The impacts of the global gag rule on global health: a scoping review

Publication date: 2019

REVIEW Open Access The impacts of the global gag rule on global health: a scoping review Constancia Mavodza1,2* , Rebecca Goldman3 and Bergen Cooper4 Abstract Background: The 1984 Mexico City Policy is a U.S. federal policy that has prohibited foreign nongovernmental organizations that receive U.S. international family planning assistance from using their own, non-U.S. funds to provide, counsel on, or refer for abortion services as a method of family planning, or advocate for the liberalization of abortion laws- except in cases of rape, incest, and life endangerment. The policy became known as the global gag rule (GGR) due to its silencing effect on abortion advocacy. Historically, it has only been attached to family planning funding, until 2017 when a presidential memorandum expanded the policy to nearly all US$8.8 billion in global health foreign assistance. In light of the aforementioned expansion, this scoping review aimed to describe and map the impacts of the GGR on global health, which in turn would identify research and policy gaps. This is the first time that all of the existing literature on the policy’s impact has been synthesized into one article and comprehensively reviewed. Methods: The review utilized Arksey and Malley’s five-stage methodological framework to conduct a scoping review. Fourteen peer-reviewed databases and 25 grey literature sources were searched for publications between January 1984 and October 2017. Organizations and individuals working on GGR research and impact were also contacted to access their works from the same time period. These publications reported on impacts of the global gag rule on 14 domains in global health. Results: The searches yielded 1355 articles, of which 43 were included. Overall, 80% of the identified sources were qualitative. The misunderstanding, miscommunication, and chilling effect of the policy underpinned the GGR’s impacts. The frequently reported impacts on family planning delivery systems (34 articles) and the loss of U.S. funding (21 articles) were often related. Sources reported on the impact of the GGR on HIV and AIDS programs, advocacy and coalition spaces, and maternal and child health. Only three studies (6.9%) quantified associations between the GGR and abortion rates, concluding that the policy does not decrease rates of abortion. Discussion: The GGR’s development and implementation was consistently associated with poor impacts on health systems’ function and outcomes. More peer-reviewed and quantitative research measuring and monitoring the policy’s impact on health outcomes are needed. More research and policy analysis exploring the GGR’s development and its implementation on the ground will improve knowledge on GGR consequences, and potentially shape its reform. Keywords: Global gag rule, Mexico City policy, Global Health, Health systems, Abortion © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. * Correspondence: Constancia-Vimbayi.Mavodza@lshtm.ac.uk 1Biomedical and Research Training Institute (BRTI), 10 Seagrave Rd, Avondale, Harare, Zimbabwe 2London School of Hygiene and Tropical Medicine (LSHTM), London, UK Full list of author information is available at the end of the article Global Health Research and Policy Mavodza et al. Global Health Research and Policy (2019) 4:26 https://doi.org/10.1186/s41256-019-0113-3 Background The Mexico City Policy (MCP) has significant impacts on global health and undermines already fragile health systems by disrupting system functions. System disrup- tions include loss of staff and resources and the reduc- tion of health service provision for populations that need them. The MCP was instated in 1984 by Presi- dent Ronald Reagan [1]. As a condition of receiving U.S. foreign assistance for family planning, the policy prohibits foreign non-governmental organizations (NGOs) from advocating for the liberalization of abor- tion laws; or counseling on, referring for, or providing abortion services as a method of family planning [1, 2]. Under the policy, abortion is permissible in the cases of rape, incest, life endangerment of the woman, and as a “passive referral”1 [2]. Since 1984, the policy has been enacted by every Republican president and rescinded by every Democratic president. The policy gags health providers from informing clients of their full range of reproductive options, as well as civil soci- ety organizations from advocating for legislative re- form. Due to its gagging effect, the policy is often referred to as the Global Gag Rule (GGR), the term used throughout this article. On January 23, 2017, President Donald Trump rein- stated the GGR, renaming it “Protecting Life in Global Health Assistance” (PLGHA), and laying the ground- work for the expansion of the policy to nearly all forms of global health assistance. This includes funding for areas such as HIV and AIDS, maternal and child health (MCH), tuberculosis and malaria, gender-based violence (GBV), health systems strengthening, and water, sanita- tion and hygiene (WASH) [3]. There is a diverse body of work on past, current, and projected GGR impact, including research arti- cles, projects, reports, and case studies, produced by a wide range of sectors including academic institutions, governments, and health and civil society organiza- tions. A handful of peer-reviewed studies [4, 5] and grey literature pieces [6–8] have investigated the im- pact of previous implementations of the GGR on fam- ily planning programs. The expanded GGR has triggered documentation of how this policy has [9, 10] and will affect global health and health systems [11, 12]. As part of a larger policy and research report on the GGR, researchers from the Center for Health and Gender Equity (CHANGE)2 designed a scoping review that assembles existing evidence on the impact of the GGR on health systems from 1984 to 2017 [13]. This is the first time that all of the existing literature on the pol- icy’s impact has been synthesized into one article and comprehensively reviewed. There is sufficient evidence to determine that the GGR is harmful and that there is insufficient existing documentation of all the harms of the policy. Consequently, there is a fragmented under- standing of the scope of the GGR’s impacts. This con- strains knowledge generation for policy development and implementation and underestimates the ripple effect that the policy has had across health system areas. Facilitating a full mapping and understanding of what is known about the GGR’s impacts is critical because it can: � Identify gaps in evidence generation; � Reveal how the GGR is conceptualized and understood by the diverse stakeholders interacting with the policy; � Inform construction of policy for effective health service delivery. This article outlines the scoping review methodology and the consequent mapping of evidence on the policy’s impacts to address the objectives stated above. A discus- sion on the key findings in relation to evidence generation, existing understanding of the policy, and policymaking is also offered. Methods This review followed Arksey and Malley’s five-stage methodological framework: (1) identifying the research question; (2) identifying relevant studies; (3) study selec- tion; (4) charting the data; and (5) collating, summariz- ing, and reporting the results [14]. A scoping review methodology was adopted as it aims to identify, map, and synthesize key concepts on broad topics, without assessing the quality of the included literature- as would be the case for a systematic review [15]. Currently, there is a dearth of empirical evidence and research on the GGR; and most of the evidence is from non-academic sources as will be seen in the findings of this review. Therefore, the scoping review methodology is most ap- propriate for mapping the evidence of the GGR’s impact. In this research, “impact” is defined as a change or 1The “passive referral” exception permits a health care provider to inform a woman where she can obtain a legal abortion, if all of the following criteria are met: A pregnant woman clearly states that she has already decided to have a legal abortion and asks where one can be obtained, and the provider believes that a response is required based on the ethics of the country’s medical profession. 2The Center for Health and Gender Equity (CHANGE) is a U.S.-based non-governmental organization whose mission is to promote sexual and reproductive health and rights (SRHR) as a means to achieve gen- der equality and empowerment of all women and girls by shaping pub- lic discourse, elevating women’s voices, and influencing the United States Government. Mavodza et al. Global Health Research and Policy (2019) 4:26 Page 2 of 21 consequence and “health systems” include health care: institutions, resources, services and programs, civil soci- ety, advocacy work, providers, health outcomes, and the individuals, and communities served [16]. Identifying the research question The preliminary research question for this review was: What is the impact of the Global Gag Rule on health sys- tems? The broad nature of this question was intended to capture the potential breadth of the GGR’s impact since its inception, and as well as any impacts recorded since the policy’s expansion. CHANGE researchers identified 17 health system focus areas for the review. Literature search strategy A three-step literature search process was performed to exhaustively capture the existing evidence of GGR im- pact. The established GGR key terms were “Global Gag Rule,” “Mexico City Policy,” and “Protecting Life in Glo- bal Health Assistance.” Key and MeSH terms were also established for the selected domains. In the peer- reviewed literature search (Table 1), the GGR key terms and the selected domains’ (Table 2) key terms were combined using the Boolean term “AND” in all the elec- tronic databases explored (see Table 7 in Appendix). For the grey literature search, each key term was put into the 25 established websites’ publication databases (Table 3) when available, and general search bars when necessary. Different websites required a different num- ber of tab selection, and a unique search strategy was used for one source due to its website format, which re- quired the selection of “Global Gag Rule” from a drop- down menu within its publications tab. In five of the websites, no publications were obtained after using the key terms and search strategy. Finally, listservs, coalition groups of organizations, and individual researchers known to be doing work on the GGR were contacted to request their work for review in- clusion. Additionally, after identifying one institution doing its own scoping review of GGR literature, search results were compared to identify research gaps. Inclusion and exclusion criteria To address time constraints and focus searches, litera- ture was only included if it was available in English and published between 1984 and 2017. Inclusion and exclu- sion criteria for this review were established and imple- mented. Inclusion criteria were peer-reviewed journal research articles, organizational reports, working papers, master’s theses, and accessible book chapters. Exclusion criteria were fact sheets, policy briefs, blog posts, news articles, press releases, newsletters, opinion pieces, toolk- its and advocacy guides, infographics, videos, letters, and transcriptions. Policy briefs were included if they had original findings, such as PAI’s case studies of GGR im- pact within countries, which were internally classified as policy briefs. Study selection The peer-reviewed search strategy identified 1275 arti- cles. Duplicate copies were removed and the remaining articles were screened for relevance by topic area. The established inclusion/exclusion criteria were applied to 297 articles, 148 of which were selected for further screening. Of these articles, the three that did not have full text accessible were removed, leaving 145 articles. Table 1 Peer-Reviewed Literature Electronic Database Sources • BioMed Central (BMC) • Google Scholar • The Lancet • Population Information Online (POPLINE) • PsychINFO • Public Library of Science (PLOS) • PubMed (ie. MEDLINE) • ScienceDirect • Scopus • Sociological Abstracts (Proquest) • UNICEF ChildInfo database • Web of Science • Wiley Online Library World Health Organization Institution Repository for Information Sharing (WHO IRIS) Table 2: Global Health Domains Searched 1. Abortion 2. Advocacy 3. Commodities (male and female condoms, emergency contraception, pre- and post-exposure prophylaxis) 4. Family planning 5. Gender-based violence (GBV) 6. Global health assistance 7. HIV and AIDS and STIs 8. Human rights 9. Infectious diseases 10. Key populations 11. Maternal morbidity and mortality 12. Maternal and child health (MCH) 13. Non-communicable diseases (NCDs) 14. Orphans and vulnerable children (OVC) 15. Prevention of mother-to-child transmission (PMTCT) 16. Reproductive health 17. Water, sanitation and hygiene (WASH) Mavodza et al. Global Health Research and Policy (2019) 4:26 Page 3 of 21 After a full-text reading, an additional 121 articles did not meet the inclusion criteria, and the remaining 24 ar- ticles were included in this review. Two additional arti- cles from colleagues were identified and included, resulting in a total of 26 articles for review inclusion (Fig. 1). The grey literature search strategy identified 75 arti- cles. These were screened using the established inclu- sion/exclusion criteria and for relevance to yield 17 articles. Four additional eligible articles were identified by colleagues also doing GGR research, and one master’s thesis was discovered after the review data collection period, resulting in a total of 22 articles for review inclusion. All the articles that addressed GGR impact were in- cluded, regardless of methodological approach. An art- icle was excluded if it referenced or talked about the GGR without addressing its impact or implications. For example, a Human Rights Watch report on the lack of access to abortion in Peru defined the GGR and recom- mended that the United States Agency for International Development (USAID) clarify the policy for the Peruvian government but did not link the GGR to abortion access or other health system indicators, so this article was ex- cluded from the review. The 26 peer-reviewed and 22 grey literature articles were combined, duplicates were removed, and after consultation with an author, one peer-reviewed article was removed due to corrupt data. The peer-reviewed search pulled some pieces that were reports and classified as grey literature. Resultantly, 43 articles addressing the impact of the GGR were included in this scoping review. Charting the data An excel spreadsheet was used as the data extraction sum- mary form to collect general citation information, study type and methodology, country and population of focus, study approach, and key findings on policy impact. Data collation, analysis, and synthesis All 43 articles were read at least twice. CM manually coded and discussed emerging themes with RG and BC. To manage the breadth of the research question and the volume of literature uncovered, narrative descriptive synthesis was used and the findings were classified using the established focus areas (Table 2), allowing for the in- ductive identification of themes [17]. The focus areas and emerging themes gave structure to the key findings. Results The 43 articles in this review include 16 peer-reviewed publications and 27 grey literature materials (Table 4). Thirty-four pieces are qualitative, and the 9 quantitative include: 3 peer-reviewed publications, one of which looks at the relationship between the GGR and sub-Sa- haran Africa abortion rates [5], one at donor money allo- cation, [47] and the third at the relationship between contraceptive supplies and fertility outcomes during GGR years [34]; one working paper on family planning aid in developing countries [18]; a country-specific study on the impact of the GGR on unintended pregnancy, abortion rate, and child health [4]; and a book chapter on the impact of the GGR on abortion rates in four global regions [48]. The remaining 3 quantitative studies are master’s theses [24, 30]. Eighteen articles come from just three organizations working in global health. The dominant qualitative approach is a case study, and the quantitative works are largely regression analyses [4, 5]. Less than half of the literature focuses on specific coun- tries. Most of the literature (86%) discusses the previous enactments of the GGR and only 7 of the 43 articles are on PLGHA. The reported impacts of the GGR are on: global health assistance, reproductive health services and outcomes, family planning programs, contraceptive supplies and demand, abortion rates, HIV and AIDS Table 3 Grey Literature Sources • amfAR, The Foundation for AIDS Research • Asian-Pacific Resource and Research Centre for Women (ARROW) • Bixby Center for Global Reproductive Health, University of California San Francisco • Center for Reproductive Rights (CRR) • The George Washington University • The Global Women’s Institute (GWI), The George Washington University • Guttmacher Institute • Human Rights Watch (HRW) • Ibis Reproductive Health • Institute for Reproductive Health (IRH), Georgetown University • International Center for Research on Women (ICRW) • International Women’s Health Coalition (IWHC) • Ipas • Kaiser Family Foundation (KFF) • London School of Economics (LSE) • The London School of Hygiene and Tropical Medicine (LSHTM) • Mailman School of Public Health, Columbia University • Management Sciences for Health (MSH) • O’Neill Institute for National and Global Health Law, Georgetown University • PAI • Population Council • Rutgers International • UAB School of Public Health • The Williams Institute, UCLA School of Law • Yale School of Public Health Mavodza et al. Global Health Research and Policy (2019) 4:26 Page 4 of 21 programs and rates, civil society participation, NGO pol- itical advocacy, and human rights. Misunderstanding the GGR Foreign NGOs to whom the GGR applied were confused about the policy [19, 23, 49]. During the Reagan policy years, prime partners in Kenya and Bangladesh were un- clear about the practical implementation of the policy, including the permissibility of post-abortion care and the repercussions of non-adherence [19, 38]. During a study visit to Kenya at the time, over 64% of implement- ing clinicians interviewed reported that the policy had never been explained to them [19]. Compared to prime non-implementing organizations, sub-prime organizations that interacted with clients tended to be even more confused about the GGR [22, 38]. During the Reagan GGR, an abortion provider in Kenya needed clarity on the permissibility of abortion for a woman living with AIDS, and another questioned if a woman verified by a psychologist to be at risk of com- mitting suicide due to an unwanted pregnancy classified as a case of life endangerment [19]. One organization in Brazil was confused about whether partners advocating for liberal abortion laws could be invited to workshops and receptions, and staff in Bangladesh did not know what abortion research was allowed [19]. Loss of funding Twenty-one articles discussed either GGR-associated loss of funding or the outcomes of direct or projected funding loss. International Planned Parenthood Feder- ation (IPPF) [31] and Marie Stopes International (MSI) Fig. 1 Search Flow Chart Mavodza et al. Global Health Research and Policy (2019) 4:26 Page 5 of 21 Ta b le 4 Su m m ar y Ta bl e of A rt ic le s In cl ud ed in Re vi ew A ut ho rs /( Ye ar ) (T itl e) pe er re vi ew /g re y lit C ou nt ry /r eg io n fo cu s Ty pe of St ud y an d m et ho ds A pp ro ac h Ke y fin di ng s on th e Im pa ct of th e G G R A si ed u, E. ,N an iv az o, M ., & N ku su ,M , (2 01 3) [1 8] :D et er m in an ts of fo re ig n ai d in fa m ily pl an ni ng :H ow re le va nt is th e M ex ic o C ity Po lic y? W or ki ng pa pe r un pu bl is he d (g re y lit ) 15 1 de ve lo pi ng co un tr ie s Q ua nt ita tiv e (d iff er en ce an d sy st em G M M es tim at or s) :p an el da ta fro m W D Ia nd O EC D A na ly ze th e de te rm in an ts of Fa m ily Pa nn in g (F P) A id an d ex am in e th e ex te nt to w hi ch U S fo re ig n po lic y on FP af fe ct s th e al lo ca tio n of FP ai d to de ve lo pi ng co un tr ie s- pa rt ic ul ar ly ex am in in g th e ef fe ct of M C P on th e al lo ca tio n of FP ai d to de ve lo pi ng co un tr ie s Im pa ct on :F am ily Pl an ni ng (F P A ID ,a ll th in gs eq ua l, de cr ea se d by 3– 6% du rin g Bu sh -e ra po lic y ye ar s) Be nd av id ,E ., A vi la ,P ., & M ill er ,G . (2 01 1) [5 ]: U ni te d St at es ai d po lic y an d in du ce d ab or tio n in su b- Sa ha ra n A fri ca Pe er - re vi ew 20 A fri ca n co un tr ie s Q ua nt ita tiv e di ffe re nc e- in -d iff er en ce an al ys is : D H S da ta fro m 26 1, 11 6 w om en ag ed 15 –4 4 yr s. D et er m in e th e re la tio ns hi p be tw ee n th e re in st at em en t of M C P an d th e pr ob ab ili ty of a w om an in SS A ha vi ng an in du ce d ab or tio n ra te Im pa ct on :a bo rt io n ra te s (G G R w as as so ci at ed w ith a 2. 55 gr ea te r in cr ea se in th e od ds of se lf- re po rt ed ab or tio n in hi gh M C P- ex po su re co un tr ie s vs .l ow M C P- ex po su re co un tr ie s) ; M od er n co nt ra ce pt iv es (re la tiv e de cl in e in co nt ra ce pt iv e us e in hi gh ex po su re co un tr ie s) Bi ng en he im er ,J .B ., & Sk us te r, P. (2 01 7) [1 1] :T he Fo re se ea bl e H ar m s of Tr um p’ s G lo ba lG ag Ru le Pe er - re vi ew co m m en ta ry n/ a Q ua lit at iv e an al ys is (c om m en ta ry ): su m m ar iz es an d an al yz es im pa ct s of th e G G R up un til 20 17 Pr ov id e a sc ie nt ifi c an d po lic y ba si s fo r th e th re e cr iti ci sm s of th e G G R: (1 ) th at th e ru le fa ils to ac co m pl is h its pr es um ed ob je ct iv e of re du ci ng th e nu m be r of ab or tio ns ; (2 ) th at it ne ga tiv el y af fe ct s th e he al th an d w el l-b ei ng of in di vi du al s an d po pu la tio ns in af fe ct ed co un tr ie s; an d (3 ) th at it in te rfe re s w ith go ve rn m en ts ’a bi lit y to m ee t th ei r in te rn at io na l ob lig at io ns . Im pa ct on :m at er na ld ea th s (p re m is ed lin ka ge as so ci at io ns ); FP pr og ra m s di sr up te d; ch ild he al th po or ;s oc io -e co no m ic de ve lo pm en ts ar e po or ; co nt ra ce pt iv e us e; ab or tio n ra te s; fe rt ili ty ;l os s of fu nd in g; ab or tio n ra te s; ad vo ca cy Bl an e, J., & Fr ie dm an ,M . (1 99 0) [1 9] :M ex ic o C ity Po lic y im pl em en ta tio n st ud y O rg an iz at io na lr ep or t 5 C oo pe ra tin g A ge nc ie s (F H I; Pa th fin de r; IP PF /W H R; C en te r fo r D ev el op m en t an d Po pu la tio n A ct iv iti es ; an d th e A ss oc ia tio n fo r Vo lu nt ar y Su rg ic al C on tr ac ep tio n) an d 49 su bg ra nt ee s of th ei rs in 6 co un tr ie s- (1 0 in Pa ki st an , 8 Ba ng la de sh ,1 2 Br az il, 8 Ke ny a, 4 Eg yp t, 7 Tu rk ey ) Q ua lit at iv e in te rv ie w s; si te in sp ec tio ns ; do cu m en t re vi ew s & an al ys is D et er m in e w he th er re ci pi en ts of gr an ts an d th ei r su b- gr an te es ar e in co m pl ia nc e w ith M C P 2) de te rm in e w he th er th e st an da rd cl au se is un de rs to od by th e gr an te es & su bg ra nt ee s 3) de te rm in e w ha t im pa ct if an y th e M C P ha s ha d on FP pr og ra m s Im pa ct on :a dv oc ac y; pa rt ne rs hi ps & co al iti on s; pr ov id er -c lie nt in te ra ct io ns ;c on fu si on & po or po lic y un de rs ta nd in g; po or co m m un ic at io n; ch ill in g ef fe ct (s el f-c en so rin g & ov er -c au tio n) ; Bo ge ch o, D ., & U pr et i, M .( 20 06 ) [2 0] .( C RR ): Th e G lo ba lG ag Ru le -- an an tit he si s to th e rig ht s- ba se d ap pr oa ch to he al th C om m en ta ry pe er re vi ew Ke ny a & N ep al Q ua lit at iv e na rr at iv e: ba se d on co un tr y ca se fin di ng s Su m m ar iz in g th e im pa ct of th e G G R in N ep al & Ke ny a. In Ke ny a, th e G G R im pa ct w as on he al th se rv ic es .I n N ep al ,t he G G R im pa ct w as on hu m an rig ht s. Im pa ct on Ke ny a: lo ss of fu nd in g fo r FP A K & M SI ;s ev er e di sr up tio n of FP se rv ic es (c lo se d 8 cl in ic s (6 FP A K & 2 M SI )- 28 ,0 00 cl ie nt s w er e de ni ed he al th se rv ic es , fir e ov er 30 % of th ei r st af f & cu t ba ck se rv ic es ); H IV pr ev en tio n ef fo rt s lik e VC T & H IV pr ev en tio n se rv ic es w er e se ve re ly re st ric te d. Mavodza et al. Global Health Research and Policy (2019) 4:26 Page 6 of 21 Ta b le 4 Su m m ar y Ta bl e of A rt ic le s In cl ud ed in Re vi ew (C on tin ue d) A ut ho rs /( Ye ar ) (T itl e) pe er re vi ew /g re y lit C ou nt ry /r eg io n fo cu s Ty pe of St ud y an d m et ho ds A pp ro ac h Ke y fin di ng s on th e Im pa ct of th e G G R Im pa ct on N ep al :R ig ht s to he al th , lif e & in fo rm at io n is ha m pe re d: lo ss of fu nd in g (F PA N su ffe re d bu dg et se tb ac ks fo r re je ct in g th e G G R) ;F P se rv ic es di sr up te d (c lin ic s w er e cl os ed & st af f la id of f ov er ni gh t) ;g ov er nm en t im pa ct (g ov er nm en t lib er al iz ed th e ab or tio n la w an d w as re lia nt on N G O s to pr ov id e ab or tio n se rv ic es ,a nd tr ac k im pl em en ta tio n of th e ne w la w , th ey w er e no t ab le to do so on ce FP A N di d no t si gn th e G G R. C am p, S. (1 98 7) [2 1] :T he im pa ct of th e M ex ic o C ity Po lic y on w om en an d he al th ca re in de ve lo pi ng co un tr ie s Pe er -r ev ie w co m m en ta ry 8 de ve lo pi ng co un tr ie s & th e U .S .A Q ua lit at iv e na rr at iv e an al ys is :R ep or tin g on in te rv ie w s w ith fa m ily pl an ni ng or ga ni za tio ns in th e U S an d 8 de ve lo pi ng co un tr ie s Re vi ew th e de ve lo pm en t & sc op e of th e M C P as w el la s pr es en t pr el im in ar y fin di ng s of on go in g re se ar ch ev al ua tin g th e im pa ct of M C P on fo re ig n FP an d po pu la tio n as si st an ce pr og ra m s Im pa ct on :l os s of fu nd in g; co nf us io n & po or po lic y un de rs ta nd in g; in cr ea se d ad m in is tr at iv e bu rd en ;c hi lli ng ef fe ct (s el f-c en so rin g & ov er ca ut io us ne ss ); pa rt ne rs hi ps & co al iti on s; C ar ro ll, L (2 01 2) [2 2] / U ni ve rs ity of N or th C ar ol in a at C ha pe lH ill : Th e Ef fe ct s of th e M ex ic o C ity Po lic y on A nt en at al C ar e an d Sk ill ed Bi rt h A tt en da nc e in D ev el op in g C ou nt rie s M as te r’s Th es is 37 de ve lo pi ng co un tr ie s Q ua nt ita tiv e an al ys is : D H S da ta fro m 98 su rv ey s be tw ee n 19 98 an d 20 08 fo r 25 1, 60 2 w om en ag es 15 –4 9 ye ar s To de te rm in e if w om en in co un tr ie s w ith a hi gh de gr ee of ex po su re to th e M ex ic o C ity Po lic y ha ve di m in is he d od ds of ha vi ng ef fe ct iv e an te na ta lc ar e an d sk ill ed bi rt h at te nd an ce at de liv er y co m pa re d to w om en in co un tr ie s w ith a lo w er de gr ee of ex po su re to th e po lic y Im pa ct on m at er na lh ea lth (s ki lle d bi rt h at te nd an ce & an te na ta lc ar e) :o ut co m es im pr ov ed in m os t pa rt s of th e w or ld be tw ee n 19 93 an d 20 00 an d 20 01 –2 00 8 re ga rd le ss of ex po su re to th e po lic y. C há ve z, S. ,& C oe ,A .-B .( 20 07 ) [2 3] : Em er ge nc y C on tr ac ep tio n in Pe ru : Sh ift in g G ov er nm en t an d D on or Po lic ie s an d In flu en ce s Pe er -r ev ie w Pe ru Q ua lit at iv e na rr at iv e an al ys is : Re po rt in g on in fo rm at io n ga th er ed fro m on -g oi ng m on ito rin g co nd uc te d by au th or s of re pr od uc tiv e he al th an d rig ht s po lic ie s in Pe ru A na ly ze th e tr aj ec to ry an d re as on s fo r se ve ra l sh ift s in U SA ID /P er u’ s po lic y on EC w ith in th e co nt ex t of ch an ge s in go ve rn m en t po lic y on FP in bo th co un tr ie s Im pa ct on :A dv oc ac y fo r lib er al ab or tio n la w s (d ue to po or un de rs ta nd in g of th e po lic y an ti- ch oi ce gr ou ps le ve ra ge d th e G G R to st op th e U SA ID /P er u fro m en ga gi ng in Em er ge nc y co nt ra ce pt iv e pr ov is io n) C ho ud hu ry ,S ./ G eo rg et ow n U ni ve rs ity (2 01 2) [2 4] : Q ua nt ita tiv e an al ys is : D H S da ta fo r in di vi du al w om en in G ha na M as te r’s Th es is G ha na Q ua nt ita tiv e an al ys is :D H S da ta (1 99 8 & 20 01 ) fo r in di vi du al w om en an d m en in M al aw i Ex am in e th e ef fe ct of th e M ex ic o C ity Po lic y on ac ce ss to m od er n co nt ra ce pt iv e m et ho ds , pr en at al ca re ,a nd de liv er y as si st an ce Im pa ct on :B us h- er a G G R ha d ne ga tiv e ef fe ct s on pr en at al ca re ac ce ss in ru ra la nd ur ba n ar ea s. C ra ne ,B .B ., & D us en be rr y, J. (2 00 4) [2 5] :P ow er an d po lit ic s in in te rn at io na l fu nd in g fo r re pr od uc tiv e he al th :t he U S G lo ba lG ag Ru le Pe er - re vi ew n/ a Q ua lit at iv e na rr at iv e an al ys is :d es cr ib es th e G G R an d its im pa ct s- es pe ci al ly th e Bu sh -e ra G G R. Re vi ew s th e hi st or y an d po lit ic al or ig in s of th e G ag Ru le un de r se ve ra l R ep ub lic an pa rt y pr es id en ts ,i nc lu di ng its ro ot s in U S do m es tic ab or tio n po lit ic s, an d an al ys es th e sh or t an d lo ng -t er m da m ag e th e Im pa ct on :l os s of fu nd in g (IP PF & M SI ); hu m an rig ht s & au to no m y; la ck of tr an sp ar en cy (U SA ID di d no t pr ov id e in fo rm at io n on po lic y im pl em en ta tio n) ;a bo rt io n (n ot re du ce d ab or tio ns ); pr oj ec te d H IV an d A ID S im pa ct s; se pa ra tin g pa rt ne rs hi ps be tw ee n ‘g ag ge d’ an d ‘u ng ag ge d’ ;c on tr ac ep tiv e Mavodza et al. Global Health Research and Policy (2019) 4:26 Page 7 of 21 Ta b le 4 Su m m ar y Ta bl e of A rt ic le s In cl ud ed in Re vi ew (C on tin ue d) A ut ho rs /( Ye ar ) (T itl e) pe er re vi ew /g re y lit C ou nt ry /r eg io n fo cu s Ty pe of St ud y an d m et ho ds A pp ro ac h Ke y fin di ng s on th e Im pa ct of th e G G R G ag Ru le is ca us in g to th e he al th an d liv es of w om en in th e de ve lo pi ng w or ld . su pp ly ; ch ill in g ef fe ct s C rim m ,N .J .( 20 07 ) [2 6] :T he G lo ba lG ag Ru le :U nd er m in in g na tio na li nt er es ts by do in g un to fo re ig n w om en an d N G O s w ha t ca nn ot be do ne at ho m e Pe er - re vi ew n/ a Q ua lit at iv e na rr at iv e an al ys is :n ar ra te s an an al ys is of th e ha rm s to hu m an rig ht s, au to no m y, re pr od uc tiv e he al th an d fa m ily pl an ni ng of G G R A na ly si s th at fo cu se s on th e G G R’ s gr av e ha rm to U .S .n at io na li nt er es ts ; hu m an rig ht s & au to no m y of fo re ig n w om en ;f am ily pl an ni ng an d re pr od uc tiv e he al th Im pa ct on :h um an rig ht s & au to no m y; w om en ’s rig ht s (o pp re ss ed w om en by co nt ro lli ng an d re st ric tin g th ei r ac ce ss to in fo rm at io n an d he al th ca re ); ch ill in g ef fe ct s; fa m ily pl an ni ng an d re pr od uc tiv e he al th (t he G G R ha s ba rr el le d an d ev en ha m pe re d th e w or k/ ef fo rt s of fo re ig n N G O s & th ei r H W s in pr ov id in g RH an d FP se rv ic es ); cl in ic cl os ur es ; fre ed om s of sp ee ch & as so ci at io n, ar e si le nc ed . C RR (2 00 9) [2 7] :E xp an de d G lo ba lG ag Ru le Li m its W om en ’s Ri gh ts an d En da ng er s Th ei r W el l-b ei ng Re po rt 14 C ou nt rie s (K en ya ,N ig er ia , M oz am bi qu e, Et hi op ia , Rw an da ,H ai ti, Ta nz an ia , U ga nd a, C ot e D ’Iv oi re ; Za m bi a, N am ib ia ,B ot sw an a, G uy an a, So ut h A fri ca ) Q ua lit at iv e de sc rip tiv e su m m ar y & an al ys is of di re ct an d po te nt ia l G G R ef fe ct s D es cr ib es G G R ex pa ns io n un de r th e Bu sh ad m in is tr at io n, an d us es an al ys is of ab or tio n la w s in 14 co un tr ie s to re ve al ha rm fu lG G R ef fe ct s Im pa ct on :L os s of fu nd in g; ab or tio n, ad vo ca cy ,F P, G BV , gl ob al he al th as si st an ce , H IV /A ID S & ST Is ,m at er na l m or ta lit y, re pr od uc tiv e he al th ; fre e sp ee ch si le nc ed C ur tis ,C ., Fa rr el l, B. ,& A hl bo rg ,J . (2 00 5) [2 8] :C am bo di a Po st ab or tio n Ca re :C am bo di a Po st ab or tio n C ar e Pr og ra m .F in al re po rt of fin di ng s an d re co m m en da tio ns . C am bo di a tr ip re po rt :d at es A pr il 25 ,2 00 5, to M ay 6, 20 05 Re po rt (g re y) C am bo di a Q ua lit at iv e de sc rip tiv e na rr at iv e an al ys is : in te rv ie w s w ith st af f fro m U SA ID / C am bo di a; C A RE ;R H A C ; RA C H A ;t he M in is tr y of H ea lth ;a nd D ire ct or s of op er at io na ld is tr ic ts . Si te vi si ts to he al th ce nt er s, co m m un ity ed uc at io n se ss io ns ;a nd th e Re d C ro ss H os pi ta l. D oc um en ts re vi ew of na tio na lp ol ic y do cu m en ts ; PA C cu rr ic ul um s; se rv ic e de liv er y gu id el in es ;U SA ID / C am bo di a po st -a bo rt io n ca re dr af t st ra te gy U SA ID re po rt :a n as se ss m en t of C am bo di a’ s Po st A bo rt io n C ar e Pr og ra m & co m pl ia nc e to th e Bu sh -e ra M ex ic o C ity Po lic y co nd uc te d by U SA ID /W as hi ng to n Im pa ct on :P os t A bo rt io n C ar e (P A C )- C am bo di a w as in co m pl ia nc e w ith th e G G R: Po te nt ia l m at er na lh ea lth im pa ct ; C on fu si on - C A RE /C am bo di a ha d en te re d a co nt ra ct w ith M O H & w as un su re at w ha t po in t th ey w ill vi ol at e th e G G R; Pr ov id er s at RH A C w er e tr ai ne d on G G R; la ck of cl ar ity - qu es tio ns re ga rd in g th e M C P an d se pa ra tio n of ab or tio n ca re vs .p os t- ab or tio n ca re es pe ci al ly in ru ra lh ea lth ce nt er s w er e th e us ua lly is on ly on e m id w ife pr ov id in g al lt yp es of ca re . Er ns t, J., & M or ,T .( C RR ) (2 00 3) [2 9] :B re ak in g th e Si le nc e: Th e G lo ba lG ag Ru le ’s Im pa ct on U ns af e A bo rt io n Re po rt Et hi op ia ,K en ya ,P er u, U ga nd a Q ua lit at iv e na rr at iv e & ov er vi ew an al ys is :i nt er vi ew s w ith a br oa d ra ng e of re pr od uc tiv e he al th ,U .N . an d go ve rn m en t ac to rs in 4 co un tr ie s (2 5– 30 in te rv ie w s pe r co un tr y) D oc um en tin g Bu sh -e ra G G R im pa ct s on or ga ni za tio ns no rm al ly re ce iv in g U SA ID fa m ily pl an ni ng fu nd in g Im pa ct s on :l os s of fu nd in g, ab or tio n, ad vo ca cy ,c om m od iti es (E C ), FP ,g lo ba l he al th as si st an ce ,H IV /A ID S & ST Is ,h um an rig ht s, in fe ct io us di se as es (im m un iz at io ns ), ke y po pu la tio ns (A G YW ), m at er na l m or ta lit y/ m or bi di ty ,r ep ro du ct iv e he al th Fo st er ,S .C ./ G eo rg et ow n U ni ve rs ity (2 00 9) [3 0] : Tr en ds in co nd om us e: M as te r’s Th es is M al aw i Q ua nt ita tiv e an al ys is : D H S da ta (2 00 0 & 20 04 ) fo r in di vi du al w om en Ex am in es th e re la tio ns hi p be tw ee n th e ch ar ac te ris tic s of in di vi du al M al aw ia ns an d Im pa ct :T he re is a po si tiv e re la tio ns hi p be tw ee n A ID S kn ow le dg e an d co nd om us e Mavodza et al. Global Health Research and Policy (2019) 4:26 Page 8 of 21 Ta b le 4 Su m m ar y Ta bl e of A rt ic le s In cl ud ed in Re vi ew (C on tin ue d) A ut ho rs /( Ye ar ) (T itl e) pe er re vi ew /g re y lit C ou nt ry /r eg io n fo cu s Ty pe of St ud y an d m et ho ds A pp ro ac h Ke y fin di ng s on th e Im pa ct of th e G G R Th e as so ci at io n in M al aw i of co nd om us e w ith A ID S kn ow le dg e an d th e re la tio ns hi p to th e gl ob al ga g ru le an d m en in M al aw i th ei r co nd om us e ov er tim e, an d ev al ua te s th e im pa ct of G G R ov er tim e in M al aw i. Th e G G R ha s a ne ga tiv e ef fe ct on co nd om us e ov er tim e; Fo x, G .H .( 19 85 ) [3 1] : A m er ic an po pu la tio n po lic y ab ro ad :T he M ex ic o C ity ab or tio n fu nd in g re st ric tio ns Pe er re vi ew n/ a Q ua lit at iv e de sc rip tiv e na rr at io n & an al ys is H is to ric al co nt ex t on th e le ga lit ie s su rr ou nd in g th e G G R w ith a po lic y/ le gi sl at iv e fo cu s. Im pa ct on :l os s of fu nd in g, la ck of cl ar ity in ho w to im pl em en t 19 85 G G R, A ID ha d no t ye t co m e up w ith th e ab or tio n fu nd in g re st ric tio ns fo r th e G G R. A ll fu nd in g to U N FP A w as te rm in at ed & it re m ai ne d un cl ea r w hi ch or ga ni za tio ns w ou ld be im pa ct ed .M C P im po se s a vi ew on ab or tio n w hi ch m an y N G O s do no t sh ar e. G ez in sk i, L. B. (2 01 1) [3 2] :T he G lo ba l G ag Ru le :I m pa ct s of a C on se rv at iv e Id eo lo gy on W om en ’s H ea lth . Pe er -r ev ie w n/ a Q ua lit at iv e lit er at ur e re vi ew & na rr at iv e po lic y an al ys is O ut lin e th e le gi sl at iv e hi st or y of th e G lo ba lG ag Ru le an d w ill de sc rib e th e ke y st ak eh ol de rs re sp on si bl e fo r th e po lic y’ s pa ss ag e an d pr om ot io n Im pa ct on :h um an rig ht s; po lit ic al ad vo ca cy ;l aw ;r ep ro du ct iv e he al th ; ab or tio n, pe rc ei ve d an d re al lo ss of fu nd in g; an d th e he al th sy st em ef fe ct s th at w er e as so ci at ed w ith th at (d ec re as ed ac ce ss to co nt ra ce pt iv es ,i nc re as ed ra te s of un w an te d pr eg na nc ie s, as w el la s in cr ea se d ab or tio ns re su lti ng in ha rm or de at h Jo ne s, A .A .( 20 04 ) [3 3] : Th e “M ex ic o C ity Po lic y” an d Its Ef fe ct s on H IV / A ID S Se rv ic es in Su b- Sa ha ra n A fri ca Pe er re vi ew Su b- Sa ha ra n A fri ca (U ga nd a, Ke ny a, Et hi op ia ) Q ua lit at iv e th em at ic - na rr at iv e & an al ys is A na ly ze an d sh ow th e im pa ct of G G R on H IV /A ID S pr og ra m s in Su b- Sa ha ra n A fri ca . Im pa ct on :l os s of fu nd in g H IV /A ID S Se rv ic es th at ar e pr ov id ed by Fa m ily Pl an ni ng cl in ic s (H ea lth ce nt er s w er e cl os ed do w n − 17 U ga nd a, 5 Ke ny a, 1 Et hi op ia ). H IV /A ID S se rv ic es ar e us ua lly in te gr at ed in to FP pr og ra m s; ad vo ca cy co al iti on s w er e di sb an de d; hu m an rig ht s vi ol at io n; le ga lr ig ht s of w om en w ith H IV Jo ne s, Ke lly ,M (2 01 5) [3 4] : C on tr ac ep tiv e Su pp ly an d Fe rt ili ty O ut co m es :E vi de nc e fro m G ha na Pe er -r ev ie w G ha na Q ua nt ita tiv e an al ys is : D H S da ta fo r in di vi du al w om en in G ha na To ex am in e G ha na ia n w om en ’s re sp on se to a re du ct io n in th e av ai la bi lit y of m od er n co nt ra ce pt iv es in te rm s of co nt ra ce pt iv e ac ce ss an d us e, re su lti ng pr eg na nc ie s, us e of in du ce d ab or tio n, an d re su lti ng bi rt hs .T he ex og en ou s ch an ge in av ai la bi lit y is du e to G G R- re la te d lo ss of fu nd in g an d th e as so ci at ed ou tc om es of th is lo ss . Im pa ct on :L os s of fu nd in g (P PA G ag re ed to si gn th e M C P to ke ep ¼ of its bu dg et th at w as U SA ID fu nd ed fo r th e C BS pr oj ec t; PP A G fu nd in g fro m IP PF (7 5% of its bu dg et ) w as re du ce d by 54 % ); co nt ra ce pt io n (c on tr ac ep tiv e ab ili ty w as re du ce d du rin g po lic y pe rio ds w hi ch af fe ct ed co nt ra ce pt iv e us e) ; fa m ily pl an ni ng pr og ra m s (P PA G cl os ed do w n 57 % of its cl in ic s) . Jo ne s, K. M .( 20 11 ) [4 ]: Ev al ua tin g th e M ex ic o C ity Po lic y: H ow U S fo re ig n po lic y af fe ct s fe rt ili ty ou tc om es an d ch ild he al th in G ha na Re po rt (g re y) G ha na Q ua nt ita tiv e an al ys is (e st im at io n em pl oy in g w om an -b y m on th pa ne l of pr eg na nc ie s & w om an -fi xe d ef fe ct s) :D H S M EA SU RE da ta fo r G ha na ia n w om en Es tim at e w he th er a gi ve n w om an is le ss lik el y to ab or t a pr eg na nc y du rin g tw o po lic y pe rio ds ve rs us tw o no n- po lic y pe rio ds . Im pa ct on :a bo rt io n (R eg re ss iv e ef fe ct s: in cr ea se d (2 00 00 0) ab or tio ns in a ru ra la re a) ; ad di tio na l 1 2% un in te nd ed pr eg na nc ie s an d 1/ 2 to 3/ 4 m ill io n ad di tio na lu ni nt en de d bi rt hs du e to lo ss of co nt ra ce pt iv e Mavodza et al. Global Health Research and Policy (2019) 4:26 Page 9 of 21 Ta b le 4 Su m m ar y Ta bl e of A rt ic le s In cl ud ed in Re vi ew (C on tin ue d) A ut ho rs /( Ye ar ) (T itl e) pe er re vi ew /g re y lit C ou nt ry /r eg io n fo cu s Ty pe of St ud y an d m et ho ds A pp ro ac h Ke y fin di ng s on th e Im pa ct of th e G G R he al th se rv ic es ;a s w el la s di la pi da te d ch ild he al th in he ig ht an d w ei gh t fo r ag e fo r ch ild re n bo rn fro m th es e un in te nd ed bi rt hs .T he G G R do es no t ac hi ev e its ai m fo r w om en in th e G ha na co nt ex t. La w ,S .A ., & Ra ck ne r, L. F. (1 98 7) [3 5] :G en de r Eq ua lit y an d th e M ex ic o C ity Po lic y Pe er re vi ew n/ a Q ua lit at iv e de sc rip tiv e na rr at io n & an al ys is Pr ov id es co m pa ra tiv e hi st or ic al co nt ex ts of th e le ga lit ie s an d co ns tit ut io n su rr ou nd in g th e M C P as w el la s ge nd er (e qu al ity ). Th en pr ov id es a ge nd er eq ua lit y an al ys is of th e M C P Im pa ct on :w om en ’s rig ht s- di sc rim in at es ag ai ns t w om en & th ei r he al th pr ov id er s by no t pr ov id in g al li nf or m at io n to m ak e fu lly in fo rm ed ch oi ce s; fa m ily pl an ni ng ;a bo rt io n; fre ed om of ch oi ce - th e G G R di sr es pe ct s ch oi ce an d di gn ity of w om en th ey ca nn ot ch oo se to be ar or no t be ar ch ild re n: th e G G R fa ils on eq ua lit y Le itn er C en te r fo r In te rn at io na l La w an d Ju st ic e / Fo rd ha m La w Sc ho ol (2 01 0) [3 6] :E xp or tin g C on fu si on :U .S .f or ei gn po lic y as an ob st ac le to th e im pl em en ta tio n of Et hi op ia ’s lib er al iz ed ab or tio n la w . N ew Yo rk :F or dh am La w Sc ho ol Re po rt Et hi op ia Q ua lit at iv e in te rv ie w s & an al ys is :w om en , do no rs ,p ro vi de rs , N G O & go ve rn m en t st af f, Ex am in es th e ef fe ct s of U S fo re ig n as si st an ce an d po lic ie s on Et hi op ia ’s at te m pt s to de al w ith un sa fe ab or tio ns ,h ig h m at er na lm or ta lit y an d lib er al ab or tio n la w s Im pa ct on :E th io pi a’ s at te m pt to ad dr es s hi gh ra te s of un sa fe ab or tio n th ro ug h th e lib er al iz at io n of its ab or tio n la w ;G G R ha s ne ga tiv el y af fe ct ed th e av ai la bi lit y of co m pr eh en si ve sa fe ab or tio n se rv ic es fo r Et hi op ia n w om en ; U S ex po rt ed do m es tic de ba te ab ou t ab or tio n to Et hi op ia N ei er ,A .( 19 87 ) [3 7] :T he rig ht to fre e ex pr es si on un de r in te rn at io na l la w :i m pl ic at io ns of th e M ex ic o C ity Po lic y Pe er -r ev ie w n/ a Q ua lit at iv e th em at ic de sc rip tio ns & an al ys is Ex pl or e ho w th e M C P is a vi ol at io n of in te rn at io na l fre ed om s of ex pr es si on , sp ee ch ,a nd op in io n in th e co nt ex t of th e U S ra tif yi ng an d ad op tin g th es e in te rn at io na ld ec la ra tio ns Im pa ct on :t he fre ed om of ex pr es si on an d op in io n- hu m an rig ht s (im pl em en tin g th e G G R m ea ns th e U S is vi ol at in g in te rn at io na lly re co gn iz ed fre ed om of ex pr es si on rig ht s) ;c hi lli ng ef fe ct s N ow el s, L. (2 00 1) [3 8] :I nt er na tio na l fa m ily pl an ni ng :t he “M ex ic o C ity ” po lic y. U pd at ed A pr il 2, 20 01 .C RS Re po rt fo r C on gr es s. Re po rt (g re y) n/ a Q ua lit at iv e th em at ic de sc rip tio ns & an al ys is Re vi ew s th e ex pe rie nc e of th e or ig in al “M ex ic o C ity ” po lic y be tw ee n 19 84 an d ea rly 19 93 : pr ov id es ba ck gr ou nd on th e 19 84 de ci si on (p ol ic y im pl em en ta tio n, le ga l ch al le ng es ,f un di ng re al lo ca tio n, an as se ss m en t of th e im pa ct an d im pl ic at io ns of th e M ex ic o C ity po lic y, an d a su m m ar y ac co un t of co ng re ss io na le ffo rt s to m od ify th e po lic y Im pa ct on :L os s of fu nd in g (IP PF ); co ur t ch al le ng es de la ye d G G R cl au se s be in g at ta ch ed fo r so m e or ga ni za tio ns ;F am ily pl an ni ng A ID (T he U S sa id it w ou ld ke ep th e Fa m ily Pl an ni ng ai d am ou nt s th e sa m e an d re al lo ca te fu nd s th at w ou ld ot he rw is e ha ve go ne to IP PF /L on do n ($ 16 .5 m il) an d U N FP A (1 0m il) in th e 19 85 ve rs io n im pl em en ta tio n, to or ga ni za tio ns th at ce rt ify fo r th e G G R) .; La ck of cl ar ity & co nf us io n. PA I( 20 05 ) [3 8, 39 ]: A cc es s D en ie d – Th e Im pa ct of th e G lo ba lG ag Ru le C as e St ud y Re po rt Et hi op ia Q ua lit at iv e in te rv ie w s w ith ke y in fo rm an ts (w om en ,g irl s, he al th pr ov id er s, N G O & go ve rn m en t st af f) & an al ys is D es cr ib es an d an al ys es th e di re ct an d po te nt ia lt hr ea ts of th e G .W .B us h- er a G G R in Et hi op ia Im pa ct on :L os s of fu nd in g, th e G G R ha s re su lte d in th e lo ss of te ch ni ca la ss is ta nc e an d co nt ra ce pt iv e do na tio ns Mavodza et al. Global Health Research and Policy (2019) 4:26 Page 10 of 21 Ta b le 4 Su m m ar y Ta bl e of A rt ic le s In cl ud ed in Re vi ew (C on tin ue d) A ut ho rs /( Ye ar ) (T itl e) pe er re vi ew /g re y lit C ou nt ry /r eg io n fo cu s Ty pe of St ud y an d m et ho ds A pp ro ac h Ke y fin di ng s on th e Im pa ct of th e G G R in Et hi op ia to ke y N G O s in Et hi op ia , w or se ni ng th e co un tr y’ s su pp ly sh or ta ge .C BD pr og ra m s w er e sh ut do w n, co nd om co rn er s w er e cl os ed .M is in fo rm at io n an d in co rr ec t po lic in g of H IV /A ID S pr og ra m s by G G R w er e w id es pr ea d. So m e or ga ni za tio ns co ul d no lo ng er ad vo ca te fo r m or e lib er al ab or tio n la w s in Et hi op ia PA I( 20 05 ) [3 8, 39 ]: A cc es s D en ie d – Th e Im pa ct of th e G lo ba lG ag Ru le in G ha na C as e St ud y Re po rt G ha na Q ua lit at iv e in te rv ie w s w ith ke y in fo rm an ts (w om en ,g irl s, he al th pr ov id er s, N G O & go ve rn m en t st af f) & an al ys is D es cr ib es an d an al ys es th e di re ct an d po te nt ia lt hr ea ts of th e G .W .B us h- er a G G R in G ha na Im pa ct on :l os s of fu nd in g; di sr up te d ke y re pr od uc tiv e he al th pr og ra m s; cu t ba ck es se nt ia lr ur al ou tr ea ch ac tiv iti es an d cl in ic se rv ic es ; di sm an tle d pa rt ne rs hi ps be tw ee n re pr od uc tiv e he al th or ga ni za tio ns an d H IV /A ID S ac tiv iti es . PA I( 20 05 ) [3 8, 39 ]: A cc es s D en ie d – Th e Im pa ct of th e G lo ba lG ag Ru le in Ke ny a C as e St ud y Re po rt Ke ny a Q ua lit at iv e in te rv ie w s w ith ke y in fo rm an ts (w om en , gi rls ,h ea lth pr ov id er s, N G O & go ve rn m en t st af f) & an al ys is D es cr ib es an d an al ys es th e di re ct an d po te nt ia lt hr ea ts of th e G .W .B us h- er a G G R in Ke ny a Im pa ct on :l os s of fu nd in g- Re pr od uc tiv e H ea lth (R H ) ca re de te rio ra te d, fe rt ili ty in cr ea se d, co nt ra ce pt iv e up ta ke st ag na te d, m ed ic al ly as si st ed bi rt h ra te pl um m et ed . Th e G G R ex ac er ba te s an al re ad y w or se re pr od uc tiv e he al th si tu at io n; cl in ic s cl os ed do w n; st af f la id of f; sp lin te re d in te gr at ed se rv ic es PA I( 20 05 ) [3 8, 39 ]: A cc es s D en ie d – Th e Im pa ct of th e G lo ba lG ag Ru le in N ep al C as e St ud y Re po rt N ep al Q ua lit at iv e in te rv ie w s w ith ke y in fo rm an ts (w om en , gi rls ,h ea lth pr ov id er s, N G O & go ve rn m en t st af f) & an al ys is D es cr ib es an d an al ys es th e di re ct an d po te nt ia lt hr ea ts of th e G .W .B us h- er a G G R in N ep al Im pa ct on :l os s of fu nd in g; In no va tiv e RH pr og ra m s ha ve be en te rm in at ed ;F re e sp ee ch , ex pr es si on an d op in io n fo r th e de m oc ra tic lib er al iz at io n of ab or tio n la w s cu rt ai le d; G ov er nm en t’s so ve re ig nt y in fri ng ed up on PA I( 20 05 ) [3 8, 39 ]: A cc es s D en ie d – Th e Im pa ct of th e G lo ba lG ag Ru le in Ta nz an ia C as e St ud y Re po rt Ta nz an ia Q ua lit at iv e in te rv ie w s w ith ke y in fo rm an ts (w om en ,g irl s, he al th pr ov id er s, N G O & go ve rn m en t st af f) & an al ys is D es cr ib es an d an al ys es th e di re ct an d po te nt ia l th re at s of th e G .W .B us h- er a G G R in Ta nz an ia Im pa ct on :L os s of fu nd in g - tw o m aj or FP or ga ni za tio ns in Ta nz an ia w ith dr ew cr iti ca l te ch ni ca ls up po rt fo r th e go ve rn m en t’s FP pr og ra m s; w or se ni ng co nt ra ce pt iv e su pp ly pr ob le m s; ru ra lc lin ic s w er e cl os ed ;K ey st af f w er e lo st /f ire d PA I( 20 05 ) [3 8, 39 ]: A cc es s D en ie d – Th e Im pa ct of th e G lo ba lG ag Ru le in Za m bi a C as e St ud y Re po rt Za m bi a Q ua lit at iv e in te rv ie w s w ith ke y in fo rm an ts (w om en ,g irl s, he al th pr ov id er s, N G O & go ve rn m en t st af f) & an al ys is D es cr ib es an d an al ys es th e di re ct an d po te nt ia l th re at s of th e G .W .B us h- er a G G R in Za m bi a Im pa ct on :a lre ad y st ru gg lin g FP an d RH pr ov is io n is ex ac er ba te d; st af f la id of f an d re du ce d se rv ic es ;H IV pr ev en tio n ef fo rt s de pr io rit iz ed w hi ch in hi bi ts of H IV /A ID S + FP in te gr at io n ef fo rt s. PA I( 20 05 ) [3 8, 39 ]: A cc es s D en ie d – C as e St ud y Re po rt Zi m ba bw e Q ua lit at iv e in te rv ie w s w ith ke y in fo rm an ts D es cr ib es an d an al ys es th e di re ct an d po te nt ia l Im pa ct on :l os s of fu nd in g; re st ric te d cr iti ca lp ar tn er sh ip s Mavodza et al. Global Health Research and Policy (2019) 4:26 Page 11 of 21 Ta b le 4 Su m m ar y Ta bl e of A rt ic le s In cl ud ed in Re vi ew (C on tin ue d) A ut ho rs /( Ye ar ) (T itl e) pe er re vi ew /g re y lit C ou nt ry /r eg io n fo cu s Ty pe of St ud y an d m et ho ds A pp ro ac h Ke y fin di ng s on th e Im pa ct of th e G G R Th e Im pa ct of th e G lo ba lG ag Ru le in Zi m ba bw e (w om en ,g irl s, he al th pr ov id er s, N G O & go ve rn m en t st af f) & an al ys is th re at s of th e G .W .B us h- er a G G R in Zi m ba bw e ad dr es si ng bo th FP an d H IV /A ID s; re du ce d fa m ily pl an ni ng fu nd s; (B ro ok e- A le xa nd er A m en dm en t + G G R) ;s ca le d ba ck fa m ily pl an ni ng pr og ra m s w ith st af f la yo ffs PA I( 20 17 ) [9 ,1 0, 40 ]: Th e G lo ba lG ag Ru le & M at er na lD ea th s D ue to U ns af e A bo rt io n Re po rt Va rio us co un tr ie s as ex am pl es Q ua lit at iv e na rr at iv e an al ys is D es cr ib es an d an al ys es th e di re ct an d po te nt ia l th re at s of th e Tr um p- er a ex pa nd ed G G R on un sa fe ab or tio ns an d m at er na lm or ta lit y Im pa ct on :a dv oc ac y to re du ce in ju rie s an d m at er na ld ea th s ca us ed by un sa fe ab or tio ns in co un tr ie s re ce iv in g U .S . ai d; si le nc es fre e sp ee ch an d na tio na ls ov er ei gn ty , an d di sc ou ra ge s de m oc ra tic de ba te on ab or tio n la w re fo rm in Ke ny a, Et hi op ia ,M oz am bi qu e, U ga nd a, N ig er ia ;h in de rs th e ef fo rt s of go ve rn m en ts an d N G O s in se ek in g in te rn at io na l as si st an ce to im pl em en t ne w , lib er al iz ed ab or tio n la w s. Th e G G R co nt ra di ct s in te rn at io na la gr ee m en ts . PA I( 20 17 ) [9 ,1 0, 40 ]: Th e G lo ba lG ag Ru le & C on tr ac ep tiv e Su pp lie s Re po rt co m m en ta ry n/ a Q ua lit at iv e na rr at iv e an al ys is D es cr ib es an d an al ys es th e di re ct an d po te nt ia lt hr ea ts of th e Tr um p- er a ex pa nd ed G G R on co nt ra ce pt iv e su pp lie s Im pa ct s on :O rg an iz at io ns th at do n’ t si gn th e G G R al so lo se ac ce ss to U .S .-d on at ed co nt ra ce pt iv es ,i nc lu di ng co nd om s, w hi ch en ab le w om en an d m en to pr ev en t un in te nd ed pr eg na nc y, pr ot ec t th em se lv es fro m H IV /A ID S, an d av oi d un sa fe ab or tio n (a le ad in g ca us e of m at er na l in ju ry ,i lln es s, an d de at h in th e de ve lo pi ng w or ld ). PA I( 20 17 ) [9 ,1 0, 40 ]: Tr um p’ s G lo ba lG ag Ru le an d Et hi op ia Re po rt Et hi op ia Q ua lit at iv e de sc rip tio ns su m m ar y (fr om fa ct -fi nd in g) & an al ys is D es cr ib es an d an al ys es th e di re ct an d po te nt ia lt hr ea ts of th e Tr um p- er a ex pa nd ed G G R Im pa ct on :l os s of fu nd in g; co nt ra ce pt iv e su pp ly di st rib ut io n fo r tw o la rg es t in -c ou nt ry co nt ra ce pt iv e se rv ic e de liv er y or ga ni za tio ns (F am ily G ui da nc e A ss oc ia tio n of Et hi op ia an d M ar ie St op es In te rn at io na lE th io pi a) - co ul d in cr ea se Et hi op ia ’s un m et ne ed ,w hi ch cu rr en tly st an ds at 22 .3 % ;P ro gr es s on im pr ov in g m at er na lm or ta lit y is lik el y to st al l; m is co m m un ic at io n ar ou nd th e G G R co ul d im pa ct th e im pl em en ta tio n of lib er al iz ed ab or tio n la w in Et hi op ia .P LG H A m ay sc al e ba ck co nd om di st rib ut io n; de te rio ra te in te gr at ed se rv ic es , in cr ea si ng th e di ffi cu lty of ac ce ss in g co m pr eh en si ve he al th se rv ic es . Th e im pa ct of PL G H A w ill be di sp ro po rt io na te ly fe lt by yo un g, ru ra l, an d po or w om en an d gi rls . Mavodza et al. Global Health Research and Policy (2019) 4:26 Page 12 of 21 Ta b le 4 Su m m ar y Ta bl e of A rt ic le s In cl ud ed in Re vi ew (C on tin ue d) A ut ho rs /( Ye ar ) (T itl e) pe er re vi ew /g re y lit C ou nt ry /r eg io n fo cu s Ty pe of St ud y an d m et ho ds A pp ro ac h Ke y fin di ng s on th e Im pa ct of th e G G R PA I( 20 17 ) [9 ,1 0, 40 ]: Tr um p’ s G lo ba lG ag Ru le an d Se ne ga l Re po rt Se ne ga l Q ua lit at iv e de sc rip tio ns su m m ar y (fr om fa ct -fi nd in g) & an al ys is D es cr ib es an d an al ys es th e di re ct an d po te nt ia l th re at s of th e Tr um p- er a ex pa nd ed G G R in Se ne ga l Im pa ct on :r is k of lo si ng fu nd in g; th re at en in g in cr ea se th e al re ad y hi gh 25 % un m et co nt ra ce pt iv e ne ed in th e co un tr y; G G R pl ac es cl os e to $8 .5 m il of SR H R fu nd s at ris k in Se ne ga l( ei th er pr og ra m s w ill be de la ye d, to ne d do w n or cl os ed ). A bo rt io n la w s in Se ne ga l ar e re st ric tiv e & G G R m ay in cr ea se th e 63 % un sa fe ab or tio ns ;i nc re as e co nf us io n + fe ar su rr ou nd in g im pl em en ta tio n re st ric tio ns & co nd iti on s Se ev er s, R. E. (2 00 5) [4 1] : Th e Po lit ic s of G ag gi ng : Th e Ef fe ct s of th e G lo ba l G ag Ru le on D em oc ra tic Pa rt ic ip at io n an d Po lit ic al A dv oc ac y in Pe ru . Pe er re vi ew Pe ru Q ua lit at iv e na rr at iv es & an al ys is Ex am in e th e da m ag in g ef fe ct s of th e G lo ba lG ag Ru le on ci vi l pa rt ic ip at io n an d po lit ic al ad vo ca cy by N G O s fo cu si ng on re pr od uc tiv e rig ht s in Pe ru an d th e ov er al le ffe ct th is m ay ha ve on th e co un tr y’ s em er gi ng co nc ep tio n of de m oc ra cy Im pa ct on :d is ru pt ed de m oc ra cy an d ad vo ca cy pr oc es se s in Pe ru . Pe ru ’s pr io rit ie s in cl ud ed ac tiv e ci vi ls oc ie ty an d N G O s en ga ge m en t. Th e sa m e N G O s th at w er e be in g en ga ge d fo r de m oc ra cy & go ve rn an ce w er e al so be in g ga gg ed by th e G G R- fre e sp ee ch ,o pi ni on an d ex pr es si on w er e he av ily re gu la te d Sk us te r, P. (2 00 4) [4 2] : A dv oc ac y in w hi sp er s: th e im pa ct of th e U SA ID G lo ba lG ag Ru le up on fre e sp ee ch an d fre e as so ci at io n in th e co nt ex t of ab or tio n la w re fo rm in th re e Ea st A fri ca n co un tr ie s Pe er re vi ew U ga nd a, Et hi op ia ,K en ya Q ua lit at iv e in te rv ie w s w ith ke y in fo rm an ts (N G O s, G ov er nm en t O ffi ci al s) in Ke ny a, U ga nd a & Et hi op ia & Th em at ic an al ys is To st ud y th e ef fe ct of th e G G R up on th e fre e sp ee ch an d fre e as so ci at io n of ad vo ca te s of ac ce ss to sa fe ab or tio n Im pa ct on :c oa lit io ns an d pa rt ne rs hi ps th at ha ve po lit ic al au th or ity an d po w er ;a dv oc ac y- th e G G R cu rt ai ls th e ab ili ty of th e re pr od uc tiv e he al th co m m un ity to br in g in fo rm at io n on th e ef fe ct of th e re st ric tiv e la w to la w m ak er s; ch ill in g ef fe ct & si le nc in g; pr om ot ed an ti- ch oi ce na rr at iv es ; sp lin te rs co al iti on s/ pa rt ne rs hi ps Sn eh a Ba ro t & Su sa n A .C oh en / G ut tm ac he r (2 01 5) [4 3] :T he G lo ba lG ag Ru le an d Fi gh ts ov er Fu nd in g U N FP A :T he Is su es Th at W on ’t G o A w ay Re po rt Le so th o an d M ad ag as ca r Q ua lit at iv e an al ys is sy nt he si zi ng G G R ef fe ct s D es cr ip tiv e sy nt he si s of G G R- re la te d lo ss of fu nd in g an d its im pa ct s on fa m ily pl an ni ng as w el la s an al ys is of U N FP A fu nd in g cu ts . Im pa ct on :l eg al ch al le ng es (C lin to n ad m in is tr at io n) ;a bo rt io n, co nt ra ce pt iv e su pp lie s; fa m ily pl an ni ng pr og ra m s, lo ss of fu nd in g, ch ill in g ef fe ct of th e G G R co nt in ue s ev en in no n- po lic y ye ar s Sn eh a Ba ro t/ G ut tm ac he r (2 01 7) [4 4] :W he n A nt ia bo rt io n Id eo lo gy Tu rn s in to Fo re ig n Po lic y: H ow th e G lo ba lG ag Ru le Er od es H ea lth ,E th ic s, an d D em oc ra cy Re po rt n/ a Q ua lit at iv e an al ys is sy nt he si zi ng G G R ef fe ct s on he al th , et hi cs ,a nd de m oc ra cy de sc rip tiv e sy nt he si s of G G R- re la te d im pa ct on lo ss of fu nd in g, he al th ,e th ic s, an d de m oc ra cy Im pa ct on :A bo rt io n, ad vo ca cy fo r lib er al ab or tio n la w s, gl ob al he al th as si st an ce ,H IV /A ID S & ST Is , hu m an rig ht s, di se as es (im m un iz at io n) : co nf us io n & la ck of cl ar ity ;d is ru pt ed he al th pr og ra m s; di si nt eg ra te d he al th pr og ra m s; fra ct ur ed pa rt ne rs hi ps be tw ee n U S N G O an d th ei r lo ca lp ar tn er s, an d co al iti on sp ac es ;h in de re d fre e sp ee ch ,e xp re ss io n, an d op in io n Su sa n A .C oh en / G ut tm ac he r (2 00 9) [4 5] : T he Re pr od uc tiv e H ea lth N ee ds of Re fu ge es an d D is pl ac ed Pe op le :A n O pe ni ng Re po rt n/ a Q ua lit at iv e de sc rip tio n an d an al ys is D es cr ib es th e ef fe ct of U S fo re ig n po lic y in cl ud in g G G R on th e re pr od uc tiv e ne ed s of re fu ge es an d Im pa ct s on :c oa lit io n sp ac es (t er m in at ed th e RH RC co ns or tiu m ) Mavodza et al. Global Health Research and Policy (2019) 4:26 Page 13 of 21 Ta b le 4 Su m m ar y Ta bl e of A rt ic le s In cl ud ed in Re vi ew (C on tin ue d) A ut ho rs /( Ye ar ) (T itl e) pe er re vi ew /g re y lit C ou nt ry /r eg io n fo cu s Ty pe of St ud y an d m et ho ds A pp ro ac h Ke y fin di ng s on th e Im pa ct of th e G G R fo r Re ne w ed U .S .L ea de rs hi p di sp la ce d po pu la tio ns Su sa n A .C oh en / G ut tm ac he r (2 01 1) [4 6] :U .S .O ve rs ea s Fa m ily Pl an ni ng Pr og ra m ,P er en ni al Vi ct im of A bo rt io n Po lit ic s, Is O nc e A ga in U nd er Si eg e Re po rt n/ a Q ua lit at iv e de sc rip tio n an d an al ys is Ex am in es es ta bl is he d im pa ct s of th e G G R re ca p/ ci ta tio ns & an al ys is Im pa ct s of th e G G R: it do es no t re du ce ab or tio ns ;e ffe ct iv e fa m ily pl an ni ng pr og ra m s cl os ed do w n, co nt ra ce pt iv e su pp ly di st rib ut io n is di sr up te d; si le nc in g of ad vo ca cy ar ou nd un sa fe ab or tio ns va n D al en ,H .P .( 20 08 ) [4 7] : D es ig ni ng G lo ba lC ol le ct iv e A ct io n in Po pu la tio n an d H IV /A ID S Pr og ra m s, 19 83 –2 00 2: H as A ny th in g C ha ng ed ? Pe er re vi ew n/ a Q ua nt ita tiv e an al ys is :P an el da ta on ex pe nd itu re s of O EC D do no rs fo r th re e ty pe s of ai d ag en ci es (m ul til at er al ,N G O s, an d bi la te ra la id ) fo r th e ye ar s 19 83 –2 00 2 Ex pl or e w hi ch fo rc es m ig ht be re le va nt in ex pl ai ni ng th e pr ov is io n of fo re ig n ai d th ro ug h th e se t of ai d ch an ne ls to w ar d fa m ily pl an ni ng an d H IV /A ID S pr og ra m s Im pa ct on ot he r do no r fu nd in g: th e G G R im pl em en ta tio n ye ar s ha d no vi si bl e ag gr eg at e ef fe ct on ot he r do no rs ’l ev el s of fu nd in g Ya na va n de r M eu le n Ro dg er s/ Ru tg er s U ni ve rs ity (2 01 8) [4 8] :I m pa ct of th e G ag :N ew Es tim at es Bo ok C ha pt er La tin A m er ic a an d th e C ar ib be an , Ea st er n Eu ro pe an d th e M id dl e Ea st ,S ou th an d So ut he as t A si a, an d Su b- Sa ha ra n A fri ca (u np ub lis he d w or k) Q ua nt ita tiv e an al ys is - re gr es si on an al ys is us in g D H S da ta D et er m in e th e re la tio ns hi p be tw ee n th e re in st at em en t of G .W .B us h G G R in du ce d ab or tio n ra te fo r w om en in 4 gl ob al re gi on s Im pa ct on in du ce d ab or tio n ra te s: W om en in La tin A m er ic a an d th e C ar ib be an ,h ig hl y ex po se d to th e G G R, ha d m or e th an 3 tim es th e od ds of ha vi ng an ab or tio n, co m pa re d to w om en in le ss ex po se d co un tr ie s & be fo re po lic y re in st at em en t. In SS A ,W om en hi gh ly ex po se d to th e G G R ha d ab ou t 2 tim es th e od ds of ha vi ng an ab or tio n, co m pa re d to w om en in le ss ex po se d co un tr ie s & be fo re po lic y re in st at em en t. In Ea st er n Eu ro pe an d th e M id dl e Ea st ,a nd in So ut h an d So ut he as t A si a, th e od ds of ha vi ng an ab or tio n de cl in ed in hi gh ly ex po se d co un tr ie s af te r re in st at em en t, co m pa re d to lo w ex po se d co un tr ie s. Th e re la tio ns hi p be tw ee n st ric t ab or tio n la w s & w om en ’s lik el ih oo d of ha vi ng an ab or tio n ne ed s fu rt he r re se ar ch . Mavodza et al. Global Health Research and Policy (2019) 4:26 Page 14 of 21 are prime partners who have not complied with any iter- ation of the GGR, resulting in the recurrent loss of U.S. funding [25]. During the Reagan GGR, IPPF/London’s abortion-related work accounted for approximately US$400,000 annually, though the organization’s rejection of the GGR caused them to lose about US$11 million [26, 38]. During the G.W. Bush GGR, IPPF lost about $18 million in U.S. aid annually and consequently had to cut funding to its affiliates, who are sub-grantees. The sub-grantee Family Planning Association of Kenya (FPAK) lost 58% of its budget, and Planned Parenthood Association of Ghana (PPAG) lost 54% [34], or US$200, 000 of funding [39]. Family Planning Association of Nepal (FPAN) lost US$100,000 in direct funding and US$400,000 worth of contraceptive supplies [20], and Family Guidance Association in Ethiopia (FGAE) lost close to half a million U.S. dollars [33, 51]. Organizations that lost funding had to restructure by reducing salaries and laying off staff members [20, 43]. Under the Reagan and G.H.W Bush GGR from 1984 to 1993, the U. S government committed to maintaining its level of family planning aid by reallocating the funds de- nied to non-compliant organizations to those in compli- ance with the policy [38]. Documentation of this reallocation remains inaccessible despite a 1991 congres- sional hearing during which USAID reported that repro- gramming notifications would be made publicly available [26, 38]. Under the G.W. Bush GGR, USAID did not pro- vide information on how the policy was implemented [25]. One study reveals that during the G.W. Bush policy years, there was a GGR-associated three to 6 % reduction in U.S. international family planning aid [18]. The most adverse impact on funding was experienced in sub-Sa- haran African countries [50]. The chilling effect The “chilling effect” of the GGR refers to when organiza- tions or health care providers restrict their activities be- yond what is required by the policy in order to protect themselves from being accused of non-compliance. In various documented cases, in order to be cautious, pro- viders failed to deliver health services permissible under the policy [23, 41]. In Bangladesh and Turkey, some pro- viders also stopped sharing information on menstrual regulation, and frustrated long-term clients stopped seeking other family planning services that could have benefitted them [19]. Health providers in Egypt ceased all discussions about sepsis after an unsafe abortion, even when this was a major public health concern [19]. An organization in Zambia removed emergency contraception content from its contraception brochure [25]. Some compliant organi- zations intentionally avoided working with, or requesting proposals from, partners who were not, or likely would reject, complying with the GGR [19, 21]. Others feared even being associated with abortion services, such as a USAID-funded family planning organization in Asia that refused to sell sterilization equipment to a legal abortion clinic, despite the fact that this would not have violated policy requirements [21]. Impact on advocacy and coalition spaces In many countries, the GGR hindered efforts to liberalize and implement abortion laws. During the G.W. Bush ad- ministration, the same organizations effectively imple- menting U.S.-funded reproductive health projects in Nepal [7, 43] and Peru [41] had been at the forefront of liberalization advocacy. Organizations in Ethiopia, Kenya, Mozambique, Nigeria, and Uganda had initiatives attempting to reform restrictive abortion laws, and re- ceived significant U.S. family planning assistance [40]. As a condition of keeping their funding for crucial programs and service provision, the aforementioned organizations were excluded from abortion reform conversations. The GGR also muted the voices of advocates for liberal abor- tion laws in Kenya and Ethiopia, while anti-choice groups had no such silencing [29, 42]. In Peru, the GGR amplified anti-choice groups’ narra- tive against emergency contraception, which resulted in USAID/Peru excusing itself from providing emergency contraception in the country [23]. In Uganda, on the dir- ective of the Catholic cardinal, the government banned emergency contraception across the nation [42]. The GGR also undermined collective advocacy and clinical work during both the Reagan [19] and G.W. Bush [23, 25, 42, 45] policy years as coalitions were often made up of both GGR-compliant and non-compliant or- ganizations. During the Reagan GGR, organizations in Bangladesh that supported menstrual regulation had to fracture their relationships with organizations that did not, which effectively hindered collaborative efforts to promote family planning [19]. Fifteen organizations in Bolivia had banded together to lobby the government on the high national unsafe abortion rate and under G.W. Bush, four of them had to resign due to GGR-related budget threats [33]. The U.S. was the primary donor for the Reproductive Health Response Conflict (RHRC) Consortium, a network of organizations including MSI, which addressed reproductive health for refugees and displaced populations. In 2003, after the GGR was ex- tended to funding from the Department of State, the U.S. ceased RHRC financing [45]. The GGR presented the false choice of continuing to receive funding for programs and services or continuing advocacy work, skewed the debate on abortion and emergency contraception, and fractured partnerships and their collective power to influence change [45]. Mavodza et al. Global Health Research and Policy (2019) 4:26 Page 15 of 21 Impact on HIV and AIDS The GGR dismantled efforts to provide comprehensive HIV and AIDS prevention, testing, and treatment. In the early years of the G.W. Bush policy era, confusion about policy restrictions led various organizations to cease their HIV and AIDS work in Ethiopia, including the provision of services that were not subject to the GGR [51]. Later during this policy era, the President’s Emer- gency Plan for AIDS Relief (PEPFAR) was conceived and exempt from the GGR. Despite this modification, the current expanded GGR does impact PEPFAR funding. The GGR undermined HIV service provision by orga- nizations that had integrated family planning and HIV and AIDS efforts [25, 26, 29, 44]. Under G.W. Bush, the GGR affected family planning services like condom edu- cation, supply, and distribution, all of which were crucial for HIV prevention [51–53]. After GGR-related funding loss, FPAK and MSI-Kenya curtailed their voluntary counseling and testing (VCT) and HIV prevention ser- vices [20]. Due to the GGR, organizations in Uganda were forced to separate abortion from HIV and AIDS services, creat- ing vulnerability for women living with HIV who had unwanted pregnancies [29]. The GGR forced organiza- tions supplying comprehensive, integrated services to choose between silos of either family planning or HIV and AIDS service provision [29]. Impact on abortion Three studies have quantified the association between the G.W. Bush-era GGR and induced abortion rates [4, 5, 48]. Bendavid et al. (2011) examined the association between 20 sub-Saharan African countries’ exposure to the GGR and induced abortion in women of reproduct- ive age, between 1994 and 2008. Countries that received U.S. financial assistance above a calculated median level were considered to have high GGR exposure. Women in these countries had two and a half times the likelihood of having an induced abortion, compared to women in low-GGR-exposed countries [5]. In a second publication, Jones (2011) evaluated the im- pact of the policy on induced abortion rates and child health outcomes in Ghana by comparing two periods during which the GGR was in effect (under Reagan and G.W. Bush) to two in which it was not [4]. When the GGR was in effect, abortion rates did not decrease for any demographic, and women living in rural areas had one and a half times the odds of having an induced abortion, compared to women living in urban areas. A third study implemented the methodology from Bendavid et al. on a global analysis of the association be- tween exposure to the GGR and induced abortion rates [48]. Women in high-exposed Latin American and Caribbean countries had three times the odds of having an induced abortion, compared to women in low-ex- posed countries. In sub-Saharan Africa, the projections were similar to those found in the Bendavid et al study, with women in high-exposed countries having two times the odds of undergoing an induced abortion, compared to women in low-exposed countries [48]. Together, the available quantitative evidence reveals that GGR imple- mentation was associated with increases in abortion rates, which may be attributable to GGR-based reduc- tions in family planning aid [5] and subsequent reduc- tions in family planning services. Impact on contraception and family planning GGR-related funding losses led to reductions in, or en- tire shutdowns of, family planning activities and out- reach programs. Under the G.W. Bush administration, USAID reduced or stopped contraceptive supplies to 16 countries in sub-Saharan Africa, Asia, and the Middle East [43]. The Lesotho Planned Parenthood Association (LPPA), the only distributor of condoms in the country, did not receive U.S. condom supplies for almost eight years [43]. “Condom corners” that supplied free con- doms to rural communities in Ethiopia, Ghana, and Kenya closed down, resulting in contraceptive supply shortages [6, 39, 40]. MSI decreased services and closed clinics in Kenya [6, 20, 33], Tanzania [52], Uganda [33], and Zimbabwe [53]. IPPF closed down clinics in the Democratic Republic of the Congo, Ethiopia, Ghana, Kenya, Zambia, and Zimbabwe [6, 8, 20, 39, 51, 53]. Planned Parenthood Association of Ghana closed 57% of their clinics, and rural areas in Ghana experienced a 45% drop in community-based distribution of contraceptive supplies [34]. Some health facilities offering a range of integrated services, including family planning, were the only providers of primary health care, so their closure dissolved communities’ only contact with the health sys- tem [50]. From 2001 through 2008, the family planning funding that IPPF lost could have prevented 36 million unin- tended pregnancies and 15 million induced abortions [43]. Dismantling family planning programs triggers the decrease in contraceptive supplies [34] and modern contraceptive use [5], and an associated increase in unin- tended pregnancies [4]. Jones’ study revealed an associ- ation between GGR-related funding loss and an estimated 12 % increase in rural pregnancies and 500, 000 to 750,000 additional unintended births, which may be attributable to the reduction of the community-based distribution of contraceptive supplies [4]. Impact on maternal and child health Jones’ estimations reveal that children born from unin- tended pregnancies related to GGR exposure had poorer health status on height- and weight-for-age indicators Mavodza et al. Global Health Research and Policy (2019) 4:26 Page 16 of 21 when compared to their siblings [4]. Additionally, a mas- ter’s thesis found that under G.W. Bush, GGR exposure in Ghana had negative effects on prenatal care access for both rural and urban populations [24], which could have been linked to the shutdown of facilities run by organi- zations like MSI [39]. Bingenheimer & Skuster (2017) hypothesize that the negative outcomes of the GGR im- plementation, including an increase in unsafe abortions and decrease in health system access, could likewise have negative repercussions on maternal morbidity and mor- tality [11]. Discussion To our knowledge, this is the first comprehensive scop- ing review to track and coalesce the impacts of the GGR from its inception to 2017. This review provides a pre- liminary mapping of the vast impacts of the policy across health systems, which researchers and policymakers can use as the first step in their GGR work. This review also reveals that the GGR is a poorly constructed and imple- mented policy (Table 5). Public policy literature demonstrates the crucial im- portance of preparation and planning when creating [54] and implementing policies [55, 56]. Decision- making on the content of the GGR neglected to con- sider all the actors who would be involved with the policy’s implementation, as evidenced by the resulting miscommunication and misunderstanding on compli- ance requirements. Studies have shown that when critical stakeholders are excluded from agenda-setting and/or the policy formulation process [57], desired policy outcomes may fail to emerge [58, 59]. In the scoped literature, there is no evidence to suggest that organizations to whom the policy applies were present when crafting the Standard Provisions, and a plethora of evidence reveals that the policy does not have its stated intended outcome of reducing rates of abortion and saving lives. GGR decision-makers have not given adequate at- tention to the contextual understanding necessary for implementing the health system changes mandated by the policy [60], which may partially explain the mis- communication between U.S. prime partners and their sub-grantees (Table 6). Prime partners operating at the macro-level of the health system may understand what policy compliance entails because they have dir- ect communication with the U.S. government. Sub- grantees at the meso level of the health system are implementing GGR-constrained services without hav- ing direct contact with the U.S. government and may be less informed about the GGR. The health care providers operating at the micro-level of the health system have to make decisions informed by the GGR, and yet they are so far removed from policy compli- ance standards. When the multiple and interacting levels of the health system must confront the GGR, there is ample opportunity for miscommunication, confusion, and chilling effects. For example, in a country like South Africa, in which abortion is per- mitted upon request [61], imposing the GGR gener- ates confusion and fear as providers negotiate between local law and GGR compliance. The recent expanded GGR worsens the confusion sur- rounding this policy as it also applies to non-family plan- ning global health stakeholders. In 2003, President G.W. Bush authorized PEPFAR to spend up to US$15 billion over five years to address HIV and AIDS, tuberculosis (TB), and malaria [62]. In its first four years, PEPFAR re- duced AIDS-related deaths by about 10.5% [63] and has supported the provision of antiretroviral therapy (ART) for about 14.6 million people since its inception [64, 65]. When G.W. Bush issued a presidential memorandum to reinstate the GGR, it specified that the policy would not apply to PEPFAR funding. In 2017, President Trump is- sued a presidential memorandum to reinstate and expand the GGR, which no longer excludes funding through PEP- FAR, threatening almost one and a half decades of pro- gress combating HIV and AIDS. Newly published research indicates that the GGR is already harming PEP- FAR efforts [16, 66]. Potential financial impacts of the GGR on programs like PEPFAR that include education and prevention of HIV and AIDS may mean that more re- sources will be needed for treatment. Table 5 Prime Partners and Sub-grantees A “prime partner” is an organization that receives U.S. funding directly from the U.S. government. Both U.S.-based NGOs and foreign NGOs can be prime partners. All U.S. funding and policy requirements are passed down from prime partners to their sub-grantees. A “sub-grantee,” “sub-recipient,” or “sub-prime” is an organization that receives U.S. funding from a prime partner, rather than directly from the U.S. government. Sub-grantees are one step removed from a direct relationship with the U.S. government, and communications about their funding are filtered through the prime partner. Table 6 The GGR- a poorly constructed and implemented policy • There is no available documentation of all the actors involved in crafting the GGR. • Preparation and planning for the implementation of the GGR are generally poor. • Confusion about the GGR presents differently for stakeholders at the micro, meso, and macro levels of the health system. • Implementation of the GGR takes a top-down approach with no bottom-up input. • Since its inception, the GGR has had harmful impacts on more than just family planning, including miscommunication and misunderstanding of policy mandates; segregation of integrated systems; loss of funding and staff; gaged advocacy; disrupted health delivery systems; and reduced health service provision. Mavodza et al. Global Health Research and Policy (2019) 4:26 Page 17 of 21 Appendix Table 7 Search Terms & Key Words per Focus Area Key Topics MeSH key search words (keywords will be searched TIAB search filter) Search strategy per topic (PubMed) Global Gag Rule none “Global Gag Rule” OR “GGR” OR “Mexico City Policy” OR “Protecting Life in Global Health Assistance” ((Global Gag Rule) OR Mexico City Policy) OR Protecting Life in Global Health Assistance Abortion “Abortion, Induced” OR “Abortion, Septic” OR “Abortion, Criminal” abortion (((abortion) OR “Abortion, Criminal”[Mesh]) OR “Abortion, Septic”[Mesh]) OR “Abortion, Induced”[Mesh] Advocacy “consumer advocacy” Advocacy Advocacy Commodities (male & female condoms; PrEP; Emergency Contraception: PEP) “Condoms” OR “Condoms, Female” OR “Pre-Exposure Prophylaxis” OR “Contraceptives, Postcoital” OR “Post- Exposure Prophylaxis” condoms OR female condoms OR male condoms OR Emergency contraceptives OR EC OR Pre-exposure Prophylaxis OR PrEP OR post-exposure prophylaxis OR PEP (((((“Condoms”[Mesh]) OR “Condoms, Female”[Mesh]) OR “Pre-Exposure Prophylaxis”[Mesh]) OR “Contraceptives, Postcoital”[Mesh]) OR “Post-Exposure Prophylaxis”[Mesh]) OR ((((((((condoms) OR female condoms) OR male condoms) OR pre-exposure prophylaxis) OR PrEP) OR emergency contraceptives) OR EC) OR post-exposure prophylaxis) Family Planning “Family Planning Services” OR “Family Planning Policy” OR “Pregnancy, Unplanned” OR “Pregnancy, Unwanted” OR “Sex Education” “unintended pregnancy” OR “unwanted pregnancy” OR family planning ((((“Family Planning Services”[Mesh]) OR “Family Planning Policy”[Mesh]) OR “Pregnancy, Unplanned”[Mesh]) OR “Pregnancy, Unwanted”[Mesh]) OR (((((unintended pregnancy) OR unwanted pregnancy) OR unplanned pregnancy) OR family planning)) Gender-based Violence Domestic Violence OR Intimate Partner Violence OR Sex Offenses gender-based violence OR domestic violence OR Intimate Partner Violence OR Sex Offenses gender-based violence Global Health Assistance “United States Government Agencies” OR “Federal Government” OR “United States Agency for International Development” OR “Center for Disease Control and Prevention” OR “US Department of Defense” OR “Peace Corps” “US foreign assistance” OR “Global Health Assistance” ((“United States Government Agencies”[Mesh]) OR “Federal Government”[Mesh]) OR “United States Agency for International Development”[Mesh] HIV/AIDS & STIs “HIV” OR “Acquired Immunodeficiency Syndrome” OR “Sexually Transmitted Diseases” sexually transmitted infections OR Sexually transmitted Diseases OR HIV/ AIDS OR HIV OR AIDS OR STD OR STI (((“HIV”[Mesh]) OR “Acquired Immunodeficiency Syndrome”[Mesh]) OR “Sexually Transmitted Diseases”[Mesh]) OR sexually transmitted infections Human Rights “Human Rights” OR “Human Rights Abuses” human rights (((“Human Rights”[Mesh]) OR “Human Rights Abuses”[Mesh])) OR Human rights Infectious Diseases “Communicable Diseases” OR “Tuberculosis” OR “Malaria” OR “Zika Virus” OR “Zika Virus Infection” OR “Hemorrhagic fever, Ebola” Infectious Diseases OR Tuberculosis OR Malaria OR Zika OR Ebola ((((((Infectious Diseases) OR (((tuberculosis) OR malaria) OR zika)) OR “Zika Virus Infection”[Mesh]) OR “Zika Virus”[Mesh]) OR “Malaria”[Mesh]) OR “Tuberculosis”[Mesh]) OR “Communicable Diseases”[Mesh] Key Populations “Sexual Minorities” OR “Sex Workers” OR “Adolescent” OR “Substance Abuse, Intravenous” OR “Prisoners” Lesbian’ OR ‘Gay’ OR ‘Bisexual’ OR ‘Transexual’ OR ‘Transgender’ OR ‘Queer’ OR ‘Intersexual’ OR ‘LGBTQI’ OR ‘Men who have Sex with Men’ OR ‘MSM’ OR ‘Sex Workers’ OR ‘HIV key populations’ OR ‘adolescent girls’ OR’ young women’ OR ‘AGYW’ OR ‘people who inject drugs’ OR PWID OR Prisoners (((((HIV Key Populations) OR “Sexual Minorities”[Mesh]) OR lesbian) OR “Sex Workers”[Mesh]) OR “Adolescent”[Mesh]) OR (((((((((((((((gay) OR bisexual) OR transexual) OR Queer) OR Intersexual) OR LGBTQI) OR Men who have sex with Men) OR MSM) OR Sex Workers) OR HIV key populations) OR Adolescent Girls) OR Young Women) OR AGYW) OR People who inject drugs) OR PWID) Maternal and Child Health “Maternal-Child Health Centers” OR “Maternal-Child Health Services” OR “Maternal Health Services” OR Maternal Health Maternal and Newborn Child Health’ OR ‘Maternal and Child Health’ (((“Maternal-Child Health Centers”[Mesh]) OR “Maternal-Child Health Services”[Mesh]) OR (maternal and newborn child health)) OR ((maternal Mavodza et al. Global Health Research and Policy (2019) 4:26 Page 18 of 21 Although the quantitative studies investigating the as- sociation between the GGR and abortion rates debunk the claim that the GGR reduces abortion incidence [4, 51], empirical evidence has been disregarded in the pol- icy-making. The evidence on the GGR has consistently revealed how the policy is rupturing effective integrated services [28] and in some instances, leaving entire com- munities without clinic access [36, 41]. This scoping re- view has provided evidence that the GGR is dismantling health systems by causing confusion about its practical implementation; unraveling integrated systems; dimin- ishing qualified staff and crucial resources; silencing ne- cessary advocacy voices and spaces; and reducing health service provision – including but not limited to family planning services – as well as health outcomes indica- tors. Policymakers can use the findings in this review to create policies based on evidence in order to effectively achieve their intended outcomes. Avenues for future research Knowledge of the conditions underpinning policy com- pliance or non-compliance is a small fraction of compre- hending the GGR. More research and policy analysis are needed to understand the organizational processes and the health systems to which the GGR gets applied to ul- timately explain why desired policy outcomes failed to emerge or why the unintended and harmful impacts of the GGR occurred. This evidence would be invaluable for GGR policy reform. In order to mitigate policy harm, more empirical re- search is needed to understand the confusion surround- ing the GGR at the individual, community, and national or global levels of the health system. More research is also needed to track and explore changes in domestic policies as a response to or consequence of the GGR. Limitations The search strategy included only articles published in English. This strategy poses a potential limitation if rele- vant works in other languages were removed. The ma- jority of the literature in this review is grey and has limited discussion and presentation of the methodology. Given the methodological constraints, the results of this scoping review should be cautiously interpreted. For ex- ample, few of the studies [4, 8, 51] used population data to explore the association between the GGR and abor- tion rates. There is a scarcity of abortion data, especially in countries in which it is criminalized and reporting systems may not exist [67]. Conclusion The evidence shows that even before recent expansion and reinstatement of the GGR, the previous iterations of the policy deteriorated health system functions beyond family planning programs. At the micro-level, provider- client interactions were affected as health care providers could not share the full range of reproductive informa- tion and options. At the meso-level, civil society was si- lenced from abortion advocacy. At the macro-level, coalition spaces dissolved and entire organizations lost funding, which had crippling effects for beneficiaries of health services, organizational functions, and health sys- tems as a whole. The policy’s development and implementation pro- cesses are flawed, and the consequences of these flaws Table 7 Search Terms & Key Words per Focus Area (Continued) Key Topics MeSH key search words (keywords will be searched TIAB search filter) Search strategy per topic (PubMed) and child health)) Maternal Mortality & Morbidity “Maternal Mortality” OR “Maternal Death” Maternal mortality’ OR maternal morbidity ((“Maternal Mortality”[Mesh]) OR maternal mortality) OR maternal morbidity Non-Communicable Diseases “Cholera” OR “Uterine Cervical Neoplasms” Cholera’ OR ‘Cervical Cancer’ OR non- communicable diseases OR ‘HPV’ [TIAB] ((“Cholera”[Mesh]) OR “Uterine Cervical Neoplasms”[Mesh]) OR (((cervical cancer) OR cholera) OR non-communicable diseases) Orphans & Vulnerable Children “Child, Orphaned” OR “Child, Abandoned” Orphans and vulnerable children [TIAB] orphans and vulnerable children Prevention of Maternal To Child Transmission none PMTCT [TIAB] OR ‘Prevention of Mother to Child Transmission’ (Prevention of Mother to Child Transmission) OR PMTCT Reproductive Health “Reproductive Health” OR “Reproductive Health Services” OR “Reproductive Rights” TIAB- reproductive health OR reproductive health services OR reproductive rights OR sexual and reproductive health and rights OR SRHR (((“Reproductive Health”[Mesh]) OR “Reproductive Health Services”[Mesh]) OR “Reproductive Rights”[Mesh]) OR “Sex Education”[Mesh] Water, Sanitation, and Hygiene “Hygiene” OR “Sanitation” ‘water, sanitation and hygiene’ [TIAB] OR WSH [TIAB] OR sanitation [TIAB] or Hygiene [TIAB] water sanitation and hygiene Mavodza et al. Global Health Research and Policy (2019) 4:26 Page 19 of 21 are experienced by low- and middle-income countries (LMICs) who are beneficiaries of U.S. foreign assistance. Policy analysis and more empirical research that investi- gates the interactions of the policy’s impact at all levels of the health system would generate the evidence needed to change the conditions of the GGR and mitigate its harms. Abbreviations AIDS: Acquired Immunodeficiency Syndrome; ART: Antiretroviral Therapy; CHANGE: Center for Health and Gender EquityGBVGender-based Violence; GGR: Global Gag Rule; HIV: Human Immunodeficiency Virus; IPPF: International Planned Parenthood Federation; LMICs: Low- and Middle- Income Countries; MCH: Maternal and Child Health; MCP: Mexico City Policy; MSI: Marie Stopes International; NGO: Non-governmental Organization; PEPFAR: President’s Emergency Plan for AIDS Relief; PLGHA: Protecting Life in Global Health Assistance; SRHR: Sexual and Reproductive Health and Rights; TB: Tuberculosis; USAID: United States Agency for International Development; VCT: Voluntary Counseling and Testing; WASH: Water, Sanitation and Hygiene Acknowledgments The authors would like to thank Serra Sippel (CHANGE), Beirne Roose-Snyder (CHANGE), and Kate Segal (CHANGE) for their intellectual contributions to this research. The authors would further like to thank members of the GGR research group, especially Emily Maistrellis and Marta Schaff (Heilbrunn De- partment of Population and Family Health, Columbia University Mailman School of Public Health) for their input on the methodological design. Authors’ contributions CM conducted the peer-review searches, and analyzed and coalesced the studies in this review. RG conducted the grey literature searches and was a major contributor in writing the manuscript. BC oversaw the design of the review and contributed to writing the manuscript. All authors read and ap- proved the final manuscript. Funding Not applicable. Availability of data and materials The search strategies generated for this review are available from the corresponding author upon reasonable request. An example of the strategy for Pubmed searches is also available. Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. 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Global Health Research and Policy (2019) 4:26 Page 21 of 21 Abstract Background Methods Results Discussion Background Methods Identifying the research question Literature search strategy Inclusion and exclusion criteria Study selection Charting the data Data collation, analysis, and synthesis Results Misunderstanding the GGR Loss of funding The chilling effect Impact on advocacy and coalition spaces Impact on HIV and AIDS Impact on abortion Impact on contraception and family planning Impact on maternal and child health Discussion show [App1] Avenues for future research Limitations Conclusion Abbreviations Acknowledgments Authors’ contributions Funding Availability of data and materials Ethics approval and consent to participate Consent for publication Competing interests Author details References

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