One morning last month, a young woman named Sabekun waited at a clinic in a crowded refugee camp in Bangladesh. She’d arrived at the camp the night before, along with her husband, mother-in-law, and sister-in-law; they’d fled their home in Myanmar’s Rakhine state and walked for seven straight days through marshes and paddy fields to reach neighboring Bangladesh.
They are among the estimated 600,000 ethnic Rohingya who have fled persecution in Myanmar in recent months. “Our movement became too restricted,” Sabekun tells an interpreter. “It wasn’t safe to leave our home — we couldn’t even go to the market for food. There was no other option for us.”
The government crackdown began in August after a militant Rohingya group claimed responsibility for attacks on police posts; according to the aid group Médecins Sans Frontières, 6,700 Rohingya Muslims were killed in the first month of clashes.
Sabekun, who asked to be identified only by her first name, was almost seven months pregnant with her first child when she arrived at the camp. When she woke up the following morning, she thought, “Something isn’t right. The baby isn’t moving as usual.”
OOf the record 65 million people currently displaced by conflict around the world, over 75 percent are women and children, according to the UN Population Fund (UNFPA). That means potentially millions of women who flee their homes are pregnant or nursing — and often face dangerous birthing conditions. In fact, more than half of the world’s estimated 800 daily maternal deaths occur in humanitarian crises.
Aid budgets are stretched notoriously thin — last year, the UN collected less than half of the $22.1 billion it requested for humanitarian aid. In Bangladesh’s Katupalong camp, the influx of displaced persons has led to overcrowding, including in the clinic that Sabekun visited. According to Hassan Abdi, a sexual and reproductive health specialist in the camp, medical personnel are working with limited supplies and manpower to attend to the newcomers, including an estimated 100,000 women who are either pregnant or nursing. Supplies are limited, from makeshift maternity wards and antiretroviral medications to contraceptives and sanitary pads.
Now, displaced women may face a new threat: under President Donald Trump, the United States has drastically cut funding to women’s health programs worldwide.
During his first week in office, Trump, like Republican presidents before him, reinstated the Mexico City policy — more commonly known as the Global Gag Rule — which restricts U.S. funding to foreign organizations that counsel abortion services. (First enacted by President Ronald Reagan’s administration in 1984, the policy has been successively rescinded by Democratic presidents and reinstated by Republican presidents).
The reinstatement was expected. But Trump went further than his predecessors: the gag now applies to all international health aid, instead of only family planning programs, meaning it could affect a budget about fifteen times the size.
Three months later, in another major blow to women’s health, the administration announced it would defund UNFPA, claiming it supported China’s “ program of coercive abortion or involuntary sterilization.” In response, the UNFPA (the UN’s family planning and maternal health organization) called the claim “erroneous.” As a contrast, last year, the U.S. provided the organization with $62 million, nearly 10 percent of its budget — over half of which went to humanitarian relief.
With a record number of displaced people, these decisions could cause immense harm. It’s difficult to project the consequences so soon, but UNFPA estimates suggest that in 2016, U.S. funding helped to prevent more than 2,000 maternal deaths, nearly one million unintended pregnancies, and 300,000 unsafe abortions.
“What looks like a bureaucratic decision has a real and immediate impact,” says Arthur Erken, UNFPA’s Director of Communications. “These are millions of dollars that immediately disappear. What do you tell a woman who’s being denied service because you don’t have any more supplies?”
In theory, humanitarian aid — like that provided in Bangladesh’s Katupalong camp — is exempt from the Mexico City policy, but in reality, many organizations self-censor. “These changes add a lot of confusion and complexity,” says Ashley Wolfington, who works in reproductive health at the International Rescue Committee. She worries that health organizations will steer clear of offering any reproductive services, for fear of losing funding.
It’s tough to advocate for reproductive health in emergency settings, largely because many people don’t understand why it matters. As a result, says Wolfington, it is often overlooked in favor of what seems more pressing — food, shelter, and water. But many women actively seek out contraception when they arrive at refugee camps as a way to deal with the uncertainty.
“If they’re fleeing their homes, they’re typically coming with their children,” she says. “They’re thinking, ‘OK, this is something I can do to take control of my life and focus on what I’m going to do for my family and where we’re going to be next week and next year.’ And that gives them stability and confidence to think about how they’re going to rebuild their lives.”
She says many women who flee conflict are also often escaping sexual violence (Human Rights Watch has documented widespread sexual assault at the hands of Myanmar’s military), and family planning clinics are often the best equipped to provide necessary physical and psychological care in the aftermath of an attack.
After all, she adds, “women are going to be the ones to build back the community after a crisis” — a difficult task if they’re having pregnancies they don’t want or dealing with unaddressed trauma.
SSometimes reproductive care extends beyond physical health. Nour, a 20-year-old Syrian refugee in Jordan’s Zaatari camp, has two small children and a third on the way. She sought out care at a UNFPA-managed clinic in the camp for her high-risk pregnancy — she has a kidney condition and has had four miscarriages — and confided to nurses that her husband had become physically and emotionally abusive. Nour, who also asked to be identified only by her first name, says the nurses sent counselors to speak with her husband and family.
“The team was so supportive,” Nour says, via Skype. “It’s just good to know I have a place to go — I can’t imagine how women would suffer if we didn’t find these places with support and services.” She says the counselors even helped her broach the subject of family planning with her husband and that her marriage has since improved.
The UNFPA manages the clinic where Nour received care, but NGOs, like International Planned Parenthood Federation and Marie Stopes International provide similar services in humanitarian settings, services they may struggle to continue after Trump’s cuts.
Under the Mexico City policy — named for the city that hosted the UN conference where it was first announced — organizations that receive U.S. funding are banned from providing information about abortion services, advocating for loosening of abortion laws, or conducting public information campaigns that discuss abortion as a method for family planning. Trump’s expansion means it could affect programs that provide vaccines and sanitation, or that work in HIV/AIDS, tuberculosis, and malaria prevention.
The irony is that the policy has actually been associated with increases in abortions. It makes it more difficult for women and girls in poor countries to access contraception, and rights groups say it leads to otherwise preventable maternal deaths.
The United States provides more international assistance than any other country, but when it comes to reproductive health, it’s an unreliable partner. With these funding cuts, experts say the U.S. is walking away from its leadership role in global health. “Every four years there’s a change and we’re scrambling to figure out who can make it up,” Erken says. “We — the Nordics, Netherlands, Belgium, the UK, and Canada — have to step up to the plate.”
Earlier this year, the governments of Belgium, Denmark, the Netherlands, and Sweden launched She Decides, an initiative to raise money for groups threatened by the Mexico City policy. At its inaugural conference in March, it raised $190 million. The move accompanies a broader trend in women-oriented foreign aid. Canada announced it would adopt a “feminist foreign assistance policy,” pledging 95 percent of foreign aid would go toward promoting gender equity by 2022, following Sweden, which adopted a similar policy in 2015.
Private donors are stepping up as well. Following the U.S. election, Planned Parenthood, which provides family planning services in the United States and abroad, saw a spike in donations. In July 2017, the Bill & Melinda Gates Foundation announced a 60 percent increase in funding for family planning.
“The actions of the U.S. administration have definitely triggered a counter movement to these decisions. There is a growing feeling among countries that we cannot let this happen,” says Erken. “We cannot let girls and women be held hostage by domestic politics of the U.S.” He says that the UNFPA, for the most part, has managed to make up for this year’s funding shortfalls, but it presents a longer term challenge.
Back at the clinic in Kutupalong, Sabekun breathed a sigh of relief. “She had just undergone an exam, and using a pinard horn (a fetal stethoscope), the midwife heard the baby’s heartbeat — Sabekun says there were no facilities like this back home. The midwife advised her to rest and return to the clinic for her delivery; she also gave her her contact information in case she was unable to return to the clinic.
Sabekun, for her part, has started thinking about the future. She says she’ll be happy whether she has a boy or a girl. “I just want my child to be educated, that is the most important thing to me.”
