Roe v Wade: How its scrapping will affect women worldwideBMJ 2022; 378 doi: https://doi.org/10.1136/bmj.o1844 (Published 11 August 2022) Cite this as: BMJ 2022;378:o1844
In 2018 a reproductive health organisation in Kenya found that anti-abortion advocates had put the address of its reproductive rights helpline on social media. “It was a veiled threat,” its programme manager, Mina Mwangi, tells The BMJ. “They wanted us to know that they knew how to get us.”
On 24 June 2022 the US Supreme Court overturned Roe v Wade, the landmark 1973 decision that protected women’s liberty to choose to have an abortion without excessive government restriction.1 Sexual and reproductive health rights organisations across the world, including Mwangi’s, feared the effects of the overturning in terms of funding and potential attacks. “We are heightening our security because of how emboldened the opposition are,” Mwangi says, adding that she dreads a potential withdrawal of funds from US non-governmental organisations: her organisation receives over 50% of its funding from US donors.
Her fears are well founded. Regressive US policy moves on abortion have historically had a profound ripple effect around the world, particularly in countries where sexual and reproductive healthcare is partly or fully funded by overseas donors.234
In the decades since Roe v Wade 55 countries, including Spain, Ireland, Argentina, Kenya, Romania, Nepal, and South Korea, have brought in legislation and policies that have improved access to abortion. Liberia, Sierra Leone, and the Democratic Republic of Congo are in the process of legally expanding access, as are several Latin American countries in a “green wave” of liberalisation led by Mexico.5
The Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa—the first treaty to recognise abortion (under certain conditions) as women’s human right—has expanded availability in the 15 member nations of the African Union.6 In sub-Saharan Africa, which has the world’s highest abortion related deaths in the world,7 Roe v Wade has been an oft invoked precedent for advocates of more liberal abortion laws. During the same period only four nations, most recently the US, have imposed further curbs.
Gains at risk of reversal
“We’ve seen amazing progress,” says Sarah Shaw, head of advocacy at Marie Stopes International, a non-governmental organisation that provides contraception and safe abortion services in 37 countries. “Malawi and Sierra Leone are in advanced stages of discussions around law reform for abortion, as are many countries in Latin America, which could lead, remarkably, to the spectre of women from US states crossing the border for safe abortions in Mexico.”
Kenneth Juma, of the African Population and Health Research Center in Kenya, points to the sexual and reproductive health bill currently at the East African Legislative Assembly, the legislative arm of the seven country East African Community, and to liberalising legislation in Liberia as causes for hope. But he fears what the US decision might bring. “I was in Liberia last week, where lawmakers are preparing a bill to expand access to abortion, and [the US Supreme Court decision] has come at the very worst time as it has awoken anti-abortion rights activists and given them a seat at the table,” says Juma, who has researched access to safe abortion in Kenya, Nepal, and Madagascar.
Shaw fears that Sierra Leone’s safe motherhood and reproductive health bill, which expands access to abortion in a country where terminations are permitted only when a mother’s life is at risk, will also “run into trouble.” The country has one of the world’s highest rates of maternal mortality and unsafe abortion,8 and the bill, though approved by cabinet ministers on 7 July,9 has not yet been enacted. “The US ruling sends [lawmakers] the message that it’s completely acceptable to disregard the reproductive healthcare needs of half of your population,” says Shaw.
“There is great concern that the dismantling of Roe may catalyse efforts towards similar retrogression in other countries,” Payal Shah, director of Physicians for Human Rights’ programme on sexual violence in conflict zones, tells The BMJ.
Health impacts of unsafe abortion
Evidence is clear that restricting abortion does not reduce its incidence but instead makes it less safe.10 Women and girls (and trans men and non-binary people) who are denied access to safe abortion are forced to use unsafe methods and providers; it is estimated that nearly 25 million unsafe abortions take place each year.11 The World Health Organization estimates that at least 7.9% of maternal deaths are due to unsafe abortion, with a greater proportion occurring in Latin America, the Caribbean, and sub-Saharan Africa.12 The complications of unsafe abortions include infection, haemorrhaging, and injury to internal organs.
“Our staff witness at first hand the maternal death and suffering that result from unwanted pregnancies and unsafe abortions,” says Maura Daly, a sexual and reproductive health adviser at Médecins Sans Frontières. In 2019 MSF treated more than 25 000 women and girls with abortion related complications, many of which resulted from unsafe attempts to end a pregnancy.
Daly lists various factors that come into play, including access to abortion drugs, outdated or harmful information on abortion, and the restrictiveness of the country’s legal framework.
Aisha Awan is a GP in Salford who has seen the effects of unsafe abortion at first hand in her voluntary work at a community clinic in Tanzania, where abortion is highly restricted and maternal morbidity and mortality remain high.13 “Women were at the mercy of cheaper untrained providers, where in some instances ‘instruments’ such as twigs to cleaning products were employed,” says Awan. “They were therefore plagued by chronic pain and in some cases torn or highly damaged cervixes [for years after the abortion], leaving them at risk of miscarriages or future preterm births.”
Poor and marginalised people bear the heaviest burden from restrictive laws, Juma adds. “Poor people die in greater numbers due to unsafe abortions,14 are forced to have more children than they can afford, and are at greater risk of poverty due to being forced to carry an unwanted child to term,”15 he says.
Antonia Mulvey of Legal Action Worldwide, which provides legal aid to victims and survivors of human rights violations and abuses, says that any further restriction of abortion provision would be “catastrophic” for victims of sexual violence in conflict. “Where medical services are available to survivors, they often do not include emergency contraception, meaning that access to free and safe abortions is life saving,” she says.
Encouraging the incorrigible
Reproductive rights activists say the US about-turn is also giving encouragement to some anti-abortion factions in poor countries that are funded by US far right groups and that conduct ugly pressure campaigns through social media and misinformation.
“When Trump strengthened the global gag rule [box 1] we saw rising social media attacks against MPs who support sexual and reproductive health in Kenya,” says Shaw. “It has also been reported in Nigeria that we [Marie Stopes International] are part of a neocolonial effort to control the population of Nigeria through abortion.”
The global gag rule
In tandem with this year’s US Supreme Court ruling on Roe v Wade comes the threat of the future return to play of the political football known as the “global gag rule.” Under this US aid policy, first enacted by Ronald Reagan in 1984, organisations outside the US that receive US government funding cannot provide, refer for, or promote abortion as a method of family planning. But the rule has see-sawed as successive Democratic and Republican presidents enact or revoke the policy as soon as they take office. Most recently, Joe Biden set it aside when he became president in November 2021.
However, the effect of Donald Trump’s unprecedented 2019 strengthening of the rule is still felt. This change cut funding not only to foreign non-governmental organisations directly involved in abortion services or abortion rights advocacy but also those that fund or support other groups that provide or discuss abortion.16
The Trump presidency saw many reproductive healthcare services in Kenya shuttered, including Family Health Options, one of the largest reproductive health organisations, says Kenneth Juma of the African Population and Health Research Center. “Suddenly, providers could not fund staff salaries overnight,” he tells The BMJ. “There was huge disruption to reproductive healthcare service delivery models, which were 50% NGO-funded, as well as a fragmentation of the HIV care platforms through which much reproductive healthcare is organised.” This capacity, he adds, has not recovered.RETURN TO TEXT
In Kenya, CitizenGO, a community group that uses social media to “defend and promote life, family, and liberty” was partly responsible for the sinking of the 2020 Reproductive Healthcare Bill that sought to expand access to safe medical abortion and other reproductive health services. Its tweets labelled the bill as an “abortion bill,” despite several researchers and rights observers arguing that the bill was in keeping with the rules of Kenya’s existing constitution. The non-profit internet software company the Mozilla Foundation found that about 15 people, mostly Kenyan, were being paid $10 to $15 per campaign to manipulate the online conversation about abortion.
“In the months to come we will see more and more from these actors,” says Phonsina Archane, programme adviser at the Safe Abortion Action Fund in Kenya.
The road ahead
Some non-governmental organisations retain hope that the US’s reversal of Roe v Wade will instead galvanise progressive groups and lawmakers to take positive action to protect abortion rights from further attack.
Marie Stopes International is increasingly focusing on advocacy to protect gains in abortion service provision from being affected by US policy fluctuations, Shaw tells The BMJ. When in 2019 an abortion provider in Kenya was falsely accused of providing abortions outside the national legal framework, Marie Stopes and local organisations successfully countered this misinformation through petitions and coordinated opinion pieces in the media, she says. Shaw also welcomes the arrival of national legal guidelines such as Nigeria’s Legal Framework on Abortion,17 which clearly states what reproductive healthcare providers can and can’t offer to patients to protect such providers from legal consequences.
Juma thinks resilience will come only when nations significantly reduce their reliance on outside aid. He would like to see Kenya’s rights advocates being “proactive rather than reactive” and making the data on abortion clear: “that restrictions increase abortions, unsafe abortions, and mortalities.” He would also like to see the United Nations Refugee Agency (UNHCR) institute a slush fund to enable it to step in and supply supplies and equipment, such as the chemical abortion drugs mifepristone and misoprostol, anaesthetics, and speculums and tenaculums. This would mitigate the effects when non-governmental organisations are forced to withdraw assistance because of external government policies.
Societies need to start treating abortion as a medical issue rather than a political one, says MSF’s Daly. “The heavy burden on people seeking abortion, and their communities, is lost in all the political justifications for not providing this care rather than seeing it for what it is: a medical decision,” she says.
Competing interests: We have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.
Commissioning and peer review: Commissioned; not externally peer reviewed.