{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,30]],"date-time":"2026-10-30T08:36:25Z","timestamp":1793349385279,"version":"4.5.0"},"reference-count":39,"publisher":"BMJ","issue":"5","license":[{"start":{"date-parts":[[2023,5,5]],"date-time":"2023-05-05T00:00:00Z","timestamp":1683244800000},"content-version":"unspecified","delay-in-days":4,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"name":"Anonymous foundation","award":["NA"],"award-info":[{"award-number":["NA"]}]},{"DOI":"10.13039\/100004439","name":"William and Flora Hewlett Foundation","doi-asserted-by":"publisher","award":["2017-6475"],"award-info":[{"award-number":["2017-6475"]}],"id":[{"id":"10.13039\/100004439","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000008","name":"David and Lucile Packard Foundation","doi-asserted-by":"publisher","award":["2020-69738; 2019-69000; 2017-66627"],"award-info":[{"award-number":["2020-69738; 2019-69000; 2017-66627"]}],"id":[{"id":"10.13039\/100000008","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2023,4,6]]},"published-print":{"date-parts":[[2023,5]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To assess the impacts of the Protecting Life through Global Health Assistance policy (otherwise known as the expanded global gag rule (GGR)) on women\u2019s 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Pre\u2013post analysis and difference-in-difference analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>Six regions of Ethiopia (Tigray, Afar, Amhara, Oromiya, SNNPR and Addis Ababa).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>Panel of 4909 reproductive-age women recruited from the Performance Monitoring for Accountability 2018 survey, administered face-to-face surveys in 2018 and 2020.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Measures<\/jats:title>\n                    <jats:p>We assessed impacts of the GGR on contraceptive use, pregnancies, births and abortions. Due to the 2019 \u2018Pompeo Expansion\u2019 and widespread application of the GGR, we use a pre\u2013post analysis to investigate changes in women\u2019s 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>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\u2013post analysis revealed statistically significant declines from 2018 to 2020 in the use of LARCs (\u22120.9, 95%\u2009CI: \u22121.6 to \u20130.2) and short-acting methods (\u22121.0, 95%\u2009CI: \u22121.8 to \u20130.2). 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 (\u22121.5, 95%\u2009CI: \u22122.9 to \u20130.1) and short-acting method use (\u22121.7, 95%\u2009CI: \u22123.2 to \u20130.1) as compared with less-exposed women.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2022-063099","type":"journal-article","created":{"date-parts":[[2023,5,5]],"date-time":"2023-05-05T10:21:18Z","timestamp":1683282078000},"page":"e063099","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":5,"title":["Impact of the global gag rule on women\u2019s contraceptive use and reproductive health outcomes in Ethiopia: a pre\u2013post and difference-in-difference analysis"],"prefix":"10.1136","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0736-2237","authenticated-orcid":false,"given":"Elizabeth A","family":"Sully","sequence":"first","affiliation":[{"name":"Guttmacher Institute, New York city, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Assefa","family":"Seme","sequence":"additional","affiliation":[{"name":"School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Solomon","family":"Shiferaw","sequence":"additional","affiliation":[{"name":"School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Doris W","family":"Chiu","sequence":"additional","affiliation":[{"name":"Guttmacher Institute, New York city, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Suzanne O","family":"Bell","sequence":"additional","affiliation":[{"name":"Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Margaret","family":"Giorgio","sequence":"additional","affiliation":[{"name":"Guttmacher Institute, New York city, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2023,5,5]]},"reference":[{"key":"2025120600025358000_13.5.e063099.1","article-title":"The unprecedented expansion of the global Gag rule: trampling rights, health and free speech","volume":"23","author":"Ahmed","year":"2020","journal-title":"Guttmacher Policy Rev"},{"key":"2025120600025358000_13.5.e063099.2","unstructured":"Senior State Department Officials . Background briefing: senior administration officials on protecting life in global health assistance, n.d.. Available: https:\/\/www.state.gov\/background-briefing-senior-administration-officials-on-protecting-life-in-global-health-assistance\/"},{"key":"2025120600025358000_13.5.e063099.3","unstructured":"Pompeo M . Remarks to the press. U.S. department of state, 2019. Available: https:\/\/www.state.gov\/remarks-to-the-press-7\/"},{"key":"2025120600025358000_13.5.e063099.4","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0231960","article-title":"Investigating the early impact of the Trump administration\u2019s global Gag rule on sexual and reproductive health service delivery in Uganda","volume":"15","author":"Giorgio","year":"2020","journal-title":"PLoS One"},{"key":"2025120600025358000_13.5.e063099.5","unstructured":"PAI . So far so bad: the wide-ranging impacts of the global Gag rule happening now, 2019. 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