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New York University New York University UNDERGRADUATE THESIS Unintended Consequences: U.S. Foreign Policy’s Effect on Sexual and Reproductive Health and Rights Access Internationally Author: Professor: Imogen Fordyce Shanker Satyanath Abstract This study examines whether the Mexico City Policy, a conservative driven U.S. foreign policy mechanism, colloquially known as the Global Gag Rule, which intends to diminish access to abortions internationally, has an unintended negative effect on access to sexual and reproductive health rights and services (SRHR) for women worldwide. Operationalizing maternal mortality ratio, contraceptive prevalence, the percentage of births with a skilled attendant present, and adolescent fertility rate as indicators of sexual and reproductive health access, this study applies a difference in difference design to observe the level of significance that the policy’s presence has, or not, on SRHR worldwide, between President Bush’s tenure when the policy was active, and President Obama’s when it was not. The study includes 112 countries, grouped by their relative exposure to the policy, low (control) or high (treatment), based on their historic level of reproductive health funding from the U.S.. The results revealed that both maternal mortality ratio and the presence of a skilled birth attendant were significantly affected by the policy’s removal. However, the other indicators were not, a result that with further investigation suggested other U.S. foreign policy programs may be compounding the effects of the Mexico City Policy, and further reducing access to SRHR support. An outcome that this study hopes will provoke further exploration of the collective effect U.S. foreign policy has on SRHR access, and what the scale of the negative repercussions of this may be for women worldwide. 1 Acknowledgements I would like to express my sincere gratitude to Professor Shanker Satyanath for his guidance, support, and feedback, without which this research project would not have been possible. I would also like to thank Nejla Asimovic for continually providing vital technical assistance and advice that helped shape this project in to what it is today. Finally my thanks go to everyone at Friends of UNFPA for constantly reminding me why I embarked upon this thesis topic, and to all those who have supported me throughout this process for helping me see it through to the end. 2 Contents 1 Introduction 4 1.1 Key Concepts . .5 2 Background 6 2.1 The History of the Mexico City Policy . .6 2.2 Significance Today . .8 3 Literature Review 9 4 Hypotheses 13 5 Data Description 15 6 Methodology 20 7 Results and Analysis 22 8 Future Implications 29 9 Conclusion 30 Appendices 36 A Figures 36 A.1 Parallel Trends Confirmations: Maternal Mortality Ratio . 36 A.2 Parallel Trends Confirmations: Skilled Birth Attendant . 36 A.3 Parallel Trends Confirmations: Adolescent Fertility Rate . 37 A.4 Regional Coefficient Plots . 38 3 1 Introduction This thesis seeks to explore the relationship between U.S. partisan politics, the interna- tionally focused federal policies that partisanship has brought to life, and the repercussions that these policies have had on a global scale. Specifically, this thesis concerns the Mexico City Policy, also known as the Global Gag Rule. Conceived by President Reagan’s Republi- can administration, the Mexico City Policy has been enacted by every Republican president since its creation, and rescinded by every Democratic president in turn. Designed to appeal to domestic Republican supporters, the Mexico City Policy imposes a key debate of U.S. domestic politics, abortion rights and pro-choice vs. pro-life sentiments, on federal fund- ing to non-governmental organizations operating internationally. When enacted by a U.S. executive, the Mexico City Policy sanctions the removal of all U.S. reproductive health gov- ernmental funding from any foreign non-governmental organization working internationally that practices or “promotes” abortion services through activities such as abortion counselling, referrals and education.1 While it is clear that the Mexico City Policy intends to affect the availability of abortion services internationally, this thesis considers the unintended effect that the policy has on access to other sexual and reproductive health and rights services internationally. In order to explore this relationship, this thesis makes the critical assumption that sexual and repro- ductive health and rights access can be measured through indicators of women’s health and family planning activities, and that a significant relationship between these indicators and the enactment of this Mexico City Policy, reflects the policy having a significant effect on sexual health and reproductive health services and access for women internationally. Specifi- cally, this thesis operationalizes Maternal Mortality Ratio (MMR), contraceptive prevalence rate, the percentage of births with a Skilled Birth Attendant present, and the adolescent fer- tility rate in a country to see the effect the policy’s enactment has on the treatment nations in this study. The results of this study suggest that there is in fact a significant relationship 1"The Mexico City Policy: An Explainer,” The Henry J. Kaiser Family Foundation, October 3, 2019, https://www.kff.org/global-health-policy/fact-sheet/mexico-city-policy-explainer/ 4 between the Mexico City Policy’s enactment and both Maternal Mortality Ratio and the presence of a Skilled Birth Attendant during delivery. Interestingly this significance is not present in the case of both contraceptive prevalence and adolescent fertility rate, an outcome to be explored more deeply in Section 7: Results and Analysis. In its exploration of the relationship between the Mexico City Policy and access to sexual and reproductive health and rights services, aside from abortion, this thesis will first intro- duce the key concept of sexual and reproductive health and rights. Following this, contextual information on the history of the Mexico City Policy, and its significance today will be pro- vided. An extensive review of existing literature that relates to the key thesis question will take place, considering how this study will contribute to the existing analysis of the Mexico City Policy and the role that U.S. domestic and foreign policy plays in the field of women’s health and rights, after which our empirical analysis will begin. Each key hypothesis will be provided, as will each variable and data source. From this the methodology of our study and the results of the analysis will be explored. Ultimately, reaching the conclusion that the Mexico City Policy does have an unintended effect on access to sexual and reproductive health and rights services internationally, a finding that warrants further exploration in the future. 1.1 Key Concepts Sexual and Reproductive Health and Rights With the exploration of this thesis focusing on the effect that the Mexico City Policy has on various indicators of access to sexual and reproductive health and rights services, it is important to define what this umbrella term, sexual and reproductive health and rights, often abbreviated to SRHR, encompasses. First introduced at the 1994 United Nations International Conference on Population and Development (ICPD) in Cairo, the term ‘sexual and reproductive health and rights’, is defined by the World Health Organization as a state of complete physical, mental and 5 social well-being in all matters relating to reproductive function.2 The debut of this term in 1994 established a new, comprehensive, approach to women’s health that looked both at physical concerns such as maternal health, sexually transmitted infections and gender-based violence, but also social well-being through sexual health education, family planning services and post-natal support.3 McIntosh and Finkle (1995) mark this as a turning point in the global attitude towards population policy, “giving prominence to reproductive health and the empowerment of women” rather than simply controlling population growth.4 While the Mexico City Policy seeks to impact just one strand of the myriad of services offered under sexual and reproductive health and rights care, abortion, this thesis considers the other physical, mental and social support services, including maternal mortality, sexual education and family planning support, it may be infringing upon in addition. 2 Background 2.1 The History of the Mexico City Policy Named after the city in which it was announced, the Mexico City Policy was first in- troduced at the United Nations International Conference on Population and Development in Mexico City in 1984. Originally enacted under the presidency of Ronald Reagan, the policy restricts the use of U.S. federal funds (most commonly issued by USAID) by for- eign non-governmental organizations who offer services relating to abortion provision and promotion.5 In order to remain eligible for U.S. funding, upon which many organizations are reliant, non-governmental organizations are required to agree to these terms, which suppress not only abortion practice but also the referral of women to abortion clinics, counselling on abortion 2“What is SRHR,” Women Win, January 1, 2019, https://guides.womenwin.org/srhr/what-is-srhr 3UNFPA (2019). Supplement to Background Paper on Sexual and Reproductive Health and Rights: An Essential Element of Universal Health Coverage. United Nations Fund for Population Activity. 4C. Alison McIntosh and Jason L. Finkle. 1995. "The Cairo Conference on Population and Development: A New Paradigm?" Population and Development Review 21, 223. 5United Nations International Conference on Population. 1984. Policy Statement of the United States of America. Mexico City, August 6-13, 1984. 6 options and advocating for the legalization of abortion. It is important to note that the Mexico City Policy was not the first piece of U.S. foreign policy to target abortion activities by non-governmental organizations around the world. The Helms Amendment to the U.S. Foreign Assistance Act, introduced by Senator Jesse Helms in 1973, in response to the Supreme Court’s ruling in the case of Roe v.
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