Preventing and Reducing the Harm of the Protecting Life in Global Health Assistance Policy in Global Public Health

  • Date: Nov 05 2019
  • Policy Number: 20199

Key Words: Global Health, Reproductive And Sexual Health, Reproductive Health, Reproductive Rights, Womens Health, Maternal And Child Health, Developing Countries, Abortion, Access, Access To Health Care

Abstract

Recurrent U.S. government policies restrict the use of U.S. global health assistance for comprehensive sexual and reproductive health services. The Mexico City Policy (MCP) was in force from 1984 to 1993 and from 2001 to 2008. “Protecting Life in Global Health Assistance” (PLGHA) is an expanded version of this policy that was instituted in January 2017. The MCP/PLGHA requires that foreign nongovernmental organizations receiving U.S. assistance certify that they are not using U.S. funds or any other funds to provide or counsel on abortion as a method of family planning. The MCP applied to U.S. family planning funding; PLGHA applies to almost all U.S. global health funding, dramatically increasing the scale and scope of the activities affected. Research reveals three key domains of MCP/PLGHA impact: (1) reduced access to contraception with attendant increases in unintended pregnancy and induced abortion, (2) decreased stakeholder coordination and a general “chilling” of discussion related to sexual and reproductive health and rights, and (3) negative outcomes in nonreproductive health domains. These three domains are known determinants of maternal morbidity and mortality. Public health and human rights actors use several strategies to address the harms associated with the MCP/PLGHA, including advocacy to modify or end PLGHA, producing data on the impacts of the policies, educating stakeholders to prevent overinterpretation, and implementing service delivery programs to mitigate harm. This APHA policy statement calls for urgent and intensified use of these action steps to counter the harms to health and human rights associated with PLGHA.

Relationship to Existing APHA Policy Statements

  • APHA Policy Statement 20153: Universal Access to Contraception
  • APHA Policy Statement 20152: Restricted Access to Abortion Violates Human Rights, Precludes Reproductive Justice, and Demands Public Health Intervention
  • APHA Policy Statement 201113: Call to Action to Reduce Global Maternal Neonatal and Child Morbidity and Mortality
  • APHA Policy Statement 20094: Ensuring the Achievement of the Millennium Development Goals: Strengthening US Efforts to Reduce Global Poverty and Promote Public Health
  • APHA Policy Statement 20089: Strengthening Health Systems in Developing Countries

Problem Statement

The 1984 Mexico City Policy (MCP) was promulgated at the beginning of the Reagan administration as an effort to reduce abortion, a Republican policy objective. Commonly known as the “Global Gag Rule,” the MCP imposed restrictions on the use of family planning assistance by foreign nongovernmental organizations (NGOs). It required that foreign NGOs receiving such U.S. assistance certify that they were not using U.S. funds or any other funds to provide abortion as a method of family planning, counsel and refer women to abortion as a method of family planning (unless women proactively stated that they were seeking an abortion in a context wherein abortions were legal), conduct public information campaigns on the availability of abortion, and advocate for the liberalization of abortion laws or lobby for the continued legality of abortion. Abortion is not considered a family planning method in cases in which the pregnancy arose from rape or incest or carrying the pregnancy to term would endanger the woman’s life. The restriction also did not apply to research activities.[1] The policy has since been rescinded by subsequent Democratic presidents and reinstated by Republican administrations. The rationale provided for the initial MCP was that the “United States does not consider abortion an acceptable element of family planning programs.”[2]

In January 2017, the policy was reinstituted by the Trump administration, renamed “Protecting Life in Global Health Assistance” (PLGHA), and expanded to apply to all “global health assistance furnished by all departments or agencies” rather than only to family planning assistance. Thus, the restrictions apply to many more organizations, projects, and health areas than in the past. U.S. government funding agencies that administer global health assistance require foreign NGO recipients to certify their intent to comply with the policy when a new agreement or modification to an existing agreement is issued. There is no way to track the exact amount of money and number of organizations affected; however, a recent Kaiser Family Foundation report analyzing U.S. global health funding obligated by the U.S. Agency for International Development (USAID) in fiscal years 2013–2015 showed that, had PLGHA been in place during that time, at least 1,275 foreign NGOs working in 91 countries would have faced restrictions.[3] The total amount of global health assistance that might be affected by PLGHA (to the extent that such funding is granted or subgranted to foreign NGOs) is approximately $9 billion annually, as compared with the approximately $625 million a year in family planning funding that was subject to the MCP from 2001 to 2009.[3]

In March 2019, U.S. Secretary of State Mike Pompeo announced an expansion of PLGHA. Foreign NGOs that receive U.S. government global health assistance as prime awardees or sub-awardees are prohibited from providing any (including non–U.S. government) financial support to any foreign NGOs that engage in activities prohibited by the policy. This expansion limits what foreign NGOs that do not receive U.S. global health assistance can do with their own money. Secretary Pompeo’s office stated that the expansion will ensure that the policy is “enforced to the broadest extent possible,” with the recognition that “money is fungible.”[4]

PLGHA does not apply to funding provided to intergovernmental organizations (e.g., the World Health Organization [WHO]), foreign governments, or U.S.-based NGOs. Humanitarian assistance is also excluded. However, U.S.-based NGOs implementing global health assistance-funded projects must include the policy in their grant agreements with foreign NGO subrecipients, which are then required to certify compliance. The policy applies irrespective of the legal status of abortion in a given country.

Finally, it is important to note that, for the first time, there is also a “domestic gag rule.” In August 2019, all grantees of the U.S. government’s Title X family planning program were required to certify their “good faith” attempt to comply with new rules that are similar to PLGHA. These rules prohibit abortion referrals, impose counseling standards for pregnant patients, and impose requirements for the separation of Title X–funded activities from a range of abortion-related activities. As is the case with PLGHA, some organizations—most notably Planned Parenthood—have forgone funding rather than comply.[5]

International human rights law upholds the right of all people to “the enjoyment of the highest attainable standard of physical and mental health.”[6] In 2000, the United Nations (UN) Committee on Economic, Social, and Cultural Rights specifically affirmed “the right to control one’s health and body, including sexual and reproductive freedom, and the right to be free from interference,” as well as the requirement that sexual and reproductive health services, education, and information be accessible.[7] UN declarations, UN treaty monitoring committees, and regional human rights mechanisms recognize unsafe abortion and barriers to safe abortion access as a violation of human rights.[8] Importantly, General Comment 22 of the International Covenant on Economic, Social and Cultural Rights calls on states to “liberalize restrictive abortion laws, guarantee women and girls access to safe abortion services…and respect women’s right to make autonomous decisions about their sexual and reproductive health.” Researchers have found that the MCP and PLGHA compromise these rights and limit interrelated rights, including the right to information and to the benefits of scientific progress.[8] Finally, it is important to note that PLGHA can conflict with the decisions made by legislatures and policymakers in countries that receive U.S. global health assistance, undermining their sovereignty. PLGHA applies to more than 60 countries that have their own informed consent, medical ethics, and abortion laws and frameworks. Depending on the country and its policies, PLGHA may violate any of these laws or frameworks.

Quantitative and qualitative research on the MCP and PLGHA have revealed three key domains of public health impact: (1) reduced access to contraception and an increased number of unintended pregnancies and induced, unsafe abortions; (2) decreased stakeholder coordination related to contraception and a general “chilling” of discussion related to contraception and abortion in policy forums; and (3) negative outcomes in domains of health other than reproductive health, including deterioration of broader health system functioning. Each of these domains of impact is outlined in detail below. These changes often disproportionately affect the most vulnerable; foreign NGOs undertake significant health outreach activities, and when funding for these activities is curtailed or ended, women in rural areas or highly stigmatized groups may have fewer options for health care.[9]

Reduced access to contraception and increased unintended pregnancies and induced abortions: Women of reproductive age who have access to family planning are less likely to experience unintended pregnancy, unsafe abortion, infant mortality, HIV/AIDS (when using condoms), and maternal mortality.[10]

Impacts on organizations that opt not to comply with the MCP/PLGHA: Foreign NGO providers of family planning services that decline to certify their compliance with the policy forfeit their access to U.S. government funding to provide health services under PLGHA. Notably, Marie Stopes International (MSI) and International Planned Parenthood Federation (IPPF) affiliates have chosen not to comply, as have many other foreign NGOs. As a result, MSI, the IPPF, and other foreign NGOs may close clinics providing services and/or impose (increased) fees for services. According to the IPPF, it “stand[s] to lose up to $100 million over the course of the policy,” and MSI stated in June 2019 that it faced a “funding gap of $50 million through to 2020.”[11,12] Client referrals between compliant and noncompliant organizations may be precluded. Referral disruptions may disproportionately affect rural areas, where clients rely on NGO-funded extension workers and have few if any other options for obtaining contraception or other health services.[9] USAID may eventually identify an NGO that is willing to comply and offer health care previously provided by the NGO that decided not to comply, but the new recipient may lack the client load capacity, management skills, local knowledge, and client familiarity of the previous grantee.[9]

Impacts on organizations that comply with the MCP/PLGHA: Organizations that opt to receive U.S. global health assistance and that work in domains related to reproductive health might deny their clients evidence-based medicine insofar as they cannot counsel or refer a woman for abortion unless she explicitly states that she has decided to have an abortion or unless national policy requires appropriate counseling and referral by providers.

Documented health outcomes of the MCP: Four quantitative studies indicate that access to modern contraception decreased and induced abortions increased in three world regions after implementation of the MCP.[13–16] One of the studies showed that these trends were reversed when the MCP was not in effect (from 2009–2014), providing further evidence that the policy was the cause of the trends.[16] The countries most affected by unsafe abortions, which result in 4.7% to 13.2% of maternal mortality annually, often rely heavily on USAID for family planning funding.[17–19] Due to the sizable proportion of USAID funding for these countries, NGOs serving women have few choices to replace this funding should they want to offer services that educate women on the diverse array of family planning options. This leads women to seek alternatives such as unsafe abortions when they are not ready to raise a child. These decisions can lead to unintended long-term morbidity or mortality, including hemorrhage, infection, injury to the genital tract and internal organs, and death.[17]

Documented health impacts of PLGHA: Several organizations have collected data from countries in sub-Saharan Africa and Asia regarding the early impacts of PLGHA. Early results suggest that the MCP and PLGHA produce the same chain of consequences: reducing access to contraception and increasing unintended pregnancies, unsafe abortions, and poor birth spacing. In addition, the findings revealed negative effects on organizational resources, including family planning program budget cuts, staff terminations, clinic closures, increased costs passed to patients for contraceptive services, reduced availability of contraceptives, and cessation of rural outreach activities.[9,20]

Decreased stakeholder coordination related to contraception and a general “chilling” of services and discussion related to abortion: Some compliant organizations have overinterpreted the MCP—and now PLGHA—such that they refrain from engaging in allowable activities (e.g., stakeholder discussions about the health impacts of current laws in a given country). Such overinterpretation can stem from incomplete or incorrect information received from USAID missions and/or fear of jeopardizing an important source of funding. As a result, compliant grantees may withdraw from coordinating bodies or platforms related to reproductive health, depriving these bodies of important expertise.[21] For example, studies in Uganda, Ethiopia, Kenya, Peru, and Nepal undertaken during the course of the MCP revealed that, as a result of this “chilling effect,” fewer stakeholders were involved in discussions about abortion law reform and lawmakers lacked access to critical information. This chilling effect can extend to services, such that organizations that opted to certify the MCP stopped providing permitted reproductive health services such as postabortion care and emergency contraception.[22–24]

These dynamics may be exacerbated by the recurrent nature of the policy. NGOs may choose to avoid the risks of working in the domain of abortion. They are constantly confused about what is and what is not allowed and assume the most restrictive interpretation, and they are bogged down by the significant transaction costs of repeatedly changing internal policies to ensure compliance as the policy cycles through being in force and not being in force.[25]

Negative outcomes in nonreproductive health domains, including deterioration of broader health system functioning: U.S. foreign assistance is essential to the health system infrastructure in many low- and middle-income countries. The United States is the largest bilateral source of global health assistance, contributing more than a third of all official health development assistance and 45% of total bilateral funding for family planning.[26] It is not feasible for another donor to provide a comparable level of replacement funding. Moreover, the global health community has invested significant human and financial resources to integrate health services, an approach that, if implemented well, can improve cost effectiveness and better serve patients.[27] Research shows that the MCP and PLGHA fragment health systems, as the policies result in broken relationships between organizations that do and do not comply and disrupt coordination and referral networks between contraception and related services.[13] In addition, clinics providing contraceptive services often provide other services, particularly HIV prevention. When these clinics are shuttered, community members lose access to contraception as well as to other HIV prevention services, potentially contributing to the spread of HIV.[13] An electronic survey of 286 prime President’s Emergency Plan for AIDS Relief (PEPFAR) implementing partners showed that 33% of respondents across 31 countries experienced an impact from PLGHA, including reducing their provision of non-abortion-related information such as information about HIV.[28]

One quantitative, peer-reviewed study has assessed the impact of the MCP on other health domains. Jones et al. found that weight and height for age were negatively associated with having been born in a period when the MCP was in effect, likely due to shorter birth intervals negatively impacting the health of pregnant women and their children.[29]

Given the expanded nature of PLGHA and the fact that many health systems have become further integrated since the previous version of the MCP was in force, it is widely expected that PLGHA will have an impact on health systems well beyond sexual and reproductive health.[30] For example, WaterAid, a large water, sanitation, and hygiene organization operating in 34 countries, has decided not to certify PLGHA because it refers women who experience sexual assault while fetching water to the closest appropriate clinic, which may be run by a noncompliant organization. As a result, USAID-funded programs and partnerships have ended, depriving long-term partners and beneficiary communities of WaterAid’s work.[31] Moreover, groups similar to WaterAid that do choose to comply can no longer cooperate with organizations providing comprehensive sexual and reproductive health and rights services. Along similar lines, a “risk index” for the harm of PLGHA in PEPFAR-supported countries, developed with data from governments and bilateral donors, suggests that countries with generalized HIV epidemics, high reliance on U.S. bilateral assistance, and a high degree of service integration could face significant disruptions to referrals and HIV and contraceptive service provision.[32]

Early evidence regarding the effect of PLGHA on health systems includes cessation of referral links,[20] termination of community health workers providing contraception and other services,[33] and closure of sites providing antiretroviral treatment, including those specifically tailored for sex workers and men who have sex with men.[20] Evidence suggests that these already marginalized populations with whom community partners have developed relationships over time may face stigma and other barriers that prevent them from seeking services elsewhere.[34]

Evidence-Based Strategies to Address the Problem

As is the case with all complex advocacy and efforts to mitigate harms associated with a policy, evaluating the impact of strategies to address the problem is extremely challenging. Insofar as possible, documenting the impact of the five main strategies described below would be an important contribution to the evidence base around PLGHA.

Advocating to policymakers in the executive and legislative branches of the U.S. government to modify or end PLGHA: Reproductive health advocates have advocated that U.S. legislators rescind the MCP and PLGHA since each was imposed. Legislators have introduced a bill to the U.S. House of Representatives that would end PLGHA by prohibiting the eligibility requirements for foreign NGOs that receive foreign assistance. In other words, foreign NGOs would not be ineligible for foreign assistance if they counseled on abortion and made referrals for abortion services in countries where this is legal. They have also tried to end the rule through appropriations.

Producing and sharing data on the public health and other impacts of the MCP/PLGHA with the U.S. government, global health stakeholders, and the public at large: Research related to PLGHA is ongoing. Such research has been discussed in peer-reviewed articles, gray literature publications, conferences, and the media. Donors, implementers, and others have held roundtables and other events to discuss research findings.

Educating and providing legal support on the policy to stakeholders in countries receiving global health assistance to prevent overinterpretation: Some U.S.-based NGOs provide help to foreign NGOs receiving U.S. funds with respect to complying with PLGHA and diminishing overinterpretation. This assistance includes a pro bono legal clearinghouse,[35] guidance in multiple languages for global health assistance grantees,[36] in-country and online training sessions, and ongoing technical assistance to staff, subgrantees, and partners. These strategies aim to ensure that foreign NGOs receiving U.S. global health assistance participate in coordination forums that are permitted and continue to work in reproductive health domains that are permitted, such as postabortion care and emergency contraception.

Identifying and promoting bilateral donor-, global-, and country-level policies that may mitigate harm: WHO, the United Nations Population Fund, and other leading global health organizations may have policies or programs—such as stop-gap contraceptive supplies—that mitigate the harm of PLGHA. In addition, some non-U.S. bilateral donors attempt to temper the impact of PLGHA as part of their assistance programs. The government of the Netherlands launched the “She Decides” initiative, a political movement that supports “the fundamental rights of girls and women to decide freely and for themselves about their sexual lives.” One goal of the initiative is to advocate that governments, foundations, and businesses invest more in sexual and reproductive health services.[37] These funds can be used to support activities that the U.S. government will not support, although the amount will undoubtedly be dwarfed by U.S. global health assistance. The Swedish International Development Agency issued guidance in response to PLGHA stating that it would review partnerships with foreign NGOs that may not be able to fulfill the scope of their agreements because they comply with PLGHA. There has not been any research to assess the opportunity costs of these efforts; some are concerned that additional conditionality will further erode NGOs’ space and ability to decide what issues to address and how to address them.

National-level policies can also mitigate harm. For example, national law regarding provider scope of practice and duty to counsel and refer for abortion may conflict with the prescriptions of PLGHA. In these cases, PLGHA stipulates that national law holds sway. Some U.S.-based reproductive rights organizations seek to maximize the impact of local laws by using non–U.S. government funding to educate country-level stakeholders as well as by supporting improvements in domestic laws, regulations, and medical guidelines on abortion.

Implementing service delivery programs to mitigate harm: We did not find examples of direct service provision activities explicitly intended to counteract the MCP/PLGHA. However, it is important to note that public health actors increasingly advocate expanding the availability of medication abortion and women’s awareness of this option, particularly in locations where safe abortion care is otherwise inaccessible or inadequate. Evidence shows that programs providing support for medication abortion with misoprostol in these settings can be feasible, safe, and effective.[38] According to WHO, mortality and morbidity attributed to unsafe abortion could largely be prevented through comprehensive sexuality education, use of modern contraceptive methods, legal abortion services, and rapid treatment of complications.[19] Thus, implementing these strategies could mitigate harm.

Opposing Arguments/Evidence

There are five key types of opposing arguments to this proposed policy statement. First, there are assertions about the harms of abortion to the fetus. These arguments are on the belief that fetuses should have the same moral status as born persons. Based on firmly held religious or philosophical convictions about when human life deserving of full protection begins, these arguments oppose abortion generally.[39] The absence of PLGHA does not compel anyone who believes that a fetus is a living being deserving protection to obtain an abortion or to act in any way against personal conscience. The metaphysical views underlying this opposing argument do not reflect existing APHA policy statements, which recognize women’s rights to bodily autonomy.[40] Moreover, as documented elsewhere in this statement, the effect of PLGHA on the distribution of contraception increases the abortion rates in many affected countries.[13,16] The presumption of many supporters of PLGHA, that it will reduce abortion rates in areas served directly or indirectly by U.S. international aid, is false.

Second, many argue that abortion causes physical and mental harm to the pregnant woman. As described in APHA Policy Statement 20152, medically provided abortion is one of the most common and safest surgical gynecological procedures.

Third, some assert that the MCP and PLGHA ensure that U.S. taxpayer money is not used to fund abortion. However, the 1973 Helms Amendment to the Foreign Assistance Act (still in effect) prohibits the use of U.S. development assistance for the provision or promotion of abortion as a method of family planning. It remains in force and is scrupulously applied by USAID in its health programs.

Fourth, some disagree that the MCP and PLGHA have deleterious effects. They note that the MCP and PLGHA do not imply a reduction in U.S. assistance to family planning and that money previously given to organizations that chose not to comply can be given to organizations that do. A formal 6-month review of PLGHA undertaken by the U.S. State Department noted that only three prime grantees have declined to comply with the policy.[41] However, subrecipients, which are more numerous and often foreign NGOs, were not included in the review. Moreover, as described above, evidence from many countries suggests that the MCP/PLGHA has deleterious effects. It contributes to a rise in induced abortions—the opposite of its intended effect. The studies indicating increased odds ratios for abortion included “exposure to the policy” as an independent variable, with exposure to the policy being defined by amount of U.S. assistance for family planning per capita.[13,15,16] Thus, the studies accounted for the fact that U.S. government family planning assistance was likely “reprogrammed” to organizations willing to comply with the MCP.

Finally, some argue that the U.S. government should not be funding family planning programs overseas at all. However, the contribution that family planning makes to reductions in unwanted pregnancies, unsafe abortion, and maternal morbidity and mortality, as well as to birth spacing and improved birth outcomes, is well documented in the peer-reviewed literature and is promulgated by APHA Policy Statements 201113 (Call to Action to Reduce Global Maternal Neonatal and Child Morbidity and Mortality) and 20153 (Universal Access to Contraception).[41] Moreover, investments in family planning are cost effective; contraception saves families and health systems money, as they are less likely to deal with morbidity and other challenges that can arise from inadequate birth spacing.[42]

Action Steps

APHA promotes evidence-based policies over ideology. The organization has an irreplaceable voice on PLGHA. The following action steps are organized according to the categories of evidence-based strategies described above.

Advocacy

  • Legislative action should be taken to repeal PLGHA and to prevent similar policies in the future. Efforts should include public health professionals communicating the evidence of harm caused by PLGHA to policymakers in the executive, legislative, and judicial branches of the U.S. government, including communicating through the submission of amicus briefs.
  • All relevant global health actors should work to prevent and address impacts of the policy that people with diverse values and perspectives can agree are undesirable outcomes, including in particular increases in unsafe abortion.

Research

  • Researchers, practitioners, the U.S. government, and other global health actors should collect and/or analyze data to document the impact of PLGHA on access to contraception, unintended pregnancy, induced abortion, access to other health services, and health outcomes. The next State Department review should include assessments of the impact on subrecipients and the impact of the March 2019 expansion and should address the research that has appeared in peer-reviewed journals regarding the negative impact of the policy.
  • As PLGHA represents a substantial expansion of the MCP, researchers should consider the impact of PLGHA on health domains beyond reproductive health.
  • Donors whose funds are gagged by the March 2019 expansion should document the amount of their own funding that is affected and that has been gagged. They should then share this information with the larger public health community, the U.S. government, and legislators.
  • The public health community, including clinicians, advocates, organizations affected by the policy, and researchers, should share the data produced on the public health and human rights impacts of PLGHA with global health decision makers, other stakeholders, and the public at large. This communication should build awareness among agencies that are in a position to mitigate the harm of PLGHA and among the voting public, legislators, and advocacy organizations.

Education

  • U.S. government funding agencies that implement the policy should develop technical support programs for stakeholders in countries receiving U.S. global health assistance. Organizations, clinicians, policymakers, and government officials within host countries must fully understand what PLGHA requires and what it does not require so that they can reduce overinterpretation, which is harmful with respect to collaboration and health service provision.
  • Researchers, practitioners, and other global health actors should provide additional educational support regarding permitted activities to NGOs that receive U.S. global health assistance. They should also continuously assess the information needs of said organizations in order to ensure that the support offered meets current needs.

Harm Mitigation

  • All relevant global health actors should identify, promote, and support bilateral donor-, global-, and country-level policies that may mitigate harm caused by PLGHA, with due attention to any unintended consequences of these policies.
  • In particular, researchers, practitioners, and other global health actors should assess and document the impact of national laws that supersede PLGHA and share this information with policymakers in countries where this is politically and otherwise feasible.
  • Researchers, practitioners, and other global health actors should identify, promote, and support service delivery programs that may mitigate harm caused by PLGHA. This includes implementation of evidence-based programs to improve access to comprehensive sexuality education, contraception, abortion (including self-administered medication abortion), and rapid treatment of complications of unsafe abortion. Family planning and comprehensive sexuality education have been studied in terms of cost effectiveness; UNFPA describes family planning as a “best buy,” and emerging evidence suggests that comprehensive sexuality education is also cost effective.[42,43]

References

1. United States Agency for International Development. Standard provisions for non-U.S. nongovernmental organizations. Available at: https://www.usaid.gov. Accessed November 27, 2019.

2. United States of America. Policy Statement of the United States of America at the United Nations International Conference on Population (Second Session), Mexico City, Mexico, August 6–14, 1984. Undated document.

3. Henry J. Kaiser Family Foundation. The Mexico City Policy: an explainer. Available at: http://files.kff.org. Accessed November 27, 2019.

4. Global Health. The pro-life agenda: Secretary Pompeo’s bold leadership fact sheet. Available at: https://globalhealth.org. Accessed November 27, 2019.

5. Guttmacher Institute. The Title X gag rule is wreaking havoc—just as Trump intended. Available at: https://www.guttmacher.org. Accessed November 27, 2019.

6. United Nations General Assembly. International Covenant on Economic, Social and Cultural Rights. Available at: https://www.refworld.org. Accessed November 27, 2019.

7. United Nations Committee on Economic, Social and Cultural Rights. General Comment No. 14: The Right to the Highest Attainable Standard of Health. Available at: https://www.refworld.org. Accessed November 27, 2019.

8. Center for Reproductive Rights. Fact sheet: the global gag rule and human rights. Available at: https://www.reproductiverights.org. Accessed November 27, 2019.

9. PAI. Access denied: U.S. restrictions on international family planning. Available at: http://trumpglobalgagrule.pai.org. Accessed November 27, 2019.

10. World Health Organization. Family planning/contraception. Available at: https://www.who.int/news-room/fact-sheets/detail/family-planning-contraception. Accessed November 27, 2019.

11. International Planned Parenthood Federation. Policy briefing: the impact of the Global Gag Rule. Available at: https://www.ippf.org. Accessed November 27, 2019.

12. Marie Stopes International. House of Representatives votes to repeal Global Gag Rule—so what next? Available at: https://mariestopes.org/news/2019/6/house-of-representatives-votes-to-repeal-global-gag-rule-so-what-next/. Accessed November 27, 2019.

13. Bendavid E, Avila P, Miller G. United States aid policy and induced abortion in sub-Saharan Africa. Bull World Health Organ. 2011;89:873–880.

14. Jones KM. Contraceptive supply and fertility outcomes: Evidence from Ghana. Econ Dev Cult Change. 2015;64:31–69.

15. Rodgers Y. The Global Gag Rule and Women’s Reproductive Health: Rhetoric Versus Reality. New York, NY: Oxford University Press; 2018.

16. Brooks N, Bendavid E, Miller G. USA aid policy and induced abortion in sub-Saharan Africa: an analysis of the Mexico City Policy. Lancet Glob Health. 2019;7:e1046–e1053.

17. Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2:e323–e333.

18. Singh S, Remez L, Sedge G, Kwok L, Onda T. Abortion worldwide 2017: uneven progress and unequal access. Available at: https://www.guttmacher.org. Accessed November 27, 2019.

19. World Health Organization. Preventing unsafe abortion. Available at: https://www.who.int. Accessed November 27, 2019.

20. Center for Health and Gender Equity. Prescribing chaos in global health: the Global Gag Rule from 1984–2018. Available at: http://www.genderhealth.org. Accessed November 27, 2019.

21. Center for Reproductive Rights. Breaking the silence: The Global Gag Rule’s impact on unsafe abortion. Available at: https://www.reproductiverights.org/sites/crr.civicactions.net. Accessed November 27, 2019.

22. Skuster P. Advocacy in whispers: the impact of the USAID Global Gag Rule upon free speech and free association in the context of abortion law reform in three East African countries. Mich J Gender Law. 2004;11:97.

23. PAI. Access denied Ethiopia. Available at: http://pai.org. Accessed November 27, 2019.

24. PAI. Access denied Nepal. Available at: http://pai.org. Accessed November 27, 2019.

25. Leitner Center for International Law and Justice. Exporting Confusion: U.S. Foreign Policy as an Obstacle to the Implementation of Ethiopia’s Liberalized Abortion Law. New York, NY: Fordham Law School; 2010.

26. Wexler A, Kates J, Lief E. Donor Government Funding for Family Planning in 2016. Washington, DC: Kaiser Family Foundation; 2017.

27. World Health Organization. Framework on integrated, people-centered health services. Available at: http://apps.who.int. Accessed November 27, 2019.

28. Sherwood J, Roemer M, Honermann B, Sharp A, Decker M, Millett G. Tracking the impact of the expanded Mexico City Policy on PEPFAR implementing partners. Poster session presented at: HIV Research for Prevention 2018, October 2018, Madrid, Spain.

29. Jones KM. Evaluating the Mexico City Policy: How US Foreign Policy Affects Fertility Outcomes and Child Health in Ghana. Washington, DC: International Food Policy Research Institute; 2011.

30. Starrs AM. The Trump Global Gag Rule: an attack on US family planning and global health aid. Lancet. 2017;389:485–486.

31. WaterAid. Washington Post highlights impact of Trump foreign policy on women’s health. Available at: https://www.wateraid.org. Accessed November 27, 2019.

32. Sherwood J, Sharp A, Honermann B, et al. Mapping the impact of the expanded Mexico City Policy for HIV/family planning service integration in PEPFAR-supported countries: a risk index. BMC Public Health. 2018;18:1116.

33. International Women’s Health Coalition. Reality check: year one impact of Trump’s Global Gag Rule. Available at: https://iwhc.org. Accessed November 27, 2019.

34. Smith R. How Trump’s abortion gag rule policy impacts the global AIDS crisis. Available at: https://www.cnn.com.

35. Center for Reproductive Rights. Pro bono legal support for organizations affected by the Global Gag Rule. Available at: https://www.reproductiverights.org. Accessed November 27, 2019.

36. PAI. What you need to know about the Protecting Life in Global Health Assistance restrictions on U.S. global health assistance. Available at: https://pai.org. Accessed November 27, 2019.

37. She Decides. Unlock resources. Available at: https://www.shedecides.com. Accessed November 27, 2019.

38. Grossman D, Baum SE, Andjelic D, et al. A harm-reduction model of abortion counseling about misoprostol use in Peru with telephone and in-person follow-up: a cohort study. PLoS One. 2018;13:e0189195.

39. White House. Remarks by Vice President Pence at the National Religious Broadcasters’ Annual Convention. Available at: https://www.whitehouse.gov. Accessed November 27, 2019.

40. American Public Health Association. Restricted access to abortion violates human rights, precludes reproductive justice, and demands public health intervention. Available at: https://www.apha.org. Accessed November 27, 2019.

41. U.S. State Department. Protecting Life in Global Health Assistance six-month review. Available at: https://www.state.gov. Accessed November 27, 2019.

42. International Center for Research on Women. Why invest in international family planning? A look at the evidence. Available at https://www.icrw.org. Accessed November 27, 2019.

43. United Nations Population Fund. Investing in family planning is a best buy. Available at: https://www.unfpa.org. Accessed November 27, 2019.