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Guttmacher study reckons with damage done by Trump-era restrictions on women in Ethiopia, Uganda

by Jodi Enda May 20, 2024

This article was republished from a Fuller Project newsletter on May 20, 2024. Subscribe here.


Former President Donald Trump brags about packing the Supreme Court with enough anti-abortion justices to overturn Roe v. Wade. What he doesn’t mention is that he also imposed tougher abortion restrictions than any other president on foreign organizations that accept U.S. aid — rules that led to an estimated 108,000 maternal and child deaths during his four-year term.

Shortly after he took office, Trump expanded the so-called Mexico City Policy, which every Republican president since Ronald Reagan has invoked as a way to reduce abortions overseas. The policy, called the “global gag rule” by its critics, prohibits foreign organizations that accept U.S. money from providing abortions or related services, such as counseling. Studies show it doesn’t work as advertised. 

Abortion-rights advocates in some of the world’s poorest countries reported that under Trump, some medical providers lost so much money that they closed health clinics. Some stopped providing contraceptives and testing and treatment for HIV, cancer and other diseases. Without birth control, more women faced unintended pregnancies and underwent abortions, many of them unsafe, even deadly. 

reported earlier this year about the serious ramifications of this policy and an older, more permanent U.S. law known as the Helms Amendment, which prohibits foreign governments and organizations from using U.S. money to pay for abortions or to “motivate or coerce” anyone to have one.

Last month, the Guttmacher Institute, a research organization that supports sexual and reproductive health and rights, released a report about the consequences of Trump’s restrictions in Uganda and Ethiopia, two countries with very different abortion laws. I interviewed Elizabeth Sully, principal research scientist and one of the report’s authors, about the findings. Our discussion has been edited for length and clarity.


Fuller Project (FP): Why did you focus on those two countries?

Sully: They provided an interesting contrast where, in Ethiopia, abortion is largely available and permitted and where the government has really been trying to expand access… and Uganda is a country where abortion is heavily restricted and very hard to access. 

Showing the ways in which even [in] a setting like that (Uganda), this policy still can lead to impacts on reproductive health care was really important. And they’re both countries that are very reliant on U.S. global health funding.

FP: What were the key findings of this research?

Sully: We found that in both countries, the global gag rule policy was associated with stalled progress in both the provision of reproductive health services and in reproductive health outcomes. Community health workers were less likely to be providing family planning services as part of their set of services that they were offering. 

In Ethiopia, we saw even bigger impacts in the provision of family planning services. There were increased contraceptive stock-outs (shortages), there were lower levels of integration of family planning care with post-abortion care services and disruptions in mobile outreach services (in rural areas).

FP: Explain why there were fewer contraceptives; this policy really targets abortions.

Sully: As soon as it comes into effect, an organization is left with the decision to sign and comply with a policy, or not sign and not comply with the policy — and lose their money. And so I think when an organization is confronted with that decision, often if they’re one that is engaged in providing, referring or advocating for abortion and they feel that is fundamental to the services that their organization offers… they choose to lose the money.

That leads to declines in the services that they’re actually able to offer. One of the really big things that was impacted, that U.S. funding had been providing in both countries, was mobile outreach services. 

What that means is you actually have a team of staff from that NGO (nongovernmental organization) who are driving to the most rural, hard-to-reach areas to health facilities where staff aren’t trained necessarily to provide implants or IUDs and offering those services to women. And so all of a sudden, they’re not coming; those people aren’t getting those methods.

FP: Were there more unintended pregnancies, and were there more or fewer abortions?

Sully: Our study wasn’t long enough to really pick that up. (Previous studies of the Mexico City Policy have concluded it leads to increased abortion rates. The most widely quoted, by Stanford University, reported that during George W. Bush’s eight years in office, abortions rose 40 percent in countries that were “highly exposed” to the restrictions.) 

What we did find in Uganda, we looked at facilities providing post-abortion care — how many people were coming in with complications from unsafe abortions? And those increased in Uganda. We saw more people coming with abortion complications than we would have expected. And so it could be that there were more abortions or it could be that more abortions were unsafe. 

FP: You focused on two countries. How does this translate to all the countries that receive family planning and health money from the U.S.?

Sully: There are other countries where there’s even a greater reliance on U.S. funding for their family planning services and for their global health more generally. I think those harms were probably much greater in other settings where there weren’t other donors able to step up and fill those gaps. 

FP: So what does this tell us going forward?

Sully: Ideally, we’d like legislation to stop this from coming back into effect, but we’re not in a place where that’s realistic and going to happen anytime soon. And so I think the big question is, what’s going to happen [with the election] in 2024?

Sometimes people have this negative, pessimistic perception that Americans aren’t really concerned with what’s happening with their foreign aid dollars and in the lives of people overseas. What’s different, maybe in 2024, is that in 14 states in this country, people have learned what it is like to live under a legal environment where abortion is not allowed and where their reproductive rights are being threatened.

Maybe the hope is, people’s direct experiences of what it is like to live in an environment like that becomes more clear, and they can understand the implications of that globally as well.

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