvert ethical standards of medical care and the principle of evidence-based policy.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION CUTTING BUDGETS—AND... FREE SPEECH AND MEDICAL... FUNDING IDEOLOGY, NOT EVIDENCE... CONCLUSIONS References

 
SINCE THE 1960S, THE UNITED States has been a leading donor to voluntary family planning programs worldwide. These programs provide health services and supplies that enable men and women to "decide freely and responsibly the number and spacing of their children and to have the information, education and means to do so," a fundamental human right reaffirmed by the global community at the 1994 International Conference on Population and Development in Cairo.^1,2 In doing so, these programs have been effective in decreasing maternal mortality, improving child survival, and promoting social and economic development.³

A series of US policy decisions made since 2001, however, have been inconsistent with the historically strong public support for family planning.⁴ In January 2001, President George W. Bush reinstated the Mexico City Policy, placing restrictions on foreign nongovernmental organizations that receive US Agency for International Development (USAID) family planning assistance.⁵ These organizations—the workhorses of the USAID program—were presented with a difficult choice: abandon all abortion-related activities undertaken with their own funds or lose USAID support. These abortion-related activities include providing abortion information or referrals and advocating for liberalizing abortion laws, in addition to providing abortion services. Since 1973, the Helms amendment has banned federal spending on any abortion-related activities internationally. The Mexico City Policy now prohibits USAID funding of any organization that carries out abortion-related activities with its own funds.

In May 2002, the United States dispatched an investigative team to study whether the United Nations Population Fund (UNFPA) was funding coercive family planning programs in China. The panel found no evidence of wrongdoing and recommended releasing the $34 million that Congress had earmarked for UNFPA.⁶ Nonetheless, in July, the State Department announced that it would withdraw all funding to UNFPA, citing concerns about the Chinese government’s 1-child policies.⁷ Soon after rescinding UNFPA’s funding, the State Department disclosed that it would redirect $3 million it was expected to contribute to the World Health Organization’s Human Reproduction Program, in objection to the international agency’s research on mifepristone, a drug that can be used for medical abortion.⁸

The following month, in December 2002, the United States delegation nearly derailed a regional United Nations population conference in Bangkok by attacking the 1994 International Conference on Population and Development Programme of Action.⁹ Endorsed by 179 nations (including the United States), this program of action has served as the cornerstone of international population policy since its adoption. The US delegates claimed that 2 terms used in the agreement—"reproductive health services" and "reproductive rights"—implied abortion, despite the fact that the program explicitly excludes the use of abortion as a means of family planning. At the conference, Assistant Secretary of State Gene Dewey created controversy by announcing that the United States "supports the sanctity of life from conception to natural death."^10(pA38) After a week of heated debate, all of the countries voted against the United States to uphold the original agreement.

Meanwhile, on the home front, President Bush has sought to increase funding for "abstinence-only" sexual education programs that promote abstinence as the only acceptable sexual behavior outside of marriage and that do not provide information about safer sex. He requested $135 million for these programs for fiscal year 2003, even though no federal funds are specially designated for comprehensive sexual education, programs that include information about abstinence as well as contraception and prevention of sexually transmitted infections.¹¹

Taken cumulatively, these decisions present a startling, worrisome prospect for the future of family planning. Although acknowledged for decades as an effective and cost-effective public health intervention, the Vatican and anti-abortion groups have successfully attacked family planning by linking it to abortion. As a result, in the short term, funding losses and restrictions have forced cutbacks in services and programs worldwide. In the long run, these conservative initiatives may set back several decades of progress in reproductive rights. In promoting an ideologically driven approach to sexual and reproductive health, the recent developments threaten to subvert ethical standards of medical care and the principle of evidence-based policy.

	CUTTING BUDGETS—AND SERVICES

TOP ABSTRACT INTRODUCTION CUTTING BUDGETS—AND... FREE SPEECH AND MEDICAL... FUNDING IDEOLOGY, NOT EVIDENCE... CONCLUSIONS References

 
Supporters of the new policies point out that total funding levels for population assistance have not been reduced. Indeed, the Mexico City Policy did not decrease USAID’s $425 million budget for population assistance, while the money initially designated for UNFPA was transferred to maternal reproductive and child health programs in Afghanistan and Pakistan.¹² The $3 million intended for the World Health Organization Human Reproduction Program will also be redirected to a different reproductive health project. However, while total funding levels have not dropped significantly, the policy changes have resulted in funding cuts to experienced organizations with extensive resources and credibility in the field.

UNFPA is perhaps the most obvious example. With more than 30 years of work, UNFPA is the world’s largest internationally funded source of population assistance to developing countries. As a result of losing US funding ($34 million, or 12% of its budget), UNFPA must scale back programs in 20 countries, a belt-tightening that United Nations officials estimate will result in 2 million unwanted pregnancies a year, along with nearly 800 000 induced abortions, 4700 maternal deaths, and 77 000 infant and child deaths (W. Ryan, UNFPA information officer, written communication, November 7, 2002; calculation based on previously published methodologies^13,14).

At least 20 organizations have lost funding or contraceptive supplies as a result of the Mexico City Policy, which requires foreign nongovernmental organizations receiving USAID family planning funds to certify that they do not provide, counsel patients about, or advocate decreasing restrictions on abortion with their own funds. Several organizations have chosen to forsake USAID funding rather than comply with the so-called "global gag rule." The Family Planning Association of Kenya and Marie Stopes Kenya are 2 such groups. Abortion is illegal in Kenya, and neither of these organizations provide abortions. They do, however, participate in the active domestic discussion about abortion.

The Family Planning Association of Kenya, an affiliate of the International Planned Parenthood Federation, closed 3 clinics as a result of loss of funds. Marie Stopes Kenya closed 2 clinics after losing an expected $750 000 5-year project and ending its $1.6 million, 3-year agreement with USAID. The clinic closures in Kenya and elsewhere around the world mean that women and men desiring contraception may no longer be able to obtain it. For some women, an undesired pregnancy could mean a dangerous illegal abortion, social and economic impoverishment, or even death: Kenya’s maternal mortality rate is estimated to be 590 per 100 000 live births, or more than 70 times the US rate.¹⁵

In countries such as Kenya, where the largest, most established organizations no longer receive USAID funds, organizations running USAID-funded reproductive health projects must find new local partners. Dr Albert Henn is the director of Amkeni, a 5-year family planning and reproductive health project in Kenya that was to have included Marie Stopes Kenya. After implementation of the Mexico City Policy, he said, "we were depending upon [Marie Stopes Kenya] to help us reverse the lamentable drop in the use of long term and permanent contraceptive methods in Kenya. We will be hard-pressed to find another partner that could play this important role as effectively as Marie Stopes."¹⁶

	FREE SPEECH AND MEDICAL ETHICS

TOP ABSTRACT INTRODUCTION CUTTING BUDGETS—AND... FREE SPEECH AND MEDICAL... FUNDING IDEOLOGY, NOT EVIDENCE... CONCLUSIONS References

 
Proponents of the Mexico City Policy argue that it is not the policy that is to be blamed for service cuts, but the organizations, such as Marie Stopes International and the International Planned Parenthood Federation, that have refused to comply. Studies dating to the Mexico City Policy’s first implementation under President Reagan in 1984 (the policy was subsequently rescinded by President Clinton in 1993 and reinstated by President Bush in 2001) suggest, however, that even organizations agreeing to the policy may be harmed by the new restrictions.

Two major studies of the 1984 Mexico City Policy have been undertaken. Sharon Camp, then vice-president of the Population Crisis Committee (now Population Action International), interviewed representatives of government agencies and nongovernmental organizations in the United States and 8 developing countries.¹⁷ She described a "chilling effect" that resulted in part from confusion over what exactly the law prohibited. One agency, for example, turned down free medical textbooks because the books discussed pregnancy termination. Another group phased out a study on the health consequences of illegal abortion. The USAID-sponsored Blane–Friedman report, which studied 49 projects in 6 countries, also found cases in which staff were overcautious in interpreting the policy: some were unsure whether they could treat women with septic abortions, for example, or study abortion trends.¹⁸

Even when correctly understood and implemented, the Mexico City Policy, by design, skews the discourse on reproductive rights. It forbids advocating for more liberal abortion laws while allowing organizations to lobby against abortion. Opponents of the policy—including the Center for Reproductive Rights, which (unsuccessfully) sued the US government—argue that it is an unconstitutional abridgement of free speech. Susana Galdos Silva, of the Peruvian women’s organization Movimiento Manuela Ramos, testified at a congressional hearing on the Mexico City Policy. She noted the irony of her situation: she was allowed to speak to the US Congress about the perils of unsafe abortion, but in her own country, because of the Mexico City Policy, "if members of congress or other Peruvian officials ask our advice about reforming the punitive abortion laws, we must refuse to help them."^19(p32)

In the case of physicians and other health care providers, the policy creates a particularly vexing conundrum: by not allowing physicians to discuss abortion with patients (except in instances of rape, incest, and threat to the life of the mother), it may preclude physicians from providing ethically sound care. According to the American Medical Association’s Code of Ethics, as the first of its "Fundamental Elements of the Patient-Physician Relationship," "The patient has the right to receive information from physicians and to discuss the benefits, risks, and costs of appropriate treatment alternatives."^20(p231) In the United States, physicians counseling a patient with an undesired pregnancy must explain her alternatives: continuing the pregnancy, carrying the pregnancy to term and placing the baby up for adoption, or terminating the pregnancy. In countries in which abortion is illegal, abortion may not be a feasible alternative. But where abortion is legal, USAID-funded physicians cannot carry out their ethical obligation to provide patients the information they need to make informed decisions.

	FUNDING IDEOLOGY, NOT EVIDENCE-BASED POLICY

TOP ABSTRACT INTRODUCTION CUTTING BUDGETS—AND... FREE SPEECH AND MEDICAL... FUNDING IDEOLOGY, NOT EVIDENCE... CONCLUSIONS References

 
The recent developments described here reflect the conservative ideology embraced by the Republican Party over the past 2 decades. Increasingly, these ideological concerns appear to trump evidence-based decisionmaking. The decision to withhold UNFPA funding, for example, came after 2 investigative teams—dispatched by the British and American governments—found no evidence of wrongdoing. The British team in fact praised UNFPA’s work in China as "a force for good."²¹ The State Department justified the elimination of UNFPA funding by invoking the Kemp–Kasten amendment, which forbids US funding to any organization that supports or participates in a program of coercive abortion or involuntary sterilization.²² Although UNFPA itself strongly condemns coercive practices, the question was whether its collaboration with the Chinese government on noncoercive projects meant that it was "supporting" the government’s 1-child system.

To encompass this kind of "guilt by association," the Kemp–Kasten amendment must be interpreted very broadly. Family planning advocates note that this broad interpretation, if applied uniformly, would disqualify many other aid programs. In June 2002, for example, US Health and Human Services Secretary Tommy Thompson promised $14.8 million for HIV/AIDS programs to the Chinese Ministry of Health, a governmental agency that also provides reproductive health services in the context of the 1-child system.²³

At home, President Bush has continued to increase funding for abstinence-only-until-marriage programs, despite no compelling evidence that they delay sexual activity or prevent teenage pregnancy.²⁴ The American Public Health Association, American Medical Association, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists are among the organizations that have called for comprehensive sexual education programs—programs that promote abstinence as the best way to prevent pregnancy and sexually transmitted diseases (STDs) but also educate teenagers about contraception and safer sex practices.

To qualify for abstinence-only funding, sexual education programs must adhere to 8 principles outlined in federal law, including the following: "sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects" and "a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity."²⁵ The Sexuality Information and Education Council of the United States conducted a review of abstinence-only curricula that rely on a fear-based approach to scare adolescents away from premarital sex. In doing so, some exaggerate the incidence of STDs.²⁶ According to one such program, "Choosing the Best," more than 100 000 cases of syphilis are reported each year²⁷; the Centers for Disease Control and Prevention reported only 6103 cases of primary and secondary syphilis in 2001.²⁸ The curricula describe the worst possible complications of STDs while downplaying common symptoms, as well as the fact that most STDs are treatable. "CLUE 2000" compares the number of people infected with STDs to the number of Americans killed in Vietnam and on highways, neglecting to mention that most people infected with an STD do not die from it.²⁹

Surprisingly, of the 9 reviewed curricula, only one included detailed information about puberty, reproductive anatomy, and reproduction.²⁶ The programs that discuss contraception only emphasize its failure rates. Several curricula offer inflated user failure rates for condoms while suggesting that condoms are inherently ineffective in preventing pregnancy, even if used properly. A few programs teach that, because the human immunodeficiency virus—the virus that causes AIDS—is smaller than a sperm cell, condoms are even less effective in preventing HIV transmission.²⁶ Condoms are described as exceedingly difficult to use—"Choosing the Best" provides a 10-step process²⁷—and one program tells students "Don’t wear revealing clothes or carry a condom."^29(p)

	CONCLUSIONS

TOP ABSTRACT INTRODUCTION CUTTING BUDGETS—AND... FREE SPEECH AND MEDICAL... FUNDING IDEOLOGY, NOT EVIDENCE... CONCLUSIONS References

 
Recent policy decisions demonstrate a worrisome pattern that could presage a continued decline in federal support for family planning programs at home and around the globe. Cuts in funding allocations to UNFPA and other well-established family planning organizations show a willingness to risk the health and well-being of vulnerable populations for ideological concerns. The abstinence-only curricula used in US schools have not been proven effective in changing sexual behavior, and some dispense inaccurate or misleading medical information. By omitting safer sex messages, they leave teenagers and young adults without the information they need to protect themselves against pregnancy and STDs.

In this context, medical professionals have a greater role than ever to play in advocating proven, effective approaches to family planning. A number of medical and public health associations, along with nongovernmental organizations, are working to turn back the tide of abstinence-only education. Congressional efforts to repeal the Mexico City Policy and to fund UNFPA are continuing but face an uphill battle.

In 1994, the International Conference of Population and Development in Cairo set forth an ambitious vision in which all people—regardless of their social or economic status—would have access to reproductive health services by 2015. With only a dozen years to go, America’s leadership in family planning has become mired in a highly politicized domestic debate—an unfortunate turn of events for the estimated 230 million women who lack effective methods to plan the number and spacing of their children.³⁰

	Acknowledgments

 
Felicia H. Stewart gratefully acknowledges grant, speaker, and consulting support from Berlex (Protocol no. 303820), Organon, Merck, Barr Lab, Ortho-McNeil (Protocol no. CAPSS-208), and Hoffman LaRoche.

We would like to thank Signy Judd and Tracy Weitz of the Center for Reproductive Health Research & Policy, University of California, San Francisco, and Barbara Crane of Ipas USA, Chapel Hill, North Carolina, for their thoughtful comments and suggestions. Stan Bernstein, United Nations Population Fund, provided details on the methodology for funding loss effects and additional helpful comments.

	Footnotes

 
Contributors
The authors jointly developed the study’s analytical framework and reviewed drafts. A. C. Hwang developed the article’s structure and led the writing. F. H. Stewart contributed the study’s conceptual underpinnings and supervised the work.

Peer Reviewed

Accepted for publication June 29, 2003.

	References

TOP ABSTRACT INTRODUCTION CUTTING BUDGETS—AND... FREE SPEECH AND MEDICAL... FUNDING IDEOLOGY, NOT EVIDENCE... CONCLUSIONS References

 
1. Programme of Action. Cairo, Egypt: International Conference on Population and Development; 1994. Principle 8.

2. Proclamation of Tehran. Tehran, Iran: International Conference on Human Rights; 1968.

3. US Agency for International Development. Saving women’s lives, protecting women’s health [fact sheet]. Available at: http://www.usaid.gov/pop_health/pop/popfpfactsheet.htm. Accessed June 28, 2001.

4. Adamson DM, Belden N, DaVanzo J, Patterson S. How Americans View World Population Issues: A Survey of Public Opinion. Santa Monica, Calif: RAND; 2000.

5. Memorandum of March 28, 2001—restoration of the Mexico City Policy. Federal Register. March 29, 2001:17301–17313.

6. Brown WA, Glick BL, Tong TG. Report of the China UN Population Fund (UNFPA) Independent Assessment Team. Available at: http://www.state.gov/g/prm/rls/rpt/2002/12122.htm. Accessed January 11, 2003.

7. Boucher R. FY 2002 funding for the UN Population Fund (UNFPA) [press statement]. Available at: http://www.state.gov/r/pa/prs/ps/2002/12035.htm. Accessed November 25, 2002.

8. Boucher R. Daily press briefing: November 7, 2002. Available at: http://www.state.gov/r/pa/prs/dpb/2002/14994.htm. Accessed November 21, 2002.

9. Dao J. Over U.S. protest, Asian group approves family planning goals. New York Times. December 18, 2002:A7.

10. An anti-life crusade [editorial]. New York Times. December 20, 2002:A38.

11. Dailard C. Abstinence promotion and teen family planning: the misguided drive for equal funding. Guttmacher Rep. February 2002:1–3.

12. U.S. diverts funds withdrawn from UN over China abortion row. Agence France Presse. January 22, 2003.

13. Meeting the Goals of the ICPD: Consequences of Resource Shortfalls Up to the Year 2000. New York, NY: United Nations Population Fund; 1997.

14. Alan Guttmacher Institute, Population Reference Bureau, Futures Group International, Population Action International. Potential impact of increased family planning funding on the lives of women and their families overseas [special report]. Available at: http://www.agi-usa.org/pubs/fund_impact.pdf. Accessed June 26, 2003.

15. Human Development Report 2002: Deepening Democracy in a Fragmented World. New York, NY: United Nations Development Program; 2002.

16. Marie Stopes International. Africa’s poorest will suffer as USA’s Mexico City Policy forces family planning clinics to close [press release]. Available at: http://www.mariestopes.org.uk/ww/press/press-ww-100901.htm. Accessed November 25, 2002.

17. Camp S. The impact of the Mexico City Policy on women and health care in developing countries. N Y University J Int Law Politics. 1987;20:35–51.

18. Blane J, Friedman M. Mexico City Policy Implementation Study. Washington, DC: Agency for International Development; 1990. Population Technical Assistance Project occasional paper 5.

19. Mexico City Policy: Effects of Restrictions on International Family Planning Funding, July 19, 2001: Hearing Before the Committee on Foreign Relations, United States Senate, 107th Cong, 1st Sess (2001) (testimony of Susana Galdos Silva).

20. Council on Ethical and Judicial Affairs. Code of Medical Ethics: Current Opinions With Annotations, 2000–2001 Edition. Chicago, Ill: American Medical Association; 2000:231.

21. McCafferty C, Leigh E, Lamb N. China mission report by UK MP’s: 1st April–9th April 2002. Available at: http://www.house.gov/maloney/issues/UNFPA/ukreport.pdf. Accessed January 13, 2003.

22. Bureau of Population, Refugees, and Migration, US Dept of State. Analysis of determination that Kemp-Kasten Amendment precludes further funding to UNFPA under Pub. L. 107-115. Available at: http://www.state.gov/g/prm/rls/other/12128.htm. Accessed November 25, 2002.

23. US Dept of Health and Human Services. Secretary Thompson announces expanded coordination of HIV/AIDS programs in China [press release]. Available at: http://www.hhs.gov/news/press/2002pres/20020628b.html. Accessed January 11, 2003.

24. Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, DC: National Campaign to Prevent Teen Pregnancy; 2001.

25. US Social Security Act 510(b)(2) (1996). Available at http://www.ssa.gov/OP_Home/ssact/title05/0510.htm. Accessed December 17, 2003.

26. Kempner M. Toward a Sexually Healthy America: Abstinence-Only-Until-Marriage Programs That Try to Keep Our Youth ‘Scared Chaste.’ New York, NY: Sexuality Information and Education Council of the United States; 2001.

27. Choosing the Best Student Manual, 1998 Edition. Marietta, Ga: Choosing the Best Inc; 1998.

28. US Centers for Disease Control and Prevention. Primary and secondary syphilis—United States, 2000–2001. MMWR Morb Mortal Wkly Rep. 2002;51:971–973.[Medline]

29. Clue2000 Curriculum. New York, NY: Pure Love Alliance; 2000.

30. United Nations Population Fund. Family planning: a human right [fact sheet]. Available at: http://www.unfpa.org/rh/planning.htm. Accessed June 25, 2003.

This Article Abstract Full Text (PDF) Submit a response Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via ISI Web of Science (2) Citing Articles via Google Scholar Google Scholar Articles by Hwang, A. C. Articles by Stewart, F. H. Search for Related Content PubMed PubMed Citation Articles by Hwang, A. C. Articles by Stewart, F. H. Related Collections Abortion Contraception Other Birth Control Health Policy Other Maternal and Infant Health