By Anu Kumar
Anu Kumar is the president and chief executive of Ipas, a nonprofit that works to increase access to contraception and safe abortions.
Abortion has been legal in Ethiopia under a broad range of circumstances for the past 17 years. Nevertheless, at the Shekebedo Health Center, abortions cannot be performed at all. The clinic, situated in a rural part of southwestern Ethiopia where quality health care is hard to access, is partially funded by the U.S. Agency for International Development. This funding has stopped the clinic from offering abortions to Ethiopian women.
The U.S. law that has impeded Shekebedo from providing abortions, known as the Helms Amendment, was passed in 1973 during the backlash to Roe v. Wade, the Supreme Court decision that legalized abortion in all 50 states — and which the current court overturned in June. Helms prohibits the federal government from using foreign aid to pay for “abortion as a method of family planning.”
A valid interpretation of that language could still allow abortions under Helms in cases of rape or when the pregnant woman’s life is at risk. But the law has not generally been implemented that way, and instead has incorrectly been applied as an outright ban on all abortions. Although the Helms restriction applies only to U.S. funds, in many cases — especially in poorer, rural areas — the complication of securing other funding that could be used for abortions is too difficult, which means the entire health care facility simply does not offer abortions at all.
Most of the political action surrounds a related rule, known as the Mexico City policy, which prevents foreign nongovernmental organizations that receive U.S. aid from using any funding, including their own, to provide or discuss abortion services. Although the Mexico City policy has been alternately implemented and rescinded by Republican and Democratic presidents since Ronald Reagan (President Biden revoked it in January 2021), it took until 2020 for Democrats to introduce legislation to repeal the Helms Amendment. Though the bill never received a vote, Democrats recently reintroduced the Abortion Is Health Care Everywhere Act in the House and also introduced it in the Senate.
As international cultural and legal standards changed drastically over the past 50 years, the Helms Amendment has stood still, holding back women’s health care access worldwide. A conservative American view of abortion continues to influence medical treatment in places as far-flung as Kenya, East Timor and Guatemala.
Sources: Data before 2005 from Abortion Liberalization in World Society by Boyle et al., provided by Elizabeth Boyle and Minzee Kim. Modern data from the Center for Reproductive Rights.
Some clinics in countries like Nepal — where the law permits women to receive abortions on request — do not provide abortions if they accept U.S. family planning funds, even if a woman has been raped or the pregnancy threatens her life. Health care workers often aren’t able to get basic supplies, like uterine evacuation kits (a tool to treat early miscarriages), because doctors can also use them to perform abortions. In some cases, confusion about U.S.A.I.D. rules has resulted in workers believing that clinics are not allowed to buy misoprostol (which treats stomach ulcers in addition to abortion complications and miscarriages), despite regulations stating otherwise.
The United States is the largest donor to global health care efforts, and the ubiquity of U.S. foreign aid amplifies the effects of the Helms Amendment. In 2020, America sent more than $592 million in family planning funds overseas — about as much as the next three countries combined — and has contributed 40 percent to 50 percent of total direct funding over the past decade. Even in countries accepting lower levels of U.S. aid, the influence of Helms is widely felt. According to data from our office in Ethiopia, the United States funded about 30 percent of total family planning foreign aid in Ethiopia from 2018 to 2020, but that funding is spread among more than 45 percent of health facilities in the country.
The United States is the single largest funder of family planning foreign aid
Total family planning funds received annually, compared with the percent funded by the U.S.
Abortion availability
On Request
On Broad Grounds
To Preserve Health
To Save the Woman’s Life
Prohibited
Where the United States is one of the top three funders
Where the United States is not a top funder
Source: Kaiser Family Foundation analysis of data from the O.E.C.D.
Data represents the average of total commitments from 2018-20, and counts only money through the Family Planning and Reproductive Health program. The United States also provides family planning aid through the Maternal and Child Health and PEPFAR programs, but not in a way that is directly comparable with other countries.
The high number of unsafe abortions still occurring in 2022 — approximately 35 million annually — is among the world’s most significant and most easily preventable public health tragedies. Restrictions on abortions, especially in areas where quality health care is difficult to access, often push women to pursue abortions through unsafe means.
In countries that currently accept U.S. family planning aid and where abortion is now legal under some circumstances, more than 19 million unsafe abortions occur annually — more than half of the global total.
These unsafe abortions result in complications requiring medical treatment — ranging from minor bleeding to shock and sepsis — for more than 11.8 million women and girls in those countries every year. And every year, more than 16,000 of the women and girls who have received these unsafe abortions die from more serious complications. Repealing Helms would no doubt save some women from this fate.
Most abortions in countries affected by the Helms Amendment are unsafe
If more abortions could be performed safely, the number of abortion-related complications requiring follow-up medical care would fall enormously.
Abortion availability
On Request
On Broad Grounds
To Preserve Health
To Save the Woman’s Life
Prohibited
Source: Guttmacher Institute’s Adding It Up report, based on 2019 data.
Projected follow-up medical care rates are based on current follow-up care rates for safe abortions observed in the country, or estimated from comparable countries.
As more countries liberalize their abortion policies, the harm seeded by the Helms Amendment continues to grow. The Abortion Is Health Care Everywhere Act would replace the Helms Amendment with language stating that countries may use U.S. aid to provide abortions, training and equipment to the extent permitted by local law.
Sadly, the reality of the filibuster in the Senate and widespread Republican support for the Helms Amendment means that this bill is unlikely to pass, even if it has majority support. It is, however, a positive sign that lawmakers are even discussing this legislation in Congress.
President Biden also has the power to mitigate some of the harms of the Helms Amendment. The president could issue federal guidance to clarify that Helms permits using U.S. funds for abortion care in cases of rape, incest and life endangerment. His administration could also ensure that clinics in countries where abortion is legal understand that U.S. rules allow them to offer abortion information and counseling.
Through its power of the purse, the United States is stripping people of the rights and health care access they are legally entitled to in their home countries in the name of a half-century-old law that exports conservative American values overseas. Everyone deserves access to abortion — no matter where they live. The Helms Amendment is an act of international interference and overreach, and it has to end.