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.”

Forty years after the establishment of diplomatic relations between the United States and China, the two superpowers are competing and contesting every arena, from trade to AI research and from space exploration to maritime rights. Instead of what Americans referred to as engagement and Chinese called reform and opening, many experts and analysts now characterize the relations between the two countries as dangerously brittle. Some see a new kind of Cold War in the making. Such assertions, however, argues Shorenstein APARC Fellow Thomas Fingar, “both ignore history and impute a level of fragility that has not existed for many years.”

Fingar reflects on the U.S.-China bilateral relationship in a new article, “Forty years of formal—but not yet normal—relations,” published in the China International Strategy Review. He claims that the relationship is resilient and not destined for conflict, albeit it is beset by a host of aspirational, perceptual, and structural differences.

A political scientist and China specialist who served over two decades in senior government positions, Fingar urges readers to remember that assertions of fragility of the U.S.-China relationship undervalue the strength, scope, and significance of interdependence, shared interests, and constituencies in both countries. These, he says, have a substantial stake in the maintenance of at least minimally cooperative relations.

U.S.-China relations are indeed highly asymmetrical: Chinese citizens and organizations have far greater access to the United States than Americans do to China, notes Fingar. He also recognizes that the troubles that have soured the relationship are more intricate and often more sensitive than those of the past. Decades ago, most of the issues that arose were handled at the governmental level. But now “the number and variety of players with stakes in the relationship and disputes with counterpart actors are much greater.” Furthermore, explains Fingar, the U.S. business community is expressing a stronger voice for government action to change Chinese behavior and is not as consistent an advocate of stability in U.S. policy toward China as it used to be. “This is an extremely important development,” he says, “because it reverses a key dynamic in the U.S.-China relationship.”

Ultimately, however, the two countries and our institutions and people are linked by myriad ties that bring mutual benefits as well as the constraints of interdependence. “I remain confident that we will continue to be able to manage the relationship,” concludes Fingar. He expresses disappointment, though, that normalization of U.S.-China relations remains a work in progress and cautions that merely managing the relationship to prevent it from deteriorating is an unsatisfactory goal that should be unacceptable to both sides. Not only does such a low bar limit what each counterpart can achieve, but it also inhibits the kind of cooperation required to address transnational challenges like climate change, infectious disease, and proliferation of dangerous technologies.

By 1978, after the “epic impoverishment” borne of Mao’s non-market, ideologically-driven economy, China was almost like “a hot air balloon [that had been held] ten feet underwater” and suddenly let go, described Daniel Rosen, founding partner of the Rhodium Group, before an audience at a recent colloquium organized by Shorenstein APARC’s China Program.

Rosen—who leads the Rhodium Group’s work in China, India, and Asia—drew on his 26 years of professional experience analyzing China’s economy, commercial sector, and external interactions, to share his insights on the implications of China’s recent divergence from liberal market norms even as the U.S. and China are trying to reach an agreement that could end a protracted trade war.

With its explosive rise, increasing U.S.-China economic tensions, argued Rosen, were inevitable. By reverting to non-market principles under Xi Jinping, however, China’s divergence from advanced economic norms has triggered a hostile reaction from the United States.  He acknowledged that China has “the sovereign right to choose the system it thinks best for itself,” including reverting to non-market principles.  But, he noted, “as an old adage goes, paraphrased, China’s freedom to swing its fists stops where other noses begin.”

China, with its thirteen trillion-dollar economy is now the world’s second largest economy.  China’s economic footprint, too—as trader, foreign investor, and lender, among others—is enormous around the world.  Thus, Rosen pointed out, now when “China sneezes, the rest of the world can catch a cold or pneumonia.”  By disavowing the primacy of market principles, furthermore, China’s decisions will now have spillover consequences for not only the way the rest of the global economy functions but also for economic prospects of the United States.

Rosen highlighted, in particular, three aspects of China’s divergence from market norms:  its financial markets, competitive regimes; and IP protection rules.  China’s capital markets give preferential treatment to its domestic state firms and discriminates against not only foreign firms but also its private firms.  He also stressed China’s uneven competition policies—as most dramatically epitomized in its “Made in 2025” policy—that establish asymmetric market access for foreign firms in China versus Chinese firms abroad; China’s state and sub-state financial subsidies set up to advantage domestic firms; and China’s domestic control of intellectual property in large swathes of critical industries.  China’s “Made in 2025” policy thereby, for example, distorts the innovation ecosystem of the world and the United States.  As Rosen asserted, “We depend for our vitality on structural conditions that non-market policy choices by a systemically important national could disrupt.”

In Rosen’s assessment, President Xi Jinping had begun his tenure with a far-reaching set of economic reforms called the “60 Decisions” of the Third Plenum Resolution in 2013.  But these market-centered initiatives, many of which Xi’s administration did push initially, led to “mini” (and “many”) crises, he stated.  These reforms, therefore, have stalled.  “The shadow over U.S.-China economic engagement comes not because China refused to reform in the Xi Jinping years,” Rosen asserted, “but because lately it has stumbled in attempting to do so.”

NEW YORK, NY - MAY 6: Traders and financial professionals work at the opening bell on the floor of the New York Stock Exchange (NYSE), May 6, 2019 in New York City. The Dow Jones Industrial Average dropped over 360 points at the open on Monday morning after U.S. President Donald Trump said that the U.S. will raise tariffs on goods imported from China. China also threatened to skip upcoming trade talks following tariff threats from President Trump.

According to Rosen, hardening U.S. approach to Chinese trade policy and the current discussion of possible “disengagement” with China are the result of U.S. recognition that China had changed course away from convergence with the liberal international economic order.  It, in fact, stems from the U.S.’s valid need to protect its economic welfare and the welfare of other market economies from the deleterious effects of China’s illiberal policies.  In the same way, he claimed, that the U.S. is not as deeply engaged with Italy as it is with Germany, and that we are not as deeply engaged with Germany as we are with Great Britain, it is not “heresy” to say that nations that do not share the same basic economic framework cannot be as engaged together—or as interoperable—as nations that do.  

But, Rosen predicted, China’s own turn away from market principles is bound to fail.  Liberal market reforms delivered double-digit growth for China since Deng Xiaoping’s Opening and Reform.  And “[u]nless everything we think we know about the relative efficiency and dynamism of free markets over politically controlled economies is wrong, the present Chinese policy turn will be, in the end, a dead-end,” Rosen remarked.  According to his prediction, therefore, we will either see a weakened China that poses less of an economic and national security threat to the U.S. or a China that eventually returns to market norms (i.e., “a reversion back to what will work.”).

In the meantime, therefore, he suggested that the American response must be “provisional,” “partial,” and “peaceful.”  American policy must be adaptable and readily reversible such that our ability to reengage to the maximum with China is carefully protected.  Secondly, it must be “partial” rather than absolute.  And, lastly, it must be “peaceful.”  When Beijing’s non-market policies fail, as it will, Rosen averred, and China re-orients itself towards economic convergence with advanced economy norms once more, we must ensure a “foundation of good will” between the U.S. and China to which China can return.

Rosen also cautioned against the U.S. abandoning its own source of national strength—i.e., its openness.  Arguing that economic protectionism has too often been confused with national security, Rosen argued that primary threats to U.S. national security now stem more from new causes like climate change, pandemics, migration pressures and access to weapons of mass destruction.  “Economic protection will do little to nothing to address those risks,” Rosen pointed out.

Rosen spoke at Shorenstein APARC as part of the China Program’s Colloquia Series “A New Cold War?: Sharp Power, Strategic Competition, and the Future of U.S.-China Relations.”  The series continues on May 3 with Ambassador Chas W. Freeman, Jr.’s seminar “On Hostile Coexistence with China.”