Impacts on Affected Countries

Romania

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Overview

The history of abortion and family planning in Romania has been exceptionally tumultuous. The imposition of the Global Gag Rule is another chapter in this country's erratic reproductive health history that has so little reflected what Romanian women themselves want and need. Romania emerged in 1989 from decades of pro-natalist policy, under which the government heavily restricted access to both contraception and abortion. Due to a desperate desire to limit fertility and in the absence of contraception, abortion rates were extremely high, with most Romanian women having multiple illegal abortions. Reliance on abortion has continued to be high following legalization, although rates are declining.

U.S. family planning assistance has played an important role in supporting Romania's transition from reliance on abortion to use of contraception. Given women's traditional reliance on abortion, however, the imposition of the Global Gag Rule has been especially counterproductive. While family planning is being successfully integrated into primary health care, the gag rule has impeded the integration of family planning counseling into existing abortion services. The gag rule has caused rifts between organizations that would otherwise be natural partners in the promotion of family planning. It has also erected barriers to nongovernmental organizations' (NGOs) advocacy and free speech on behalf of efforts to reduce abortion complications and improve the quality of care.

Although the Romanian health NGOs currently receiving U.S. family planning assistance neither provide nor promote abortion, the Global Gag Rule disrupts their work. The policy has reinforced the complete separation of abortion and family planning services, and in doing so, has limited the reach of family planning information and counseling. As the largest reproductive health organization, Societatea de Educatie Contraceptiva si Sexuala (SECS) potentially had the most to lose. But SECS, having accepted the terms of the policy in 1992, resolved not to include abortion in its counseling, referral or advocacy from the outset. Staff commented that the decision not to provide abortion counseling or referrals to clients was not a problem because virtually every Romanian knew about abortion and where to get it. On the other hand, if SECS had chosen to work more closely with abortion providers and women experiencing abortion, they would have reached a high-risk group who could have benefited greatly from their services.

Shift From Abortion to Family Planning Harmed

Because of Romania’s unique historical reliance on abortion, women often first learn about family planning and decide to start using it after they have abortions. If family planning providers are prohibited from having any association with abortion, they will not be able to reach a key group of women who could benefit greatly from access to contraception. In this way, the Global Gag Rule is self-defeating. When there is no post-abortion counseling, and women do not have the chance to learn about modern contraceptive methods, they will almost inevitably return for future abortions. A new Ministry of Health and Family protocol on post-abortion family planning (not yet in place) would require abortion providers to talk about family planning. In the meantime, however, years will have passed in which the separation of these two dimensions of reproductive health has had negative consequences.

In a country where abortion is so widespread, integrating family planning counseling into government abortion services would have made sense from the outset of the U.S. Agency for International Development's (USAID's) program. Had family planning and reproductive health programs been integrated normally with abortion services, post-abortion counseling could have been a powerful tool in facilitating Romanians' shift – in mindset and in practice – to contraception. Though technically legal under the gag rule restrictions because governments are exempt, this important opportunity was nonetheless missed, a probable casualty of overly cautious interpretation by U.S. officials and NGOs. Territoriality within the Romanian health system reinforced this split.

Collaboration Among Reproductive Health Providers Stymied

It is clear that the Global Gag Rule has split reproductive health organizations into two camps in Romania. As one USAID staff member expressed, the politics are being oversimplified as the promotion of access to abortion versus its alternatives. In Romania, where significant NGO players are few and far between, the gag rule has squandered goodwill and impeded cooperation between groups that could otherwise work together to great advantage – and have done so in the past.

Marie Stopes Interational Romania (MSI Romania), which has never received USAID assistance, is being disparaged by people who know little about its work. The head of one NGO that agreed to the gag rule restrictions criticized MSI Romania as inferior to SECS, accusing it of mentioning family planning only in the post-abortion context and doubting that they "have the interest to provide family planning." Yet the main MSI clinic in Bucharest sees thousands of patients every month – a large proportion of them for family planning and nothing else. Furthermore, MSI Romania has collaborated with the Romanian Anti-AIDS Association (ARAS) in a project for high school students providing contraceptive and HIV information and worked earlier in an outreach program with Youth for Youth. MSI Romania has been interested in working with young people in schools and universities and would like to collaborate with other NGOs on sex-education efforts.

By polarizing groups along lines inappropriate to the Romanian context the Global Gag Rule caused SECS, USAID's major partner, to lose important support for its work. SECS's acceptance of the gag rule has weakened its relationship with the International Planned Parenthood Federation (IPPF), which was instrumental in helping SECS get started. Over the years, IPPF provided SECS with program funds, contraceptive supplies, technical support and links to an international network of reproductive health care providers. USAID will now be the main source of technical support and contraceptive supplies for SECS.

Censorship of Abortion Information Emerging

The Romanian government's pilot project on sex education is based on Youth for Youth's accredited manual for high school students. Given the role that abortion has played in Romania's history and its continued heavy use, young people need information and guidance on the topic as part of sex education. Yet, because Youth for Youth agreed to the gag rule restrictions, the USAID-funded curriculum on which the government's program is based makes no reference to abortion.

Barriers to NGO Advocacy and Free Speech Erected

All medical services in Romania – including abortion – require improvement. Yet many NGOs that would be involved in lobbying for improvement of abortion services are now not permitted to do so. One NGO staff member explained that there is no activism on quality of care because the health system as a whole lacks funds and is beset with problems. NGOs can encourage people to organize for what they want rather than waiting for the state to provide it. This is especially key in Romania, where there was no tradition of women's health advocacy or civil society before 1990.

Through its POLICY Project, USAID supported the Reproductive Health Coalition of advocates in Bucharest, whose main advocacy goal was the inclusion of reproductive health services in the national health insurance plan. The Coalition continues to be very active in Constanta even though financial support from the POLICY Project has ended. There, the Women's League, Muslim League, Turk-Tatar organization, and other ethnic women's groups (Bulgarian, Greek, Roma, Russian and others) are focusing on public education and advocacy with the government around health issues. They decided more recently to monitor the government's actions on HIV/AIDS, including the requirement that HIV-positive individuals register with doctors each year. The future for such advocacy remains highly uncertain in Romania, but one thing is clear: NGOs that seek or accept USAID funding will not be able to participate in efforts to improve national policies or guidelines affecting the quality of abortion.

Reputation of the United States Damaged

Most family planning clinics in Romania are run by the government, which is not bound by the Global Gag Rule. Yet almost without exception, when they speak freely, government and NGO representatives decry the gag rule and the political constraints it has imposed on Romania's efforts to encourage contraception rather than abortion for family planning. Romanian NGOs say that they accept the policy for now, but intend to terminate their agreement with USAID on the day that abortion rights in Romania are restricted in any way.

Leaders of some NGOs have expressed anger and frustration at being "bullied" by the United States and note that USAID is alone among donors in making such demands in exchange for assistance. Yet the scale and importance of USAID's support for reproductive health in Romania force them to accept the restrictions. Romanian reproductive health leaders agree that because dependence on abortion is the core of the problem, the transition to family planning must come through education on sexual and reproductive health and should start with making contraceptives available to women at the time they have abortions, a strategy that has been avoided by USAID. Abortion care is much more than provision of the procedure; it should include links to family planning, counseling and other services.

Conclusion

Although everyone working in reproductive health in Romania is committed to reducing rates of abortion, the Global Gag Rule is compromising efforts to do so. In splitting USAID-funded institutions that provide family planning from those that provide abortion, the gag rule prevents the integration of comprehensive post-abortion contraceptive counseling for women in the context of government services. After more than a decade of working in Romania, USAID is now taking small steps to address this issue. Yet the Global Gag Rule has weakened the base of interested and capable Romanian organizations that could work with USAID to promote family planning. The exclusion of any mention of abortion in the NGO sex education program on which the national school health education curriculum will be based is an unfortunate decision in a country where abortion is so common. The poor quality of abortion services could be an important area of advocacy by Romanian NGOs, but this is also prohibited by the gag rule. Finally, the policy has produced in Romania a thinly concealed resentment toward the United States and its imposition of an inappropriate external constraint on reproductive health services and education.

"We learn from history that we do not learn from history," said a high-level government official, quoting the prominent 19th century philosopher, G.W.F. Hegel. Romania’s history shows that abortion cannot be stopped by making it illegal or stifling public discussion. Indeed, doing so leads to a higher number of illegal and unsafe procedures and drives up the number of maternal deaths. Romania's legalization of abortion has caused maternal mortality to drop. The challenge now is to provide Romanian women who seek abortions with the complete family planning information they need. Until it is rescinded, the Global Gag Rule will stand in their way.

Case Study Sources

Kligman, Gail. 1998. The Politics of Duplicity: Controlling Reproduction in Ceausescu's Romania. Berkeley, CA: University of California Press.

Johnson, Brooke R, Mihai Horga and Laurentia Andronache. 1996. "Women's Perspectives on Abortion in Romania." Social Science and Medicine, 42(4): 521-530.

Baban, Adriana and Henry P. David. 1994. Voices of Romanian Women: Perceptions of Sexuality, Reproductive Behavior, and Partner Relations During the Ceausescu Era. Bethesda, MD: Transnational Family Research Institute. Available from http://www.ceausescu.org/ceausescu_texts/overplanned_parenthood.htm; Internet; accessed 29 March 2003.

United Nations Population Division, Department of Economic and Social Affairs. 2002. "Romania." Available from http://www.un.org/esa/population/publications/abortion/doc/romania.doc; Internet; accessed 28 March 2003.

Serbanescu, Florina, Leo Morris and Mona Marin. 2001. Reproductive Health Survey, Romania, 1999. Atlanta, GA: Division of Reproductive Health, Centers for Disease Control and Prevention.

U.S. Agency for International Development/Romania. 2003. “Children with HIV in Romania – Report.” Available from http://www.usembassy.ro/USAID/Documents/ArchiveReportChwHIV.htm; Internet; accessed 3 April 2003.

World Health Organization and European Union. 1999. Highlights on Health in Romania. Copenhagen, Denmark: Regional Office of WHO. Available from http://europa.eu.int/comm/health/ph/programmes/ monitor/highlight_reports/romania_en.pdf; Internet; accessed 28 March 2003.

Ministry of Health, Romania. 1998. Center for Health Statistics and Information, in Serbanescu, Florina, Leo Morris and Mona Marin. 2001. Reproductive Health Survey, Romania, 1999. Atlanta, GA: Division of Reproductive Health, Centers for Disease Control and Prevention.

Based in 1990-1998 data. The MMR continues to fall rapidly. The World Bank. 2002. "Focus on Romania." Available from http://www.worldbank.org/html/schools/regions/eca/romania.htm; Internet; accessed 29 March 2003.

Directorate of Family and Social Health. 2002. Interview by author, Bucharest, Romania, October.

U.S. Agency for International Development/Romania staff. 2002. Interview by author. Bucharest, Romania, October.

Societatea de Educatie Contraceptiva si Sexuala (SECS). 2001. "A Romanian (Hi)story: The Story of Reproductive Health in Romania" [unpublished report]. Bucharest: SECS; Serbanescu, Florina, Leo Morris and Mona Marin. 2001. Reproductive Health Survey, Romania, 1999.; World Health Organization. 2002. Contraception and Abortion in Romania: A Strategic Assessment of Policy, Programme, and Research Issues [preliminary draft].

United Nations Population Fund. 2002. Interview by author. Bucharest, Romania, October.

Lazarescu, Dan Aurelian. 2001. "Reproductive Health Financing Issues in Romania: An Update." Washington, DC: The Futures Group International.

The World Bank Office, Romania. Interview by author, Bucharest, Romania, October.

U.S. Agency for International Development (USAID). 2003. "Romania: Program Summary." Available from http://www.usaid.gov/policy/budget/cbj2004/europe_eurasia/Romania.pdf; Internet; accessed 19 August, 2003.

Societatea de Educatie Contraceptiva si Sexuala (SECS). 2002. Interview by author, Bucharest, Romania, October.

East European Institute for Reproductive Health (EEIRH). 2002. Interview by author, Bucharest, Romania, October.

Government and NGO representatives decry the gag rule and the political constraints it has imposed on Romania's efforts to encourage contraception rather than abortion.