Situating the Mexico City Policy: what shapes contraceptive access and abortion?
Authors: Joseph Mumba Zulu, Marte E S Haaland
Journal: The Lancet Global Health (2019)

The Mexico City Policy, a US policy of withdrawing foreign assistance to organisations that offer abortion services or abortion counselling, has been enacted or rescinded with every political party change in the US government since Ronald Reagan's presidency. In this issue of The Lancet Global Health, Nina Brooks and colleagues examine the impact of the policy in sub-Saharan Africa and thereby make an important contribution to the literature on sexual and reproductive health and policy analysis.1Brooks N Bendavid E Miller G US aid policy and induced abortion in sub-Saharan Africa: an analysis of the Mexico City Policy.Lancet Glob Health. 2019; (published online June 27.)http://dx.doi.org/10.1016/S2214-109X(19)30267-0Scopus (16) Google Scholar In doing so, they address some of the global dynamics of reproductive health and their implications for national health systems and individual health practices in low-income and middle-income countries. The authors argue that the Mexico City Policy has the unintended consequence of increasing abortion uptake and decreasing use of modern contraceptives, since organisations affected by the policy also are important distributors of modern contraceptives. They note that the policy has influence on availability of contraceptives and subsequently on increasing reporting of pregnancy. As such, they propose an outline of the mechanisms through which the Mexico City Policy has the seemingly counterintuitive outcome of increased prevalence of abortions. Worldwide, abortion is a sensitive and disputed topic and its controversy is related to a variety of factors that might be differently configured from context to context.2Kumar A Hessini L Mitchell EMH Conceptualising abortion stigma.Cult Health Sex. 2009; 11: 625-639Crossref PubMed Scopus (324) Google Scholar To better understand under what conditions abortion uptake and access to modern contraceptives change, it is necessary also to examine how abortion and contraceptives are understood in the national and local contexts. Brooks and colleagues1Brooks N Bendavid E Miller G US aid policy and induced abortion in sub-Saharan Africa: an analysis of the Mexico City Policy.Lancet Glob Health. 2019; (published online June 27.)http://dx.doi.org/10.1016/S2214-109X(19)30267-0Scopus (16) Google Scholar find a considerable rise in abortion rates of approximately 40% in countries most exposed to the Mexico City Policy from 2001 to 2008, and relate the finding to availability of contraceptives, but when considering how the policy is implemented in a specific social, cultural, and political context, the link between availability of contraception and abortion services on the one hand and the increase in abortion prevalence on the other becomes more complex. In Zambia (a country in sub-Saharan Africa), where abortion is legal on broad socioeconomic grounds, it is commonly understood as a moral transgression. Zambia's approximately 15 million inhabitants are predominantly Christian and the country was declared a Christian nation in 1991. Politics and religion are closely connected with consequences for people's access to and decisions about sexual and reproductive health and rights.3Haaland MES Haukanes H Zulu JM et al.Shaping the abortion policy—competing discourses on the Zambian termination of pregnancy act.Int J Equity Health. 2019; 18: 20Crossref PubMed Scopus (11) Google Scholar Despite the legal framework that broadly allows abortions, girls and women face a series of barriers when seeking the service.4Coast E Murray SF “These things are dangerous”: understanding induced abortion trajectories in urban Zambia.Soc Sci Med. 2016; 153: 201-209Crossref PubMed Scopus (45) Google Scholar The literature suggests that religious values, political climate, and dominating moral understandings are of great importance in facilitating access to safe abortion and modern contraceptives, independent of the availability of contraceptives.5Unnithan M de Zordo S Re-situating abortion: bio-politics, global health and rights in neo-liberal times.Glob Pub Health. 2018; 13: 657-661Crossref PubMed Scopus (9) Google Scholar In the Zambian public sphere, simply discussing issues of contraception and abortion is problematic, making it difficult for organisations to address these issues on a community level.6Zulu JM Ali J Hallez K Kass N Michelo C Hyder AA Ethics challenges and guidance related to research involving adolescent post-abortion care: a scoping review.Reprod Health. 2018; 15: 71Crossref PubMed Scopus (5) Google Scholar As a consequence, people's knowledge about contraception and abortion remains low.7Cresswell JA Schroeder R Dennis M et al.Women's knowledge and attitudes surrounding abortion in Zambia: a cross-sectional survey across three provinces.BMJ Open. 2016; 6e010076 Crossref PubMed Scopus (24) Google Scholar Moreover, because of the dominant moral understanding about abortion and contraceptives, Zambian health workers are commonly uncomfortable providing sexual and reproductive health services, especially to young and unmarried clients.8Freeman E Coast E Conscientious objection to abortion: Zambian healthcare practitioners' beliefs and practices.Soc Sci Med. 2019; 221: 106-114Crossref PubMed Scopus (9) Google Scholar This means that in Zambia, other, more socially embedded factors might be just as important for preventing unsafe abortions as fluctuation in the availability of contraceptives caused by the Mexico City Policy. Contraceptive use and abortions are also conditioned by national level policies. The Zambian abortion law requires three medical doctors, including a specialist, to sign the required documentation for a legal abortion. In a country with less than half of the health workforce that is needed to meet the demands of the population, this constitutes an important barrier to provision of safe abortion services, independent of the Mexico City Policy. Although comprehensive sexuality education has been rolled out in schools, reviews in Zambia and elsewhere show that many teachers neglect the subject altogether, or omit what is considered sensitive topics such as contraception and abortions.9Vanwesenbeeck I Westeneng J De Boer T Reinders J Van Zorge R Lessons learned from a decade implementing comprehensive sexuality education in resource poor settings: The World Starts With Me.Sex Education. 2015; 16: 1-16Google Scholar This reduces awareness about sexual and reproductive health and rights among young women. Furthermore, the Ministry of Education forbids distribution of contraception in schools, effectively limiting the space for adolescents to access contraceptives, independent of their availability. In their article, Brooks and colleagues provide much needed documentation of the wide-ranging effects of the Mexico City Policy that allow us some insight into the sometimes subtle mechanisms of global reproductive governance.1Brooks N Bendavid E Miller G US aid policy and induced abortion in sub-Saharan Africa: an analysis of the Mexico City Policy.Lancet Glob Health. 2019; (published online June 27.)http://dx.doi.org/10.1016/S2214-109X(19)30267-0Scopus (16) Google Scholar, 10Morgan LM Roberts EFS Reproductive governance in Latin America.Anthropol Med. 2012; 19: 241-254Crossref PubMed Scopus (117) Google Scholar We would like, however, to encourage readers to situate these global mechanisms in the specific contexts where they take effect. Our examples from Zambia describe a complex web of socially, morally, and politically embedded factors that along with the Mexico City Policy have implications for contraceptive use and abortions. We urge readers to keep these factors in mind in further discussions about the consequences of the policy in sub-Saharan Africa. Only by situating the policy in the contexts it is implemented in and considering the wide range of relevant factors can we get a better understanding of what conditions unwanted pregnancies and unsafe abortions. We declare no competing interests. USA aid policy and induced abortion in sub-Saharan Africa: an analysis of the Mexico City PolicyOur findings suggest that curbing US assistance to family planning organisations, especially those that consider abortion as a method of family planning, increases abortion prevalence in sub-Saharan African countries most affected by the policy. Full-Text PDF Open Access