Family Planning and U.S. Foreign Policy: An Analysis of the Protecting Life in Global Health Assistance Policy in sub-Saharan Africa

Abstract

The Mexico City Policy is one of the most influential policies surrounding U.S. aid to foreign non-governmental organizations (NGOs). First announced by President Ronald Reagan in 1984, the Mexico City Policy is an executive order that prohibits U.S. family planning assistance to any foreign NGO that performs abortion or promotes it as a method of family planning. In 2017, President Donald Trump reinstated and expanded the Mexico City Policy as the Protecting Life in Global Health Assistance (PLGHA) policy. While past iterations of the Mexico City Policy only applied to U.S. family planning assistance, the PLGHA policy expanded these restrictions to all U.S. global health assistance, bringing more health domains and foreign NGOs under its purview than ever before. This new iteration of the policy calls for further scholarly investigation, as it marks a significant expansion in the policy’s scope of funding and application.

Through a mixed methods approach, this thesis explores the impact of the PLGHA policy on contraceptive use in four countries in sub-Saharan Africa — Ethiopia, Kenya, Niger, and Uganda. In the quantitative analysis, I use logistic difference-in-difference regressions to determine the policy’s impact on contraceptive use among women. I find that the PLGHA policy had a major effect on contraceptive use, resulting in a decline in modern contraceptive use and a rise in traditional contraceptive use. After the policy change, women in countries with a high exposure to the PLGHA policy had significantly lower rates of using any modern method of contraception compared to women in countries with a low exposure to the policy. Conversely, women in countries with a high exposure to the PLGHA policy had significantly higher rates of using any traditional method of contraception compared to women in countries with a low exposure to the policy.

To understand why this change occurs, this thesis turns to qualitative interviews with key stakeholders in healthcare and the NGO sector. In the qualitative analysis, I find that shifts in contraceptive use among women at the individual level can be explained by the PLGHA policy’s impact on foreign NGOs at the organizational level. Under the PLGHA policy, foreign NGOs experienced major disruptions, which limited the availability of family planning services. I identify three key mechanisms that caused these disruptions: (1) the loss of U.S. funding, (2) the chilling effect, and (3) disruptions to partnerships.

This thesis ends with a series of policy recommendations to a diverse set of stakeholders — foreign NGOs, the international community, and the U.S. government. These policy recommendations seek to aid policymakers and activists in their efforts to counteract the harms of the PLGHA policy and its unprecedented expansion of the Mexico City Policy. Ultimately, this thesis advances the growing body of literature on the PLGHA policy. Whereas past studies have focused on individual countries or tend to use a single methodology, I conduct a cross-country analysis with a mixed method approach, expanding the breadth and depth of analysis. Notably, my thesis represents the first mixed methods study on the PLGHA policy, bringing together quantitative and qualitative insights to investigate its far-reaching impacts on the use and provision of contraceptives, a crucial aspect of family planning.