International Women’s Day on March 8 is especially significant this year. It marks the 30th anniversary of an international declaration on gender equality, and 25 years since efforts to address gender inequality in conflict were formally enshrined in peace and security work at the United Nations with Security Council Resolution 1325 on Women, Peace, and Security. And, at least in many quarters, this year will be marked by concerns about backtracking rather than celebrations of progress on women’s rights.
Under the second administration of President Donald Trump, programs supporting women in sustaining their health, income, and participation in public life have become toxic. The first of these basic rights, health, is critical to the others and is perhaps most immediately at risk, especially when it comes to the support the United States has traditionally offered women and girls living in conflict zones. Through a combination of aid cuts and the reimposition (and possible further expansion) of the “Mexico City policy” which aims to prevent recipients of U.S. health funds from supporting abortion, these conflict survivors are likely to lose access to life-saving assistance such as health care after a miscarriage, pre- and post-natal care, and other sexual and reproductive health services.
The need for sexual and reproductive health care in war is especially acute. For one thing, sexual violence is used as a weapon of war, which means access to care after rape is in high demand. And yet, medical care generally tends to be scarce. International organizations work to address these challenges through mobile clinics and similar initiatives. Their work, of course, hinges on donor support.
But financial resources are shrinking rapidly in the current global environment. Since Trump’s inauguration on Jan. 20, the administration has cut U.S. foreign assistance to the bone. It began with the 90-day freeze on development aid the day Trump took office, supposedly to allow time for a review of whether U.S.-supported programs aligned with the new administration’s values. This was followed several days later by a full “stop work” order issued by Secretary of State Marco Rubio on nearly all foreign aid. That was then adjusted in late January with some exceptions and a waiver that seem to have been haphazardly and chaotically rolled out to affected organizations, leaving major gaps. After the administration essentially merged the U.S. Agency for International Development (USAID) into the State Department in early February, USAID contracts were cancelled entirely amid a cascade of litigation. All of this created an overall feeling of enormous uncertainty about U.S. foreign assistance, and sweeping instability in the aid sector. In humanitarian emergencies, the disruptions led to reduced or terminated services such as famine relief and HIV treatment.
11.7 Million Women and Girls
By the time the current 90-day aid “freeze” is due to end for anything still left on April 15, this gutting of U.S. aid will have left 11.7 million women and girls across the globe without access to contraceptives. U.S. cuts to U.N. programming have left those agencies unable to implement life-saving maternal health-care projects, with no exemptions for humanitarian crises such as war, as were carved out during previous Republican administrations.
But there is another, less remarked-upon challenge that risks condemning women and girls in conflict settings to unsafe births, unsafe abortions, and myriad other sexual and reproductive health complications. The little U.S. health assistance that is still being disbursed, and that stands a chance of being deployed after the current freeze, is conditioned on the Protecting Life in Global Health Assistance policy or “Mexico City” policy – called the global gag rule by its critics. It prohibits the NGOs that receive U.S. funds from using any of that funding, or even funding from any other donor, to “perform or actively promote abortion as a method of family planning.” During Trump’s first term in office, the rule was expanded to include not only assistance for family planning (which was the extent of the policy’s reach under previous Republican administrations since President Ronald Reagan) but also most U.S. global health assistance, including for maternal and child health, as well as for nutrition. President Joe Biden rescinded Trump’s version of the policy, and on Jan. 24 this year, Trump reinstated it.
While the policy is intended to reduce abortions, it actually leads to a reduction in the provision of health-care services. The result, most often, is decreased access to contraception and other sexual and reproductive health care and, consequently, upticks in both unintended pregnancy and abortion. This is especially problematic in humanitarian crises, where more than half of all maternal deaths worldwide occur.
Three Connected Effects
This reduction in service provision stems from three connected effects of the rule. The first is that the Mexico City policy forces recipient organizations to choose between accepting U.S. funding and complying with the rule. Compliance requires ending the provision of any abortion services, including even the mention of the procedure, under most circumstances. When organizations opt not to comply with the policy because they do not see a way to stop providing abortion as part of their health-care services without reducing the quality and effectiveness of care, they often cannot continue many services because they cannot fully replace U.S. funding.
Secondly, those who accept U.S. funding often do not understand the fine print of the policy, such as its exceptions for rape, incest, and to save the pregnant patient’s life. This misunderstanding is compounded by nervousness among NGOs that they will violate the conditions of the policy and face legal repercussions — for example by failing to provide proof of a rape to support a case of exemption, even in conflict, where forensic evidence is notoriously hard to collect. This apprehension causes providers to refrain from offering abortions even in cases in which they would be permitted by the Mexico City policy. In some cases, it has even led to the mistaken withholding of emergency contraception due to confusion over whether it might be considered abortion, which it is not.
Finally, organizations that accept U.S. funding face an unwieldy compliance burden. Compliance reports take enormous amounts of time to complete and require on-site visits to ensure health-care providers are conforming to the policy’s restrictions. This can involve lengthy and dangerous travel. All of this compliance requires NGOs to allocate funds away from service provision in order to fulfill the requirements of the Mexico City policy.
Overall, the policy has a chilling effect in which service provision is reduced, and the consequences for women and girls are grim. In countries in sub-Saharan Africa in which the original version of the rule governed a large proportion of health-care services from 2001 to 2008, access to contraceptives fell by 14 percent, rates of pregnancy rose by 12 percent, and abortions, including unsafe abortion, increased 40 percent – due in part to the loss of access to contraception. The policy also has been associated with higher maternal and child mortality and HIV incidence rates when it is in effect.
Women and Girls in Conflict Zones Especially Hard Hit
Women and girls in conflict-affected areas are especially hard hit. Take Colombia, where young girls in communities controlled by armed groups are raped or “rented out” by armed group commanders, or enter exploitative arrangements with armed group members in their search for economic or physical security. This happens so frequently that their parents sometimes seek long-term contraceptive implants such as intrauterine devices (IUDs) for them, to ensure that these experiences don’t result in their pre-teenage daughters becoming pregnant. When the Mexico City policy was first imposed from 2017-2021, one large Colombian organization, Profamilia, had to close four clinics after forfeiting more than $2 million instead of complying with the rule, leaving 60,000 people in conflict-affected rural communities without access to sexual and reproductive health care. For women and girls who have had long-term devices implanted, such a decrease in access to sexual and reproductive health services may mean that they have nowhere to go when the time comes to have them removed.
Elsewhere, in Cox’s Bazar, Bangladesh – home to almost 1 million Rohingya refugees who have fled violence in Myanmar, and where the U.S. government has been the largest provider of assistance – prenatal complications such as anemia and eclampsia are the leading cause of death among adolescent girls. When the Mexico City policy was first in place in 2017-2021, organizations cut many essential healthcare services as they struggled to find funding to fill gaps left after having forfeited U.S. dollars, or due to increased apprehension about fulfilling their legal obligations to the United States under the rule. This reduction in services resulted in a drop in care for survivors of sexual violence in Bangladesh.
The effects of the Mexico City policy will be exacerbated by the current cuts in aid. Moreover, the administration may follow the Project 2025 suggestion to expand the policy even further. Per the Project 2025 blueprint, the policy would apply to all U.S. foreign assistance, rather than only health assistance to foreign NGOs – meaning that it would cover multilateral entities like the U.N. Even though U.S. aid is likely to be meager at the end of the freeze, the effects of the rule could still be wider spread than only U.S.-funded projects. This is because the rule applies not only to U.S. aid dollars but to any other non-U.S. funds received by the same organizations, no matter their intended use by those entities. This is especially concerning if the rule is to apply to humanitarian assistance, which is supposed to be deployed rapidly to assist populations affected by emerging crises such as conflict and natural disasters. Although it might be unrealistic to prevent an expansion of the Mexico City policy, humanitarian assistance is one area that the Trump administration should seriously consider exempting, to ensure that life-saving aid is not hindered by its compliance requirements.
There are also things that outside actors can do to help blunt the impact of the policy. At a time when the global international aid purse is contracting, it might seem impractical to expect that the gaps left by the U.S. withdrawal could be filled by other donors. Nonetheless, scarce funds can be allocated in targeted ways, for example to small organizations that are both more susceptible to financial shocks and best-placed in their communities to be trusted providers of health care.
Lessons from past commemorations of gender equality — U.N. meetings to mark International Women’s Day in 2019, for example, when the United States led damagingly vocal efforts to push back against sexual and reproductive health — should inform the efforts of supporters of gender equality. This kind of campaigning can be expected once again. If advocates don’t coalesce to stand firm for women’s rights now, girls and women living both in and out of conflict settings will be at even greater risk as these forces drive their agenda forward unimpeded. The result could be a roll back of the standards that are supposed to be celebrated this year.