While the Trump administration is gutting U.S. foreign aid across the board, programs aimed at women and girls’ sexual and reproductive health will be among those hardest hit. Crisis Group expert Cristal Downing describes why those living in conflict settings could pay the heaviest price.
What is happening?
Since taking office, President Donald Trump has implemented an unprecedented cutoff of U.S. foreign aid. On 20 January 2025, he froze international assistance for 90 days, claiming that this was so the federal government could review and ascertain whether U.S.-supported programs reflect U.S. interests and values. On 24 January, the State Department issued a “stop work” order, pausing all existing and new foreign aid. Secretary of State Marco Rubio initially provided for some exceptions to that order, including food assistance and military support for Egypt and Israel. On 29 January, he issued an additional waiver so that “life-saving humanitarian assistance” including medicine and other supplies would continue to flow, although it is unclear whether this has happened in practice. In early February, in an alleged effort to reduce federal spending, the administration subsumed the U.S. Agency for International Development into the State Department. Toward the end of the month, a flurry of contract cancellations and litigation added further to enormous global uncertainty about the future of U.S. foreign assistance – and led to disruptions in services ranging from famine relief to HIV treatment.
These tectonic changes to U.S. assistance – which in some respects outstrip recommendations in the Project 2025 policy blueprint that anticipated many early Trump administration’s moves – leave observers with little sense of what the administration’s assistance policy will look like. The administration has made clear that the U.S. will be tying assistance more closely to its political agenda. But how specifically that will play out will have to await further announcements.
Still, it is not too early to gauge that within the overall panorama of reduced foreign assistance, programming serving women is at particular risk. In one of its first communications about the freeze, the Trump administration singled out initiatives aimed at gender equality, including sexual and reproductive health, as failing to fulfil the priorities of making “America stronger, safer, or more prosperous”. In the early days of the freeze some experts estimated that it would by itself deprive 11.7 million women and girls of family planning care across the globe – the consequences of which will be felt for years to come. This did not take into account the subsequent wave of contract cancellations, which call into question whether any of the relevant programs has a future.
But beyond the slashing of assistance writ large, and the deprioritisation of funding for gender equality initiatives, there is a further twist when it comes to the provision of health care for women and girls. On 24 January 2025, President Trump signed a presidential memorandum reinstating the “Mexico City policy”. The policy was introduced in the Mexican capital by President Ronald Reagan in 1984 and applied by Republican administrations for a cumulative 21 years since then, with Democratic administrations rescinding it when entering office. The policy has traditionally conditioned U.S. assistance for family planning on a foreign NGO recipient’s commitment to not “perform or actively promote abortion as a method of family planning”. This limits not just what recipient NGOs can do with U.S. funding, but also how they can use other monies. Because the U.S. government reads the phrase “actively promote” to include any counselling that refers to abortion (with exceptions for rape, incest, and to save the patient’s life) critics have labelled the Mexico City policy a “global gag rule”.
How did the Mexico City policy evolve over time?
The Mexico City policy took shape in a complex legal and political landscape surrounding abortion in the U.S. In 1973, the Supreme Court’s ruling in Roe v. Wade constitutionally enshrined the right to abortion. A more conservative Supreme Court overturned Roe in 2022*,* leaving it up to each state to decide whether abortion is legal there. Generally, throughout the Roe and post-Roe eras, the U.S. Republican party has favoured more restrictions on abortion based on the argument that a foetus enjoys the right to life, while Democrats have argued for fewer restrictions, asserting that barring abortion violates the right of women to make choices about their health.
There have been variations in how the rule is administered under Republican administrations since Reagan. Presidents George Bush and George W. Bush both implemented the Mexico City policy in the form which Reagan created. Then, during President Trump’s first administration (2017-2021), he expanded it – applying the rule to all foreign NGOs receiving U.S. aid for the provision of health care, not just family planning. This included NGOs that received U.S. funding for the fight against HIV, maternal and child health, malaria, and nutrition. The expansion supercharged the policy’s impact: while U.S. assistance for family planning amounted to some $600 million in 2020, the Trump administration’s expansion made it applicable to recipients of up to $7.3 billion of health care assistance that year. It is this expanded version of the Mexico City policy that the second Trump administration reinstated.
The [Mexico City] policy has a particularly detrimental effect in countries heavily reliant on U.S. aid to support their health systems.
The policy has a particularly detrimental effect in countries heavily reliant on U.S. aid to support their health systems because of the way it ends up reducing funding, as will be explained below. At the global level, the policy led to an 8 per cent increase in maternal mortality in these countries when it was in effect between 1985 and 2019. It led to a 13 per cent drop in women’s use of contraception when it was active between 2001-2008. In Sub-Saharan Africa – a region that is home to more than one billion people – the health consequences were particularly severe. During President George W. Bush’s tenure from 2001 to 2009 – when the rule pertained to U.S. funding for family planning services – rates of pregnancy in countries that received large amounts of U.S. family planning aid rose by 12 per cent and abortions increased by 40 per cent, due in part to the loss of access to contraception. These effects reversed during the Obama administration, from 2009-2017, when the policy was not in effect: rates of abortion fell and contraceptive use increased.
How has the policy affected women and girls in conflict settings?
NGO practitioners say the policy has an outsized effect on the health care women and girls can access in conflict settings, where insecurity, scarcity of health care, and high rates of sexual violence are endemic. For example, in communities controlled by armed groups in Colombia, girls and women often enter relationships with group members in an attempt to ensure family protection or economic sustenance. Community members in Cauca told Crisis Group that girls as young as twelve or thirteen are recruited by armed groups. In some cases, commanders consider girls to be their “property”, allowing for all manner of abuse, including the practice of charging a fee for fellow group members to “rent” the girl. Parents bring daughters of this age to NGO clinics for long-term contraception because they know the girls will eventually be raped by or enter some sort of association with armed group members. In this setting, the need for sexual and reproductive health care is particularly acute – and the Mexico City policy means it is less available.
The policy also reduces the provision of health care in refugee camps, where civilians are often forced to seek shelter during warfare. Consider Cox’s Bazar in Bangladesh – home to almost one million Rohingya refugees from Myanmar – where armed gangs are known to abduct Rohingya women and girls, rape them, and then demand the survivor marry the perpetrator of the assault. Pregnancy rates tend to be high: 10 per cent of women and girls of reproductive age (fifteen to 49) in the camps were pregnant in 2019 alone. Prenatal complications such as anaemia and eclampsia are the leading cause of death among adolescent girls. Cox’s Bazar also has some of the highest rates of maternal mortality in the world. This is largely attributed to poor sanitary conditions, which can lead to bladder infections and other complications. NGO-provided healthcare is crucial for helping women and girls in Cox’s Bazar and similar refugee camps navigate these risks, but providers aver that Mexico City inhibits the quality of services they can offer their patients.
It is not just in camps that the policy can diminish the health care on offer. In rural conflict-affected areas, one clinic may offer a range of health services, from contraception and cervical cancer screenings to abortion. They don’t just serve women: they are often the sole provider for local populations. These sorts of clinics are common in countries like Ethiopia, a country that was hard hit by the Mexico City policy during Trump’s previous tenure. The two largest health care organisations in the country opted not to comply with the policy because they did not see a way to stop providing abortion as part of their health care services without reducing the quality and effectiveness of care. As a result, they lost U.S. funding.
This had consequences for all their patients. The organisations shut down youth programs, mobile outreach and technical support to the public health sector across Ethiopia, including in rural areas beset by conflict, such as Oromia, Tigray and Amhara. Others ceased operating mobile clinics in hard-to-reach places where they had offered HIV care and post-abortion services (which include post-miscarriage care). This left Ethiopian women with limited options, including unsafe pregnancy termination, which can lead to complications and death. In some cases they were forced to travel to cities for safe reproductive care – a dangerous undertaking in many parts of the country due to ongoing conflict.
Is the Mexico City policy well understood, and are compliance requirements straightforward?
No, and for that reason the Mexico City policy impinges on access to services even when the policy theoretically allows for some flexibility. NGO practitioners often do not understand that the policy contains exceptions for abortion in cases of rape, incest, and to save the patient’s life. Even when they do, they sometimes worry that if U.S. government personnel disagree that exceptions applied in a particular case, the organisation could lose its funding. According to NGO workers, in some cases organisations in places like Cox’s Bazar have refrained from providing abortions to survivors of rape.
Moreover, there is widespread confusion about whether the policy bans emergency contraception (sometimes known as “the morning-after pill”). It does not, but that fact is not widely known. As a result, some practitioners have mistakenly refused to provide this medication. Confusion over the coverage of the rule has also led organisations to withhold post-abortion care, resulting in patients bleeding to death. One NGO staffer said widespread misunderstanding is the Mexico City policy’s “worst effect”.
The U.S. has disseminated educational materials to counter misunderstandings about the Mexico City policy, albeit to little effect. Most of the literature focuses more on what is not permitted than what kinds of activities are permissible. Sexual and reproductive health organisations say over-emphasis on banned activities contributes to over-implementation of the rule. The U.S. has also not made clear under what conditions organisations could apply for and be granted an exemption to the Mexico City policy: only two organisations requested that the Department of State issue such an exemption under the first Trump administration and both were denied for reasons that the department did not disclose.
Compliance burdens are another way in which the Mexico City policy reduces the provision of health care. Recipients must file regular reports that take hours to complete, as well as conduct on-site visits to ensure health care providers are conforming to the restrictions. In some cases this entails dispatching staffers on a monthly or bi-monthly basis to multiple remote community clinics; travel between them can take days. In regions mired in conflict, these journeys can be unsafe. Some NGOs hire personnel for this purpose; in other cases, existing employees carry out such visits in addition to their regular work.
Other compliance issues relate to the exceptions to the policy for rape, incest, and to save the life of the pregnant patient. Across the world, health care providers reportedly become nervous about providing proof that would satisfy the U.S. government. NGOs pointed out to Crisis Group that it was “absurd” and “unrealistic” to think that every provider would be able to gather such proof, especially in conflict contexts where forensic evidence collection, especially to prove sexual violence, is known to be enormously difficult. Organisations are forced to reduce programming in order to allocate funds – including from non-U.S. donors – to compliance instead of service provision.
As U.S. foreign aid undergoes massive changes across the board, how will the Mexico City policy fit into the overall picture?
We don’t yet know. The effects of seemingly monumental changes may dwarf those of the Mexico City policy, but even so the rule stands out, as it remains one of the only U.S. conditions that applies to both its own and other donors’ funds. Moreover, if the administration follows Project 2025 recommendations on this file, it could wind up broadening the Mexico City policy in two key ways. First, it might stretch the policy so it does not just pertain to foreign NGOs – which was historically the case when the rule was in effect – but rather all recipients of U.S. foreign aid. This would include U.S. NGOs and multilateral organisations such as UN agencies, which were previously exempted. Secondly, the plan proposes that the policy apply not only to health care funding but to all foreign aid, including humanitarian assistance.
If implemented, these expansions would mean that a much larger swathe of the international aid sector will be forced to choose to comply and accept whatever U.S. funding is on offer, or opt not to accept U.S. funding at all. NGO staffers who work in conflict environments are particularly concerned about the expansion to humanitarian assistance, which encompasses aid that is meant to be rapidly deployed to benefit populations embroiled in conflict. Here, the U.S. has been the largest bilateral donor at the global level, having provided $13.5 billion in global humanitarian aid in 2023, more than three times the amount given by the second-largest contributor, Germany. In fact, one of the reasons that humanitarian funding was previously protected from the Mexico City policy was to ensure that its layers of bureaucratic red tape did not interfere with the rapid delivery of aid in crises.
If the Trump administration applies the Mexico City policy to the UN – which receives approximately one quarter of the U.S. foreign aid budget annually – the organisation will be forced to choose between adapting its work to keep U.S. financial contributions, and trying to secure alternative funding, for which competition will be fierce. UN entities brought in $67 billion in 2023, and the U.S. is the UN system’s largest contributor, having contributed almost $13 billion that year. Of that total, approximately $9 billion were so-called “voluntary” contributions that are most frequently used to support programs implemented by agencies such as the United Nations Commission for Refugees and the Joint United Nations Programme on HIV/AIDS. Placing restrictions on all U.S. aid would also affect the use of funding from other UN member states, even if this funding was allocated to other projects implemented by the same UN entity. This could cause donors to avoid allowing the use of their funds alongside U.S. contributions and making it more difficult to share the burden of supporting UN operations.
What should be done?
With so much up in the air about the future of U.S. assistance, it is difficult to offer concrete advice, but at the very least those with influence over the administration should urge them to avoid expanding the Mexico City policy beyond its present contours. If that proves impossible to stop, then the next line of effort should be to exempt humanitarian assistance – consistent with past practice – to make sure that the trade-offs the policy forces recipients to make do not delay or reduce life-saving support.
Whatever version of the Mexico City policy is in place, it is essential that the U.S. provide clear, concise and realistic implementation guidance. This should include as much information on what is permitted by the policy as information on prohibited activities, so that organisations can continue permissible activities without disruption. The educational materials should also provide clarity on the conditions in which organisations can request exemptions. An obvious example would be organisations working in conflict contexts where the demand for sexual and reproductive health care is high, and sending officers to remote communities to ensure compliance presents almost unsurmountable challenges.
Other donors – already under huge strain – should quickly consider what they can do to fill the gaps left by the U.S. across the aid sector, including on sexual and reproductive health. To be sure, no entity can easily make up for the vast cutback in U.S. funding. Budgets across Europe and elsewhere are also tighter than during the last Trump term, when some member states stepped in to fill some of the gaps left by the Mexico City policy.
But non-U.S. donors can commit their spending in ways that can help mitigate the fallout, for example by concentrating support toward small organisations that are likely to be hardest hit by both the overall withdrawal of U.S. aid and the Mexico City policy. Member states that have prioritised gender in their foreign policies and have made commitments to sexual and reproductive health could lead. These nations include Germany or France with their feminist foreign policies; Norway with its commitment to global gender equality; and Canada with its feminist international assistance policy. EU institutions also already have commitments to sexual and reproductive health that would allow them to allocate funding in this way. Elsewhere in Europe, the UK could build on its commitment to supporting civil society and promoting sexual and reproductive health by expanding its sexual health funding to support NGOs in conflict contexts. The British government did this in East African countries including Sudan last year.
Donors at the UN could focus on global or country-based pooled funds that allow UN entities more flexibility in responding to specific needs. For example, the Multi-Partner Trust Fund in Colombia allows individual donors to contribute and sit on a decision-making board, alongside UN entities and the government of Colombia, to decide how to allocate their amassed contributions. A funding vehicle like this would allow donors to target initiatives that are most affected by the Mexico City policy.
Similarly, at the UN, countries and NGOs that support abortion as an essential part of health care may find it helpful to coalesce now behind robust information campaigns to promote their position. Whereas for many years countries expressed their positions for and against abortion rights at the UN in a relatively civil manner, under the first Trump administration the U.S. led more outspoken coalitions that successfully rolled back political commitments on sexual and reproductive health. Such a coalition was highly vocal at the annual convening of the Commission on the Status of Women (CSW) in 2019, including by interrupting meetings and protesting outside the UN building. The Trump administration also circulated a declaration “protecting the right to life” to which 32 other nations signed on. Supporters of sexual and reproductive health should be cognisant that this kind of campaigning is likely at the next CSW from March 10 to 21 and work together to protect funding decisions made by negotiation in UN committees from being unduly swayed by U.S.-led political messaging.
Reproductive rights supporters might also consider how several European governments, Canada, and a group of NGOs created the SheDecides platform in 2017 to counter U.S. global influence on this issue. This global platform could continue to help ensure that funding from non-U.S. sources is guided to where it’s most needed, as well as raise awareness about the full spectrum of reproductive health care.
Finally, private donors will have a key role to play. Foundations commit millions of dollars per year to sexual and reproductive health programming, often alongside other priorities like education, water and nutrition. They can also be more agile than governments in rapidly committing funding. Such entities could therefore play an important role in responding not only to the withdrawal of sexual and reproductive health funding but also to the broader fluctuation in humanitarian funding that is likely after April 2025.