Impact of the global gag rule on women's contraceptive use and reproductive health outcomes in Ethiopia: a pre-post and difference-in-difference analysis

Abstract

Objective: To assess the impacts of the Protecting Life through Global Health Assistance policy (otherwise known as the expanded global gag rule (GGR)) on women's sexual and reproductive health (SRH) in Ethiopia. The GGR prohibits all non-US non-governmental organisations (NGOs) receiving US Government global health funding from providing, referring or advocating for abortion.

Design: Pre-post analysis and difference-in-difference analysis.

Setting: Six regions of Ethiopia (Tigray, Afar, Amhara, Oromiya, SNNPR and Addis Ababa).

Participants: Panel of 4909 reproductive-age women recruited from the Performance Monitoring for Accountability 2018 survey, administered face-to-face surveys in 2018 and 2020.

Measures: We assessed impacts of the GGR on contraceptive use, pregnancies, births and abortions. Due to the 2019 'Pompeo Expansion' and widespread application of the GGR, we use a pre-post analysis to investigate changes in women's reproductive outcomes. We then use a difference-in-differences design to measure the additional effect of NGOs refusal to comply with the policy and the resulting loss in funding; districts are classified as more exposed if organisations impacted by lost funding were providing services there and women are classified based on their district.

Results: At baseline, 27% (n=1365) of women were using a modern contraceptive (7% using long-acting reversible contraceptive methods (LARCs) and 20% using short-acting methods. The pre-post analysis revealed statistically significant declines from 2018 to 2020 in the use of LARCs (-0.9, 95% CI: -1.6 to -0.2) and short-acting methods (-1.0, 95% CI: -1.8 to -0.2). These changes were deviations from prior trends. In our difference-in-differences analysis, women exposed to non-compliant organisations experienced greater declines in LARC use (-1.5, 95% CI: -2.9 to -0.1) and short-acting method use (-1.7, 95% CI: -3.2 to -0.1) as compared with less-exposed women.

Conclusions: The GGR resulted in a stagnation in the previous growth in contraceptive use in Ethiopia. Longer-term strategies are needed to ensure that SRH progress globally is protected from changes in US political administrations.

Keywords: health policy; public health; reproductive medicine.

Figure 1

Sample inclusion and loss-to-follow-up. *Baseline survey included all regions in Ethiopia. †Refused at follow-up (n=65), not at home (n=50), could not locate respondent or get information on current residence (n=14), died (n=11), incapacitated (n=4), other (n=33).

Figure 2

Pre–post estimates of the impact of the global gag rule on contraceptive use and births in Ethiopia (2018–2020) and prior trends in PMA data (2014–2017). Unintended pregnancy was excluded due to inconsistent measurement of pregnancy between prior PMA data and out study. Prior PMA data only accounts for women’s pregnancy status at the time of the interview. Our analysis uses data from a contraceptive calendar to account for all reported pregnancies and their intention status in the 12 months prior to the survey interview. As a result, we are unable to look at prior trends in unintended pregnancy that would be comparable to our pre–post model predicted probabilities. LARC, long-acting reversible contraceptive; PMA, Performance Monitoring for Accountability.

Figure 3

Difference-in-difference estimates of the impact of the global gag rule on contraceptive use and births in Ethiopia, 2018–2020. LARC, long-acting reversible contraceptive.