Ms Matilda Owusu-Ansah
Former Director of Resource Mobilization
Planned Parenthood Association of Ghana,
a Member Association of the International Planned Parenthood Federation

31 October 2007

Chairman Lantos, members of the House Committee on Foreign Affairs, Committee Staff and my esteemed colleagues, I would like to thank you for holding this hearing to assess the Mexico City Policy/Global Gag Rule and its impact on international women’s reproductive health in US-funded programs. Additionally, Mr Chairman, we are very aware that only the strong support of Congress has prevented an even more serious erosion of the United States program in international family planning. On behalf of the volunteers and staff of the 150 Member Associations of the International Planned Parenthood Federation – and the women and families we serve -  we thank you.

My name is Matilda Owusu-Ansah. Today, I speak to you as the former Director of Marketing and Resource Mobilization at the Planned Parenthood Association of Ghana (PPAG). I held this position when the Global Gag Rule was being implemented in Ghana, a time of tremendous turmoil. I personally witnessed the destructive impact the Gag Rule had on our programs and on the clients we serve. It is my hope that by telling the story of PPAG, I can give voice to those people most affected – women and girls. The experience of PPAG mirrors the experience of IPPF around the world.

First, I will explain a little bit about how PPAG has come into existence, and then provide you with some overall context of Ghana. I will then describe the work of PPAG before we were affected by the Gag Rule and the impact the Global Gag Rule has had on the ground and in our clinics. Finally, I will offer some thoughts on the overall effect of the Gag Rule.

The Birth of a National Organization

Planned Parenthood of Ghana was founded in 1967 when a small group of doctors and lawyers came together to confront a persistent public health issue they faced on a daily basis. Women were suffering and even dying from pregnancy-related ill health which they knew could be prevented by quality family planning services. Our founders believed in “children by choice, not by chance”. This was the motto in those early days and it remains the motto of PPAG today.

Over the years, PPAG grew into a national organization, reaching people in 63 districts, spanning seven of Ghana’s ten regions. PPAG is a proud member of IPPF, a global service provider and leading advocate of sexual and reproductive health and rights. IPPF is a worldwide movement of national organizations working with and for communities. We envisage a world where women, men and young people have control over their own bodies, and therefore their destinies. IPPF’s strong sense of solidarity and unified vision transcend political, economic, religious and ethnic boundaries.

Advances and Challenges in Sexual and Reproductive Health in Ghana

Ghana has a long history of voluntary family planning. We approved our first national policy on population and family planning in 1969 – among the first in Africa – and the total fertility rate (TFR)  has gradually declined. Since 1988, use of contraception among married women has doubled to 25.2 per cent and use of modern methods has more than tripled to 18.7 per cent.  

While we are making some progress, the challenges facing us are daunting. There is a serious disparity between urban and rural areas - contraceptive use remains low and fertility rates are high in rural Ghana . In addition, Ghana’s population is young and 50 per cent of adolescents aged 12 to 19 live in rural areas . The rural poor, including a large proportion of young people, cannot afford contraceptives and family planning services and also may not be able to afford the journey to the nearest service outlet because almost half of Ghanaians earn less than $1 a day. The pregnancy rate of young, rural girls aged 15 to 19 is double that of those living in cities  and many of those pregnancies are unintended.

In my country, one in 35 women will die during pregnancy or in childbirth . (By comparison, only one in 2,500 women living in the United States will ever die of pregnancy-related causes).  For us, childbearing remains an important role for women. It is simply unacceptable that women face a real risk of dying every time they give birth merely because they do not have access to the reproductive health services and supplies that they need and want.

If you live in a rural area of Ghana, you may have to walk for miles for a prenatal examination or to buy contraceptives. Sometimes, when you arrive, there are none in stock. We are lucky that the prevalence rate of HIV/AIDS in Ghana is low at this point in time, but as long as access to condoms is limited, the rate could rise.

Snapshot of the Planned Parenthood Association of Ghana Pre-Global Gag Rule

Let me take you back to the Planned Parenthood Association of Ghana, circa 2002, before we were faced with the Global Gag Rule.

At this time, PPAG offered a comprehensive range of sexual and reproductive health information and services. These included family planning methods, specialized youth-friendly clinics, mother-and-child health welfare services, such as child immunizations, and antenatal and post-natal services. We provided HIV/AIDS prevention, voluntary counseling and testing (VCT) for HIV/AIDS, sexually transmitted infection management, post-abortion care, fertility management, specialized male reproductive health services, laboratory services, treatment of minor ailments and referrals.

In 2002 we distributed more than 6.5 million condoms – twice the number reached by the government-run health service. We were the second largest distributor of contraceptives in rural areas (rural outreach is the hallmark of PPAG’s services), and third in the country. The reach and extent of PPAG’s family planning services was achieved, in part, with the generosity of US taxpayers and the long-standing cooperation and partnership we shared with USAID.

A $2.8 million USAID grant, from 1999 to 2004, gave PPAG the means to realize a long-desired plan: to implement an innovative community-based services project to reach the most vulnerable groups in rural areas. PPAG grew to include over 1,800 trained community-based volunteers and 13 staffed clinics. This project vastly increased the uptake of contraceptives.

Let me share with you the words used in an independent case study report:
 
“Since [1967], PPAG has been in the forefront of advocating for reproductive health and rights and delivering services at the clinic and community levels.

PPAG pioneered the introduction of a small community-based [services (CBS)] program in 1974. The program continued to expand with support from various sources, including USAID… The difference between the earlier distribution of contraceptives and [community-based services] was a more holistic approach to reproductive health. Volunteers and nurses took into account the needs of the clients, made more information available and increased referrals for clinical services beyond family planning (sexual health, maternal and child health, and STI prevention).”

Galvanizing their combined expertise and resources, USAID and PPAG effectively prevented significant numbers of unwanted pregnancies and reduced maternal mortality among Ghana’s women and girls.

This USAID-PPAG initiative was, remember, just one example of collaboration between USAID and an IPPF Member Association. The achievements of the community-based services program in Ghana were echoed in many countries and communities across the IPPF network. A joint review of the USAID-IPPF partnership, completed in 2000, noted

“There is high interest on the part of USAID and IPPF in increased dialogue and mutual engagement. IPPF and USAID should seek opportunities to exchange information on their priorities, strategies, and field experiences… Both USAID and IPPF see the value of continuing the relationship (USAID 2000).”

Why We Could Not Sign the Global Gag Rule

After the reinstatement of the Mexico City Policy in 2001, PPAG, along with many other IPPF Member Associations, faced a nearly impossible choice. We had to choose between losing our 30-year partnership with USAID, which helped us reach the poorest and most vulnerable people in Ghana with family planning services and supplies, or to violate the trust we painstakingly built with these same people and communities. If we signed the Global Gag Rule, we would breach the medical ethics of our staff by requiring them to withhold life-saving, medically-necessary information from our clients – requirements that were being imposed by a foreign government.

Let me explain further. The people of Ghana come to our clinics or seek out our community-based health workers because they trust us. They trust us because we give them full information and confidential counselling so they, in turn, can make their own reproductive health choices. Family planning and contraceptive distribution comprise the majority of our services because we know that the best way to prevent unintended pregnancies and to reduce the need for abortion is to make sure that women, couples and young people have information about and access to contraception.

At the time that we were faced with this decision, PPAG did not perform abortions. Rather, we counselled women and, if needed, referred them to our government hospitals where upon advice of a qualified doctor abortion services are provided according to Ghanaian law .

We wrestled with the decision of whether to sign the Global Gag Rule; it was deeply debated within PPAG as well as throughout all parts of IPPF. To sign it would have been to turn our back on women, consigning them to risk their lives and health through unsafe abortion.

To sign the Global Gag Rule would have meant breaking with medical standards in our own country by not informing our clients about the full range of medical services legally available to them. It seemed to us that the Global Gag Rule was playing politics with women’s lives. We found it morally offensive and totally at odds with our mission and medical ethics to risk the lives of Ghanaian women because of domestic politics in another country.

From a completely different part of the world, Dr Nirmal Bista of the Family Planning Association of Nepal, in his testimony before the Senate Foreign Relations Committee in July 2001, expressed well the anguish we were experiencing:

“Were we to accept the restricted U.S. funds, I would be prevented from speaking in my own country to my own government about a health care crisis I know first-hand. But by rejecting U.S. funds, I put our clinics — clinics addressing that same health care crisis — in very real jeopardy.

It is an untenable situation. But, we simply could not stand by and watch countless women suffer and die without doing everything we could to prevent the misery .”

In the end, we chose to refuse to abide by the Global Gag Rule requirements as did the whole of IPPF. The Global Gag Rule endangers the lives and health of women and families around the world. It undermines the provision of family planning services and information; it causes more women and couples to face the reality of unwanted pregnancies; it exposes women to the dangers of unsafe abortions. As our founder and special adviser to the President of Ghana, Dr Fred Sai compellingly stated

“A straightforward public health problem with a known solution has been allowed to become the killing fields of women in developing countries, particularly Africa.”

The Detrimental Impact of the Global Gag Rule in Ghana

Around the world, the imposition of the Global Gag Rule and the consequent loss of funding have had a dramatic impact on the ability of IPPF Member Associations, and many other organizations, to provide full sexual and reproductive health services. The impact on PPAG was immediate, deep and damaging. PPAG lost all of its in-country USAID funding as well as USAID funding received via IPPF headquarters. In one fell swoop, PPAG had to absorb budget cuts of nearly $2 million.

An independent evaluation developed for Repositioning Family Planning, an initiative funded by USAID, stated:

“Losing PPAG as a cooperating agency, and the resulting dismantling of a huge operation of contraceptive services and distribution, certainly had a negative effect on family planning coverage in Ghana. In 2003, 17% of all contraceptive sales were from the PPAG system, and most importantly, from rural areas. More than half of PPAG's 192 staff members were laid off, and more than 1,000 volunteers were without the structure that kept them motivated and supplied.”

When PPAG lost USAID-donated contraceptive supplies, we experienced contraceptive shortages and stockouts in some regions, at times for several months. We were no longer able to provide free contraceptives to the poorest of the poor. In less than a year, PPAG’s condom distribution of 6.5 million fell by 40 per cent.

We were compelled to create a new ‘cash and carry’ system to fund the purchase of contraceptives. Despite this attempt to bolster contraceptive availability, PPAG was able to provide only half the number of contraceptive supplies in 2004 that we provided in 2003. This shortage meant that 38,000 women who had come to rely on PPAG for contraceptives were no longer able to obtain them.

PPAG has kept in touch with some of its community-based volunteers. Six of them who live in the areas surrounding Kparigu, one of the poorest and most rural areas of Ghana, recently spoke with us. I will share with you their first hand experiences.

Their names are:

• James Manga from Boayili
• Sam Duud and Kasim Sumani from Kparigu
• Abraham Aduku from Zasilari
• Haruna Mahamodu from Boamasa 
• Abubakir Yamusa from Guakudow

They keep in contact with the PPAG Kparigu clinic even though there is no money to pay them for their travels to and from the clinic and no contraceptives to distribute. James, Sam, Kasim, Abraham, Haruna and Abubakir were all trained to be community-based service volunteers about seven years ago with USAID funds.

Haruna said, “We are all ready to work, but we need the contraceptives.”

Kasim said, “I need 60,000 cedis  to buy 600 condoms and another 60,000 cedis to buy 50 cycles of pills. In my community these will last about six weeks, but most of the time I do not have this money”.

At the same time, 20,000 women and their babies who had maternal and child health care (including immunizations for the babies and family planning for the mothers) in the outreach programs could not get that anymore and over 8,000 people could no longer be reached with treatment for STIs.

Sam said, “We still refer women to the PPAG clinic but because we have stopped many of the community programmes there are fewer referrals.”

Finally, and most tragically, we saw 50 per cent more women come to our clinics for post-abortion care. Some of these women died from self-induced post-abortion complications in one rural community in the North.

“In Ghana complications of unsafe abortion contribute [to] 22 to 30 percent of all maternal deaths. This exceeds the World Health Organization estimate of 13% [worldwide]” . The tragedy of unsafe abortion in Ghana is so heartbreaking that it inspired a British radio (BBC) program to document the situation and share the personal stories of Ghanaians whose lives have been changed as a result.

Affecting Real People, Real Lives

Perhaps the impact of the Global Gag Rule will become more real with a personal account of the tragedy it has brought about. Benjamin Baavugi, a 40-year-old farmer from Boayili village, is currently caring for his niece and nephew because their parents have been severely and directly affected by the impact of the Gag Rule. A few kilometres from the PPAG Kparigu Clinic, in Benjamin’s village, he told me the story of his sister-in-law, Kolgu Inusah, who died of an unsafe abortion.

I will let Benjamin tell this tragic story of an unnecessary and preventable death of a young mother for lack of contraceptives:

“To understand what happened to Kolgu, I have to describe the situation in our village about seven years ago. We had a [community-based services] agent who was working in the village, regularly giving talks on family planning and the use of contraceptives, HIV/AIDS and environmental sanitation. The education was good for us, especially for the women, and many of them started using contraceptives to space their births… My wife used contraceptives and we spaced our children.

About the middle of 2004, we noticed that the frequency of the agent’s house to house visits and talks had reduced and sometimes he did not have enough contraceptives, and then after some time he stopped everything. There was no education and no contraceptives. When the women visited him he informed them that they had to go to Kparigu Clinic. Since this was a few kilometres away it was easier said than done.

A few months after this we noticed that the number of pregnancies had increased and there were rumours of women having abortions. Kolgu and my brother, Kala Inusah, already had two children, Helene, 5, and Nurdee, 2. One day she started complaining of severe abdominal pains and when it became serious she confessed to her husband that she found out she was pregnant and went to a woman for some herbs to abort it. Kala rushed her to the PPAG clinic, but he did not tell anybody in the village the real problem. The medical team at the PPAG clinic tried to save her but it was too late.

After Kolgu’s death there was a lot of trouble in the village because the elders interpreted this sudden death as coming from the ancestors. Somebody had to be blamed and Kolgu’s sister, Abu Bahe, was accused of causing her sister’s death and she was banished from the village. We reported the case to the Medical Assistant at the PPAG clinic and the issue has been resolved. However my brother is not very well so I am looking after his two children.”

David Kansuk, the medical assistant and head of the PPAG team at Kparigu, is a tribal chief in Nalerigu. He understands his people and has their trust. He explained that traditionally after childbirth the woman goes to stay with her parents for about two years. This naturally creates space between births. Although things have changed and most couples continue to stay together after having a baby, there is a lot of mocking if the woman becomes pregnant again before the child is two years old. The use of contraceptives had therefore become important and was gaining ground among both men and women. This explains the situation Kolgu found herself in.

 
David continued the story of Kolgu:

“Before this lady died she told the nurses what she had done, using herbs to try and abort her pregnancy. We were surprised therefore to get a delegation from the village with the news that a woman had been banished because she had been accused for causing the death of Kolgu. We confronted Kala Inusah and after discussions he agreed to tell the community the truth. We went to the village and a meeting of the elders was arranged at which Kala told them what had happened. He confessed that he was ashamed of what his wife had done. It was agreed that Abu had been wrongly accused and she was brought back to the village. After this PPAG organized a sensitization seminar for the community and educated them on the dangers of unsafe abortion.

In many of the communities where we had community-based service providers, reports of unsafe abortion have increased and we have had more post-abortion complications and deaths in this clinic since the Gag Rule and the end of our community-based services program which was supported by USAID. We see on average two to three women a month for post-abortion care. Those who can afford it travel to clinics in Bolgatanga and Walewale where they get safer abortion services. Unfortunately poor and young women are the ones who are at greatest risk for unintended pregnancies and who end up having the unsafe services and suffering through the consequences.”

PPAG’s community-based services program through which thousands of rural women, men and young people were given quality sexual and reproductive health services, including distribution of contraceptives, was the biggest rural outreach program in the area. PPAG is the only NGO providing sexual and reproductive health services through community volunteers in this district. The Ghana Health Service and some Christian organizations like the Baptist Mission have clinics in three towns. However, the extent to which we mobilize the community and the reach of our community-based service volunteers cannot be equalled, and a vacuum has been created that the public health service cannot fill. 
 
The table below illustrates the magnitude of the reduction in PPAG’s services to the poor and marginalized women of Ghana.

Undermining Family Planning and Prevention of HIV/AIDS

Reduced access to family planning – condoms specifically – was a clear result of the Global Gag Rule. With limited access to contraceptives and reproductive health services, not only did the number of unintended pregnancies increase, but so did the number of new sexually transmitted infections.

In my country there are 7.5 million young people . This is a group that is particularly vulnerable to HIV/AIDS but, unfortunately, many of them don’t believe that HIV is a real threat to them and they do not protect themselves against it.

Young people understand unwanted pregnancy, however. The Guttmacher Institute did a study in four sub-Saharan African countries, including Ghana, and they found that young people were more likely to use condoms to prevent pregnancy than to prevent HIV (only 5% of females used a condom for protection solely against STIs, including HIV/AIDS) . In fact, Ghana has a high proportion of women living with HIV - 64 per cent of HIV-infected adults in Ghana are women – the highest recorded rate among 16 West African countries listed by PRB .

Those of us working in the field of reproductive health know that integrating HIV prevention and family planning programs is one of the most effective ways of getting young people to protect themselves, against unintended pregnancy and sexually transmitted infections.

Partnering with local churches and mosques, PPAG runs a dedicated program for youth called ‘Young and Wise’. At Young and Wise we educate young people to help them make informed choices, to prevent HIV infection and to prevent teenage pregnancy. By refusing to sign the Global Gag Rule, PPAG was unable to continue promoting condoms through Young and Wise. In an article published in the L.A. Times in June 2004, Barbara Crossette illustrates the loss felt by Young and Wise following the implementation of the Gag Rule. She writes

“The problem is that the supplier to Ghana of the best condoms, the United States Agency for International Development, can no longer give any to this project. Does this make any sense? … Because Ghanaians – Christian and Muslim – are a religious people, the effect has been to undermine many programs that conservatives could support .”

The U.S. government maintains separate funding programs for family planning and HIV/AIDS, and integration is discouraged owing to funding and policy constraints. When PPAG lost funding from USAID, we hoped that we would be able to continue our HIV prevention programs at Young and Wise by applying to the President’s Emergency Plan for AIDS Relief (PEPFAR).

Sadly, this was not the case. Any partner that receives PEPFAR funds for integrated family planning/reproductive health – HIV/AIDS programs must comply with the restrictions on both U.S. family planning and HIV/AIDS assistance. This includes the Global Gag Rule. We know from years of experience that to get young people to pay attention - to really change their behaviour so that they are protecting themselves from sexually transmitted infections as well as unintended pregnancies – you have to promote condoms within family planning programs.

Our Conclusions

In my country the Global Gag Rule has had the exact opposite effect of its stated intent. It did not reduce abortions. Indeed PPAG began to see a sharp rise (almost double) in post-abortion care services in our clinics, especially in the rural areas which is a reflection of the worsened access to reproductive health care and supplies. The Gag Rule undermined family planning and reproductive health services across the country. Fewer pregnant women were able to access much-needed care, and access to HIV/AIDS and STI prevention services, especially among young people, were reduced.

We will never know the real cost of this harmful policy because we can never know the total number of lives that have been irreversibly altered. It is the lives of poor and rural women, men and young people who were denied the right to make choices that could have improved their living conditions: an STI or maybe HIV infection that could have been prevented, a poor rural mother that could have received quality prenatal care to help her survive a pregnancy and deliver a healthy baby, a woman that could have avoided an unwanted pregnancy and therefore no need for an unsafe abortion and its related complications.

When PPAG refused to sign the Gag Rule, USAID hoped to find another NGO to take over the program. This was not possible then and it’s still not possible now. There was simply no local or international NGO with the structure and expertise that PPAG had built over 33 years to take over. Not only did PPAG lose a key funder for its core services, but USAID also lost an irreplaceable partner, and the women and children of rural Ghana were the most severely affected.

Ironically, the Global Gag Rule has resulted in an inefficient use of US tax-payers money. No other Ghanaian organization compares to our rural outreach and our youth programs nor the trust and credibility we have with the community we come from. By funding other organizations with smaller reaches into the community, you fund a piecemeal and less cost-effective approach to development.

If USAID-donated contraceptives were made available to PPAG, the effect would be immediate and thousands of women would once again be able to access the services and contraceptives they need most. PPAG could resume community outreach programs to the rural poor. In our experience, the increase in contraceptive provision would dramatically and directly reduce unwanted pregnancies and avert unsafe abortion – thereby saving women’s and mother’s lives.

Read the news release

(Please note, the news release quotes Mrs Joana Nerquaye-Tetteh though Ms Matilda Owusu-Ansah was supposed to testify on behalf of PPAG.  This was not possible due to the death of one of the Committee representatives. The hearing was postponed to the 31st and Mrs Joana Nerquaye-Tetteh, as a former Executive Director made the statement).