The Global Gag Rule: America’s Deadly Export

The policy that plucks U.S. dollars from any international health care initiative tied to abortion has been reinstated by President Trump — and a lot of African women are going to die as a result.

Photography by Nichole Sobecki

Fred Gbagbo recognized the woman right away, even though the blood had drained from her face and was instead pooling between her legs. There was no trace of the pushy, even demanding young woman in this listless body lying semiconscious in front of him. During their first encounter just hours earlier, he’d concluded that she was a devil trying to tempt angels. Now, seeing her so pale, he wasn’t so sure.

That morning, she had interrupted a pre-work prayer he was conducting with other student doctors in the gynecology unit of a teaching hospital in Ghana; she was pregnant, she said, and she wanted an abortion. Gbagbo and his colleagues, devout Christians all, knew what to do. They told her no, preached her the Gospel, and sent her on her way, proud they had so uncompromisingly cast her out, certain they had deterred her from sin.

But here she was back again, and Gbagbo couldn’t shake the nagging, nauseating feeling that perhaps it was he who had sinned. Their examination revealed a perforated uterus, the likely result of an attempt to perform the abortion herself, or the botched efforts of a local freelancer; either way, she wasn’t talking, and her body told only the worst of the story. They took her to the operating room, but it didn’t matter. She died there hours later, a first-year medical student and her parents’ only daughter.

A decade later, one question still haunts Gbagbo: “Who killed this poor girl?”

The possible answer — that in refusing the woman care, it was Gbagbo who was culpable for her death — branded a mark of guilt on his heart so deep that it set him on a new path. Not long after, he started his work as an advocate for safe abortion, which led him to become a leader in developing Ghana’s national policy on comprehensive abortion care. Now, he is the national director of medical development in Ghana for Marie Stopes, an international NGO, overseeing private facilities that provide family planning, infertility treatment, prenatal care, and safe abortions for women in need.

Women sell plantain chips and water amid traffic in central Accra.

Children stand in the street in Medina, a poor predominantly Muslim neighborhood in Accra.

A sign reads "Viva Ghana" in Medina.

In many ways, Gbagbo’s personal journey mirrors the evolution experienced across this coastal West African nation. Alarmed by research showing that unsafe abortion was the second-leading cause of Ghana’s startlingly high maternal death rates, since 2006 the Ghanaian government has embraced a more liberal policy on reproductive health, slowly working to integrate both safe abortion and effective contraception into the formal health care system. The past decade has brought significant progress in making abortion safer and more accessible across Ghana, coming hand in hand with easier access to family planning measures than ever before — putting the country ahead of the many other African nations where abortion remains illegal and disturbingly unsafe. Though abortion is still stigmatized and often clandestine, people in big cities are increasingly aware of where to get access (if not quite yet in the country’s rural reaches). As a result, more women are able to get procedures performed by trained medical professionals.

But that progress may have just hit a wall in the form of an American president bowing to domestic anti-abortion forces and implementing a restrictive new policy that will cut off U.S. aid to any foreign organization that so much as talks about abortion.

This policy, an executive memorandum also known as the Global Gag Rule or the Mexico City Policy and signed by President Donald Trump on his fourth day in office, says that foreign aid can go only to organizations abroad that “neither perform nor actively promote abortion as a method of family planning.” The foreign aid includes money that pays for contraception, safe pregnancy and delivery, childhood vaccinations, and treatment of HIV/AIDS, malaria, Ebola, and other infectious diseases. What it means to “actively promote” abortion is vexing. It’s not defined in the text of the policy itself, so organizations scared of losing American funding interpret it in exceedingly broad terms. The Gag Rule is widely understood to yank financial support from groups that offer abortions with their own non-U.S. money, refer their clients for safe, legal abortions, or advocate for abortion rights in their countries. The effect, advocates say, is wide-sweeping and chilling. Recipients of U.S. funds are afraid to talk about abortion at all, ultimately putting women at risk.

The order doesn’t apply to U.S.-based organizations because it violates Americans’ First Amendment rights; no such protections extend overseas. Family planning advocates from Washington, D.C., to Addis Ababa in Ethiopia worry that Trump’s Global Gag Rule will not only roll back many of the modest but critical gains African countries have made on safe abortion, but also the decade’s worth of progress in increasing family planning, decreasing maternal mortality, and promoting democracy and women’s rights more broadly.

“Murder does not mean just picking a gun or a knife and killing people,” Gbagbo said. “Denying someone their legitimate, rightful access to a service, as a health worker, is equally as murderous as killing someone.” This is exactly what he and the organization he works for fear the Gag Rule will do.

Marjorie Newman-Williams, vice president and director of international operations at Marie Stopes posits the problem this way: When organizations that receive money from the U.S. government are prohibited from mentioning abortion, referring women to an abortion provider, or telling them about their legal rights, the most vulnerable person in the equation isn’t a legislator in Washington or a dedicated NGO employee. It is “a woman needing care because she’s had an unsafe abortion walking into a public health clinic that cannot speak about abortion because they’re taking U.S. money,” Newman-Williams says. “They will look that woman in the face and turn their back on her.”

At a Methodist high school in Mando, Ghana, students attend the weekly meeting of a sexual-health club that teaches young people about contraception.

Every year, despite increased access to safe abortion procedures, 6 million African women end their pregnancies unsafely, and 1.6 million are treated for complications. Africa has more abortion-related deaths than any other continent.

This problem of pregnant women shamed, injured, and dying from unsafe and often illegal abortions is steeped in combative politics more than 100 years old, imported to African shores by colonial France and Britain. They outlawed abortion across the continent, and Christian missionaries did their part to create a deep stigma about the procedure. But for the past 30 years, the hand most obviously manipulating the landscape of reproductive rights in Africa has been the United States. America has injected its own uniquely volatile abortion politics, hindering the efforts of African governments and health workers to improve conditions for their people and subverting the ability of citizens of sovereign nations to openly debate abortion rights.

In the immediate wake of Roe v. Wade — the 1973 U.S. Supreme Court decision legalizing abortion — Congress approved the Helms Amendment, which barred American foreign assistance dollars from paying for “abortion as a method of family planning” and has ever since been largely interpreted as a wholesale ban on U.S. dollars paying for abortion — even for rape victims. As the American religious right gained political power, even Helms was deemed insufficiently anti-abortion, and so in 1984, President Ronald Reagan put forward a more expansive executive order then known as the Mexico City Policy. It pulled USAID family planning funds from any foreign organization that provided abortions with non-U.S. money, advocated for abortion rights in their country, or directed women on how to get a safe and legal procedure. This order is what abortion rights advocates now refer to as the Global Gag Rule; the name refers to the fact that the policy gags health care providers and advocates from even speaking about abortion.

While the Gag Rule was effective in limiting access to abortion, it did not affect instances of abortion itself. Across Africa, the story was the same. Maternal deaths were the highest in the world, and unsafe abortions were a leading cause.

These numbers proved sufficiently alarming that even governments hostile to abortion rights agreed something needed to be done. After President Bill Clinton rescinded the Gag Rule in 1993, the restrictive culture of silence began to break apart; abortion was discussed more openly as a public health issue. Many African governments increasingly allowed for post-abortion care, an emergency procedure to keep women who have had unsafe procedures from dying. Years ago, women would regularly “come in with incomplete abortion, and some are septic, some they cannot have children anymore, some die,” said Christina Addo, a veteran nurse-midwife at the Planned Parenthood in Ghana’s capital city, Accra. “When post-abortion care came, it helped to save a whole lot of lives.”

In 2001, President George W. Bush put the Global Gag Rule back into place, and again USAID family planning funds could not go to organizations that provided, referred, or advocated for safe abortion. This yielded disastrous results.

Planned Parenthood Association of Ghana, which had been doing USAID-supported family planning outreach since the 1970s, was in the middle of a rural outreach program that made up a third of its budget and was funded entirely by USAID. That money, none of which paid for abortions but rather funded contraception, testing for pregnancy and HIV, STI treatment, and infertility management, was pulled. Almost half of Ghana’s Planned Parenthood nursing staff lost their jobs, and programs serving thousands of women were scaled back or dismantled.

Ultimately, the Global Gag Rule meant that fewer resources went to the very groups that, like Planned Parenthood, were on the front lines of preventing unintended pregnancies. As a result, abortions increased across sub-Saharan Africa when the Gag Rule was in place, and many were unsafe. In an attempt to stave off deaths caused by unsafe procedures, the Bush administration did carve out a tiny but crucial exception to the Gag Rule, allowing U.S. funds to go to groups offering post-abortion care as long as they didn’t allow safe, legal, elective abortions.

Worshippers attend a Sunday service at a Pentecostal church in Mando.

Anti-abortion church groups across Africa have lobbied against signs that abortion laws are loosening.

Worshippers attend a Sunday service at a Methodist church in Mando.

Still, post-abortion care has its limitations. As Patrick Djemo, the Francophone regional program manager for Ipas, an abortion-access organization, put it, “It’s more like wiping the floor when the tap continues to flow.”

But Bush’s Gag Rule had another unintended effect. It woke up reproductive rights activists to the vulnerability of the small progress they had made.

“That is when civil society sat up, especially in Ghana,” said Aba Oppong, who works on gender and reproductive health for the Center for the Development of People. In the aftermath of Bush’s Gag Rule, she helped form the Alliance for Reproductive Health Rights, which aimed to combat unsafe abortions in Ghana. Advocates made a big push for their government to draft a formal protocol implementing the long-standing but largely ignored abortion law. These efforts dovetailed with research showing that worldwide, there is no correlation between abortion’s legality and its prevalence. However, there is a correlation between legality and safety — that is, women have abortions whether they’re legal or not, but when they are legal, the procedures are safer and women are less likely to die.

Since 1994, more than a dozen African countries have liberalized their abortion laws. Beginning in 2003, 36 African states ratified the Maputo Protocol, pledging to “take all appropriate measures” to “protect the reproductive rights of women by authorising medical abortion in cases of sexual assault, rape, incest, and where the continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the foetus.”

Progress took off from there. Take Ethiopia, a new leader on the continent when it comes to safe abortion. In 2005, the government decriminalized abortion; in 2006, it issued implementation protocols; and today, three-quarters of facilities able to provide abortion or post-abortion care, including 98 percent of the country’s 120 public hospitals, do so. Unsafe abortion used to be the No. 1 driver of maternal mortality in Ethiopia, accounting for nearly one-third of deaths among pregnant women; by the late 2000s, one study found that figure had dropped to 6 percent.

The abortion rights landscape on this continent remains chokingly restrictive, but it has been, slowly, relaxing.

This was helped along in 2009, when a newly elected Barack Obama rescinded Bush’s Gag Rule. For many organizations, funding returned. Marie Stopes and the International Planned Parenthood Federation received millions of dollars for family planning services around the world during the next eight years. Marie Stopes estimates that in 2015 alone, it brought family planning to 20.9 million women, preventing more than 6 million unintended pregnancies, 4 million unsafe abortions, and 18,000 maternal deaths. USAID funded nearly 20 percent of the organization’s budget.

But as many African nations were changing their abortion laws and expanding access to contraception, the abortion wars in the United States were reaching a fever pitch. Since 2010, American states have approved almost 300 restrictions on abortion, accounting for about a quarter of the more than 1,000 restrictions on abortion rights since Roe v. Wade. Many of these restrictions aim to inhibit what some African nations are embracing: easier availability of medication abortion, more accessible early procedures, and skilled midlevel providers like nurses and midwives offering abortion services.

Under Ghanaian law, midwives and other medical providers who aren’t doctors can perform abortions up to 12 weeks of pregnancy; after that, a gynecologist has to do the procedure. Similar laws are in place in Ethiopia, Zambia, and Mozambique, among other African nations. By contrast, in 38 American states, abortions can be legally performed only by a physician, even though studies have shown that the procedure is just as safe when conducted by a trained nurse-midwife. Ninety percent of U.S. counties lack an abortion provider. As abortion becomes harder to get for poor and rural women in America, reports of self-induced abortion in the United States are increasingly surfacing, and some women are being arrested and jailed for it.

Obama’s retracting of the Gag Rule in 2009 didn’t mean that family planning dollars were fully restored. “When the Gag Rule lifted, then the doors were open,” said Planned Parenthood’s Albert Wuddah-Martey. In ensuing years, his organization has been working to meet USAID’s strict requirements to secure new grants. “They came to look at our procurement plan, staff, time sheets,” he said. “All those things that USAID looks out for.”

Then came Donald Trump.

The new president’s Gag Rule is significantly more aggressive than previous versions. The rule encompasses all global health funding, not just funds earmarked for family planning. USAID requested $544 million for family planning and reproductive health for 2017. The projected global health funding for 2017 is an estimated $9.5 billion, all of which is subject to this new rule. Sub-Saharan Africa, the largest recipient of American humanitarian aid dollars, will be the hardest hit. There is no doubt, advocates say, that the Gag Rule will mean more unplanned pregnancies, more unsafe abortions, and more women injured and dead. Although it won’t take away a single dollar spent on elective abortions, it will cut money that was going to contraception, HIV/AIDS treatment, and the antenatal care that reduces maternal and child deaths.

“Just as we were about to finish and we started some engagement with USAID Ghana here, this new Gag Rule has come in,” Wuddah-Martey said. “So we are back to square one.”

Linda Asantewaa, 24, had an abortion in 2013 at a Marie Stopes clinic in Ghana. She now works as a community volunteer.

Marie Stopes in Ghana does not rely heavily on USAID funds, but its family planning work in other countries, including Niger, which has the highest fertility rate in the world, does. The Gag Rule translates into a loss of nearly $30 million every year, money they will no longer receive because they refuse to stop providing safe abortions where they’re legal and advocating for them where they’re not. “In terms of women affected, we estimate that if this money is taken away, we are going to be reducing services to about 1.5 million women in the poorest countries,” said Marie Stopes’s Newman-Williams. “And by that I’m referring to sub-Saharan Africa, Niger, Burkina Faso, Mali. Niger, really? Where women still have on average seven children, who have no access to modern contraception, where the women are destitute? This is going to be really hard on the poorest women in the world.”

There’s another revision to the rule that has advocates worried. While the Reagan and Bush Gag Rules applied to “nongovernmental organizations,” Trump’s rule removed the word “nongovernmental” from the text. The administration has so far refused to clarify if that means they may pull funds to national health systems — and USAID supports national health systems across Africa — if sovereign governments allow legal abortion for their citizens.

One of the most important, and least quantifiable, components of this new rule’s impact will be its effect on spreading reliable information and building trust in a public that may have good reason to doubt both those advocates who are seen as outsiders and their own governments. International organizations rely heavily on local groups that people trust to speak frankly and competently, and that encourage open discussion about often-taboo issues, including family planning and abortion. Now, if these organizations receive USAID money, they have to choose: much-needed funding in some of the poorest places on Earth, or the freedom to speak. Unlike the Bush administration, the Trump administration has offered no clarity on whether its Gag Rule allows providers to at least offer post-abortion care to women who show up dying on their doorsteps.

The impact, said Aba Oppong of the Center for the Development of People, will be “tremendous.… Without that funding, you cannot promote the life that safe abortion saves.” Oppong’s group does not perform abortions, but she works with many young people in need. She’s seen 10-year-old girls diagnosed with HIV, girls married in adolescence, girls without family support sleeping with older men to survive. Trump’s Gag Rule, she said, “gives me the chills, because I know the life of a girl without information.”

At the Marie Stopes clinic in Kumasi, Ghana’s second-largest city, Yaa, a mother of eight with full cheeks and a bronze bird-print scarf wrapping her hair, sits in one of the counseling rooms, a painting of a tree on the wall at her back. Next to her, an older midwife deftly arranges a clutter of objects on the table: a packet of pills, an IUD sitting snugly in a wooden carving of a cervix, an illustrated flipbook of voluptuous naked women and curving pink uteruses, a model penis. A few days earlier Yaa had discovered she was pregnant again, and when a friend got hold of an abortion-inducing drug from a local store, Yaa took it.

This is fairly common. Although abortion-inducing drugs are prescription-only in Ghana and kept under tight control by reputable clinics like Marie Stopes and Planned Parenthood, women often get them under the table elsewhere. Some of these women aren’t aware that abortion is legal for them; others assume they can’t afford it; still others are too ashamed to walk into a clinic and ask for help.

Andrena Gryekye helps a pregnant woman who has come to the public clinic in Mando for a checkup.

Many women who try to end their pregnancies themselves end up at local clinics or hospitals. A few make their way to a Marie Stopes center, a chain of nine bright, tidy buildings where staff members wear sky blue to match the paint, and every exam room has a wall stenciled with a leafy tree, a cheery little bird flying off the side. Each center sees 25 to 50 clients a day, four of whom come for early abortions, and perhaps six of whom have tried the procedure on their own. The rest come in for other services, such as cervical cancer screenings, contraception, infertility treatments, cryotherapy (a remedy for abnormal cervical cells that can develop into cancer), vasectomies, and STI regimens and testing. Marie Stopes also has a network of BlueStar clinics across the country, where they train and audit other providers who offer a range of reproductive health services.

For all of the country’s gains, unsafe abortion remains a significant cause of maternal death in Ghana, where more than one in 10 women who die during pregnancy or birth perishes from an unsafe abortion. Many more survive — some because of post-abortion care, and some because innovations in abortion-inducing medication mean that even unsafe abortions have become a lot safer — but still, for every woman dead from an unsafe procedure, 15 are physically injured.

Clandestine and off-label use of abortion-inducing drugs (like the kind that Yaa took), is far less optimal than procuring them by prescription from legitimate sources where the drug is sure to be real and the dosing correct. But even these technically illegal abortions are infinitely safer than the options women had a decade or two ago, which largely amounted to drinking herbal concoctions or inserting sticks or ground glass into their vaginas. But governments across the world, including in Ghana, are nonetheless cracking down on the illicit use of medications that cause abortion, leaving women with only the more dangerous options.

Yaa is lucky. Edith Offei, the midwife laying out a carnival of reproductive health paraphernalia on the table, is not only trained in post-abortion care, but is also prepared to discuss preventing future pregnancies. After going through her options using an illustrated chart, Offei shows Yaa physical samples of various methods — an IUD, a pack of pills, an implant — and Yaa, certain she doesn’t want any more children, opts for a tubal ligation.

Offei, clad in her sky blue scrubs, flips through her book to find an illustration of a uterus and fallopian tubes, showing Yaa where the tubes would be cut. Does she understand? Is she sure? Yaa nods, yes, she understands, she is sure. Offei pulls out a medical consent form and peers through her glasses to read it, line by line, her eyes flickering up to meet Yaa’s after each section to repeat her questions. Does she understand? Is she sure? Yaa rubs her forefinger on an inkpad and stamps the form with her consent. Then it’s time for Offei to remove the leftover tissue in Yaa’s uterus so that she doesn’t get a potentially deadly infection. Yaa stands up and follows Offei, skirt swishing, down the blue corridor until she disappears behind a blue curtain adjacent to the procedure room.

According to Gbagbo, Yaa’s experience is typical. “Ninety-five out of 100 women who received abortion services leave here with one form of family planning or the other,” he says — and the contraceptives are free. Post-abortion contraception is an intentional strategy aimed at decreasing the abortion rate, giving women the tools to plan their families and ultimately saving women’s lives. “If the women we see for an abortion are here, it means we have failed as a family planning service organization,” Gbagbo says. “We should have been able to identify them, reach out to them with information and services.” If they don’t offer family planning services when women come for abortions or after trying abortions on themselves, “then we have failed them twice.”

The women who are failed the most often are not city dwellers like Yaa, but villagers. As much as Ghana has improved its laws and as much as health care providers are honing their skills, misinformation remains an intractable challenge. Women, especially in rural areas, may not know they can seek a safe and affordable abortion at a health clinic. Even if they know abortion is legal, the stigma laid on women seeking abortions often drives them to try self-inducing first, and drives health providers away from offering the service. Out in the villages, many women still rely on traditional healers and herbalists to brew concoctions to induce a miscarriage.

Andrena Gryekye, a 26-year-old mother and one of the midwives at a public clinic in Mando, with her 2-year-old at home.

Three days a week, Gryekye walks 20 minutes to put her daughter into a taxi to take her to preschool.

While the girl is in child care, Gryekye visits with women to discuss antenatal care, infant vaccination, and contraception.

Seventy-five miles outside of Accra, down the coast and then inland, sits Mando, a lush town where the main road is flanked by churches, small stands selling phone credit or eggs, and heavy banana trees. This is the type of area reproductive health organizations try to reach, when they have the resources. The lifting of the Gag Rule during the Obama years meant these organizations could rely on USAID to expand their family planning work, bringing contraception and sex education to women who had not been able to easily access it. The Ghana Health Service is here too, as it increasingly is in towns and villages far more rural than this one, all across the country. One of the nation’s more innovative health strategies has involved dispatching midwives to agrarian enclaves, putting access to health care — including, crucially, family planning and antenatal care for pregnant women — at Ghanaians’ fingertips, no matter where they live. A handful of these midwives have been trained by groups like Ipas or Marie Stopes to offer safe abortions and function as a kind of one-woman reproductive health clinic, armed with the skills to offer contraception, improve the health of pregnant women, assist a woman in childbirth, and end a pregnancy safely. But the abortion part of that full spectrum of services is, predictably, the least common, only on offer by the midwives who have intentionally sought it out.

Andrena Gryekye, a warm 26-year-old mother with a generous smile and a soft, lulling voice, is one of the midwives at the public clinic in Mando. Three days a week, she pulls her green midwife’s uniform over her visibly pregnant belly, straps her 2-year-old girl to her back, walks 20 minutes to put her daughter into a taxi to preschool, and then spends the hours before the sun becomes too punishing visiting women door to door in their cinder block multifamily homes. She encourages the pregnant ones to come in for antenatal care, tells mothers to vaccinate their babies, and talks to all of them about spacing out their pregnancies with modern contraception. Sometimes, women come to her clinic having tried to end pregnancies themselves, and she knows how to stop the bleeding and refer them to a bigger hospital for serious complications. Elective abortions, though, are another matter.

“We say a lot of things to stop them,” she says. “But if they are planning to abort the baby, with any means they will do it.” Her clinic doesn’t offer abortions, and as far as she knows, the local hospital will terminate pregnancies only when there are fetal abnormalities. “In our country, no hospital will do a normal abortion,” she says — although according to many other advocates, some hospitals and many Ghana Health Service midwives will. “But [women] know if they do the normal abortion they will go to the hospital and the hospital will probably save them,” Gryekye says. “So they plan on taking the medicine at the home and then going to the hospital.”

This knowledge gap is a pervasive challenge in Ghana. The farther one gets from the city, the greater, it seems, that information gap grows. One risk of the Gag Rule is that it will stifle conversation about abortion, not just leading to a lack of movement in the policy realm, but keeping women and even some health care providers ignorant about their options. Health providers, too, are interested in moving forward and expanding their knowledge, not seeing their speech restricted. Despite her personal misgivings about elective abortion, Gryekye says, if she were invited to a training session on safe abortion, she would want to learn.

Women come to Gryekye and other midwives because these providers live, socialize, and invest their time in the communities where they work. That trust in the health care system can take years to form, and it’s been built on the efforts of midwives as well as health outreach workers who often partner with reproductive health NGOs. These workers have gotten many Ghanaians to gradually and unevenly break through their wariness of the formal health system and seek care. If outreach workers withhold information from women or flat-out lie to them in an effort to maintain their U.S. dollars, these fragile gains could collapse and take a generation or more to rebuild.

This is the trajectory the Gag Rule interrupts. For unsafe abortion rates to decline significantly, nations have to liberalize restrictive abortion laws, increase accessibility by training providers across the country to offer safe procedures, stamp out misinformation, reduce stigma, and build trust in the health system. In countries where abortion is legally restricted, the Gag Rule shuts down discussions on liberalization. In places like Ghana, where it’s mostly legal and increasingly accessible, the Gag Rule makes it harder for health care providers to tell women the truth about their rights and options and, as a result, compromises trust in the system.

A health care worker weighs and measures a patient at the public clinic in Mando.

The question looming over health care workers in Ghana and every other nation affected by the Gag Rule is: How do we move forward? But this question is impossible to answer; the opacity of Trump’s rule means no one really understands it.

At the offices of Planned Parenthood in Accra, Albert Wuddah-Martey ticks off a list of groups that refer to his organization: community volunteer workers, midwives, local NGOs, even churches. If those groups receive USAID funding for, say, childhood vaccination campaigns and a mother asks about family planning, can they no longer mention Planned Parenthood? He pauses, furrowing his brow, and asks, “Does it include partnerships? If it does, then we are doomed.”

In Ghana, a slew of organizations already work together to leverage their resources and knowledge. Oppong, of the Center for Development of People, doesn’t perform abortions but does refer women to another provider if they should ask. For women, the Gag Rule means “that opportunities for information will be stifled,” she said. “Without funding for us to conduct research, to engage more, we don’t have more information about emerging issues, so we can never save that group of people who live in the community, who have never been to school, who don’t have the knowledge.”

These partnerships include abortion providers like Marie Stopes and Planned Parenthood, but also researchers, activists, and many other members of civil society who don’t work on abortion, including groups like JSI, which has successful projects in the country to reduce and treat malaria.

“Beyond the fact that we work for different organizations, we are from the same community, we go to the same church, we are from the same family — you know, we are brothers and sisters and uncles,” Wuddah-Martey said. At meetings on coordinating contraceptive delivery, for example, “there are a lot of players there, and we all discuss issues related to family planning, safe abortion, and maternal mortality. So if it means a USAID-funded partner like JSI cannot come and sit and share his views, then where are we going?”

A woman checks in at the reception desk in the Marie Stopes clinic in Kumansi.

A midwife at the clinic in Kumansi discussed birth control options with Dora Gyamfi, an 18-year-old patient who came to the clinic for an abortion.

Dora waits to receive a birth control implant. She was too far along in her pregnancy to have the abortion at the clinic, and the midwife directed her to a local hospital for the procedure.

Across town, in another one of those blue-painted Marie Stopes rooms adorned with a tree and a little bird flying away, Dinah, 27, a mother of four with a short angular haircut, hasn’t heard about the Global Gag Rule and doesn’t know much about Donald Trump. But she has seen how a little information can change the world of a person who knew little and had less. Her kids, two sets of twins, are 3 and 6. She had her first abortion at 16, having never heard about family planning; she’s had about six more abortions since then, she’s not sure exactly, all of them done by herself. She told no one. When she was pregnant with her second set of twins, she arrived at Marie Stopes in Accra, desperate, scared, and unaware of what to do. After a long counseling session where it was clear Dinah wanted to keep the pregnancy but didn’t know how she would manage financially, the organization’s staff rented a room for her so she wouldn’t go homeless. After she gave birth, she came back for an IUD to prevent future unplanned pregnancies.

None of Dinah’s care was abortion-related, although Marie Stopes would have performed an early procedure had she requested it. However, it did cost money — money the organization stands to lose across the globe. Marie Stopes’s Newman-Williams is hopeful that private donors and more progressive governments will fill the funding gap that could prevent the organization from providing the holistic care it offered Dinah. Private donors are stepping up, and the Netherlands has pledged some funds, so she hopes more nations will follow suit. But her organization can’t sign the Gag Rule. No matter how much money is at stake, she says, “we will not turn our back on women.”

When Dinah walked into Marie Stopes for help, she was thinking about killing herself — retelling the story, her voice wavers and tears land on her white polo shirt. That Marie Stopes offered a roof over her head and the ability to plan her pregnancies wasn’t just a lifeline; it was an assertion that she had a future to plan for. Things are still hard — she’s living in a slum, sleeping in the hallway of her parents’ place — but they’re different; she feels as if she’s finally moving forward. She runs her own shop and wants to get a degree in information and communications technology, “so that I can build some small home for me and my children so that my children will be safe,” she says.

Women like Dinah, Gbagbo says, are the reason he does this job even in the face of social judgment and great personal risk. “We do it because we believe in what we do,” he says. When many women come into the clinic, they feel “like life is not worth living. But thereafter, you give them a sign of hope, a sign of relief. That is more fulfilling than being the president of the U.S.”

Today, Dinah says it’s a relief, little but significant, to know an accidental pregnancy won’t derail her careful, tenuous plans. “For now,” she says, “I’m free. I’m free.”

A version of this article originally appeared in the March/April 2017 issue of FP magazine.

Jill Filipovic is the author of the forthcoming "The H-Spot: The Feminist Pursuit of Happiness." (@JillFilipovic)