Global Abortion Access After Roe

Globally, there is broad medical consensus that access to safe abortion and reproductive care saves womens’ lives. And nations around the world have acknowledged this fact, expanding access to reproductive health services over the past three decades.

Still, in 2022, the U.S. Supreme Court overturned Roe v. Wade, taking away nearly 50 years of constitutional protections for abortion care and making the United States one of just four countries to roll back access to abortion.

And what the U.S. does, matters. This decision has - and could continue to - spark action in other countries, for both those that want to restrict abortion care and those that want to protect it.

My name is Gabrielle Sierra and this is Why It Matters. Today, why abortion is a public health issue and how the United States’ ruling could play out globally.

Onikepe OWOLABI: Public health aims to promote and protect the health of all people and all communities. Even though abortion has been typically politicized, it's important to note that abortion is basic healthcare and ties into bodily autonomy and thus public health.
 

This is Onikepe Owolabi. She’s a physician epidemiologist and the director of international research at the Guttmacher Institute, a research and policy NGO focused on reproductive health.

OWOLABI: When you think of reproductive care, it's supposed to be care across the spectrum that caters to all the needs of people, and in this space, an abortion is a complete health intervention. And if reproductive health really aims to ensure complete physical, mental, and social well-being, and not merely the absence of disease, then abortion is a key part of care that we should provide to women. 

So what does reproductive care entail? 

Reproductive care includes access to prenatal services, safe childbirth, and contraception, which prevents pregnancy from happening in the first place. Contraceptives like Plan B and IUDs are often conflated with abortion, and, in recent years, some lawmakers in the U.S. have even tried to ban these birth control methods in their state legislatures.

Reproductive care also encompasses legal and safe abortion, which is different from contraception. And in the last thirty years, more than sixty countries have liberalized their abortion laws. And over the past twenty, maternal mortality has declined by over 30 percent, potentially putting the world on track to meeting a core UN Sustainable Development Goal which seeks to “ensure universal access to sexual and reproductive health-care services” by 2030.

OWOLABI: Safe abortions are extremely safe and extremely effective, with very, very low prevalence of complications, in an adequate environment, or even when a woman takes medication abortion at the right dose, the right prescription, and she has access to healthcare system, it's extremely effective. And when women don't have access to safe abortion care, they simply will typically seek out unsafe abortions. Abortions have happened for many generations, and so it's not like, oh, they don't have access, and then they don't do anything about it, and this is why all the data we have shows that the abortion rates in countries where the laws are restricted and in countries where the laws are liberal are pretty similar to each other. The only thing that changes is the process of the abortion, and thus the woman's outcome.

But according to the Center for Reproductive Rights, 40 percent of women worldwide live in countries with restrictive abortion laws. And each year, the World Health Organization estimates that 39,000 women and girls still die from the consequences of unsafe abortions. 

OWOLABI: The evidence we have from countries like Latin America, including Mexico, and countries like Nepal, where the abortion law has been liberalized, suggests very clearly to us that when abortion laws are changed and more women have access to safe abortion, we see reductions in some of the worst outcomes of unsafe abortion, so hemorrhage, sepsis, perforation of the uterus, we see those go down in hospital admissions dramatically. In fact, if you look at some of the evidence available from Southeast Asia, they will often tell you that you just don't see severe complications of abortions go down, you see maternal mortality reduce dramatically, because unsafe abortions are a major cause of maternal mortality in many of these contexts, they're often amongst the most marginalized, and when you're able to increase access to safe abortions, it basically takes away a very easily preventable cause of maternal mortality.

Because abortion is highly stigmatized, many women and health-care providers don’t report the procedure, which then makes data limited. This has led some experts to believe that deaths and complications from unsafe abortions are undercounted.

This theme could play out increasingly in the U.S. too, where women in some states could soon face legal action for admitting to having an abortion.

Gabrielle SIERRA: Can you give me a quick breakdown of why are we talking about this today? What's the current landscape of abortion policy in the U.S.?

Patty SKUSTER: So for nearly 50 years, the U.S. had a constitutionally protected right to abortion under Roe v. Wade.

This is Patty Skuster. She teaches about global abortion law and reproductive rights at the University of Pennsylvania and works with the World Health Organization on abortion law implementation.

SKUSTER: There are a lot of different contours around that. But basically, before viability, abortion was legal in the U.S., no matter what state you were in, there were a lot of other restrictions, but that was the baseline.

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The Nation Speaks: The supreme court really ever since 1973, has said that there’s a right to choose abortion before fetal viability. Which usually comes somewhere between the 22nd and 24th week of pregnancy.

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KETV NewsWatch 7: Fetal viability addresses whether a pregnancy is expected to continue developing normally, and addresses whether a fetus might survive outside of the uterus.

In 2021, the last year before the overturning of Roe v. Wade, the Center for Disease Control and Prevention reported that less than 1 percent of U.S. abortions occurred after 21 weeks. The timeframe for viability varies around the world, but many countries are in the same ballpark as the United States.

SKUSTER: In 2022, we had the Dobbs decision where the U.S. Supreme Court removed the right to abortion for Americans, basically from the interpretation of the constitution that they had. And then that enabled states across the country to make abortion illegal.

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WFAA: Real time reaction to the high courts decision overturning Roe v. Wade, striking down the constitutional right to abortion, leaving that decision for states to decide.

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ABC News: “Roe was on a collision course with the constitution from the day it was decided.” Alito wrote, “It is time to heed the constitution and return the issue of abortion to the people's elected representatives.”

SKUSTER: Legally, there's been tons of litigation. The Supreme Court just heard a case on the FDA's approval of abortion pills. And so we're in a real legal quagmire now following the Dobbs decision but with the range of abortion legality across the country.

SIERRA: How does abortion access in the U.S. compare globally? Are we that unique in our policies? Does anyone have similar policies?

SKUSTER: Where we're really, really an outlier is looking at trends. Globally, we've seen massive undeniable trends toward loosening of restrictions on abortion, towards steps toward making abortion more available, making more abortions legal, while a very small handful, including the U.S., have made their abortion laws more restrictive.

Alongside the United States, Nicaragua, El Salvador, and Poland have decreased access to abortion.

SKUSTER: But then also, particularly with Nicaragua and El Salvador, we can see a rise of authoritarianism. And I think we're starting to understand the links between restrictive abortion laws, restricting rights of women, restricting gender equality and links to authoritarianism. But I also think kinda putting the U.S. with its retrogression on abortion in the context, so the world really illuminates, kind of, the authoritarian danger. Not to go too far afield, but that's happening in the U.S. When we see ourselves in the company of Nicaragua, El Salvador specifically, which also have repressive governments, we can see there are very clear connections between wanting to roll back women's rights, roll back rights to abortion, and establish a government that has a tremendous amount of power. 

The United States, of course, is a leading global democracy which has an outsized role in global health efforts. The U.S. directs $13 billion in funding for global health each year - and this means that the U.S. can decide what money goes where, including with a program called PEPFAR.

SKUSTER: PEPFAR is the funding to combat the AIDS crisis around the world. It's actually a President George W. Bush program that promotes treatment for HIV, reductions in HIV. And so PEPFAR has been successful in reducing transmission and AIDS rates around the world and is really the largest chunk of global health funding that the U.S. has given to countries primarily in Africa, Asia and Latin America. However, the U.S. has had an anti-abortion global health policy since the '70s, right after Roe v. Wade. The U.S. restricted its funding to say that no U.S. foreign assistance can go for abortion. But the Dobbs decision really sets more of a tone of the U.S. as being very against abortion across the world.

There are two major pieces of policy that restrict U.S. funds for abortion overseas. The first is the Helms Amendment, which prohibits the use of U.S. aid to pay for abortions, abortion research, or abortion lobbying. It was passed by Congress in 1973 before being signed by President Richard Nixon. The second is the global gag rule, commonly known as the Mexico City policy, which went even further than the Helms Amendment by requiring foreign NGOs to certify that they would not perform or actively promote abortion as a method of family planning. President Ronald Reagan implemented that rule in 1985 to prevent organizations that receive U.S. global health funds from using any foreign aid money for abortion-related purposes. Every Republican president since has supported the global gag rule, and every Democratic president has rolled it back.

And this pattern continues. One of Donald Trump’s first acts as president was to reinstate and expand the global gag rule, policies that President Joe Biden rescinded soon after taking office.

SKUSTER: So all of the money that the U.S. gives to lower and middle-income countries around the world, the Helms Amendment says none of that funding can be used for abortion. And so even in countries, for example, Ethiopia, which is a big recipient of U.S., foreign assistance, abortion is legal in Ethiopia, the U.S. gives a lot of funding for various programs on reproductive health, but none of that can be used for abortion. And so the result of that is not only reducing the availability of funds for abortion, but then also stigmatizing abortion, “Abortion is different than other healthcare services.” And so while the U.S. has had an important role in promoting reproductive health, it's always been problematic from an abortion rights perspective. It really sends that message through the Helms Amendment.

SIERRA: Do other governments restrict foreign aid dollars on abortion like the U.S. does because of Helms or the global gag rule?

SKUSTER: No. We are in fact, the only donor government that has an explicit restriction on funding for abortion. That's not to say every government funds abortion. Some governments might have other priorities, but we are the only one that restricts funding for abortion. And that's important because the U.S., as I mentioned, is the largest funder of reproductive health around the world. And so by carving out abortion, which is a key part of reproductive health, of course, really has an impact not only on programming, but also reinforces abortion stigma and forms an impression of abortion as being this other thing when in fact it is an essential part of reproductive healthcare.

We’ll be back after a quick break.
 

SIERRA: How influential is the United States with regard to abortion policy in other countries?

SKUSTER: It's undeniable that the U.S. is a highly influential country in many different ways, including in the way that courts decide things here in the U.S. The decision of Roe v. Wade was based on legal precedent going back a couple decades before Roe, but basically said reproductive rights have to do with privacy, have to do with the right of someone to decide what to do with themselves during pregnancy. And that was a real novel argument, but we've seen it kind of seep into other places, including international human rights law, where the committee that oversees a treaty on civil and political rights at the UN started to recognize abortion as an issue of the right to privacy. 

SIERRA: Have other countries seized on Dobbs to enforce their own abortion bans?

OWOLABI: We have seen that the U.S. is really impactful, because since the Supreme Court Dobbs decision in 2022 when they reversed Roe v. Wade, we have already started to see ripple effects globally. And the Dobbs decision has been cited in multiple other regressive laws, including Uganda's anti-LGBTQIA law, in Nigeria in the bid to roll back the Safe Abortion Act in Lagos State. It has also been cited in Kenyan courts as a reason not to push forward with a more liberal abortion law, because when Dobbs was repealed, they said, "Well, if the USA, they've backtracked and they made a bad decision, why should we make progress?" And so, the impact of the U.S. decisions on abortion is affecting countries globally, and empowering people to make decisions that really affect the human rights of women and girls all around the world.

SIERRA: So then let me ask you this - can U.S. law be used as a basis for law abroad?

SKUSTER: Judges and justices can and often do look to other courts in deciding law. I've seen it firsthand in drafting legislation. When someone's drafting legislation, they might say, "Okay, how does the U.S. do it?" And so legislators very deliberately might look around the world to see, I've played this role at how do we draft abortion laws? Well, let's look at how other countries do it. And judges do the same thing explicitly or not explicitly. And so it's not that unusual, but to really directly cite it and use the same analysis in that robust way, certainly was unusual.

SIERRA: So perhaps it's fair to say that decisions like Dobbs are at least politically useful for leaders around the world who are seeking to block abortion access in their own countries.

SKUSTER: Yeah. It's sort of putting a very influential tool in the toolbox of repressive regimes. And on the non-legal influence piece of it, when you criminalize abortion, you're really stigmatizing it. You're saying this thing is criminal. And so the fact that the U.S. has now said, "Okay, we're going to allow criminalization of abortion," really helps deem it something bad. And when you stigmatize it, you treat it as people who have it as bad people, even though it's totally common, and it's usually women who are having abortions.

But not all countries are using Dobbs to restrict abortion. In some nations, Dobbs has had the opposite effect, with the law serving as motivation for enshrining abortion protections.

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Guardian News: I’ve got to tell you I think it’s a big step backwards.

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Global News: The judgment coming out of the United States is an attack on women's freedom, and quite frankly it's an attack on everyone's freedoms and rights.

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CBS News: In a historic move, France has become the only country to guarantee abortion as a constitutional right.

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Emmanuel Macron/Guardian News: (Translation) This is why I wish for the inscription of this guaranteed liberty to access to abortion in the chart of fundamental rights of the European Union.

SKUSTER: Abortion was legal in France before, but here they're saying, "Okay, let's change the constitution and make abortion a right." And so in the same way that we're seeing the same types of votes in U.S. states where, when given the opportunity for a population of a state to vote on the constitutionality of abortion, even in I think Kansas was the first one, even in states that are conservative, we see the popular vote is supportive of abortion rights. And that happened in France and spurred on by Dobbs. Dobbs has really brought abortion, to the forefront, and really the realization that we don't want to go backwards.

And this ripple effect of support for abortion access extends into access to reproductive care as well, where both abortion pills and contraceptives like IUDs and Plan B are becoming more widespread options for women.

OWOLABI: There are some things that have made abortion care safer, and what I'm referring to is medication abortion pills. And so, since the development and marketing of misoprostol and mifepristone, which is a combination often used for self-managed medication abortion, it has been easier for many women to get access to safe abortions. It's also been easier to do something called task shifting, or task sharing, in many countries, which means to take abortion care from being the sole preserve of a physician or an obstetrician gynecologist, and to allow mid-level or other cadres of staff, including nurses, midwives, and physician assistants, to provide this care. And it is important to recognize that task sharing, especially with the availability of medication abortion pills, has the potential to expand access for many women, self-managed or in conjunction with providers, and to really make abortion safer globally.

Even in a country like Honduras, which has one of the toughest abortion laws in the world, there is momentum behind the decriminalization of non-abortion related reproductive care. This March, the President of Honduras, Xiomara Castro, signed an executive order ending the country’s ban on the use and sale of emergency contraceptives like Plan B.

SIERRA: Do you think we will continue to see ripples from Dobbs?

OWOLABI: I do think so. I think we will likely continue to see ripples from Dobbs, because the United States has established itself as a very influential country, both politically, and it is also one of the largest funders of development in many countries. It funds many maternal reproductive health programs, and like we've seen over time, every time something happens in our policy space, it affects the direct funding countries get. But beyond the direct funding they get, it affects the policy environment. The impact of Dobbs is likely to be felt in all low income countries, but many countries are at a point where they're in an election period so they're changing their governments. We hope that the Dobbs decision does not embolden conservative governments to try to backtrack on legislative progress that has already been made.

This November, a seemingly divisive choice on abortion will loom large in the minds of many American voters. Around a dozen states may have abortion-related ballot items this fall, and the issue motivated voters to come out in droves in 2022. Many analysts believe it could be an issue that defines the 2024 election.

But the stakes of the election go far beyond U.S. borders.

SIERRA: What’s at stake for these issues in the 2024 election?

SKUSTER: Certainly, directly from a policy perspective, the global gag rule is the real direct thing that is of great concern. We've seen when the global gag rule is on, organizations really shy away from any type of abortion work at all. And there are some examples of where coalitions working for liberalization of abortion laws have shrunk under the global gag rule because organizations weren't allowed to participate in advocacy on abortion. And so that, we would expect, would be one of the things that a Republican, that a Trump Administration would do in the first act, but then also, kind of thinking about appointing judges, potentially appointing justices. And here's where I'm seeing the connections between gender equality, LGBTQ rights, abortion rights, all of these rights. All of our rights, every one of our rights is really at stake when we're looking forward to the next election.

Most OB-GYNs say the overturning of Roe v. Wade has worsened their ability to manage pregnancy-related emergencies, and a majority of them say they are concerned about their own legal risk when making decisions about patient care. If doctors are unable to provide necessary care based on legal restrictions, that could put many womens’ lives in danger. And that’s scary, especially when one in four women in the United States are expected to have an abortion during their lifetime.

How the United States views abortion access matters globally, and with a pivotal American election on the horizon, the way the country moves forward could affect the trajectory of how reproductive rights and services are provided globally for years to come.

Our interns this semester were amazing, and we wish them the best of luck on their future endeavors. So, as is tradition, here they are to read us out!

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Why It Matters is a production of the Council on Foreign Relations. The opinions expressed on the show are solely that of the guests, not of CFR, which takes no institutional positions on matters of policy.

This episode was produced by Asher Ross, Molly McAnany, Noah Berman and Gabrielle Sierra. Our sound designer is Markus Zakaria. Our interns this semester are me, Olivia Green.

And me, Meher Bhatia. Production assistance for this episode was provided by Mariel Ferragamo. Special thanks to the team at Think Global Health for their collaboration on this episode. Robert McMahon is our Managing Editor. Our theme music is composed by Ceiri Torjussen.

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