The Mexico City Policy: An Explainer

Key Points

  • On January 28, 2021, President Joe Biden rescinded the Mexico City Policy, marking an end to a four-year period under the Trump administration that saw the greatest expansion of the policy in its history.
  • First announced in 1984 by the Reagan administration, the policy has been rescinded and reinstated by subsequent administrations along party lines and has been in effect for 21 of the past 36 years.
  • Historically, the policy required foreign non-governmental organizations (NGOs) to certify that they would not “perform or actively promote abortion as a method of family planning” using funds from any source (including non-U.S. funds) as a condition of receiving U.S. government global family planning funding. President Trump reinstated the policy but also significantly expanded it to encompass the vast majority of U.S. bilateral global health assistance.
  • Under the Trump administration’s expansion, the policy applied to PEPFAR, maternal and child health, malaria, nutrition, and other U.S. programs, and potentially encompassed $7.3 billion in FY 2020 alone, to the extent that such funding was ultimately provided to foreign NGOs, directly or indirectly (family planning assistance accounted for approximately $600 million of that total). The Trump administration also moved to further tighten restrictions, reaching other areas of U.S. development assistance beyond global health and other non-U.S. funding streams.
  • In rescinding the policy, President Biden required agencies involved in foreign assistance to immediately end the imposition of the policy in future awards, waive the policy’s application in existing awards, and notify recipients as soon as possible that the policy conditions have been waived.
  • This explainer provides an overview of the history of the policy, including the changes made by President Trump, as well as the implications of the Biden administration rescinding the policy for programs going forward.

What is the Mexico City Policy?

The Mexico City Policy is a U.S. government policy that – when in effect – has required foreign NGOs to certify that they will not “perform or actively promote abortion as a method of family planning” using funds from any source (including non-U.S. funds) as a condition of receiving U.S. global family planning assistance and, when in place under the Trump administration, most other U.S. global health assistance.

Box 1:  The Original Language of the Mexico City Policy, 1984
“[T]he United States does not consider abortion an acceptable element of family planning programs and will no longer contribute to those of which it is a part. …[T]he United States will no longer contribute to separate nongovernmental organizations which perform or actively promote abortion as a method of family planning in other nations.”1

The policy was first announced by the Reagan administration at the 2nd International Conference on Population, which was held in Mexico City, Mexico, on August 6-14, 1984 (hence its name; see Box 1).2  Under the Trump administration, the policy was renamed “Protecting Life in Global Health Assistance” (PLGHA). Among opponents, it is also known as the “Global Gag Rule,” because among other activities, it prohibits foreign NGOs from using any funds (including non-U.S. funds) to provide information about abortion as a method of family planning and to lobby a foreign government to legalize abortion.

When first instituted in 1984, the Mexico City Policy marked an expansion of existing legislative restrictions that already prohibited U.S. funding for abortion internationally, with some exceptions (see below). Prior to the policy, foreign NGOs could use non-U.S. funds to engage in certain voluntary abortion-related activities as long as they maintained segregated accounts for any U.S. money received, but after the Mexico City Policy was in place, they were no longer permitted to do so if they wanted to receive U.S. family planning assistance.

The Trump administration’s application of the policy to the vast majority of U.S. bilateral global health assistance, including funding for HIV under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), maternal and child health, malaria, nutrition, and other programs, marked a significant expansion of its scope, potentially encompassing $7.3 billion in FY 2020 alone, to the extent that such funding was ultimately provided to foreign NGOs, directly or indirectly (family planning assistance accounted for approximately $600 million of that total).3 The Trump administration also moved to further tighten restrictions, reaching other areas of U.S. development assistance beyond global health and other non-U.S. funding streams. See “What is the definition of ‘financial support’?” below.4

When has it been in effect?

The Mexico City Policy has been in effect for 21 of the past 36 years, primarily through executive action, and has been instated, rescinded, and reinstated by presidential administrations along party lines (see Table 1).

The policy was first instituted in 1984 (taking effect in 1985) by President Ronald Reagan and continued to be in effect through President George H.W. Bush’s administration. It was rescinded by President Bill Clinton in 1993 (although it was reinstated legislatively for one year during his second term;5 see below).6 The policy was reinstated by President George W. Bush in 2001,7 rescinded by President Barack Obama in 2009,8 and reinstated and expanded by President Trump in 2017.9 It was rescinded by President Biden at the beginning of his term in 2021.10

Table 1: The U.S. Mexico City Policy Over Time
Years In Effect? Presidential Administration
(Party Affiliation)
Executive (E) or Congressional (C) Action?
1985-1989 Yes Reagan (R) E
1989-1993 Yes Bush (R) E
1993-1999 Sept. No Clinton (D) E
1999 Oct.-2000 Sept. Yes* Clinton (D) C
2000 Oct.-2001 No Clinton (D) E
2001-2009 Yes Bush (R) E
2009-2017 No Obama (D) E
2017-2021 Yes Trump (R) E
2021-present No Biden (D) E
NOTES: Shaded blue indicate periods when policy was in effect. * There was a temporary, one-year legislative imposition of the policy, which included a portion of the restrictions in effect in other years11 and an option for the president to waive these restrictions in part; however, if the waiver option was exercised (for no more than $15 million in family planning assistance), then $12.5 million of this funding would be transferred to maternal and child health assistance. The president did exercise the waiver option.

SOURCES: “Policy Statement of the United States of America at the United Nations International Conference on Population (Second Session), Mexico City, Mexico, August 6-14, 1984,” undated; Bill Clinton Administration, “Subject: AID Family Planning Grants/Mexico City Policy,” Memorandum for the Acting Administrator of the Agency for International Development, January 22, 1993, Clinton White House Archives,  https://clintonwhitehouse6.archives.gov/1993/01/1993-01-22-aid-family-planning-grants-mexico-city-policy.html; FY 2000 Consolidated Appropriations Act, P.L. 106-113; George W. Bush Administration, “Subject: Restoration of the Mexico City Policy,” Memorandum for the Administrator of the United States Agency for International Development, January 22, 2001, Bush Administration White House Archives, https://georgewbush-whitehouse.archives.gov/news/releases/20010123-5.html; “Subject: Restorion of the Mexico City Policy,” Memorandum for the Administrator of the United States Agency for International Development, March 28, 2001, Federal Register, https://www.federalregister.gov/documents/2001/03/29/01-8011/restoration-of-the-mexico-city-policy; George W. Bush Administration, “Subject: Assistance for Voluntary Population Planning,” Memorandum for the Secretary of State, August 29, 2003, Bush Administration White House Archives, http://georgewbush-whitehouse.archives.gov/news/releases/2003/08/20030829-3.html; Barack Obama Administration, “Mexico City Policy and Assistance for Voluntary Population Planning,” Memorandum for the Secretary of State, the Administrator of the United States Agency for International Development, January 23, 2009, Obama White House Archives, https://obamawhitehouse.archives.gov/the-press-office/mexico-city-policy-and-assistance-voluntary-population-planning; Donald J. Trump Administration, “The Mexico City Policy,” Memorandum for the Secretary of State, the Secretary of Health and Human Services, the Administrator of the Agency for International Development, Jan. 23, 2017, Trump Administration  White House Archives, https://trumpwhitehouse.archives.gov/presidential-actions/presidential-memorandum-regarding-mexico-city-policy/; White House, “Memorandum on Protecting Women’s Health at Home and Abroad,” presidential actions, Jan. 28, 2021, https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/28/memorandum-on-protecting-womens-health-at-home-and-abroad/; White House, “FACT SHEET: President Biden to Sign Executive Orders Strengthening Americans’ Access to Quality, Affordable Health Care,” statements and releases, Jan. 28, 2021, https://www.whitehouse.gov/briefing-room/statements-releases/2021/01/28/fact-sheet-president-biden-to-sign-executive-orders-strengthening-americans-access-to-quality-affordable-health-care/.

How has it been instituted (and rescinded)?

The Mexico City Policy has, for the most part, been instituted or rescinded through executive branch action (typically via presidential memoranda12). While Congress has the ability to institute the policy through legislation, this has happened only once in the past: a modified version of the policy was briefly applied by Congress during President Clinton’s last year in office as part of a broader arrangement to pay the U.S. debt to the United Nations.13 (At that time, President Clinton was able to partially waive the policy’s restrictions.14) Other attempts to institute the policy through legislation have not been enacted into law,15 nor have legislative attempts to overturn the policy.16 See Table 1.

Who did the policy apply to?

Historically, when in effect, the policy had applied to foreign NGOs as a condition for receiving U.S. family planning support and, under the Trump administration, most other bilateral global health assistance, either directly (as the main – or prime – recipient of U.S. funding) or indirectly (as a recipient of U.S. funding through an agreement with the prime recipient; referred to as a sub-recipient). Specifically, a foreign NGO “recipient agrees that it will not, during the term of this award, perform or actively promote abortion as a method of family planning in foreign countries or provide financial support to any other foreign non-governmental organization that conducts such activities.”17

Foreign NGOs include:

  • international NGOs that are based outside the U.S.,
  • regional NGOs that are based outside the U.S., and
  • local NGOs in assisted countries.18

U.S. NGOs have not been directly subject to the Mexico City Policy but, when in place, must also agree to ensure that they do not provide funding to any foreign NGO sub-recipients unless those sub-recipients have first certified adherence to the policy. Specifically, a U.S. NGO “recipient (A) agrees that it will not furnish health assistance under this award to any foreign non-governmental organization that performs or actively promotes abortion as a method of family planning in foreign countries; and (B) further agrees to require that such sub-recipients do not provide financial support to any other foreign non-governmental organization that conducts such activities.”19

Certain recipients of U.S. assistance have always been exempt from the policy, including foreign governments (national or sub-national) and public international organizations and other multilateral entities, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi, the Vaccine Alliance.20 However, this funding was subject to the policy if it flowed through a foreign NGO that has accepted the policy;21 see “What is the definition of ‘financial support’?” below.

To what assistance did it apply?

“Assistance” includes “the provision of funds, commodities, equipment, or other in-kind global health assistance.”22 In the past, foreign NGOs have been required to adhere to the Mexico City Policy – when it was in effect – as a condition of receiving support through certain U.S. international funding streams: family planning assistance through the U.S. Agency for International Development (USAID) and, beginning in 2003, family planning assistance23 through the U.S. Department of State. In the 2003 memorandum announcing the policy’s expansion to include the Department of State, President Bush stated that the policy did not apply to funding for global HIV/AIDS programs and that multilateral organizations that are associations of governments are not included among “foreign NGOs.”24 The Trump administration greatly expanded the policy to apply to the vast majority of U.S. bilateral global health assistance furnished by all agencies and departments, including:25

  • family planning and reproductive health
  • maternal and child health (including household-level water, sanitation, and hygiene (WASH))26
  • nutrition
  • HIV under PEPFAR
  • tuberculosis
  • malaria under the President’s Malaria Initiative (PMI)
  • neglected tropical diseases
  • global health security
  • certain types of research activities27

The policy applied to the assistance described above that was appropriated directly to three agencies and departments: USAID; the Department of State, including the Office of the Global AIDS Coordinator, which oversees and coordinates U.S. global HIV funding under PEPFAR; and for the first time, the Department of Defense (DoD).28 When such funding was transferred to another agency, including the Centers for Disease Control (CDC) and the National Institutes of Health (NIH), it remained subject to the policy, to the extent that such funding was ultimately provided to foreign NGOs, directly or indirectly.

The policy applied to two types of funding instruments: grants and cooperative agreements.29 The Trump administration had sought to apply the policy to contracts and issued a proposed rule to this effect, but it was not finalized.30

The policy did not apply to U.S. assistance for: water supply and sanitation activities, which is usually focused on infrastructure and systems;31 humanitarian assistance, including activities related to migration and refugee assistance activities as well as disaster and humanitarian relief activities; the American Schools and Hospitals Abroad (ASHA) program; and Food for Peace (FFP).32 However, this funding was subject to the policy if it flowed through a foreign NGO that has accepted the policy;33 see “What is the definition of ‘financial support’?” below.

What activities did it prohibit?

When in effect, the policy prohibited foreign NGOs that receive U.S. family planning assistance and, when expanded as during the Trump administration, most other U.S. bilateral global health assistance from using funds from any source (including non-U.S. funds) to “perform or actively promote abortion as a method of family planning.” In addition to providing abortions with non-U.S. funds, restricted activities also included the following:

  • providing advice and information about and offering referral for abortion – where legal – as part of the full range of family planning options,
  • promoting changes in a country’s laws or policies related to abortion as a method of family planning (i.e., engaging in lobbying), and
  • conducting public information campaigns about abortion as a method of family planning.

The prohibition of these activities is why the policy has been referred to by its critics as the “Global Gag Rule.”

Additionally, for the first time, the expanded policy during the Trump administration prohibited foreign NGOs from providing any financial support with any source of funds (including non-U.S. funding) and for any purpose to other foreign NGOs that perform or actively promote abortion as a method of family planning;34 see “What is the definition of ‘financial support’?” below.

When in effect, the policy, however, did not prohibit foreign NGOs from:

  • providing advice and information about, performing, or offering referral for abortion in cases where the pregnancy has either posed a risk to the life of the mother or resulted from incest or rape;35 and
  • responding to a question about where a safe, legal abortion may be obtained when a woman who is already pregnant clearly states that she has already decided to have a legal abortion (passively providing information, versus actively providing medically-appropriate information).

In addition, the expanded policy during the Trump administration did not apply to healthcare providers who have an affirmative duty required under local law to provide counseling about and referrals for abortion as a method of family planning.

Did it restrict direct U.S. funding for abortion overseas?

U.S. funding for abortion was already restricted and remains restricted under several provisions of the law.36 Specifically, before the Mexico City Policy was first announced in 1984, U.S. law already prohibited the use of U.S. aid:

  • to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortion (the Helms Amendment, 1973, to the Foreign Assistance Act);
  • for biomedical research related to methods of or the performance of abortion as a means of family planning (the Biden Amendment, 1981, to the Foreign Assistance Act); and
  • to lobby for or against abortion37 (the Siljander Amendment, first included in annual appropriations in 1981 and included each year thereafter).

Then, shortly after the policy was announced in 1984, the Kemp-Kasten Amendment was passed in 1985, prohibiting the use of U.S. aid to fund any organization or program, as determined by the president, that supports or participates in the management of a program of coercive abortion or involuntary sterilization (it is now included in annual appropriations).

Before the Mexico City Policy, U.S. aid recipients could use non-U.S. funds to engage in certain abortion-related activities but were required to maintain segregated accounts for U.S. assistance.38 The Mexico City Policy reversed this practice: no longer were foreign NGOs allowed to use non-U.S. funds, maintained in segregated accounts, for voluntary abortion-related activities if they wished to continue to receive or be able to receive U.S. family planning funds.

Has the policy prohibited post-abortion care?

The Mexico City Policy does not restrict the provision of post-abortion care, which is a supported activity of U.S. family planning assistance. Whether or not the Mexico City Policy is in effect, recipients of U.S. family planning assistance are allowed to use U.S. and non-U.S. funding to support post-abortion care,39 no matter the circumstances of the abortion (whether it was legal or illegal).

What has been the impact of the policy?

Several studies have looked at the impact of the policy. A 2011 quantitative analysis by Bendavid, et. al, found a strong association between the Mexico City Policy and abortion rates in sub-Saharan Africa.40 This study was recently updated to include several more years of data, again identifying a strong association. Specifically, the updated study found that during periods when the policy was in place, abortion rates rose by 40% in countries with high exposure to the Mexico City Policy compared to those with low exposure, while the use of modern contraceptives declined by 14% and pregnancies increased by 12% in high exposure compared to low exposure countries. In other words, it found patterns that “strengthen the case for the role played by the policy” in “a substantial increase in abortions across sub-Saharan Africa among women affected by the U.S. Mexico City Policy … [and] a corresponding decline in the use of modern contraception and increase in pregnancies,” likely because foreign NGOs that declined U.S. funding as a result of the Mexico City Policy – often key providers of women’s health services in these areas – had fewer resources to support family planning services, particularly contraceptives.41 Increased access to and use of contraception have been shown to be key to preventing unintended pregnancies and thereby reducing abortion, including unsafe abortion.42 The study also found patterns that “suggest that the effects of the policy are reversible” when the policy is not in place.43

Additionally, there has been anecdotal evidence and qualitative data on the impact of the policy, when it has been in force in the past, on the work of organizations that have chosen not to agree to the policy and, therefore, forgo U.S. funding that had previously supported their activities.44 For example, they have reported that they have fewer resources to support family planning and reproductive health services, including family planning counseling, contraceptive commodities, condoms, and reproductive cancer screenings.45

While it is likely too early to assess the full effects of the most recent iteration of the policy during the Trump administration on NGOs and the individuals they served, as the policy was applied on a rolling basis as new funding agreements or modifications to existing agreements were made, some early data are available. Several early qualitative and quantitative studies have been released,46 and at least one long-term, quantitative assessment is underway. KFF analyses found that during the Trump administration, the expanded policy applied to a much greater amount of U.S. global health assistance, and greater number of foreign NGOs, across many program areas.47 KFF found that more than half (37) of the 64 countries that received U.S. bilateral global health assistance in FY 2016 allow for legal abortion in at least one case not permitted by the policy and that had the expanded Mexico City Policy been in effect during the FY 2013 – FY 2015 period, at least 1,275 foreign NGOs would have been subject to the policy. In addition, at least 469 U.S. NGOs that received U.S. global health assistance during this period would have been required to ensure that their foreign NGO sub-recipients were in compliance. Additional foreign NGOs were likely impacted by the policy due to the revised interpretation of “financial support” announced in March 2019 and implemented beginning June 2019;48 see “What is the definition of ‘financial support’?” below.

During the Trump administration, two official assessments by the U.S. Department of State were released (see below).49 Additionally, a report released in March 2020 by the U.S. Government Accountability Office (GAO) provided new information on the number of projects (awards) and NGOs affected by the expanded policy during the Trump administration. It found that from May 2017 through FY 2018:

  • the policy had been applied to over 1,300 global health projects, with the vast majority of these through USAID and CDC, and
  • NGOs declined to accept the policy in 54 instances, totaling $153 million in declined funding – specifically, seven prime awards amounting to $102 million and 47 sub-awards amounting to $51 million (more than two-thirds of sub-awards were intended for Africa) – across USAID and CDC; the Department of State and DoD did not identify any instances where NGOs declined to accept the policy conditions.

What did the U.S. government’s reviews of the expanded policy during the Trump administration find?

During the Trump administration, the U.S. government published two reviews of the expanded policy, with the first examining the initial six months of the policy released in February 2018 and the second examining the first 18 months of the policy released in August 2020.

First Review

In February 2018, the Department of State announced the findings of an initial six-month review of implementation of the policy through the end of FY 2017 (September 2017).50 The report directed agencies to provide greater support for improving understanding of implementation among affected organizations and provided guidance to clarify terms included in standard provisions of grants and cooperative agreements. In the six-month review report, the Department of State report identified a number of “actions” for implementing agencies, such as a need for:

  • more central and field-based training and implementation tools,
  • a clearer explanation of termination of awards for NGOs found to be in violation of the policy, and
  • a clarification of “financial support,” which was not defined in the standard provisions (see “What is the definition of ‘financial support’?” below).

The six month review also identified the number of affected agreements with prime implementing partners and the number of those that have accepted the Mexico City Policy as part of their agreements through September 2017 (see Table 2).

Table 2: Findings of the U.S. Department of State’s Initial Six-Month Review of the Implementation of the Expanded Mexico City Policy During the Trump Administration
U.S. Agency or Department Policy Implementation Date Overall # of Grants and Cooperative Agreements with Global Health Assistance Funding Of Overall #:
(From the Policy Implementation Date through 9/30/2017)
# That Received New Funding and Accepted Policy # That Received New Funding and Declined to Accept Policy^ # That Had Not Received New Funding Yet
USAID May 15, 2017 580 419 3 158
State* May 15, 2017 142 108 0 34
HHS+ May 31, 2017 499 160 0 339
DoD May 15, 2017 77 42 1 34
TOTAL 1298 729 4 565
NOTES: * reflects PEPFAR funding implemented through the Department of State; other departments and agencies implement the majority of PEPFAR funding. + At HHS agencies, only certain assistance funding transferred from USAID, State, and DoD are subject to the policy. ^ As of September 30, 2017, USAID reported it was aware of three centrally funded prime partners, and 12 sub-awardee implementing partners, that declined to agree to the  Protecting Life in Global Health Assistance (PLGHA) terms in their awards; DoD reported that one DoD partner, a U.S. NGO, declined to agree in one country but accepted the PLGHA standard provision in other countries; and HHS reported that no HHS partners declined to agree.

SOURCES: KFF analysis of data from Department of State, “Protecting Life in Global Health Assistance Six-Month Review,” report, Feb. 6, 2018, https://2017-2021.state.gov/protecting-life-in-global-health-assistance-six-month-review/index.html.

Second Review

On August 17, 2020, the Department of State released its second review of the policy, updating its initial six-month review (as an action item in the six-month review report, the department stated it would “conduct a further review of implementation of the policy by December 15, 2018, when more extensive experience will enable a more thorough examination of the benefits and challenges”). The long-anticipated review, which examines the period from May 2017 through September 2018, found:

  • the awards declined spanned a variety of program areas, including family planning and reproductive health (FP/RH), HIV and AIDS (HIV/AIDS), maternal and child health (MCH), tuberculosis (TB), and nutrition, in addition to cross-cutting awards;
  • the awards declined spanned geographic areas but many were for activities in sub-Saharan Africa;
  • agencies and departments made efforts to transition projects to another implementer in order to minimize disruption; but
  • nevertheless, among USAID awards involving health service delivery where prime and sub-award recipients declined to accept the policy, gaps or disruptions in service delivery were sometimes reported.

The second review also identified the number of affected agreements with prime implementing partners and the number of those that have accepted the Mexico City Policy as part of their agreements through September 2018 (see Table 3).

Table 3: Findings of the U.S. Department of State’s Second Review of the Implementation of the Expanded Mexico City Policy During the Trump Administration
(From the Policy Implementation Date Through 9/30/2018)
U.S. Agency or Department Policy Implementation Date # of Grants and Cooperative Agreements with Global Health Assistance Funding # of Prime Awardees That Declined to Accept Policy^
USAID May 15, 2017 486 6
State* May 15, 2017 335 0
HHS+ May 31, 2017 466 1
DoD May 15, 2017 53 1
TOTAL 1340 8
NOTES: * reflects PEPFAR funding implemented through the Department of State; other departments and agencies implement the majority of PEPFAR funding. + At HHS agencies, only certain assistance funding transferred from USAID, State, and DoD are subject to the policy. ^ As of September 30, 2018, USAID reported it was aware of six centrally funded prime partners, and 47 sub-awardee implementing partners, that declined to agree to the  Protecting Life in Global Health Assistance (PLGHA) terms in their awards; DoD reported that one DoD partner, a U.S. NGO, declined to agree in one country but accepted the PLGHA standard provision in other countries; and HHS reported that one HHS partner declined to agree.

SOURCES: KFF analysis of data from Department of State, “Review of the Implementation of the Protecting Life in Global Health Assistance Policy ,” report, Aug. 17, 2020, https://2017-2021.state.gov/wp-content/uploads/2020/08/PLGHA-2019-Review-Final-8.17.2020-508.pdf, and Department of State, “Protecting Life in Global Health Assistance Six-Month Review,” report, Feb. 6, 2018, https://2017-2021.state.gov/protecting-life-in-global-health-assistance-six-month-review/index.html.

Additionally, the review reported that 47 sub-awardees, all under USAID awards, declined to accept the policy. It is important to note that the review also stated that information on sub-awards is not systematically collected by departments and agencies and that DoD was not able to collect information on sub-awards.

What is the definition of “financial support”?

The Trump administration also expanded the interpretation of “financial support” to apply to more funding and organizations, albeit indirectly. In February 2018, in the initial six-month review issued when then-Secretary of State Tillerson led the department, the Department of State report included an “action” statement to clarify the definition of “financial support” as used in the standard provisions for grants and cooperative agreements. At issue was whether it applied more narrowly to certain funding provided by foreign NGOs (i.e., funding other than U.S. global health funding) to other foreign NGOs specifically for the purpose of performing or actively promoting abortion as a method of family planning or if it applied more broadly to certain funding provided by foreign NGOs to other foreign NGOs for any purpose, if that foreign NGO happened to perform or actively promote abortion as a method of family planning. The State Department clarified that it was the more narrow interpretation.51

However, on March 26, 2019, then-Secretary of State Pompeo reversed this interpretation, announcing further “refinements” to the policy to clarify that it applied to the broader definition of financial support.52 Specifically, under the policy, U.S.-supported foreign NGOs agree to not provide any financial support (global health-related as well as other support), no matter the source of funds, to any other foreign NGO that performs or actively promotes abortion as a method of family planning. In June 2019, USAID provided additional information to reflect this broader interpretation of the standard provisions.53

This marked the first time the policy had been applied this broadly, as it could then affect funding provided by other donors (such as other governments and foundations) and non-global health funding provided by the U.S. government for a wide range of purposes if this funding was first provided to foreign NGOs who had accepted the policy (as recipients of U.S. global health assistance) that then in turn provided that donor or U.S. non-global health funding for any purpose to foreign NGOs that perform or actively promote abortion as a method of family planning. For example, under the prior interpretation, a foreign NGO recipient of U.S. global health funding could not provide any non-U.S. funding to another foreign NGO to perform or actively promote abortion as a method of family planning but could provide funding for other activities, such as education, even if the foreign NGO carried out prohibited activities. Under the broader interpretation, a foreign NGO could not provide any non-U.S. funding for any activity to a foreign NGO that carried out prohibited activities. Similarly, while under the prior interpretation a foreign NGO recipient of U.S. global health funding could provide other U.S. funding (such as humanitarian assistance) to another foreign NGO for non-prohibited activities, even if the foreign NGO carried out prohibited activities, under the subsequent broader interpretation, it could not do so.

What are the next steps in rescinding the expanded policy?

Since President Biden has rescinded the policy, agencies involved in foreign assistance, including the Department of State, USAID, HHS, and DoD, are required to “immediately cease” imposing the conditions of the Mexico City Policy in any future assistance awards; therefore, it can be expected that the standard provisions for grants and cooperative agreements will soon be revised to remove the policy so that it will not be added to new funding agreements or modifications to existing agreements. Furthermore, these agencies are required to “immediately waive” Mexico City Policy conditions that were imposed during the Trump administration in assistance awards and to notify current recipients “as soon as possible” that such conditions have been waived. They are also required to “suspend, revise, or rescind any regulations, orders, guidance documents, policies, and any other similar agency actions that were issued pursuant to” the imposition of the Mexico City Policy during the Trump administration. However, it will likely take time for this information to reach the field and for funding to flow to organizations that may have stopped getting aid due to the restrictions. This explainer will be updated as more information on next steps becomes available.

Endnotes
  1. “Policy Statement of the United States of America at the United Nations International Conference on Population (Second Session), Mexico City, Mexico, August 6-14, 1984,” undated, https://www.jstor.org/stable/1973537?seq=1.

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  2. “Policy Statement of the United States of America at the United Nations International Conference on Population (Second Session), Mexico City, Mexico, August 6-14, 1984,” undated, https://www.jstor.org/stable/1973537?seq=1; United Nations Division of Economic and Social Affairs/Population Division, “United Nations Conferences on Population,” webpage, undated, http://www.un.org/en/development/desa/population/events/conference/index.shtml.

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  3. KFF analysis of Trump Administration/Department of State: “Protecting Life in Global Health Assistance,” fact sheet, May 15, 2017, https://2017-2021.state.gov/protecting-life-in-global-health-assistance-2/index.html; “Background Statement: Announcement of ‘Protecting Life in Global Health Assistance,’” background opening statement, May 15, 2017; “Implementation of Protecting Life in Global Health Assistance (Formerly known as the ‘Mexico City Policy’),” PRM press guidance, May 15, 2017; “Background Briefing: Senior Administration Officials on Protecting Life in Global Health Assistance,” press release of special briefing by senior Department of State officials via teleconference, May 15, 2017, https://2017-2021.state.gov/background-briefing-senior-administration-officials-on-protecting-life-in-global-health-assistance/index.html; “Subject: Protecting Life in Global Health Assistance,” Federal Assistance Management Advisory Number 2017-01; “Protecting Life in Global Health Assistance (May 2019),” MCP-related portion of standard provisions for cooperative agreements and grants to U.S. NGOs (May 2020) and foreign NGOs (Aug. 2020)); and KFF analysis of data from: Congressional Appropriations Bills, Press Releases, and Conference Reports; Federal Agency Budget and Congressional Justification documents and Operating Plans; ForeignAssistance.gov; Office of Management and Budget, personal communication.

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  4. USAID, “Protecting Life in Global Health Assistance Frequently Asked Questions and Answers,” Oct. 2019, https://www.usaid.gov/sites/default/files/documents/1864/
    FINAL_Protecting_Life_in_Global_Health_Assistance_FAQs_Oct_2019_USAID.pdf
    .

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  5. The temporary, one-year legislative imposition of the policy occurred as part of a broader deal related to paying the U.S. debt to the United Nations. See FY 2000 Consolidated Appropriations Act, P.L. 106-113, https://www.congress.gov/bill/106th-congress/house-bill/3194/text; PAI, Global Gag Rule Timeline, July 12, 2011; and Richard Cincotta and Barbara Crane, “The Mexico City Policy and U.S. Family Planning Assistance,” Science, Oct. 19, 2001, Vol. 294: pp. 525-526, https://science.sciencemag.org/content/294/5542/525.

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  6. Bill Clinton Administration, “Subject: AID Family Planning Grants/Mexico City Policy,” Memorandum for the Acting Administrator of the Agency for International Development, January 22, 1993, Clinton White House Archives, https://clintonwhitehouse6.archives.gov/1993/01/1993-01-22-aid-family-planning-grants-mexico-city-policy.html.

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  7. George W. Bush Administration, “Subject: Restoration of the Mexico City Policy,” Memorandum for the Administrator of the United States Agency for International Development, January 22, 2001, Bush Administration White House Archives, https://georgewbush-whitehouse.archives.gov/news/releases/20010123-5.html; “Subject: Restoration of the Mexico City Policy,” Memorandum for the Administrator of the United States Agency for International Development, March 28, 2001, Federal Register, https://www.federalregister.gov/documents/2001/03/29/01-8011/restoration-of-the-mexico-city-policy; George W. Bush Administration, “Subject: Assistance for Voluntary Population Planning,” Memorandum for the Secretary of State, August 29, 2003, Bush Administration White House Archives, http://georgewbush-whitehouse.archives.gov/news/releases/2003/08/20030829-3.html.

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  8. Barack Obama Administration, “Mexico City Policy and Assistance for Voluntary Population Planning,” Memorandum for the Secretary of State, the Administrator of the United States Agency for International Development, January 23, 2009, Obama White House Archives, https://obamawhitehouse.archives.gov/the-press-office/mexico-city-policy-and-assistance-voluntary-population-planning.

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  9. Donald J. Trump Administration, “The Mexico City Policy,” Memorandum for the Secretary of State, the Secretary of Health and Human Services, the Administrator of the Agency for International Development, Jan. 23, 2017, Trump Administration  White House Archives, https://trumpwhitehouse.archives.gov/presidential-actions/presidential-memorandum-regarding-mexico-city-policy/.

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  10. White House, “Memorandum on Protecting Women’s Health at Home and Abroad,” presidential actions, Jan. 28, 2021, https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/28/memorandum-on-protecting-womens-health-at-home-and-abroad/; White House, “FACT SHEET: President Biden to Sign Executive Orders Strengthening Americans’ Access to Quality, Affordable Health Care,” statements and releases, Jan. 28, 2021, https://www.whitehouse.gov/briefing-room/statements-releases/2021/01/28/fact-sheet-president-biden-to-sign-executive-orders-strengthening-americans-access-to-quality-affordable-health-care/.

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  11. The policy included language that prohibited USAID from providing family planning assistance to any foreign private, nongovernmental, or multilateral organizations until they certified that during the period for which the funding was made available 1) they would not perform abortions as a method of family planning in any foreign country and 2) they would not violate the laws of any foreign country regarding abortion and would not engage in lobbying any foreign country regarding abortion. FY 2000 Consolidated Appropriations Act, P.L. 106-113, https://www.congress.gov/bill/106th-congress/house-bill/3194/text.

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  12. Presidential memoranda “are often used to carry out routine executive decisions and determinations, or to direct agencies to perform duties consistent with the law or implement laws that are presidential priorities” and are not required to be published in the Federal Register (although those pertaining to the Mexico City Policy sometimes have been). These presidential instruments or directives “may have the force and effect of law only if the presidential action is based on power vested in the President by the U.S. Constitution or delegated to the President by Congress.” Memoranda have the same legal authority as executive orders, although the latter is always required to be published in the Federal Register. Quotes as stated in Congressional Research Service (CRS), Executive Orders: Issuance, Modification, and Revocation, April 16, 2014, RS20846, https://fas.org/sgp/crs/misc/RS20846.pdf.

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  13. The legislative application of the policy – applying to FY 2000, which was from Oct. 1, 1999, until Sept. 30, 2000 – included language that prohibited USAID from providing family planning assistance to any foreign private, nongovernmental, or multilateral organizations until they certified that during the period for which the funding was made available 1) they would not perform abortions as a method of family planning in any foreign country and 2) they would not violate the laws of any foreign country regarding abortion and would not engage in lobbying any foreign country regarding abortion. FY 2000 Consolidated Appropriations Act, P.L. 106-113, https://www.congress.gov/bill/106th-congress/house-bill/3194/text; PAI, Global Gag Rule Timeline, July 12, 2011; and Richard Cincotta and Barbara Crane, “The Mexico City Policy and U.S. Family Planning Assistance,” Science, Oct. 19, 2001, Vol. 294: pp. 525-526, https://science.sciencemag.org/content/294/5542/525.

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  14. The legislation included an option for the president to waive these restrictions; however, if he exercised the waiver option (for no more than $15 million in family planning assistance), then $12.5 million of this funding would be transferred to maternal and child health assistance. The president did exercise the waiver option. FY 2000 Consolidated Appropriations Act, P.L. 106-113, https://www.congress.gov/bill/106th-congress/house-bill/3194/text.

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  15. CRS, Abortion and Family Planning-Related Provisions in U.S. Foreign Assistance Law and Policy, May 17, 2016, R41360, https://digital.library.unt.edu/ark:/67531/metadc855791/.

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  16. CRS, Appropriations for FY2000: Foreign Operations, Export Financing, and Related Programs, updated August 4, 1999, RL30211, https://digital.library.unt.edu/ark:/67531/metadc814156/; CRS, International Family Planning: The “Mexico City” Policy, updated April 2, 2001, RL30830, https://digital.library.unt.edu/ark:/67531/metacrs1906/; CRS, Abortion and Family Planning-Related Provisions in U.S. Foreign Assistance Law and Policy, May 17, 2016, R41360, https://digital.library.unt.edu/ark:/67531/metadc855791/; PAI, Global Gag Rule Timeline, July 12, 2011.

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  17. USAID: “Standard Provisions for U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303maa, partial revision May 18, 2020, https://www.usaid.gov/ads/policy/300/303maa; “Standard Provisions for Non-U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303mab, partial revision Aug. 18, 2020, https://www.usaid.gov/ads/policy/300/303mab; USAID, “Protecting Life in Global Health Assistance Frequently Asked Questions and Answers,” Oct. 2019,  https://www.usaid.gov/sites/default/files/documents/1864/
    FINAL_Protecting_Life_in_Global_Health_Assistance_FAQs_Oct_2019_USAID.pdf
    .

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  18. The USAID Standard Provisions state that “a foreign non-governmental organization is a for-profit or not-for-profit non-governmental organization that is not organized under the laws of the United States, any State of the United States, the District of Columbia, or the Commonwealth of Puerto Rico, or any other territory or possession of the United States.” USAID: “Standard Provisions for U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303maa, partial revision May 18, 2020, https://www.usaid.gov/ads/policy/300/303maa; “Standard Provisions for Non-U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303mab, partial revision Aug. 18, 2020, https://www.usaid.gov/ads/policy/300/303mab.

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  19. USAID: “Standard Provisions for U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303maa, partial revision May 18, 2020, https://www.usaid.gov/ads/policy/300/303maa; “Standard Provisions for Non-U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303mab, partial revision Aug. 18, 2020, https://www.usaid.gov/ads/policy/300/303mab.

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  20. Department of State: “Protecting Life in Global Health Assistance,” fact sheet, May 15, 2017, https://2017-2021.state.gov/protecting-life-in-global-health-assistance-2/index.html; “Background Statement: Announcement of ‘Protecting Life in Global Health Assistance,’” background opening statement, May 15, 2017; “Implementation of Protecting Life in Global Health Assistance (Formerly known as the ‘Mexico City Policy’),” PRM press guidance, May 15, 2017; “Background Briefing: Senior Administration Officials on Protecting Life in Global Health Assistance,” press release of special briefing by senior Department of State officials via teleconference, May 15, 2017, https://2017-2021.state.gov/background-briefing-senior-administration-officials-on-protecting-life-in-global-health-assistance/index.html; “Subject: Protecting Life in Global Health Assistance,” Federal Assistance Management Advisory Number 2017-01; “Protecting Life in Global Health Assistance (May 2019),” MCP-related portion of standard provisions for cooperative agreements and grants to U.S. NGOs (May 2020) and foreign NGOs (Aug. 2020).

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  21. USAID, “Protecting Life in Global Health Assistance Frequently Asked Questions and Answers,” Oct. 2019, https://www.usaid.gov/sites/default/files/documents/1864/
    FINAL_Protecting_Life_in_Global_Health_Assistance_FAQs_Oct_2019_USAID.pdf
    .

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  22. As stated in Department of State, “Implementation of Protecting Life in Global Health Assistance (Formerly known as the ‘Mexico City Policy’),” PRM press guidance, May 15, 2017.

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  23. George W. Bush Administration, “Subject: Assistance for Voluntary Population Planning,” Memorandum for the Secretary of State, August 29, 2003, Bush Administration White House Archives, http://georgewbush-whitehouse.archives.gov/news/releases/2003/08/20030829-3.html.

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  24. George W. Bush Administration, “Subject: Assistance for Voluntary Population Planning,” Memorandum for the Secretary of State, August 29, 2003, Bush Administration White House Archives, http://georgewbush-whitehouse.archives.gov/news/releases/2003/08/20030829-3.html. In other words, when President Bush extended the policy to include funding at the Department of State, he stated in the memorandum that the policy did not apply to foreign aid funding for global HIV/AIDS, malaria, and tuberculosis programs (including those under the U.S. President’s Emergency Plan for AIDS Relief or PEPFAR). He also stated that “foreign NGOs” do not include multilateral organizations that are associations of governments, such as the U.N. Population Fund (UNFPA) and the Global Fund to Fight AIDS, Tuberculosis and Malaria. For more information about PEPFAR, see the KFF fact sheet.

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  25. Department of State: “Protecting Life in Global Health Assistance,” fact sheet, May 15, 2017, https://2017-2021.state.gov/protecting-life-in-global-health-assistance-2/index.html; “Background Statement: Announcement of ‘Protecting Life in Global Health Assistance,’” background opening statement, May 15, 2017; “Implementation of Protecting Life in Global Health Assistance (Formerly known as the ‘Mexico City Policy’),” PRM press guidance, May 15, 2017; “Background Briefing: Senior Administration Officials on Protecting Life in Global Health Assistance,” press release of special briefing by senior Department of State officials via teleconference, May 15, 2017, https://2017-2021.state.gov/background-briefing-senior-administration-officials-on-protecting-life-in-global-health-assistance/index.html; “Subject: Protecting Life in Global Health Assistance,” Federal Assistance Management Advisory Number 2017-01; “Protecting Life in Global Health Assistance (May 2017),” MCP-related portion of standard provisions for cooperative agreements and grants to NGOs, May 11, 2017; USAID: USAID: “Standard Provisions for U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303maa, partial revision May 18, 2020, https://www.usaid.gov/ads/policy/300/303maa; “Standard Provisions for Non-U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303mab, partial revision Aug. 18, 2020, https://www.usaid.gov/ads/policy/300/303mab; CDC, “Additional Requirement – 35: Protecting Life in Global Health Assistance,” webpage, https://www.cdc.gov/grants/additionalrequirements/ar-35.html; NIH, “Protecting Life in Global Health Assistance,” webpage, https://grants.nih.gov/policy/protecting-life-global-health-assistance.htm,

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  26. The policy applies to certain safe water, sanitation, and hygiene activities at the household-level, particularly those related to behavior, which are described under the Health (HL) program element of the Updated Foreign Assistance Standardized Program Structure and Definitions (available at: https://www.state.gov/f/releases/other/255986.htm#HL6). However, HL.8: Water Supply and Sanitation is exempt from the policy; activities under this sub-element are usually focused on infrastructure and systems.

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  27. “The policy covers implementation-science research, operational or programmatic research, surveys, needs assessments and related capacity-building conducted for the purpose of making improvements to global health assistance programs funded by the U.S. Government and implemented through a foreign NGO with a primary purpose or effect of benefiting a foreign country,” as stated in Department of State, “Implementation of Protecting Life in Global Health Assistance (Formerly known as the ‘Mexico City Policy’),” PRM press guidance, May 15, 2017.

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  28. It also applies to global health assistance provided to foreign NGOs by other agencies and departments using funds transferred through the interagency process from USAID, the Department of State, and DoD.

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  29. As of May 15, 2017, the policy applies to all new grants and cooperative agreements that provide global health assistance, as well as to all existing grants and cooperative agreements that provide global health assistance when such agreements are amended to add new funding. As of March 2, 2017, the same holds true for USAID grants and cooperative agreements that provide family planning assistance. Department of State: “Subject: Protecting Life in Global Health Assistance,” Federal Assistance Management Advisory Number 2017-01; “Protecting Life in Global Health Assistance (May 2017),” MCP-related portion of standard provisions for cooperative agreements and grants to NGOs, May 11, 2017; and USAID: “Standard Provisions for U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303maa, partial revision May 18, 2020, https://www.usaid.gov/ads/policy/300/303maa; “Standard Provisions for Non-U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303mab, partial revision Aug. 18, 2020, https://www.usaid.gov/ads/policy/300/303mab.

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  30. The exception to this is “grants under contracts,” which were previously subject to the policy; they are essentially grants made to sub-awardees by recipients of contracts.

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  31. The policy applies to certain safe water, sanitation, and hygiene activities at the household-level, particularly those related to behavior, which are described under the Health (HL) program element of the Updated Foreign Assistance Standardized Program Structure and Definitions (available at: https://www.state.gov/f/releases/other/255986.htm#HL6). However, HL.8: Water Supply and Sanitation is exempt from the policy; activities under this sub-element are usually focused on infrastructure and systems.

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  32. Department of State: “Subject: Protecting Life in Global Health Assistance,” Federal Assistance Management Advisory Number 2017-01; “Protecting Life in Global Health Assistance,” fact sheet, May 15, 2017, https://2017-2021.state.gov/protecting-life-in-global-health-assistance-2/index.html; USAID: “Standard Provisions for U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303maa, partial revision May 18, 2020, https://www.usaid.gov/ads/policy/300/303maa; “Standard Provisions for Non-U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303mab, partial revision Aug. 18, 2020, https://www.usaid.gov/ads/policy/300/303mab.

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  33. USAID, “Protecting Life in Global Health Assistance Frequently Asked Questions and Answers,” Oct. 2019, https://www.usaid.gov/sites/default/files/documents/1864/
    FINAL_Protecting_Life_in_Global_Health_Assistance_FAQs_Oct_2019_USAID.pdf
    .

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  34. USAID, “Protecting Life in Global Health Assistance Frequently Asked Questions and Answers,” Oct. 2019, https://www.usaid.gov/sites/default/files/documents/1864/
    FINAL_Protecting_Life_in_Global_Health_Assistance_FAQs_Oct_2019_USAID.pdf
    .

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  35. While the policy allows exceptions for foreign NGOs that perform abortions with non-U.S. funds in the cases of a pregnancy that threatens the life of the woman or was a result of rape or incest, long-standing USAID interpretation of the Helms Amendment to the Foreign Assistance Act has not permitted U.S. funding to support the performance of abortions in these exceptional cases.

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  36. For information about other U.S. government requirements and policies related to family planning and reproductive health, see: KFF, The U.S. Government and International Family Planning & Reproductive Health: Statutory Requirements and Policies; KFF, Statutory Requirements & Policies Governing U.S. Global Family Planning and Reproductive Health Efforts, 2012; USAID, USAID's Family Planning Guiding Principles and U.S. Legislative and Policy Requirements webpage, http://www.usaid.gov/what-we-do/global-health/family-planning/usaids-family-planning-guiding-principles-and-us-0l; CRS, Abortion and Family Planning-Related Provisions in U.S. Foreign Assistance Law and Policy, May 17, 2016, R41360, https://digital.library.unt.edu/ark:/67531/metadc855791/.

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  37. When initially introduced, the amendment prohibited only lobbying for abortion, but in subsequent years Congress modified the language to include lobbying against abortion as well.

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  38. CRS, International Family Planning: The “Mexico City” Policy, updated April 2, 2001, RL30830, https://digital.library.unt.edu/ark:/67531/metacrs1906/.

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  39. Post-abortion care is the treatment of injuries or illnesses caused by legal or illegal abortions.

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  40. Specifically, the study found that abortion rates rose in countries with high exposure to the Mexico City Policy compared to those with low exposure, while the use of modern contraceptives declined over the same period in high exposure compared to low exposure countries. In other words, it found patterns “suggesting that the Mexico City Policy is associated with increases in abortion rates in sub-Saharan African countries,” likely because foreign NGOs that declined U.S. funding as a result of the Mexico City Policy – often key providers of women’s health services in these areas – had fewer resources to support family planning services, particularly contraceptives. The study stated, “Although we are unable to draw definitive conclusions about the underlying cause of this increase, the complex interrelationships between family planning services and abortion may be involved. In particular, if women consider abortion as a way to prevent unwanted births, then policies curtailing the activities of organizations that provide modern contraceptives may inadvertently lead to an increase in the abortion rate.” Eran Bendavid, Patrick Avila, and Grant Miller, “United States aid policy and induced abortion in sub-Saharan Africa,” Bulletin of the World Health Organization, Sept. 27, 2011 (online publish date): Vol. 89, pp. 873-880C, http://www.who.int/bulletin/volumes/89/12/11-091660/en/.

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  41. Nina Brooks, Eran Bendavid, and Grant Miller, “USA aid policy and induced abortion in sub-Saharan Africa: an analysis of the Mexico City Policy, The Lancet, June 27, 2019, https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30267-0/fulltext.

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  42. Eric Zuehlke, “Reducing Unintended Pregnancy and Unsafely Performed Abortion Through Contraceptive Use,” PRB, 2009, https://www.prb.org/unintendedpregnancyandabortion/.

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  43. Nina Brooks, Eran Bendavid, and Grant Miller, “USA aid policy and induced abortion in sub-Saharan Africa: an analysis of the Mexico City Policy, The Lancet, June 27, 2019, https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30267-0/fulltext.

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  44. For example, two earlier qualitative studies are discussed in Richard Cincotta and Barbara Crane, “The Mexico City Policy and U.S. Family Planning Assistance,” Science, Oct. 19, 2001, Vol. 294: pp. 525-526, https://science.sciencemag.org/content/294/5542/525.

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  45. PAI, “30 Years of the Global Gag Rule,” special project, Nov. 17, 2016, http://pai.org/special-projects/30-years-of-the-global-gag-rule/; CHANGE, “Global Gag Rule,” fact sheet, July 2018, http://www.genderhealth.org/files/uploads/change/publications/CHANGE_GGR_fact_sheet.pdf.

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  46. For example, MSI, “A World Without Choice: The Global Gag Rule’s Impact in Madagascar,” fact sheet, Jan 2018, https://www.mariestopes-us.org/wp-content/uploads/2018/01/MSI_Madagascar_GGR-Fact-Sheet_Jan-2018.pdf; MSl, The Global Gag Rule’s Impact in Zimbabwe,” fact sheet, Jan. 2018, https://www.mariestopes-us.org/wp-content/uploads/2018/01/MSI_Zimbabwe_GGR-Fact-Sheet_Jan-2018.pdf; PAI, Access Denied: Nigeria Preliminary Impacts of Trump’s Expanded Global Gag Rule, March 2018, https://pai.org/wp-content/uploads/2018/03/Access-Denied-Nigeria-2.pdf; PAI, Access Denied: Uganda Preliminary Impacts of Trump’s Expanded Global Gag Rule, March 2018, https://pai.org/wp-content/uploads/2018/03/Access-Denied_Uganda_March-2018.pdf; PAI, Access Denied: Ethiopia Preliminary Impacts of Trump’s Expanded Global Gag Rule, July 2018, https://pai.org/wp-content/uploads/2018/07/Access-Denied-Ethiopia-JULY-2018.pdf; PAI, Access Denied: Nepal Preliminary Impacts of Trump’s Expanded Global Gag Rule, Sept. 2018, https://pai.org/wp-content/uploads/2018/09/Access-Denied-Nepal-Brochure-V6.pdf; PAI, Access Denied: Senegal Preliminary Impacts of Trump’s Expanded Global Gag Rule, Nov. 2018, https://pai.org/wp-content/uploads/2018/12/Access-Denied-Senegal.pdf; Human Rights Watch, “Re: Early Impact of the Protecting Life in Global Health Assistance Policy in Kenya and Uganda,” letter to Secretary of State Tillerson dated Oct 13, 2017, posted online Oct. 26, 2017, https://www.hrw.org/news/2017/10/26/re-early-impact-protecting-life-global-health-assistance-policy-kenya-and-uganda; CHANGE, Prescribing Chaos in Global Health: The Global Gag Rule from 1984-2018, June 2018, http://www.genderhealth.org/files/uploads/change/publications/Prescribing_Chaos_
    in_Global_Health_full_report.pdf
    ; amfAR, The Effect of the Expanded Mexico City Policy on HIV/AIDS Programming: Evidence from the PEPFAR Implementing Partners Survey, issue brief, Jan. 2019, https://www.amfar.org/Issue-Brief-The-Effect-of-the-Expanded-Mexico-City-Policy/.

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  47. KFF analysis of data from: Congressional Appropriations Bills, Press Releases, and Conference Reports; Federal Agency Budget and Congressional Justification documents and Operating Plans; ForeignAssistance.gov; Office of Management and Budget, personal communication.

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  48. USAID, “Protecting Life in Global Health Assistance Frequently Asked Questions and Answers,” Oct. 2019, https://www.usaid.gov/sites/default/files/documents/1864/
    FINAL_Protecting_Life_in_Global_Health_Assistance_FAQs_Oct_2019_USAID.pdf
    .

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  49. Department of State, “Protecting Life in Global Health Assistance Six-Month Review,” report, Feb. 6, 2018, https://2017-2021.state.gov/protecting-life-in-global-health-assistance-six-month-review/index.html.

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  50. Department of State, “Protecting Life in Global Health Assistance Six-Month Review,” report, Feb. 6, 2018, https://2017-2021.state.gov/protecting-life-in-global-health-assistance-six-month-review/index.html.

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  51. Department of State, “Protecting Life in Global Health Assistance Six-Month Review,” report, Feb. 6, 2018, https://2017-2021.state.gov/protecting-life-in-global-health-assistance-six-month-review/index.html.

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  52. Department of State, “Remarks to the Press,” press release of remarks by Michael R. Pompeo, Secretary of State, March 26, 2019, https://2017-2021.state.gov/remarks-to-the-press-7/index.html; Trump Administration White House, “The Pro-Life Agenda: Secretary Pompeo’s Bold Leadership,” fact sheet, March 26, 2019, https://globalhealth.org/wp-content/uploads/2019/04/Mexico-City-Fact-SheetFinal.pdf.

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  53. USAID, “Protecting Life in Global Health Assistance Frequently Asked Questions and Answers,” Oct. 2019, https://www.usaid.gov/sites/default/files/documents/1864/
    FINAL_Protecting_Life_in_Global_Health_Assistance_FAQs_Oct_2019_USAID.pdf
    .

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