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The lengthy shadow of the International Gag Rule in Pakistan

PROVINCES OF PUNJAB and SINDH, Pakistan – On a Saturday in February, four women came to a reproductive health clinic in Rawalpindi, Pakistan to terminate their pregnancy. Three of the four were married mothers with multiple children, like many women receiving abortion care in Pakistan. When Naseem Tariq, a doctor at the clinic, lifted a client's shirt to do an ultrasound, the stretch marks from her last baby were still visible.

Tariq sees patients with unwanted pregnancies almost every day. After each consultation, she informs women about their family planning options. Most patients do not have access to long-term contraception, often because husbands or mothers-in-law do not allow it or because they cannot easily afford it. Only 34 percent of married Pakistani women use contraception and only 25 percent rely on modern methods, based on the latest government-sponsored survey. "They are poor. They have seven to eight children. There is no access to family planning services," said Tariq. "What do you get? Unwanted pregnancies."

Although abortion is only legal in Pakistan under certain conditions, the country has one of the highest abortion rates in the world – an estimated 50 abortions per 1,000 women. This emerges from research by the Population Council in 2012, one of the most comprehensive reports on the subject. This makes health organizations in Pakistan particularly vulnerable to funding restrictions targeting abortion. Family planning initiatives in Pakistan suffered under the Trump administration, which reintroduced and expanded Mexico City's policy to provide abortions, advise women on abortion, or refer abortion services to recipients of U.S. aid to global health forbid – even with your own private means.

US President Joe Biden lifted the so-called global gag rule shortly after taking office in January, ending restrictions on an estimated $ 12 billion in foreign aid. Although the change reopens funding channels, restrictions on abortion remain a defining feature of the U.S. model of family planning that affects the care reproductive health organizations can offer. Given the remaining funding constraints and the ongoing impact of the global gag rule, local organizations in Pakistan still face barriers to family planning and safe abortion care.

A nurse takes care of a mother and her new baby at the Services Institute of Medical Sciences, a public hospital in Lahore, Pakistan, on April 2.

A delivery room is pictured on March 9 at the Anila Maternity Center in northwest Karachi. The clinic, which was previously supported by the U.S. Agency for International Development, lost its birth control when U.S. funds were withdrawn before the global gag rule of women in the community with few other options for family planning.

The success of family planning in Pakistan is vital as the population increases and puts pressure on infrastructure and resources. Despite pressure from the Pakistani government to increase the use of contraception, many women still do not have access. Birth control and birth rates have actually declined slightly, according to the 2013 and 2018 Pakistan Demographic and Health Surveys, which suggest that more women seek abortions, according to reproductive health advocates.

Abortion is legal in Pakistan to save a woman's life or to provide “necessary treatment” early in pregnancy. However, some doctors do not perform the procedure due to personal values, social pressures, or a misinterpretation of the law. Many women seek services from untrained providers or instead use traditional methods to terminate their pregnancy, complications for 68 percent of rural poor women. The private sector, including non-governmental organizations, is bridging the gap for the safest abortion services, as well as training in advice and legal clarification for doctors. Given the frequency of complications and the stigma associated with abortion, reproductive health providers in Pakistan are particularly focusing on post-abortion care.

Family planning organizations typically rely on foreign donors, and those who receive US funding face the same conservative pressures that US domestic organizations face. The US government has played a significant role in the Pakistani family planning program since its inception in 1965, providing up to 40 percent of program supplies including contraception at times. Just over 3 percent of Pakistan's GDP was spent on health care in 2018, and provincial budgets for the well-being of the population are limited.

On April 1, a poster about birth control hangs on a wall at a women's health center for Afghan refugees in the suburbs of Islamabad.

When the Trump administration reintroduced the global gag rule, it linked organizations offering these services as recipients and sub-recipients of U.S. aid, forcing some of them to close clinics. "We were not ready to sign this certification and our funding stopped immediately," said Syed Kamal Shah, CEO of the Rahnuma-Family Planning Association of Pakistan, one of the country's pioneers for the good of the people.

But even with Biden's repeal, organizations face different funding constraints on US aid. The Helms novella, published in 1973 as part of a backlash against Roe v. Wade passed, US foreign aid still bans "abortion as a family planning method" or institutions that "encourage or compel a person to practice abortion". The policy is designed to prevent US tax dollars from being used for abortion overseas. In practice, however, it also prevents organizations from providing appropriate services, including counseling and, crucially in Pakistan, post-abortion follow-up care.

While technically an exception to post-abortion care, the Helms change limits funding for the tools used to provide them, which are the same as those used for abortion. According to Asma Balal, the Marie Stopes Society Pakistan country director, the organization has historically not been able to use U.S. Agency for International Development (USAID) money to procure misoprostol or manual vacuum aspiration kits to treat women who botched treatment for Seek abortions. “Post-abortion care is a life-saving service. But we weren't even allowed to provide that, ”said Balal.

Men stand at a container clinic providing women's health services in a village outside of Sargodha, Pakistan, March 17.

A boy rides a motorcycle through an empty field near a midwifery clinic in western Karachi, Pakistan on March 10. Family planning services in Pakistan are often limited in remote areas where women rely on clinics that are free or inexpensive with humanitarian assistance. Cost of birth control.

US support for the Pakistani population program has fluctuated across the White House party since former US President Ronald Reagan introduced the global gag rule in 1984. Under pressure to appease religious groups and right-wing lobbies , Republican governments have consistently scaled back USAID population and family planning activities just so democratic administrations can restart them. This rocking effect can be staggering for aid recipients, Balal said. "If the project is pulled, it's not just the project. Then your whole system is shaken," she said.

Due to the limitations associated with US assistance, reproductive health providers still have some concerns about receiving US assistance. In Pakistan, where foreign funding is sometimes viewed with suspicion, premature termination of programs due to restrictions can undermine the credibility of organizations providing safe abortion services. “Your clinic was suddenly closed. And then people will say, “Yeah, but what was your agenda? Something was wrong with them, ”said Shah.

Women wait for the outpatient gynecology department at the Services Institute of Medical Sciences in Lahore, Pakistan on April 2.

A woman sits with her baby at the Services Institute of Medical Sciences in Lahore, Pakistan on April 2.

The ideological constraints of US abortion policy have a profound impact on family planning as a whole. US funding constraints have made it more difficult for reproductive health organizations to obtain birth control. A USAID project that spent $ 160 million on contraception in Pakistan ended in 2016 and took a large chunk off the table for four years. "With the gag rule, every negotiation and opportunity was lost," said Sana Durvesh, assistant director general for programs at Greenstar Social Marketing, a social enterprise that provides reproductive health products and services.

Under Biden, it will be some time before new purchases are updated with US funds. Pakistan currently receives most of its contraceptives through international tenders and critical shortages remain. Intrauterine devices are particularly scarce due to the poor trade relations between Pakistan and India affecting imports.

The chilling effects of conservative policies also disrupted partnerships between reproductive health organizations in Pakistan, which are slow to resume. Ghulam Shabbir Awan, the Pakistani director of Ipas, said he noticed that organizations with US-American ties had shied away from working together or stopped attending meetings on abortion services. "You said categorically that if you are going to partner with us it shouldn't be related to abortion," he said. The ability not to work with others in this area is another challenge in advocating for safe abortions and limiting the scope of services and training.

Above and below: Health workers Safina Bibi and Zubaria Mukhtar from a clinic supported by Greenstar Social Marketing visit women in a settlement for Afghan refugees in the suburbs of Islamabad on April 1st.

Although the global gag rule is no longer in place, the ideologies underlying it remain – particularly in the Helms Amendment, which continues to discourage billions of dollars from going towards abortion care. With a Democratic president, the tone on reproductive health has changed, but the issue of abortion still polarizes Congress. The Global Health, Empowerment and Rights Act, which would permanently repeal the global gag rule, and the newer Abortion Law, Health Care Everywhere, which aims to repeal the Helms Amendment, will both face significant opposition from Republicans.

For comparison, while Pakistan has a stigma about abortion, it largely stays off the radar of the most conservative factions, partly because the law is vague enough to appease opponents and leave some space for doctors who provide abortion services. “We are in a good place right now in the sense that abortion is not on the right-wing agenda (in Pakistan). It's not a hotly contested debate like it is in the US, ”said Sara Malkani, lawyer and advisor for the Center for Reproductive Rights.

As long as unsafe abortions continue to be a problem in Pakistan, policies that restrict reproductive health care will only further put women at risk. "If they are not offered safe services, they will certainly lose their lives," said Awan. "Abortions don't stop in Pakistan."

This story was made possible with support from the Pulitzer Center for Crisis Reporting.

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