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President Obama's ambitious Global Health Initiative — announced to a receptive international community in 2009 — is faltering as budget constraints and shaky implementation limit the impact of the multibillion-dollar program.

GHI's missing piece in Nepal

U.S. law prevents Global Health Initiative funding for abortion.

LAMAHI, Nepal – United States President Barack Obama set up the Global Health Initiative to take a more comprehensive approach to improving health care in developing nations. In particular, his administration has given great weight to saving the lives of women and to supporting countries’ priorities in health care.

But there’s one exception: abortion.

In Nepal, that exclusion is in plain view, and many say the lack of support disregards evidence that safe abortions can save women’s lives. Nearly all experts here — with the notable exception of those employed by the U.S. government — publicly state that the best way to improve maternal health is by offering a wide range of services that includes more awareness about and access to safe abortion.

In a long-standing U.S. law, stretching back nearly 40 years, Congress has prevented any foreign aid for abortions.

The politics in Washington around the issue of funding abortion have become so heated in recent months that many global health supporters on Capitol Hill won’t even talk about family planning services because so many conservatives falsely equate it with abortion.

“Most of the young women don’t know about abortion facilities or that it is legal.”
~Khem Karki, Executive Director of SOLID Nepal

Anti-abortion advocates have accused Obama and his administration of using the GHI as part of a larger strategy to link abortion rights to universal access to reproductive health. An article in the New American last year by senior editor William F. Jasper argues that Secretary of State Hillary Clinton has used “‘reproductive health’ and other similar code words ... in attempts to camouflage policies that promoted abortion.”

Clinton’s State Department has dismissed such claims and stressed that U.S.- funded programs through the GHI are simply trying to offer comprehensive reproductive health within the accepted health practices of the host countries, including saving a woman's life if she suffered an unsafe abortion and working on family planning issues that adhere to the accepted health practices of the host country.  

Some 7,000 miles from Washington and far from the charged debate around international aid and the question of abortion, there is a more pointed question in the villages of Nepal. That is, whether the unyielding U.S. policy against funding abortions is hurting its efforts to improve health care?

Some in Nepal say it does. U.S. officials say that’s not so.

Anne Peniston, the GHI Field Deputy in Nepal, said the best way to improve maternal health in Nepal is by providing more access to family planning services.

She cited a 2010 study published in the British health journal The Lancet, in which the four main drivers of maternal mortality were total fertility, per capita income, maternal education, and skilled birth attendance. Abortion, she noted, was not in the top four.

“Abortion should not be used as a method of family planning in any case,” she said. “It’s too risky for a woman’s health.”

But inside a primary healthcare center in Terai, Nepal’s plains region that runs along the border with India, a program that provides safe abortions is considered an integral part of maternal health.

Lamahi Primary Healthcare Center doctor Mahesh Gautan says that women in the area, like in much of rural Nepal, often have unsafe abortions because they do not know where to have a safe procedure or cannot afford to pay for a private clinic.

“They usually have unsafe abortion, and they’re coming with a complication,” he said. His center has about 40 cases a year of women showing up with life-threatening bleeding or infections from unsafe abortions.

The government-run center in Lamahi, which sits in Dang district, therefore decided it needed to improve its maternal health service beyond providing family planning, and antenatal, postnatal, and delivery services. The center sent nurse Dila Bhusal, 25, for training on safe deliveries and safe abortions.

Nepal legalized abortion in 2002 because so many women were dying due to unsafe abortions. Professor Sharad Onta in the department of community medicine and family health at Tribhuvan University’s Institute of Medicine in Kathmandu said the death rate, while reduced, remains high in part because too many women are not aware of the abortion services.

Onta said that a donor cannot be forced to do something that its country does not allow. But he said that the U.S. Agency for International Development should not claim that they are offering comprehensive health services in Nepal.

“Donors should understand their own limitation and not claim they’re complying with the national health plan [when they’re not],” he said.

The Nepal Ministry of Health in 1998 estimated that 54 percent of gynecological and obstetric hospital admissions were due to women having complications after ending a pregnancy in an unsafe manner, according to a report by Ipas, an international organization that works on increasing women’s access to safe abortion.

An information void

While abortion is now available in government hospitals and at private clinics, health advocates say there is still a serious need for awareness and education about the change in law, the dangers of medical imposters and where to go for a safe procedure. Too many women continue to end unwanted pregnancies by using unsafe methods like inserting pointed bamboo rods or ground up bangles into their uteri, or by following the misguided directions of untrained chemists.

“This is a big challenge for our communities. Most of the young women don’t know about abortion facilities or that it is legal,” said Khem Karki, the executive director of SOLID Nepal, an organization that works on sexual and reproductive health.

Furthermore, advocates say it would be more cost effective, efficient and logical for a woman to be able to receive all services related to maternal health, including abortion, in one place.

“Especially developing countries, poor countries, we can’t afford to offer one service by itself,” said Indira Basnett, the Nepal country director of Ipas. She said all reproductive health services should be delivered like a “package” through the health system.