USA aid policy and induced abortion in sub-Saharan Africa: an analysis of the Mexico City Policy

U.S. global health aid policy and family planning in sub-Saharan Africa

The Trump administration reinstated and expanded the Mexico City Policy (MCP) in 2017 as the Protecting Life in Global Health Assistance (PLGHA) policy, forbidding international organizations receiving all U.S. health assistance from promoting abortion. Existing evidence suggests that abortion rates rise under the MCP, but the direct effect of U.S. funding restrictions on supply and use of family planning has received less attention. By studying PLGHA's impact on health service delivery providers and women in eight sub-Saharan African countries, we are able to fill this gap. We find that health facilities provide fewer family planning services, including emergency contraception, and that women are less likely to use contraception and more likely to have given birth recently under the policy. These findings suggest that PLGHA has important unintended consequences that are detrimental to reproductive health and the autonomous decision-making of health service providers and women.

Impact of the global gag rule on women's contraceptive use and reproductive health outcomes in Ethiopia: a pre-post and difference-in-difference analysis

OBJECTIVE

To assess the impacts of the Protecting Life through Global Health Assistance policy (otherwise known as the expanded global gag rule (GGR)) on women's sexual and reproductive health (SRH) in Ethiopia. The GGR prohibits all non-US non-governmental organisations (NGOs) receiving US Government global health funding from providing, referring or advocating for abortion.

DESIGN

Pre-post analysis and difference-in-difference analysis.

SETTING

Six regions of Ethiopia (Tigray, Afar, Amhara, Oromiya, SNNPR and Addis Ababa).

PARTICIPANTS

Panel of 4909 reproductive-age women recruited from the Performance Monitoring for Accountability 2018 survey, administered face-to-face surveys in 2018 and 2020.

MEASURES

We assessed impacts of the GGR on contraceptive use, pregnancies, births and abortions. Due to the 2019 'Pompeo Expansion' and widespread application of the GGR, we use a pre-post analysis to investigate changes in women's reproductive outcomes. We then use a difference-in-differences design to measure the additional effect of NGOs refusal to comply with the policy and the resulting loss in funding; districts are classified as more exposed if organisations impacted by lost funding were providing services there and women are classified based on their district.

RESULTS

At baseline, 27% (n=1365) of women were using a modern contraceptive (7% using long-acting reversible contraceptive methods (LARCs) and 20% using short-acting methods. The pre-post analysis revealed statistically significant declines from 2018 to 2020 in the use of LARCs (-0.9, 95% CI: -1.6 to -0.2) and short-acting methods (-1.0, 95% CI: -1.8 to -0.2). These changes were deviations from prior trends. In our difference-in-differences analysis, women exposed to non-compliant organisations experienced greater declines in LARC use (-1.5, 95% CI: -2.9 to -0.1) and short-acting method use (-1.7, 95% CI: -3.2 to -0.1) as compared with less-exposed women.

CONCLUSIONS

The GGR resulted in a stagnation in the previous growth in contraceptive use in Ethiopia. Longer-term strategies are needed to ensure that SRH progress globally is protected from changes in US political administrations.

Postabortion and safe abortion care coverage, capacity, and caseloads during the global gag rule policy period in Ethiopia and Uganda

BACKGROUND

Abortion-related complications contribute to preventable maternal mortality, accounting for 9.8% of maternal deaths globally, and 15.6% in sub-Saharan Africa. High-quality postabortion care (PAC) can mitigate the negative health outcomes associated with unsafe abortion. While the expanded Global Gag Rule policy did not prohibit the provision of PAC, other research has suggested that over-implementation of the policy has resulted in impacts on these services. The purpose of this study was to assess health facilities' capacity to provide PAC services in Uganda and PAC and safe abortion care (SAC) in Ethiopia during the time in which the policy was in effect.

METHODS

We collected abortion care data between 2018 and 2020 from public health facilities in Ethiopia (N = 282) and Uganda (N = 223). We adapted a signal functions approach to create composite indicators of health facilities' capacity to provide basic and comprehensive PAC and SAC and present descriptive statistics documenting the state of service provision both before and after the GGR went into effect. We also investigate trends in caseloads over the time-period.

RESULTS

In both countries, service coverage was high and improved over time, but facilities' capacity to provide basic PAC services was low in Uganda (17.8% in 2019) and Ethiopia (15.0% in 2020). The number of PAC cases increased by 15.5% over time in Uganda and decreased by 7% in Ethiopia. Basic SAC capacity increased substantially in Ethiopia from 66.7 to 82.8% overall, due in part to an increase in the provision of medication abortion, and the number of safe abortions increased in Ethiopia by 9.7%.

CONCLUSIONS

The findings from this analysis suggest that public health systems in both Ethiopia and Uganda were able to maintain essential PAC/SAC services during the GGR period. In Ethiopia, there were improvements in the availability of safe abortion services and an overall improvement in the safety of abortion during this time-period. Despite loss of partnerships and potential disruptions in referral chains, lower-level facilities were able to expand their capacity to provide PAC services. However, PAC caseloads increased in Uganda which could indicate that, as hypothesized, abortion became more stigmatized, less accessible and less safe.

An investigation of the impact of the Global Gag Rule on women's sexual and reproductive health outcomes in Uganda: a difference-in-differences analysis

In 2017, the Trump administration reinstated the Global Gag Rule (GGR), making non-U.S. non-governmental organisations ineligible for US government global health assistance if they provide access to or information about abortion. Little is known about the impact of the Trump administration’s GGR on women’s outcomes. Data for this analysis come from a panel of women surveyed in 2018 and 2019 in Uganda (n = 2755). We also used data from meetings with key stakeholders to create a detailed measure of exposure to the GGR within Uganda, classifying districts as more or less exposed to the GGR. Multivariable regression models were used to assess changes in contraceptive use, all births, unplanned births, and abortion from before to during implementation of the GGR. Difference-in-differences (DID) estimates were determined by calculating predicted probabilities from interaction terms for exposure/survey round. Descriptive analyses showed long-acting reversible contraceptive use increased more rapidly among women in less exposed districts after GGR implementation. DID estimates for contraceptive use were small. We observed a DID estimate of 3.5 (95% CI −0.9, 7.9) for all births and 2.9 (95% CI −0.2, 6.0) for unplanned births for women in more exposed districts during the period the policy was in effect. Our results suggest that the GGR may have attenuated Uganda’s recent progress in improving SRHR outcomes, with women in less exposed districts continuing to benefit from this progress, while previously increasing trends for women in more exposed districts levelled off. Although the GGR was rescinded in January 2021, the impact of these disruptions may be felt for years to come.

The impact of COVID-19 on safe abortion access in Africa: An analysis through a framework of reproductive justice and lens of structural violence

The SARS-CoV-2 virus causing the coronavirus disease (COVID-19) global pandemic heightened restrictions on sexual and reproductive health and rights (SRHR), especially concerning safe abortion access. The African region has been particularly susceptible to the impact of COVID-19 on sexual and reproductive health services. Using a framework of reproductive justice, we interviewed key informants from the Mobilizing Action around Medication Abortion (MAMA) Network regarding the impacts of structural violence and COVID-19 on SRHR programming in Africa, particularly programming on self-managed abortion. We identified themes of lacking infrastructures of support, emergent marginality, and neocolonial funding environments as facets of structural violence within the context of the MAMA Network, as heightened by the COVID-19 global pandemic.

The future of sub-Saharan Africa’s biodiversity in the face of climate and societal change

Many of the world’s most biodiverse regions are found in the poorest and second most populous continent of Africa; a continent facing exceptional challenges. Africa is projected to quadruple its population by 2100 and experience increasingly severe climate change and environmental conflict—all of which will ravage biodiversity. Here we assess conservation threats facing Africa and consider how these threats will be affected by human population growth, economic expansion, and climate change. We then evaluate the current capacity and infrastructure available to conserve the continent’s biodiversity. We consider four key questions essential for the future of African conservation: (1) how to build societal support for conservation efforts within Africa; (2) how to build Africa’s education, research, and management capacity; (3) how to finance conservation efforts; and (4) is conservation through development the appropriate approach for Africa? While the challenges are great, ways forward are clear, and we present ideas on how progress can be made. Given Africa’s current modest capacity to address its biodiversity crisis, additional international funding is required, but estimates of the cost of conserving Africa’s biodiversity are within reach. The will to act must build on the sympathy for conservation that is evident in Africa, but this will require building the education capacity within the continent. Considering Africa’s rapidly growing population and the associated huge economic needs, options other than conservation through development need to be more effectively explored. Despite the gravity of the situation, we believe that concerted effort in the coming decades can successfully curb the loss of biodiversity in Africa.

Beyond abortion: impacts of the expanded global gag rule in Kenya, Madagascar and Nepal

Since 1984, Republican administrations in the US have enacted the global gag rule (GGR), which prohibits non-US-based non-governmental organisations (NGOs) from providing, referring for, or counselling on abortion as a method of family planning, or advocating for the liberalisation of abortion laws, as a condition for receiving certain categories of US Global Health Assistance. Versions of the GGR implemented before 2017 applied to US Family Planning Assistance only, but the Trump administration expanded the policy’s reach by applying it to nearly all types of Global Health Assistance. Documentation of the policy’s harms in the peer-reviewed and grey literature has grown considerably in recent years, however few cross-country analyses exist. This paper presents a qualitative analysis of the GGR’s impacts across three countries with distinct abortion laws: Kenya, Madagascar and Nepal. We conducted 479 in-depth qualitative interviews between August 2018 and March 2020. Participants included representatives of Ministries of Health and NGOs that did and did not certify the GGR, providers of sexual and reproductive health (SRH) services at public and private facilities, community health workers, and contraceptive clients. We observed greater breakdown of NGO coordination and chilling effects in countries where abortion is legal and there is a sizeable community of non-US-based NGOs working on SRH. However, we found that the GGR fractured SRH service delivery in all countries, irrespective of the legal status of abortion. Contraceptive service availability, accessibility and training for providers were particularly damaged. Further, this analysis makes clear that the GGR has substantial and deleterious effects on public sector infrastructure for SRH in addition to NGOs.

The U.S. Global Gag Rule in Ethiopia: a foreign policy challenging domestic sexual and reproductive health and rights gains

BACKGROUND

Ethiopia's government and civil society have driven crosscutting initiatives in the last 15 years to improve sexual and reproductive health outcomes, including passing a 2005 abortion law that facilitated reduced rates of maternal death due to unsafe abortion. However, both the government and nongovernmental organizations have relied on external funding for sexual and reproductive health and rights, particularly from the U.S. government, which has been Ethiopia's largest global health donor. This article explores how the implementation and expansion of the 2017-2021 U.S. foreign policy "Protecting Life in Global Health Assistance," also known as the Global Gag Rule-which attached itself to a nongovernmental organization's funding-impacted sexual and reproductive health and rights, including safe abortion care, in Ethiopia.

METHODS

This article is based on research conducted by PAI staff in Ethiopia in 2018 with follow-up in 2019. PAI held in-depth semistructured interviews with representatives of 30 organizations in Ethiopia's capital, Addis Ababa. Among these groups were U.S.-based and non-U.S. nongovernmental organizations, including community-based organizations, non-U.S. government donors, and Ethiopian government officials.

RESULTS

Nongovernmental organizations have been essential to sexual and reproductive health service provision and advocacy in Ethiopia. Because of the sector's reliance on U.S. global health assistance, these organizations; their activities; and, consequently, the wider health system were negatively impacted by the Global Gag Rule. Certain vulnerable groups, particularly adolescents and youth, have traditionally relied on the private sector for sexual and reproductive health services. PAI's research demonstrates that U.S. policy disrupted activities and service delivery, threatened the closure of private clinics, stalled mobile outreach, and impacted safe abortion training of health personnel. Additionally, the Global Gag Rule dismantled partnerships, affected non-U.S. government donors' investments, and caused confusion that limited activities permissible under the policy.

CONCLUSIONS

The Trump administration's Global Gag Rule forced non-U.S. organizations to choose between providing comprehensive care or losing U.S. global health assistance, ultimately impacting populations in need of services. Ethiopia provides a clear example of how the Global Gag Rule can threaten a country's domestic health agenda by targeting nongovernmental organizations that are vital to health service delivery and safe abortion care.

Impact of the Trump Administration's Expanded Global Gag Rule Policy on Family Planning Service Provision in Ethiopia

The Global Gag Rule (GGR) makes non‐U.S. nongovernmental organizations (NGOs) ineligible for U.S. Government global health funding if they provide, refer, or promote access to abortion. This study quantitatively examines the impacts of the GGR on family planning service provision in Ethiopia. Using a panel of health facilities (2017–2020), we conduct a pre–post analysis to investigate the overall changes in family planning service provision before and after the policy came into effect in Ethiopia. Our pre–post analyses revealed post‐GGR reductions in the proportions of facilities reporting family planning provision through community health volunteers (−5.6, 95% CI [−10.2, −1.0]), mobile outreach visits (−13.1, 95% CI [−17.8, −8.4]), and family planning and postabortion care service integration (−4.8, 95% CI: [−9.1, −0.5]), as well as a 6.1 percentage points increase in contraceptive stock‐outs over the past three months (95% CI [−0.6, 12.8]). We further investigate the impacts of the GGR on facilities exposed to noncompliant organizations that did not sign the policy and lost U.S. funding. We do not find any significant additional impacts on facilities in regions more exposed to noncompliant organizations. Overall, while the GGR was slow to fully impact NGOs in Ethiopia, it ultimately resulted in negative impacts on family planning service provision.

US foreign aid restrictions and maternal and children's health: Evidence from the "Mexico City Policy"

Although family planning services are crucial for global health and achievement of the Sustainable Development Goals, their funding remains controversial. We document the health consequences of the “Mexico City Policy” (MCP), which restricts US funding for abortion-related activities worldwide. Since its enactment in 1985, the MCP has been enforced only under Republican administrations and quickly rescinded when a Democrat wins the presidency. Our analysis shows that the MCP makes it harder for women to get information on and support for reproductive health and is associated with higher maternal and child mortality rates and HIV rates worldwide. We estimate that reinstating the MCP between 2017 and 2021 resulted in approximately 108,000 maternal and child deaths and 360,000 new HIV infections.

This paper analyzes the link between foreign aid for family planning services and a broad set of health outcomes. More specifically, it documents the harmful effects of the so-called “Mexico City Policy” (MCP), which restricts US funding for nongovernmental organizations that provide abortion-related services abroad. First enacted in 1985, the MCP is implemented along partisan lines; it is enforced only when a Republican administration is in office and quickly rescinded when a Democrat wins the presidency. Although previous research has shown that MCP causes significant disruption to family planning programs worldwide, its consequences for health outcomes, such as mortality and HIV rates, remain underexplored. The independence of the MCP’s implementation from the situation in recipient countries allows us to systematically study its impact. Using country-level data from 134 countries between 1990 and 2015, we first show that the MCP is associated with higher maternal and child mortality and HIV incidence rates. These effects are magnified by dependence on US aid while mitigated by funds from non-US donors. Next, we complement these results using individual-level data from 30 low- and middle-income countries and show that, under the MCP, women have less access to modern contraception and are less exposed to information on family planning and AIDS via in-person channels. Moreover, pregnant women are more likely to report that their pregnancy is not desired. Our findings highlight the importance of mitigating the harmful effects of MCP by redesigning or counteracting this policy.

Trends in Abortion Policies in Low- and Middle-Income Countries

The decision to terminate a pregnancy is not one that is taken lightly. The need for an abortion reflects limited sexual autonomy, ineffective or lack of access to contraceptive options, or a health indication. Abortion is protected under human rights law. That notwithstanding, access to abortions continues to be contested in many parts of the world, with vested interests from politically and religiously conservative states, patriarchal societies, and cultural mores, not just within local contexts but also within a broader geopolitical context. Criminalization of a women's choice not to carry a pregnancy is a significant driver of unsafe procedures, and even where abortions are provided legally, the policies remain constrained by the practice or by a lack of coherence. This review outlines the trends in abortion policy in low- and middle-income countries and highlights priority areas to ensure that women are safe and able to exercise their reproductive rights.

Slowing progress: the US Global Gag Rule undermines access to contraception in Madagascar

Madagascar's health system is highly dependent on donor funding, especially from the United States (US), and relies on a few nongovernmental organisations (NGOs) to provide contraceptive services in remote areas of the country. The Trump administration reinstated and expanded the Global Gag Rule (GGR) in 2017; this policy requires non-US NGOs receiving US global health funding to certify that neither they nor their sub-grantees will provide, counsel or refer for abortion as a method of family planning. Evidence of the impact of the GGR in a country with restrictive abortion laws, like Madagascar - which has no explicit exception to save the woman's life - is limited. Researchers conducted semi-structured interviews with 259 representatives of the Ministry of Health and NGOs, public and private health providers, community health workers and contraceptive clients in Antananarivo and eight districts between May 2019 and March 2020. Interviews highlighted the impact of the GGR on NGOs that did not certify the policy and lost their US funding. This reduction in funding led to fewer contraceptive service delivery points, including mobile outreach services, a critical component of care in rural areas. Public and private health providers reported increased contraceptive stockouts and fees charged to clients. Although the GGR is ostensibly about abortion, it has reduced access to contraception for the Malagasy population. This is one of few studies to directly document the impact on women who themselves described their increased difficulties obtaining contraception ultimately resulting in discontinuation of contraceptive use, unintended pregnancies and unsafe abortions.

Global health without sexual and reproductive health and rights? Analysis of United Nations documents and country statements, 2014-2019

INTRODUCTION

The initial International Conference on Population and Development in 1994 contains the first reference to sexual and reproductive health and reproductive rights (SRHR). It has been considered agreed language on SRHR in future United Nations (UN) documents. However, opposition to SRHR in global forums has increased, including in conjunction with an increase in religious, far-right populist politics. This study provides an empirical analysis of UN documents to discover whether opposition to SRHR has resulted in changes in the language on SRHR between and what these changes are.

METHODS

This is a qualitative policy analysis in which 14 UN resolutions, 6 outcome documents from the Commission on the Status of Women (CSW) and 522 country and group statements and 5 outcome reports from the Commission on Population and Development were collected from the organisations websites from 2014 to 2019. Framework analysis was used. The text from documents was charted and indexed and themes developed from these.

RESULTS

The results demonstrated a disappearance of the language on abortion in the CSW outcome documents from 2017 and a change in the language on comprehensive sexuality education in the CSW as well as the UN General Assembly resolutions from 2018. This change included a removal of 'sexuality' to an increased emphasis on the role of families. Furthermore, documents showed an inability of some states to accept any mention of sexual and reproductive health at all, expanding from the usual contestations over abortion.

CONCLUSION

Our findings suggest that the global shift in politics and anti-SRHR actors at UN negotiations and conferences have removed previously agreed on language on SRHR from future UN resolutions and outcome documents. This is a concern for the global realisation of SRHR.

Restrictions On US Global Health Assistance Reduce Key Health Services In Supported Countries

The 2017 expanded Mexico City Policy prohibits non-US-based nongovernmental organizations from receiving US global health assistance if they either perform or refer for abortion services. We study the effects of the expanded policy on implementing partners of US-funded HIV programming by the President's Emergency Plan for AIDS Relief (PEPFAR) via a primary survey in all recipient countries and key-informant interviews in South Africa and the Kingdom of Eswatini (May-November 2018). Survey results showed that 28 percent (56 of 198) of organizations reported stopping or reducing at least one service in response to the policy. Reported service reductions included reducing the delivery of information about sexual and reproductive health, pregnancy counseling, contraception provision, and HIV testing and counseling. Interview data highlighted how these reductions were often a result of decreased patient flows or implementation of the expanded policy beyond what is required. Reductions disproportionately harmed pregnant women, youth, and key populations such as sex workers and men who have sex with men. Reduced delivery of sexual and reproductive health services has the potential to negatively affect many intended beneficiaries of PEPFAR funding, especially in areas with high HIV prevalence. Policy makers must respond to disruptions in service delivery and end any implementation that undermines US investment in high-quality HIV and sexual and reproductive health services.

Does provider access to technology improve health care? Evidence from a national distribution of phototherapy in Rwanda

This study assessed a large-scale national distribution of phototherapy (PT) for infants at risk for severe hyperbilirubinemia. We combined healthcare data for infants with jaundice (using local clinical definitions) with a randomized roll-out of PT devices to estimate the causal effect of the national distribution. Pre-intervention, <3.0% of infants were diagnosed as jaundiced, 41.7% of these infants were not tested for bilirubin, and 17.5% and 34.3% were treated with direct sunlight or standard PT, respectively. We found that providing hospitals with PT devices increased care practices: infants with jaundice were more likely to receive PT [+6.26 percentage points (pp)], and less likely to receive sunlight (-6.96 pp) or standard (irradiance < 30 µW/cm²/nm) PT (-14.0 pp). However, the intervention did not affect the low diagnosis rate. Our findings suggest that complementary investments in improving diagnosis and monitoring of bilirubin levels increases the benefits of expanding provider access to PT devices.

Impacts of the Global Gag Rule on sexual and reproductive health and rights in the Global South: A scoping review

The Global Gag Rule is a United States policy that blocks global health funding to foreign non-governmental organisations if they engage in abortion-related activities. It has been implemented by every Republican administration since 1984 and remains in operation at the time of writing in its most stringent and extensive form. It has been criticised for its implications for women's bodily autonomy, its censorship of non-governmental organisations and health professionals, and for its impact on the health of populations in affected countries. To capture the effects of the policy to date, we conducted a scoping review in April 2020. Forty-eight articles met our eligibility criteria, and were analysed thematically, noting the effects on: the operations of non-governmental organisations; maternal health; sexually transmitted infections; marginalised groups; reproductive rights. We found that the policy increased the abortion rate and had a negative impact on maternal health, STIs, and the health of marginalised groups. We conclude that the policy amounts to the neocolonial co-optation of sexual and reproductive health in the Global South to advance an ideological agenda in the Global North. We urge that the policy be repealed as part of the broader project of protecting and decolonising sexual and reproductive health globally.

Foreign ideology vs. national priority: impacts of the US Global Gag Rule on Nepal's sexual and reproductive healthcare system

In recent decades, bold steps taken by the government of Nepal to liberalise its abortion law and increase the affordability and accessibility of safe abortion and family planning have contributed to significant improvements in maternal mortality and other sexual and reproductive health (SRH) outcomes. The Trump administration’s Global Gag Rule (GGR) – which prohibits foreign non-governmental organisations (NGOs) from receiving US global health assistance unless they certify that they will not use funding from any source to engage in service delivery, counselling, referral, or advocacy related to abortion – threatens this progress. This paper examines the impact of the GGR on civil society, NGOs, and SRH service delivery in Nepal. We conducted 205 semi-structured in-depth interviews in 2 phases (August–September 2018, and June–September 2019), and across 22 districts. Interview participants included NGO programme managers, government employees, facility managers and service providers in the NGO and private sectors, and service providers in public sector facilities. This large, two-phased study complements existing anecdotal research by capturing impacts of the GGR as they evolved over the course of a year, and by surfacing pathways through which this policy affects SRH outcomes. We found that low policy awareness and a considerable chilling effect cut across levels of the Nepali health system and exacerbated impacts caused by routine implementation of the GGR, undermining the ecology of SRH service delivery in Nepal as well as national sovereignty.

Foreign assistance or attack? Impact of the expanded Global Gag Rule on sexual and reproductive health and rights in Kenya

In 2017, the Trump Administration reinstated and expanded the Global Gag Rule (GGR). This policy requires non-governmental organisations (NGOs) not based in the US to certify that they will not provide, counsel, refer, or advocate for abortion as a method of family planning in order to receive most categories of US global health assistance. Robust empirical evidence demonstrating the policy’s impacts is acutely lacking. This paper describes the effects of the expanded GGR policy in Kenya eighteen months after its reinstatement. We conducted semi-structured interviews with purposively selected representatives of US- and non-US-based NGOs, as well as managers and health providers at public and private health facilities, between September 2018 and March 2019. Organisations reported critical funding loss as they were forced to choose between US government-funded projects and projects supporting safe abortion. This resulted in the fragmentation of sexual and reproductive health and HIV services, and closure of some service delivery programmes. At public and private health facilities, participants reported staffing shortages and increased stock-outs of family planning and safe abortion commodities. The expanded GGR’s effects transcended abortion care by also disrupting collaboration and health promotion activities, strengthening opposition to sexual and reproductive health and rights in some segments of Kenyan civil society and government. Our findings indicate that the GGR exposes and exacerbates the weaknesses and vulnerabilities of the Kenyan health system, and illuminates the need for action to mitigate these harms.

Investigating the early impact of the Trump Administration's Global Gag Rule on sexual and reproductive health service delivery in Uganda

Background

The Global Gag Rule (GGR), reinstated by President Trump in January 2017, makes non-U.S. non-governmental organizations ineligible for U.S. foreign assistance if they provide access to or information about abortion. While evidence suggests previous iterations of the GGR negatively impacted sexual and reproductive health outcomes, no studies have quantitatively assessed the impacts of the Trump administration’s GGR.

Methods

We constructed a panel dataset of facilities (76% public) using 2017/2018 Performance Monitoring and Accountability 2020 service delivery point (SDP) surveys in Uganda. Based on information from stakeholder meetings, we classified districts as more or less exposed to the GGR; 45% (N = 34) of study districts were classified as “more exposed”, which corresponded to 145 “more exposed” and 142 “less exposed” health facilities in our sample. We assessed changes in provision of long-acting reversible contraceptives, contraceptive stock-outs, mobile outreach services, engagement with community health workers (CHWs), service integration, and quality of care from 2017 (pre-GGR) to 2018 (post-GGR). Multivariable regression models were estimated, and difference-in-differences impact estimators were determined by calculating predicted probabilities from interaction terms for exposure and survey round.

Findings

We observed no immediate impact of the GGR on the provision of long-acting reversible contraceptives, contraceptive stock-outs, mobile outreach services, service integration, or quality of care. We did observe a significant impact of the policy on the average number of CHWs, with “more exposed” facilities engaging 3.8 fewer CHWs post-GGR (95% CI:-7.31,-0.32).

Conclusions

The reduction in CHWs could reduce contraceptive use and increase unintended pregnancies in Uganda. The lack of other significant findings may not be surprising given the short post-GGR observation window. Rapid organizational responses and stopgap funding from foreign governments may have mitigated any immediate impacts on service delivery in the short term. The true impact may not be felt for many years, as stopgap funding potentially ebbs and service providers adapt to new funding environments.

Reproductive health and the politics of abortion

This editorial provides an overview of a thematic series that brings attention to the persistently deficient and unequal access to sexual and reproductive health services for young women in sub-Saharan Africa. It represents an effort to analyze the multifaceted relationship between laws, policies and access to services in Ethiopia, Zambia and Tanzania. Using a comparative perspective and qualitative research methodology, the papers presented in this issue explore legal, political and social factors and circumstances that condition access to sexual and reproductive health services within and across the three countries. Through these examples we show the often inconsistent and even paradoxical relationship between the formal law and practices on the ground. Particular emphasis is placed on safe abortion services as an intensely politicized issue in global sexual and reproductive health. In addition to the presentation of the individual papers, this editorial comments on the global politics of abortion which represents a critical context for the regional and local developments in sexual and reproductive health policy and care provision in general, and for the contentious issue of abortion in particular.

'Protecting Life in Global Health Assistance'? Towards a framework for assessing the health systems impact of the expanded Global Gag Rule

During his first week in office, US President Donald J Trump issued a presidential memorandum to reinstate and broaden the reach of the Mexico City policy. The Mexico City policy (which was in place from 1985–1993, 1999–2000 and 2001–2009) barred foreign non-governmental organisations (NGOs) that received US government family planning (FP) assistance from using US funds or their own funds for performing, providing counselling, referring or advocating for safe abortions as a method of FP. The renamed policy, Protecting Life in Global Health Assistance (PLGHA), expands the Mexico City policy by applying it to most US global health assistance. Thus, foreign NGOs receiving US global health assistance of nearly any type must agree to the policy, regardless of whether they work in reproductive health. This article summarises academic and grey literature on the impact of previous iterations of the Mexico City policy, and initial research on impacts of the expanded policy. It builds on this analysis to propose a hypothesis regarding the potential impact of PLGHA on health systems. Because PLGHA applies to much more funding than it did in its previous iterations, and because health services have generally become more integrated in the past decade, we hypothesise that the health systems impacts of PLGHA could be significant. We present this hypothesis as a tool that may be useful to others’ and to our own research on the impact of PLGHA and similar exogenous overseas development assistance policy changes.