It was a decision Nirmal Bista never really wanted to make: a choice between money and principles, shutting up or sticking it out, and most harrowingly, one that involved the lives — and potential deaths — of millions of his countrywomen.
On Jan. 22, 2001 — his second day in office — President Bush issued an executive order denying U.S. aid money to any foreign nongovernmental organization offering women abortion counseling, services, or campaigning to liberalize their country's abortion laws.
Commonly called the "Mexico City Policy," the order also prohibits aid to groups that use funding from other sources for these activities. It does, however, make exceptions for abortion-related services due to rape, incest, or a threat to the woman's life.
On the 31st anniversary of Roe v. Wade, anti-abortion rights and pro-abortion rights groups are converging in Washington and across the country today to voice their differing opinions on the landmark 1973 Supreme Court decision legalizing abortion in the United States.
But halfway around the world — far from Washington's vitriolic political conflagration between the two sides on the abortion debate — Bista was faced with an unenviable choice.
As the director general of the Family Planning Association of Nepal, the leading reproductive health NGO in an impoverished country where an estimated six women die every day due unsafe abortions, Bista opted to forego U.S. government funding for his group.
"It was by no means an easy decision," Bista said in a phone interview with ABCNEWS.com from Katmandu, the Nepali capital.
"By refusing to sign [on to the Mexico City Policy] we have lost approximately $600,000 out of a core budget of $1.2 million," he said. "This may not sound like a lot of money in U.S terms, but here in Nepal, it has meant having to make decisions about closing clinics, laying off staff and medical professionals, and discontinuing critical services to thousands of needy women."
Raped, Then Imprisoned for Infanticide
But the decision, as far as Bista is concerned, did lead to one important gain. In September 2002, Nepal's King Gyanendra approved a law legalizing most abortions after decades of campaigning against the country's colonial-era laws by rights and medical professional groups — including FPAN.
In her tiny home in Katmandu, Min Min Lama says she's happy about the new legislation. A former carpet weaver, Lama was sentenced in 1997 to 20 years in prison on infanticide charges for having an illegal abortion. She was 13 years old at the time, and had become pregnant after being raped by a relative.
Luckily for Lama, she served only 18 months before local rights groups took up her case and secured her release. But not everyone, she notes, is as fortunate.
In a nation where infanticide charges accounted for a substantial proportion of female incarcerations, several women previously imprisoned for abortions still languish in Nepal's prisons — many with no access to lawyers — despite the recent legalization of abortions.
Now 19, Lama is married to a tempo (a three-wheeled, motorized rickshaw) driver, and occasionally, she still goes to Katmandu's Central Jail to visit her inmate friends.
Exporting America’s Conflict
While the uneducated former carpet weaver has heard about Nepal's legalization of abortion, she says she knows nothing about the Mexico City Policy or its likely effects on women across the developing world.
But many international health and reproductive rights groups are keenly aware of its influence.
While there is a consensus across ideological divides that abortion is a horrible business, a number of women's rights groups accuse the United States of exporting one of its most contentious conflicts abroad, where the realities are far removed from the ideological rift tearing America.
The policy, they say, is not stopping abortions, but is hurting family-planning work across the developing world.
"Women abroad are having a very tough time and not too many Americans are aware of what's happening," said Carol Schlitt of the Margaret Sanger Center International at Planned Parenthood of New York City. "This administration's policies are undermining women's health around the world — and that's quite scary."
Sticks, Powdered Glass and Cow Dung
First imposed by President Reagan at a 1984 Mexico City conference, the policy was suspended by President Clinton in one of his first acts after taking office, but then reinstated by Bush.
While the measure was hailed by several domestic abortion-rights groups, the primary concern for many medical practitioners in Asian and African countries affected by the policy is the impact on maternal deaths and health complications due to illegal, unsafe abortions.
According to the World Health Organization, around 78,000 women die due to complications resulting from an estimated 20 million unsafe abortions that occur every year, mostly in the developing world, where anything from sticks to powdered glass to herbal mixtures, catheters, coat hangers and cow dung is used to induce abortions.
In Kenya, for instance, where abortion is illegal, there are a staggering 1,300 maternal deaths for every 100,000 live births. According to "Access Denied," a recent collaborative research report, an estimated one-third of maternal deaths in the East African nation have been attributed to unsafe abortions.
‘Global Gag Rule’
For NGOs in an estimated 60 countries heavily dependent on funding from the U.S. Agency for International Development and other State Department branches, the inability to participate in public awareness or abortion-education campaigns has led a number of health and rights groups to dub the Mexico City Policy the "global gag rule."
A recent study by the U.S.-based Center for Reproductive Rights found that in several less-developed countries, the fear of being cut out of much-needed U.S. aid money, coupled with an overzealous adherence to the "global gag order," had led to slow — and at times, an absence — of any moves to reform often antiquated family planning laws.
While the USAID mandate officially states that "the development of civil society depends on freedom of expression and association," the study concluded that by imposing the policy, the U.S. government had "taken on the role historically assumed by authoritarian regimes."
Lester Munson, chief of staff for global health at USAID, dismisses this characterization.
"It's nonsense," he said. "If they chose not to sign [onto the policy] we can find someone else. They can choose to work with us — or find another funder. We're mandated by Congress and the president to carry out a certain amount of family planning policy and we continue to carry out these programs."
The Mexico City Policy has also come in for criticism from some conservative groups, but for very different reasons.
"I'm not satisfied with it because I don't think there should be exceptions for babies conceived by rape or incest," said Judy Brown, president of the American Life League, a Virginia-based anti-abortion rights group with partnerships across Africa and Asia.
"But it's better than not having one," she added. "What the Mexico City Policy does do is make it clear that no American funds are used for abortions — except for rape, incest and the mother's health, of course."
Impeding the Fight Against AIDS?
But critics note that American tax dollars have not been funding abortion abroad since the 1973 Helms Amendment to the Foreign Assistance Act prohibited direct U.S. financing of abortion services.
Instead, they accuse the "global gag rule" of inadvertently impeding the global fight against HIV/AIDS. By isolating reproductive health services, the policy has cut funding to a number of leading health organizations in seriously affected countries where government health services are often inadequate, critics say.
And with that funding, organizations have lost their ability to distribute condoms and provide other public health awareness programs.
But Munson insists USAID is committed to fighting AIDS around the globe. He pointed out that President Bush has pledged $15 billion to battling HIV in Africa, and cited the administration's adoption of the "ABC strategy" — Abstinence, Being faithful and Condom use.
"The best thing about the 'ABC strategy' is that there's something in there for everyone," said Munson.
Some critics say promoting "abstinence only" degrades the use of condoms as an HIV-prevention measure. But Munson counters that it works both ways.
"If there are fears that 'abstinence-only' groups will denigrate the importance of condoms in the field, there's also the fear that those promoting condom use will badmouth abstinence," he said. "We need to recognize that the only way to win the war against AIDS is to work together — that's the best part of ABC."
From his office in Katmandu, Bista also hopes for an end to the acrimony over the abortion fight so that his group can best serve the needs of Nepali women.
"There needs to be an understanding that family planning associations do not advocate abortions," he said. "The first focus of our work is to avoid abortions by preventing unwanted pregnancies. If, however, there is an unwanted pregnancy, we think it's the right of the woman to decide whether to terminate the pregnancy or not."