This briefing gives an overview of the Mexico City Policy, explores its impact on global health programs and looks to the broader implications and potential policy considerations in this area. This piece was written by Hana Reid and edited by Koshiki Chauhan.
Overview
The Mexico City Policy, commonly referred to as the Global Gag Rule, has been a recurring fixture of U.S. foreign aid policy since its introduction by President Ronald Reagan in 1984. The policy conditions U.S. foreign assistance on an organisation’s stance regarding abortion, prohibiting funding to any entity that provides, counsels on, refers for, or advocates for the liberalisation of abortion services—even if such activities are conducted with non-U.S. funds. If organisations do not comply, they risk losing prime and subprime project funding, leaving patients without services for maternal healthcare, sexual and reproductive healthcare and gender-based violence. The policy has been reinstated by every Republican administration and rescinded by every Democratic administration, leading to a cycle of policy reversals that has significant implications for global health, particularly in low-resource areas reliant on U.S. aid.
Historical Context and Policy Evolution
The origins of the Mexico City Policy are rooted in the broader U.S. foreign assistance framework. Before its introduction, the 1973 Helms Amendment to the Foreign Assistance Act of 1961 prohibited the use of U.S. foreign aid for performing or promoting abortion services. The Mexico City Policy included additional restrictions by barring funding to organisations that engage in abortion-related activities. However, unlike the Helms Amendment, under the Mexico City Policy, abortions are permitted in cases of rape, incest and life endangerment of the woman.
Over the years, the policy has evolved in scope, with the Bush administration expanding the policy to family planning assistance provided by the Department of State. The most significant expansion occurred under the first Trump administration when it was extended beyond family planning programs to encompass nearly all global health assistance: a 20-fold increase in total funding affected.. This expansion had far-reaching consequences, impacting programs related to maternal and child health, HIV/AIDS (including PEPFAR), tuberculosis, malaria, and water and sanitation initiatives.
Impact on Global Health Programs
The implementation of the Mexico City Policy has led to disruptions in health service delivery, particularly in sub-Saharan Africa, where U.S. foreign assistance is a key component of national healthcare systems. While intended to reduce abortion rates, qualitative and quantitative evidence suggests the policy has had the opposite effect.
A 2019 study published in The Lancet analysing data from 26 sub-Saharan African countries found that during periods when the policy was in effect, abortion rates increased by 40%, modern contraception use declined by 13.5%, and unintended pregnancies rose by 12%. These findings suggest that by restricting access to contraception and reproductive health services, the policy indirectly contributes to an increase in unsafe abortions, contradicting its intended purpose. One analysis suggests that with every 10% decrease in modern contraceptive usage, abortions increase by 20-90%, although this varies depending on factors such liberalisation, education, and income. Additionally, the withdrawal of funding from NGOs that provide a range of reproductive health services has weakened healthcare infrastructure, leading to clinic closures, discontinued mobile outreach services, decreased accessibility of contraceptives, fragmented partnership networks, and a diminished advocacy environment for reproductive health.
Qualitative reports from health organisations operating under the Trump administration highlight the widespread uncertainty surrounding the policy’s application. Many organisations struggle with ambiguities regarding permissible activities, particularly concerning post-abortion care, which is essential in addressing complications arising from unsafe abortions. This uncertainty places healthcare providers in a difficult position, further restricting the services available to women in need and increasing maternal mortality. Additionally, the forced silence on abortion and reproductive health education reduces awareness surrounding the legal status of abortion. For example, in Cambodia where certain women are unaware of the legal status of abortion and instead seek out unsafe practices, which account for 30% of the maternal mortality rate. One study in rural Ghana found an overall decrease in contraceptive provision and use, as well as an increase in unintended pregnancies. Overall, the Mexico City Policy does not appear to have its intended effect with reduced contraceptive use, and increased pregnancy and maternal mortality rates evident. The policy also serves to undermine the efforts of national community and aid programs working to support women.
Case Studies: Uganda and Ethiopia
Uganda: Uganda has historically struggled with low contraception use and high rates of unintended pregnancies compared to countries with similar economic status. However, in recent years there has been progress in reproductive health outcomes, largely due to the role of community health workers (CHWs) trained and funded by foreign NGOs. These CHWs have played a critical role in providing contraceptive education and counseling, particularly in low-resource communities.
Uganda receives a significant contribution to its reproductive health budget from the U.S. with NGOs delivering more than half of the family planning budget, providing training, commodities, and outreach. The implementation of the Mexico City Policy caused programs to be scaled back or discontinued, leading to a reduction in mobile outreach for contraceptive care and a slowdown in the adoption of long-acting contraceptives. The result was an increase in post-abortion care cases due to unsafe abortions. In communities where the policy had less reach, contraceptive use continued to increase, and unintended births decreased. However, in areas heavily affected by the policy, there was a decline in CHW-led reproductive health outreach, weakening the progress that had been made in previous years.
Ethiopia: Ethiopia has made significant strides in reproductive health over the past two decades, particularly following the liberalisation of its abortion laws in 2005. Maternal mortality due to unsafe abortions has decreased, and modern contraceptive use has more than doubled. NGOs have played a key role in this progress through supporting the Ministry of Health by providing mobile outreach services for long-acting contraceptives and training public health workers to deliver reproductive health services to rural communities.
Ethiopia heavily relies on aid, receiving 50-60% of its budget from foreign aid. The top three donors, the US, Global Fund and UK respectively, provided 60% of the health budget in 2018, with the top fifteen donors comprising 90% of the budget. In the previous Trump administration, the reinstatement of the Mexico City Policy led to a countrywide reduction in family planning services, disrupting integrated programs that provided both family planning and post-abortion care including the capacity of CHWs and mobile outreach. However, due to proactive efforts by the Ethiopian government and NGOs that continued to operate within the constraints of the policy, safe abortion services within public health facilities expanded. Consequently, whilst the policy disrupted contraceptive service delivery, the focus on strengthening the public health system allowed Ethiopia to mitigate some of the policy’s intended restrictions on abortion services.
Broader Implications and Policy Considerations
The Mexico City Policy extends beyond the immediate impact on sexual and reproductive health services (SRHS); it also affects broader health initiatives. Many NGOs that provide family planning services (inclusive of maternal mortality) are also key implementers of programs addressing HIV/AIDS, disease prevention, humanitarian and crises aid, and women’s and LGBTQIA+ rights . The funding restrictions imposed by the policy have led to disruptions in these critical services, further weakening healthcare systems in aid-dependent countries.
Moreover, the policy’s oscillation between Republican and Democratic administrations creates instability in global health funding. This unpredictability hampers long-term planning and programming for NGOs and local health ministries, leading to inefficiencies and gaps in service delivery. Organisations are often forced to adjust their operations with each policy change, diverting resources away from service provision towards compliance and restructuring efforts.
From a policy standpoint, the Mexico City Policy has resulted in the opposite outcome of its purported goal, as well as undermining international development efforts. Political ideologies should not have a place in foreign aid policy to maintain the most effective use of funds, and to achieve development goals as defined by the UN SDGs. Although the Mexico City Policy permits abortion when women face violence or the risk of losing their life, the mandated silence on abortion ensures that women will remain unaware of key services; ultimately being denied justice, dignity and healthcare.
There are alternatives to the Mexico City Policy that could achieve the intended goal of reducing abortion rates while maintaining comprehensive reproductive healthcare services. Evidence-based approaches—such as increasing access to modern contraception, improving sexual health education, and strengthening healthcare infrastructure, as well as legalised safe abortion—have been shown to be more effective in reducing unintended pregnancies and, by extension, the demand for abortion services. A consistent, bipartisan approach to U.S. global health assistance could ensure stability and continuity in healthcare provision, maximising the impact of foreign aid investments.
Conclusion
The Mexico City Policy has been in effect intermittently for over four decades, creating instability in global health funding and service delivery. While intended to limit abortions, evidence overwhelmingly indicates that it exacerbates reproductive health challenges by restricting access to contraception, leading to higher unintended pregnancy rates and unsafe abortions. The policy’s expansion under the Trump administration further weakened healthcare networks in aid-dependent regions. Given the policy’s demonstrably counterproductive outcomes, a reevaluation of U.S. foreign aid strategies is necessary to ensure continuity and effectiveness in global health interventions.
A long-term, evidence-based approach to global health assistance—one that prioritises comprehensive reproductive healthcare, access to modern contraception, and sustainable health systems—would be a more effective strategy for reducing abortion rates while supporting broader public health objectives. Policymakers should consider alternatives that focus on pragmatic, data-driven solutions to improve health outcomes in developing countries rather than solely ideological goals.
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