Impact of the Mexico City Policy: Literature Review

Overview

There is an increasing literature assessing the impact of the Mexico City Policy over time and during different presidential administrations. We conducted a literature review to identify studies examining this impact, from 2001 to the present, with particular focus on capturing recent studies assessing the policy under the Trump administration. Overall, we identified 71 studies or documents for inclusion in our review. They employed a variety of methodological approaches (including more than one approach in a single study) with the majority using qualitative methods (48), followed by those using quantitative methods (27); seven were scoping or literature reviews. Most of the literature assessed the impact of the policy under the Trump administration (45), followed by the George W. Bush administration (31). Fewer studies looked at the policy under other presidential administrations. Taken together, the literature documents a range of impacts associated with the policy, including: increases in abortion rates and reductions in contraceptive prevalence (among other health outcomes); disruption and gaps in services; reduction in service integration; over-implementation and chilling effects; confusion about the policy; loss of civil society/NGO coordination and partnerships; and increased administrative burden. In addition, several studies sought to calculate or estimate the reach of the policy, as measured by amount of funding, countries, and/or NGOs affected.

Box 1: Impacts Associated with the Mexico City Policy in the Literature

Increased abortion rates Increased pregnancy Decreased contraceptive prevalence Disruption in family planning and other services Gaps in family planning and other services Reduced service integration Over-implementation and chilling effect Confusion Loss of civil society/NGO coordination and partnerships Increased administrative burden

Findings

Below, we summarize the literature reviewed and provide findings in key areas (see Appendix Table for a complete list of studies, including their findings and other information).

Reach and Impacts of the Policy

Reach

The U.S. government has not routinely provided data (such as data on the amount of funding or number of recipients subject to the policy) when the Mexico City Policy has been in effect. As such, several studies have attempted to calculate or estimate its reach. Our analyses have found that the expanded policy during the Trump administration applied to a much greater amount of U.S. global health assistance, and a greater number of foreign NGOs, across many program areas than during prior periods when the policy was in effect. Specifically, we found that the Trump policy potentially encompassed $7.3 billion in global health assistance, a significantly greater amount than the $600 million in family planning funding that would have been subject to the policy under prior iterations (Moss & Kates 2021). Using prior periods as proxies, we also found that had the expanded Mexico City Policy been in effect during the FY 2013 – FY 2015 period, approximately 1,275 foreign NGOs would have been subject to the policy, and more than 460 U.S. NGOs recipients of U.S. global health assistance would have been required to ensure that their foreign NGO sub-recipients were in compliance (Moss & Kates 2017). Finally, we found that more than half (37) of the 64 countries that received U.S. bilateral global health assistance in FY 2016 allowed for legal abortion in at least one case not permitted by the policy, suggesting that the policy would be at odds with country law in many cases (Kates & Moss 2017).

A Congressionally-requested GAO (GAO 2020) study of the Trump administration’s policy analyzed U.S. government project data from May 2017 through FY 2018 (Sept. 2018) and found that the policy had been applied to more than 1,300 global health assistance awards (that is, grants or cooperative agreements), primarily at USAID and CDC. NGOs had declined to accept the policy in 54 instances, totaling $153 million in declined funding. These included seven prime awards totaling $102 million and 47 sub-awards totaling $51 million (more than two-thirds of sub-awards were intended for Africa).

Effects on Abortion Rates, Contraceptive Prevalence, and Pregnancy

Several studies have sought to estimate the association between the Mexico City Policy and a range of health outcomes among women, including abortion rates, contraceptive prevalence, and pregnancy:

• Brooks et al. (2023), using data from eight countries in sub-Saharan Africa between 2014-2019, found that women were significantly less likely to be using any method of contraception when the Trump administration’s policy was in effect, equivalent to a 13% reduction in contraceptive prevalence. They also found that women appeared to be substituting traditional methods of family planning for modern methods. Finally, they found that women were 5.7% more likely to have given birth when the policy was in place.
• Kavakli and Rotondi (2022), using data from 134 countries between 1990-2015, found that, when in place, the policy was associated with higher maternal and child mortality and HIV incidence rates. In addition, their analysis of individual data in 30 countries found that women had less access to modern contraception and were more likely to report that their pregnancy was not desired. Finally, they used their findings to estimate that reinstatement of the policy by the Trump administration could result in 108,000 maternal and child deaths and 360,000 new HIV infections over a four year period.
• Brooks et al. (2019), using data from 26 countries in sub-Saharan Africa between 1995-2014, found that when the policy was in place, abortion rates rose by 40%, use of modern contraceptives declined by 14%, and pregnancies increased by 12%.
• Rodgers (2018), using data from 51 countries between 1994-2008, assessed the impact of the policy on abortion rates before and after its reinstatement in 2001 by President George W. Bush, finding that the policy was associated with a threefold increase in the odds of women getting an abortion in Latin America and the Caribbean and a twofold increase in sub-Saharan Africa; there was no net change in the Middle East and Central Asia. They also found that there was no consistent relationship between strict abortion laws and abortion rates.
• Bendavid et al. (2011), using data from 20 African countries between 1994-2008, found that women had 2.55 times the odds of having an induced abortion after the policy’s reinstatement and that the prevalence of contraceptive use was almost 2% lower.

Disruption and Gaps in Family Planning Services

Numerous studies have documented disruption and gaps in family planning services when the policy has been in place. For example, a recent quantitative analysis of the policy during the Trump administration, based on data from eight countries in sub-Saharan Africa, found that health facilities provided fewer family planning services, including fewer short-acting methods, long-acting reversible contraceptives (LARCs), and emergency contraception (Brooks et al., 2023). Studies in Ethiopia also found statistically significant declines in the use of LARCs and short-acting methods under the Trump administration’s policy (Sully et al., 2023) and decreases in the proportions of facilities reporting family planning provision through community health volunteers, mobile outreach visits, and family planning and postabortion care service integration, as well as increases in contraceptive stock-outs (Sully et al., 2022).

A recent GAO analysis (2022) documented delays, gaps, and disruptions in the provision of family planning services in Senegal, Uganda, and the West Africa region due to the Trump administration’s policy. Similarly, the Department of State (2020), in its second review of the expanded policy during the Trump administration, found that although agencies and departments made efforts to transition projects to another implementer to minimize disruption, gaps and disruptions were sometimes reported when recipients of U.S. funding declined to accept the policy. An analysis by Sherwood et al. (2020) found significant decreases in services offered by PEPFAR implementing organizations, including reductions in the delivery of information about sexual and reproductive health, pregnancy counseling, contraception provision, and HIV testing and counseling, due to the policy.

Qualitative analyses have also found disruptions and gaps in family planning and other services – including clinic closures, loss of staff, reduction in services, and increased commodity insecurity – during the Trump administration’s policy, including in: Ethiopia (Vernaelde 2022; PAI 2018), Kenya (Ushie, et al., 2020; Human Rights Watch 2017), Madagascar (Ravaoarisoa et al., 2020; MSI 2018), Nepal (Puri et al., 2020; Adhikari 2019; PAI 2018), Nigeria (PAI 2018), South Africa (du Plessis et al., 2019), and Uganda (MSI 2018; PAI 2018; Human Rights Watch 2017).

Analyses of the impacts of the policy during prior administrations also found disruptions and gaps (see, for example, Jones 2015; GGR Impact Project 2003-2006).

Reduction in Service Integration

Studies have also examined how the policy might affect service integration and/or documented impacts on integration. For example, a study in PEPFAR countries found a high risk of disruption in integration of family planning and HIV services (Sherwood et al., 2018) under the Trump administration’s policy. Disruption of service integration was documented in Cambodia (Frontline AIDS & Watipa 2019), Ethiopia (Sully et al., 2022), and the West Africa region (GAO 2022).

Over-Implementation and Chilling Effect

Several studies have documented an “over-implementation” of the policy (that is, implementers, providers or others taking steps to curtail services beyond what was required by the Mexico City Policy), resulting in further limitations. This was found in a survey of PEPFAR implementers (Sherwood et al., 2020) as well as in qualitative research in Malawi (Iyer et al., 2022), Nigeria (Rios 2019), and interviews with broader groups of stakeholders (Planned Parenthood Global 2019), among other studies. Similarly, several studies cited a “chilling effect” among implementers and others, resulting in reluctance to provide services or partner with certain organizations even where abortion was legal. This was found in Kenya (Maistrellis et al., 2022), Nepal (Maistrellis et al., 2022; Tamang et al., 2020), Nigeria (PAI 2018), and Uganda (PAI 2018).

Confusion

Confusion about the policy, including what is required, has been documented throughout its history. For example, the Department of State (2018), in its initial six-month review of implementation of the Trump administration’s policy, found a number of areas needing clarification to reduce confusion. Specifically, the review directed agencies to provide greater support for improving understanding of implementation among affected organizations and provide additional guidance to clarify terms and conditions. A range of qualitative analyses have similarly documented confusion about the expanded Trump policy including among respondents in Cambodia (Frontline AIDS & Watipa 2019), Ethiopia (PAI 2018), Kenya (Rios 2019), Malawi (Frontline AIDS & Watipa 2019), Nepal (Puri 2020; Rios 2019), Nigeria (Rios 2019), and South Africa (Rios 2019), and among key informants in multiple other settings (PPFA, CHANGE).

Confusion about the policy has even been found during times when it was not in place. For example, one study found that even after the policy was rescinded by the Obama administration, interviewees in Nepal reported a range of misunderstandings from believing that all U.S. abortion restrictions were lifted to believing that the policy was still in place, and interviewees also often conflated the policy with the Helms Amendment, which prohibits U.S. funding for the performance of abortion (Ipas & Ibis Reproductive Health  2015). Similar confusion was found in Ethiopia after the policy was rescinded (Leitner Center for International Law and Justice 2010).

Loss of Civil Society/NGO Coordination and Partnerships

Several studies have documented negative impacts of the policy on civil society, including on partnerships and networks. This was found in Ethiopia (Vernaelde 2022; PAI 2018), Kenya (Maistrellis et al., 2022; Ushie et al., 2020; Rios 2019), Nepal (Dhakal et al., 2023; Maistrellis et al., 2022; Puri et al., 2020; PAI 2018), Senegal (PAI 2018) and South Africa (du Plessis et al., 2019). For example, organizations in Cambodia (Frontline AIDS & Watipa 2019) felt that the policy led to reputational risk and affected their partnerships, and coalitions in Malawi reported that the policy resulted in fragmentation, tension and mistrust.

Increased Administrative Burden

Finally, studies have documented the administrative and cost burden associated with implementing and monitoring compliance with the policy, including that it increased workload and required implementers who refuse to agree to the policy to spend time and resources searching for new partners and training them. This was found, for example, in Kenya (Rios 2019), Nepal (Puri et al., 2020), Nigeria (Rios 2019; PAI 2018), South Africa (Rios 2019), and Uganda (PAI 2019; PAI 2018).

Methods

To identify literature documenting the impact of the Mexico City Policy, we employed a multi-pronged search strategy. First, we searched for literature using Google Scholar and targeted follow-up searches of key organizations websites for documents that had the keywords “Mexico City Policy” or “Global Gag Rule” and “impact.” We reviewed those documents for relevance and for additional references. We also used selected other scoping and literature reviews to identify additional documents for review. This yielded a total of 129 documents, of which 71 were included for analysis (we excluded documents that were only descriptive or speculative in nature and did not include findings of impact, or documents that reported on impacts from other studies). We included only resources published from 2001 through the present. For each document, we assessed: the method(s) employed; main findings; the presidential administration(s) assessed or studied; geographic scope; and the type of literature (e.g., peer reviewed, government document).