Part 2 Global Health Under Pressure: How US Policy Affects Sexual and Reproductive Health and Rights
The new US administration has been in office for less than a month, yet it has already had far-reaching consequences for global health. In the second part of our article series, we examine how current US global health policy affects sexual and reproductive health and rights (SRHR) and its impact on NGOs. For this, we spoke with various experts from academia, politics, and international cooperation.
Impacts of US Global Health and Development Policy on Sexual and Reproductive Health Worldwide
The new US administration has been in office for less than a month, yet it has already had far-reaching consequences for global health. In the second part of our article series, we examine how current US global health policy affects sexual and reproductive health and rights (SRHR) and its impact on NGOs. For this, we spoke with various experts from academia, politics, and international cooperation.
In 2017, during his last term, Trump also cut the budget for the United Nations Population Fund (UNFPA) by 70 million USD. Since UN organizations like UNFPA are not affected by the Mexico City Policy, Republican administrations have invoked the Kemp-Kasten Amendment to justify funding cuts. Introduced in 1985, this amendment states that no US funds may be used for organizations that support or participate in coercive abortions or involuntary sterilizations. UNFPA does not advocate for coercive abortions or involuntary
In this article, we use the terms girls* and women* because data on sexual and reproductive health, particularly regarding pregnancies and abortions, often focuses on women* and girls*. However, we would like to emphasize that non-binary, intersex, and trans* individuals can also be affected by pregnancy, menstruation, and gender-based violence. We use the gender asterisk to acknowledge and create space for this gender diversity.
sterilizations, but US administrations under Reagan, Bush, and Trump spread misinformation to the contrary because of UNFPA’s involvement in China. For Republican administrations, this was sufficient to use the amendment as a political tool to cut or withdraw funding from organizations like UNFPA.
The 90-day funding freeze during the current administration is particularly disastrous for HIV/AIDS treatment and prevention. Angela Bähr, a board member of the German Foundation for World Population (DSW) responsible for its programs, has learned from partner organizations in Kenya that due to the funding freeze, HIV medications can no longer be supplied. While Kenya still has some stock, it is expected to last no more than six months. A supply disruption of HIV medications would have devastating public health consequences and could, in the worst case, undermine the progress made in fighting HIV/AIDS over the past decades. She explains that even short interruptions in antiretroviral therapy lead to a rapid increase in viral load among affected individuals. The PEPFAR program (The United States President’s Emergency Plan for AIDS Relief) received a limited exemption one week after the 90-day funding freeze took effect, allowing it to resume some services. For Angela Bähr, this exemption is lifesaving. However, she notes that it will be very difficult to implement under a stricter "Global Gag Rule" and questions how PEPFAR will continue its programs when staff has already been laid off.
In this article, we use the terms girls* and women* because data on sexual and reproductive health, particularly regarding pregnancies and abortions, often focuses on women* and girls*. However, we would like to emphasize that non-binary, intersex, and trans* individuals can also be affected by pregnancy, menstruation, and gender-based violence. We use the gender asterisk to acknowledge and create space for this gender diversity.
In many countries, especially in sub-Saharan Africa, abortions are illegal. According to the Center for Reproductive Rights, the situation has generally improved since 1994. However, other countries, such as the USA and Poland, have tightened their laws. Among 15- to 19-year-old girls*, complications during pregnancy and childbirth remain one of the leading causes of death, as highlighted in a 2023 UNFPA report. Unsafe abortions are often responsible. Unwanted pregnancies can also lead to mental health issues. Angela Bähr explains that young women* often develop suicidal thoughts as a result.
The Guttmacher Institute, a US-based research and policy organization, has examined the effects of the "Global Gag Rule" on health systems in Ethiopia and Uganda. Before Trump reinstated the policy in 2017, Uganda had significantly improved access to family planning and contraceptives. Under Trump, this progress stalled, especially in districts affected by the "Protecting Life in Global Health Assistance" (PLGHA) policy. Health services even deteriorated in these areas due to a shortage of community health workers. In Uganda, abortions are illegal and are rarely performed even when a woman’s life is at risk. Nevertheless, the number of post-abortion care treatments in clinics increased by 16% between 2017 and 2021—not despite but because of PLGHA. Schools often provide inadequate sex education, as Angela Bähr reports. During a visit to a secondary school in Uganda, a teacher told students that abstinence is the best form of contraception, as mandated by the curriculum for students under 18. Local NGOs providing effective sexual education for young women* are also scaling back their work for fear of losing funding due to the "Global Gag Rule."
The lack of US funding also affects the availability of contraceptives. In Ethiopia, where there had been significant progress in family planning and contraception for decades, the "Global Gag Rule" reversed these gains between 2017 and 2021. Contraceptives became scarce in some health facilities, as described by Colette Rose from the Berlin Institute for Population and Development, an independent think tank analyzing demographic changes and their societal, economic, and development policy implications. Unlike in Uganda, abortions are legal in Ethiopia. The Ethiopian government, together with NGOs opposing the "Global Gag Rule," ensured that access to safe abortions was maintained. However, this effort would not have been possible without additional external funding.
The impact of the current administration on healthcare remains to be seen. Since Trump took office, there have already been further cuts and restrictions on US development cooperation, as outlined in "Project 2025" before the election. Additionally, ongoing crises and conflicts may reduce funding from other donors.
Colette Rose, who has worked for years in sexual and reproductive health research focusing on Africa—three years at the Berlin Institute and previously at the Guttmacher Institute—emphasizes the devastating effects of the Global Gag Rule, particularly if extended to humanitarian aid. In war, conflict, or natural disaster settings, women* and girls* are particularly dependent on access to sexual and reproductive health services. Colette Rose explains that the policy has historically increased the stigma surrounding abortions.
Ottmar von Holtz is again member of the German Bundestag since January 2024 and development policy spokesperson for the Green Party. He warns that US policy will lead to a general setback in global health. This would not only impact sexual and reproductive health and rights and infectious diseases worldwide but also initiatives for local vaccine production in Africa, a sector in which the US has previously invested significantly. Such policies would further entrench African states' dependence on the so-called Global North.
Impacts of the "Global Gag Rule" and Funding Freeze on NGOs
Currently, NGOs worldwide are particularly affected by the 90-day funding freeze for US development cooperation. Other donors cannot fully compensate for this gap, especially as "Official Development Assistance" (ODA) is being questioned and cut in many countries, including Germany. The "Global Gag Rule" further complicates matters for NGOs. While non-US NGOs can still receive funding for global health if they comply with "Protecting Life in Global Health Assistance," many organizations face a moral dilemma.
The international NGO MSI Reproductive Choices, which provides contraception and safe abortion services worldwide, is one such organization affected by the policy. According to its estimates, it expects to lose up to 14 million USD in US funding under the current administration. MSI anticipates that this could deny approximately 2.6 million people access to SRHR services. As a result, MSI estimates that around 2.4 million unintended pregnancies could occur.
The International Planned Parenthood Federation (IPPF) also expects to lose over 61 million USD in funding for sexual and reproductive health programs. Sixteen IPPF health projects in 13 countries are currently affected by the "Global Gag Rule." Some organizations sign the policy to continue their work in a limited capacity.
In an interview with us, Ottmar von Holtz emphasized that Germany has a responsibility to identify NGOs affected by the US funding freeze in partner countries and support them where possible. However, he acknowledged that Germany alone cannot close the entire funding gap.
International and German Stance on the Political Course of the USA
In response to the tightening of the Mexico City Policy at the beginning of Donald Trump's last term, the SheDecides movement was launched by former Dutch Minister for Development Cooperation Lilianne Ploumen. The campaign advocates for the health and self-determination of women* and girls*. Today, it is one of the leading advocacy movements for women's rights worldwide. Germany also supports the campaign.
Ottmar von Holtz emphasizes that now, more than ever, it is crucial to continue supporting initiatives like SheDecides and to remain committed to the issue of sexual and reproductive health and rights (SRHR). He states that Germany has built international credibility through its engagement in the campaign and its continuous work in the field of SRHR.
Advocating for SRHR in international forums is becoming increasingly challenging. According to the Berlin-Institute, resistance against bodily autonomy and LGBTIQ+ rights is consolidating into the so-called anti-gender movement, which is now receiving support at the highest political level in the USA. Achievements such as those of the 1995 Beijing World Conference on Women must be defended. Ottmar von Holtz warns that repressive forces are attempting to roll back existing concepts. This is evident, for example, in the Geneva Consensus Declaration on Promoting Women's Health and Strengthening the Family, which explicitly opposes abortion and was signed by 34 countries, including the USA, in 2020.