A handful of women clad in brightly colored dresses sat just out of the reach of the sun, focusing their attention on Felicity Lanyero and her presentation on family planning methods. Another woman, often with a baby in tow, joined every few minutes and found a seat among the group. The gathering took place in the yard of Parabongo Health Center, a basic facility down a dirt path in rural northern Uganda.
“What is family planning?” an older woman among the group asked aloud.
“Family planning is about spacing children. You find someone with five children. She is already busy, and then she becomes pregnant. That’s difficult,” Lanyero answered in Acholi, the local language. The older woman clasped her hands and nodded in agreement.
“As for me, I have two children and they are well-spaced. If I walk on the street shaking my butt, what man can resist me?” Lanyero posed, her lecture veering into stand-up to keep the mood light and engaging. She shimmied in front of the women, which sparked a round of laughter. Lanyero continued: “This is 2018. The world is changing. You need to see your children grow older.” In other words, when women become pregnant less often, they are less likely to die in childbirth. Maternal mortality in Uganda is high — 343 women for every 100,000 births in 2015 — and it’s not uncommon for women to have given birth to 10 children.
“You are telling the truth. I’m always telling my sisters about this,” piped in 22-year-old Brenda Akwero from the center of the group.
Photos: Alex Potter for The Intercept
Lanyero’s presentation was, in all likelihood, the most comprehensive information these women had ever received about contraception and reproductive health. She was visiting Parabongo Health Center for the day as part of an outreach team from the Ugandan branch of London-based Marie Stopes International, a reproductive health organization.
Marie Stopes International Uganda does not provide abortions, but the entire organization has lost funding by refusing to agree to the Global Gag Rule’s stipulations.
After her presentation, Lanyero, a midwife, met with each woman individually to discuss which family planning method was right for them. Akwero, already a mother, decided that she wanted an intrauterine device, or IUD, which other Marie Stopes staff would give her inside one of the clinic’s private rooms. This was Akwero’s second visit to a Marie Stopes outreach team mobile clinic. She came because friends had told her that “Marie Stopes provides a lot of information.” Akwero was also tested for HIV and ovarian cancer before she got the IUD, as is protocol. “Now, I will wait to have another child until my baby is grown,” she told me. Akwero knew she was fortunate to have access to free contraception thanks to the Marie Stopes team. Yet that access was at risk due to the politics of a country far away.
Marie Stopes International’s work around the globe is being stretched thin due to a dramatic loss of funding from the United States government — the result of the Trump administration reinstating an executive order known as the global gag rule, or GGR, also sometimes called the “Mexico City Policy.”
The GGR prohibits U.S. aid money from going to international organizations that either provide abortions, suggest abortions as a family planning method, or lobby to make abortion legal in foreign countries, even when they do so with non-U.S. funds.
Marie Stopes International Uganda does not provide abortions, as the procedure is illegal in almost all circumstances in the country, but the entire organization has lost funding by refusing to agree to the GGR’s stipulations. The U.S. had been giving Marie Stopes International Uganda around $6.5 million per year at the time the GGR was enacted. As a direct result of the rule, five of Marie Stopes’s 35 outreach teams, like the one that visited Parabongo, have had to stop operations, meaning the teams are no longer able to access some more remote areas. The British government has filled in some of the gaps that the U.S. left behind in Uganda, but not to the same level of funding. Reproductive Health Uganda, the country’s other prominent reproductive health organization, has lost the $500,000 it received annually from the U.S. due to the GGR, which went, in particular, toward its programming that focused on educating communities about sexual health practices.
Trump’s iteration of the so-called global gag rule goes farther than those of his Republican predecessors, affecting around $9 billion in U.S. aid.
The ramifications of the order are still being played out as funding cycles come to fruition and sexual health programs are canceled around the globe. Marie Stopes International headquarters announced that it has lost $80 million as a result of the GGR. The International Planned Parenthood Federation, a London-based organization that funds sexual and reproductive health around the globe, often in countries where abortion is illegal, estimates that it will lose around $100 million. The Trump administration has issued a domestic version of the gag rule as well, which would bar federal family planning funds from going to organizations that provide abortions or refer women to places that offer them.
Where the order hits the hardest is in countries like Uganda, where comprehensive health care, particularly when it comes to sexual health, is largely provided by charity organizations, not the government. For example, Marie Stopes International Uganda and Reproductive Health Uganda are the country’s two largest distributors of contraceptives.
A 2011 Stanford University study found that abortion rates more than doubled in the African countries that were most impacted by funding cuts when the GGR was reinstated under the George W. Bush administration. The vast majority of these abortions are performed secretly at home, or by unskilled local medical practitioners. Already in Uganda, 14 percent of pregnancies end in induced abortion, according to the Guttmacher Institute, a research and advocacy organization for global reproductive rights. A recent State Department six-month review of the GGR focused almost entirely on how to better implement the executive order. It did not mention that, by limiting women’s access to contraception, the GGR could increase the prevalence of abortions around the world,.
“We are concerned about the effect GGR will have in terms of us not being able to deliver services,” said Alhassan Bah, managing director of Marie Stopes International Uganda, when we met for an interview in Kampala. “And the increase in the number of unintended pregnancies and maternal death that will occur because we are not there, or the effect that it will have on a rural woman, or that young girl who will not be able to go to secondary school or university because someone wasn’t there to provide them services that would allow them to make their own life better.”
Like the women at Parabongo, Lakot was impressed with the amount of information she received from Marie Stopes. It made her feel comfortable, even though using birth control is still quite stigmatized within her community. Fewer than half of the sexually active women in Uganda — and only 26 percent of married women — use modern contraception, according to 2013 statistics from the Guttmacher Institute. (In the U.S., around 62 percent of women of reproductive age use contraception.) Myths that contraception causes cancer or infertility contribute to Uganda’s low rates, as do problems around accessibility.
Unsure about the implant itself, Lakot still doesn’t want more children. “If they could remove the tubes, I would be happy,” she said.
Atim, a slight 21-year-old with fuchsia hair, brought plastic chairs from the courtyard into her small square room to sit down for an interview. “Family planning is very important to me because I am already a mother,” she said. “I only want to have one more child, and I only want to have another child when there is a man in my life.”
Atim had dropped out of high school when she became pregnant, which happens quite frequently in Uganda. Her father is blind, and her 5-year-old child lives with him in nearby Lira and “guides him around.”
Atim had obtained contraception from a Marie Stopes outreach team in Lira before she left home, and once again when the team visited Karuma in 2017. She is on the Depo-Provera injection. Now that Marie Stopes does not come to Karuma, Atim said she will have to travel an hour to a larger hospital when she is due for a shot after a few weeks. It’s more likely that a hospital will have the injection than a small local clinic, where she may wait all day to learn that no contraception is available. Or she will have to go to a private clinic, where she says the injection costs around 40 U.S. cents. Atim pays $3.50 a day for rent, so that’s no small price. She is trying to save her money to get out of this place. “My hope and prayer is that I will get money and be able to start my own business,” she said. “I want to manage a restaurant.”
At another village health center, in the town of Bobi — a blip on the road between northern Uganda’s biggest city, Gulu, and the capital, Kampala — a nurse from Marie Stopes used to help regular staff at the maternity ward. That nurse stopped working in December 2017, because Marie Stopes needed to pull back its programming in the wake of GGR funding cuts. A midwife at the Bobi health center, Filder Akello, said the Marie Stopes nurse had been a welcome addition to their team. For example, he was useful when only one other midwife was working, as sometimes happened. “If the midwife is stuck in the labor suite, those who come for family planning will have to wait,” Akello explained.
Akello herself had received specialized training from Marie Stopes. (In Uganda, midwives are often overworked, and also poorly trained when they come out of public training centers or smaller fly-by-night for-profit schools.) Marie Stopes also had provided supplies to the clinic, and without the organization’s support, the clinic hadn’t been able to test for sexually transmitted infections due to government stock-outs.
Another local organization that had provided training for midwives, called the Center for Health, Human Rights and Development, or CEHURD, had to stop its training because the program was funded by the U.S. government, and CEHURD did not agree to the GGR’s stipulations. “We were doing advocacy to increase human resources for health, especially with regard to midwives knowing that they play a critical role in fighting maternal mortality,” said Joy Asasira, program manager of research documentation and advocacy at CEHURD, when we met for an interview in Kampala. CEHURD lost around $100,000 in funding as a result of the GGR, a big cut for a smaller, local organization.
In much of sub-Saharan Africa, the best health services are provided by charity organizations or the United Nations, which makes their populations extremely susceptible to massive funding cuts that can come when a foreign government changes its priorities. The GGR is a prime example. Asasira felt that the Ugandan government’s reliance on nonprofit organizations to fill its massive gaps in public services needed to be remedied.
“The global gag rule happened, fine, it happened. But is the Ugandan government doing enough to provide health care for its citizens, in particular family planning?” she asked. “Our government can’t say President Trump ruined everything — ‘Look, see the global gag rule happened and we can’t provide contraceptives.’ We are trying to shake up our government and say there is social contract.”
It’s an uphill battle. When it comes to sexual and reproductive health, Uganda’s government is influenced heavily by evangelical and conservative voices from the United States. Christian churches in Uganda — both Catholic and even Protestant in some cases — teach against using modern contraception. “In the born-again fraternity, people are not comfortable with the use of condoms,” said Patrick Okecha, the overseer of the Born Again Faith Federation for Acholi Sub-Region in northern Uganda, a conglomeration of pentecostal churches. “If you are using condoms, that means you are trying to protect yourself for HIV. So if you are married, why do you need to use condoms?”
“We expect that Trump’s global gag rule will stymie maternal health and family planning progress around the world.”
Despite these odds, more women in Uganda had been using contraceptives in recent years. According to the Guttmacher Institute, between 2003 and 2013, the percentage of married women in Uganda using modern contraception increased from 14 to 26 percent. (Although, the percentage of sexually active, unmarried women who use modern contraception didn’t change over the decade, remaining at 38 percent. These percentages declined sharply when it came to poorer women in rural areas.) Meanwhile, maternal mortality in Uganda has improved dramatically since the early 2000s.
Those who work in reproductive health worry that those statistics might regress while Trump’s GGR is in effect.
“We expect that Trump’s Global Gag Rule will stymie maternal health and family planning progress around the world,” said Serra Sippel, president of the Washington-based Center for Health and Gender Equity. “Now more than ever, progress in Uganda should be celebrated and sustained with funding for evidence-based health interventions. The United States should support — not obstruct — increased access to contraceptives for women to safely space and deliver pregnancies.”
To Gloria Munguchi, a comprehensive nurse based in Gulu who works on Marie Stopes’s outreach team in the region, the contradictions embedded in the GGR were puzzling, but mostly troublesome.
“When they said USAID [U.S. Agency for International Development] is stopping funding, I got scared,” she said. “If they could give us a chance, I would tell them that we are just doing family planning methods, and the mothers will miss us. You will find a mother with 10 children, and if we don’t reach these communities …” Munguchi trailed off for a second. Then she asked: “In the U.S., can you not have family planning?”
Correction, May 28, 10:43 a.m.: Captions for photos of Grace Lakot and Tracy Atim originally misidentified the location in which they were taken. They were in Karuma, not Gulu.