US foreign aid swings may be costing lives abroad, data analysis suggests

Maternal deaths rise by around 11% in countries that rely on US aid following a switch from a Democratic to a Republican administration, suggest the findings of a data analysis published in the open access journal BMJ Global Health. This is equivalent to around 45 additional deaths for every 100,000 live births, eroding a fifth of the decline in global maternal deaths that has been achieved since 1985, conclude the researchers.

How US policy shapes global aid

US foreign aid for family planning and reproductive health services has been heavily influenced by changes in the implementation of the Mexico City Policy—first introduced as the US Policy on Population Assistance under the Reagan administration in 1984, and often referred to as the Global Gag Rule (GGR), explain the researchers.

The policy prohibits disbursal of US aid for family planning to overseas non-governmental organizations that provide, make referrals to, or promote abortion-related services or information, even when these services are financed through non-US funds.

The policy was rebranded as the Protecting Life in Global Health Assistance policy and expanded to apply to all US global health assistance during President Trump’s first term of office in 2017.

Study design and data sources

To estimate the impact of shifts in funding on maternal deaths, the researchers used data from the World Bank’s World Development Indicators for every year between 1985 and 2023 to measure the maternal mortality ratio for 150 countries.

This is defined as the number of 15–49 year-old women who die from pregnancy-related causes while pregnant or within 42 days of a termination for every 100,000 live births.

The data were also used to capture the intermediate effects of the GGR on contraception and the percentage of births attended by skilled health professionals.

The GGR was activated during the Republican administrations of 1985–92, 2001–08, and 2017–20, and deactivated during the Democratic administrations of 1993–2000, 2009–16, and 2021–24.

Differences in aid flows by party

Analysis of the data between 1985 and 2024 indicates that aid for family planning is, on average, 48% higher under Democratic than under Republican administrations.

In those countries most reliant on financial assistance aid, receipts plummet by around 34% per head of the population during Republican administrations. The corresponding falls are about 10% in those countries less reliant on this aid.

While heavily aid-reliant countries start from substantially higher levels and remain worse off throughout, declines in maternal deaths have been large over the past four decades across the board, the estimates indicate.

The gap in the average maternal mortality ratio between the most and least reliant countries ranges from roughly 445 additional deaths/100,000 live births to around 120/100,000 live births. The gap narrows most noticeably when the GGR isn’t in force.

Impact on maternal deaths worldwide

For those countries with above average reliance on US family planning aid, a Republican presidency is associated with a 10.5% increase in maternal deaths, equivalent to approximately 45 lives lost for every 100,000 live births.

“The effect is consistently observed across regions including Africa, Latin America, and Asia, indicating that the detrimental impact of the policy is not confined to a single geographical context,” point out the researchers.

“Although Africa experiences the largest impact in absolute terms, the percentage impact is greatest in Latin America (16%), followed by Asia (15%), and Africa (7%),” they add.

A US$1 per head higher reliance on US aid for reproductive and maternal health is associated with 25 additional maternal deaths/100,000 live births under the GGR, estimate the researchers.

“The magnitude of this effect suggests that the GGR erodes a meaningful share of the progress made in reducing maternal mortality over recent decades,” they suggest.

Effects on contraception and birth care

What’s more, the GGR also decreases the proportion of skilled birth attendance by around 1%, and reduces contraceptive prevalence by around 2%, both of which likely contribute to the rise in maternal deaths, say the researchers.

This study is based on estimates, and the researchers acknowledge various limitations to their analysis, including that maternal deaths in the World Development Indicators may be under-reported or misclassified, particularly in low and middle income countries with less well developed reporting infrastructures.

But they point out, “An estimated 11% increase in maternal deaths corresponds to roughly one-fifth of the global decline in maternal mortality achieved between 1985 and 2024.”

They add, “Maternal mortality represents only the visible portion of a much larger set of reproductive health risks, including hemorrhage, sepsis, reproductive tract infections, uterine perforation, cervical tears, chronic pain, infertility and elevated risks in subsequent pregnancies.”

Policy shifts and future vulnerability

During Trump’s second term, substantial cuts have been made to foreign aid and it’s estimated that over 90% of all USAID awards for family planning and reproductive health programs have been terminated, highlight the researchers.

The U.S. is not the only nation, however, to have cut overseas development aid, they point out, concluding, “These results underscore the vulnerability of health systems to abrupt shifts in donor policy and highlight the importance of stable international support for reproductive health services.”