A U.S. foreign policy that cuts money to nongovernmental organizations performing or promoting abortions abroad has actually led to an increase in abortions, according to Stanford researchers who have conducted the most comprehensive academic study of the policy’s impact.

Eran Bendavid and Grant Miller — both associate professors at Stanford University School of Medicine and core faculty members at Stanford Health Policy — and doctoral candidate Nina Brooks find that abortions increased among women living in African countries where NGOs, such as the International Planned Parenthood Federation, were most vulnerable to the policy’s requirements.

The policy, widely known as the Mexico City Policy, explicitly prohibits U.S. foreign aid from flowing to any NGO that will not abide by the policy’s main condition: no performing or discussing abortion as a method of family planning, even if just in the form of education or counseling.

The policy has been a political hot potato since its inception. Enacted under Ronald Reagan in 1984, it’s been enforced by subsequent Republican administrations while Democrats in the White House revoked the policy within days of taking office.

The study by Brooks, Bendavid and Miller, published June 27 in The Lancet Global Health, looked at the policy’s effects in more than two dozen African countries over a span of 20 years under three presidents: Bill Clinton, George W. Bush and Barack Obama. It finds that, when the policy was in place during the Bush years, abortions were 40 percent higher relative to the Clinton and Obama administrations.

When the policy was suspended during Obama’s two terms, the research shows that the upward trend in abortion rates reversed.

“Our research suggests that a policy that is supported by taxpayers ostensibly wishing to drive down abortion rates worldwide does the opposite,” said Bendavid, a faculty affiliate of the Stanford King Center on Global Development, which is part of the Stanford Institute for Economic Policy Research (SIEPR).

A key reason for the uptick in abortions is that many NGOs affected by the policy also provide contraceptives – and funding cuts mean birth control is harder to get, said Brooks.

“By undercutting the ability to supply modern contraceptives, the unintended consequence is that abortion rates increase,” she said.

And the policy’s scope has expanded under the Trump administration. While it originally restricted aid directed only toward providing family planning and reproductive health services, President Trump has extended the policy to cover any group engaged in global health, including organizations providing services for HIV or child health – not just family planning.

Groundbreaking Research

The stakes are high. America is the world’s largest provider of development assistance and spent about $7 billion on international health aid in 2017. Many women in sub-Saharan Africa depend on this aid for contraceptives.

In sub-Saharan Africa, NGOs are often primary providers of family planning services. Two of the world’s largest family planning organizations – International Planned Parenthood Federation and Marie Stopes International – have forfeited large sums of U.S. cash for refusing to comply with the policy, according to news reports.

The research findings were based on records of nearly 750,000 women in 26 sub-Saharan African countries from 1995 to 2014. When the policy was in effect under George W. Bush, contraceptive use fell by 14 percent, pregnancies rose by 12 percent and abortions rose by 40 percent relative to the Clinton and subsequent Obama years – an impact sharply timed with the policy and in proportion to the importance of foreign assistance across sub-Saharan Africa.

The paper is the second study of the rule’s impact by Bendavid and Miller, who are both faculty members of Stanford Health Policy. The research is also one of the very few evidence-based analyses of the policy.

Their earlier research, the first quantitative, large-scale effort to examine the policy’s impacts, looked at a smaller set of African countries during the Clinton and Bush administrations and also found an increase in abortion rates when the policy was enacted in 2001.

“Our latest study strengthened our earlier findings because we were able to look at what happens when the rule was turned off, then on, and then off again,” said Bendavid, referring to the policy’s whipsawing under Clinton, Bush and then Obama.

Miller, who is the director of the King Center and a SIEPR senior fellow, says the team’s research reveals a deeply flawed policy.

“We set out to provide the best and most rigorous evidence on the consequences of this policy,” he said. “What we found is a clear-cut case of government action that everyone on all sides of the abortion debate should agree is not desirable.”

Signs of a Global Pushback

Brooks also notes that their findings may underestimate the rule’s full impact.

“The excess abortions performed due to the policy are more likely to be performed unsafely, potentially harming women beyond pregnancy terminations,” she said.

Under Trump, the international response to U.S. funding cuts has shifted. Norway, Canada and several other countries have pledged to increase funding of international NGOs affected by the policy – though not by enough to cover the expected shortfall, says Miller.

“This shows us,” he said, “that despite the intense partisanship in the U.S. over the rule and its implementation, there are ways that policymakers around the world can offset its effects – by ensuring higher levels of family planning funding, for example.”

Those who live and die behind prison walls don’t usually get much public attention. Incarceration is, after all, meant to remove criminals from society. But contagious and potentially deadly diseases can’t be locked and left in a penitentiary, especially when infected inmates are eventually released.

The problem of prisoners and ex-convicts transmitting diseases to the general population is especially bad in the countries of the former Soviet Union, where rates of tuberculosis and drug-resistant strains of TB are among the world’s highest.

But Stanford researchers have identified solutions that could help curb tuberculosis in Russia, Latvia, Tajikistan and the 12 other countries in the region. Led by Jeremy Goldhaber-Fiebert, an assistant professor of medicine, the team has shown that a genetic TB and drug resistance screening tool called GeneXpert is more cost effective and better at reducing the spread of the disease than other methods currently recommended by the World Health Organization. Their findings were published online Nov. 27 in PLoS Medicine.

“Tuberculosis doesn’t stop at any border or any locked gate,” said Goldhaber-Fiebert, who is also a faculty member at Stanford Health Policy, a research center at the university’s Freeman Spogli Institute for International Studies.

“Drug-resistant TB is rampant in prisons,” he said. “When infected prisoners get out, they are thought to drive the TB epidemic in the general population. We are looking to find better ways to deal with that.”

About 400,000 cases of TB were diagnosed last year in the 15 former Soviet Union states – 40 times the number reported in the United States. Nearly 80,000 of the sick had drug-resistant TB. According to several studies, the prevalence of TB among the region’s prisoners is 10 times greater than that of the general population.

The WHO suggests three ways to screen for TB in prisons: relying on inmates to report symptoms, actively interviewing prisoners about their health, and administering chest X-rays. The organization doesn’t recommend one method over another, and currently, prisoners in the former Soviet Union are screened annually with miniature chest X-rays.

While X-rays can show whether a lung looks healthy, they don’t always catch TB. And when they do, they cannot differentiate between a TB that can be cured with standard medications and its drug-resistant cousins that require more expensive and extensive treatments.

That’s where GeneXpert has an upper hand.

Since it was introduced in 2005, the diagnostic has been hailed as a potentially powerful tool that can help to cut TB and drug-resistance rates by more accurately diagnosing people and getting them treated. With just a small sample of mucous analyzed by a machine, the GeneXpert system can instantly detect TB and its drug-resistant genetic mutations, well suited to mass screening within the prison systems of the former Soviet Union.

But the GeneXpert test is more expensive than alternative screening methods. And while it promises to be more effective, its impact on total costs had not been quantified in the former Soviet Union region until Goldhaber-Fiebert and his colleagues began their work nearly three years ago.

By developing computer models of the former Soviet Union’s prison populations, the team predicted that using GeneXpert can cut the prevalence of TB among inmates by about 20 percent within four years – provided the screening is combined with standard regimens of drug treatment for infected patients and for those with drug-resistant TB.

“For this to make sense, you need to have the right drugs to cure those individuals you identify,” Goldhaber-Fiebert said.

The additional cost of screening with GeneXpert averages to $71 per prisoner compared to the next best alternative approach, he said.

When compared to the decreases in illness and increases in survival, and factoring the financial and societal costs of TB in the broader population, the method makes good economic sense, he said.

“There is a large, direct value to using this technology for screening in prison settings, and there are potentially substantial secondary benefits to the general population of the former Soviet Union and to the world,” Goldhaber-Fiebert said.

Douglas K. Owens, a professor of medicine who is one of the paper’s co-authors and director of Stanford Health Policy, said the findings could give governments and medical experts the evidence they need to change the way they tackle TB.

“This is the kind of work we hope will inform policymaking about TB control,” Owens said. “We’ve shown there’s a more effective approach for trying to catch TB in prisons, and that means a better chance for preventing the disease from spreading.”

Co-authors on the PLoS Medicine paper also include former Stanford medical student Daniel Winetsky and current Stanford doctoral student in Management Science and Engineering, Diana Negoescu.

The researchers collaborated with the AIDS Foundation East-West. Funding for the study came from Äids Fonds, the International Research & Exchanges Board, the Department of Veterans Affairs, the National Institutes of Health, and Stanford.