New York University

UNDERGRADUATE THESIS

Unintended Consequences: U.S. Foreign Policy’s Eﬀect on Sexual and Reproductive Health and Rights Access Internationally

Author: Professor:

Imogen Fordyce Shanker Satyanath Abstract

This study examines whether the Mexico City Policy, a conservative driven U.S. foreign policy mechanism, colloquially known as the Global Gag Rule, which intends to diminish access to abortions internationally, has an unintended negative effect on access to sexual and reproductive health rights and services (SRHR) for women worldwide. Operationalizing maternal mortality ratio, contraceptive prevalence, the percentage of births with a skilled attendant present, and adolescent fertility rate as indicators of sexual and reproductive health access, this study applies a difference in difference design to observe the level of significance that the policy’s presence has, or not, on SRHR worldwide, between President Bush’s tenure when the policy was active, and President Obama’s when it was not. The study includes 112 countries, grouped by their relative exposure to the policy, low (control) or high (treatment), based on their historic level of reproductive health funding from the U.S.. The results revealed that both maternal mortality ratio and the presence of a skilled birth attendant were significantly affected by the policy’s removal. However, the other indicators were not, a result that with further investigation suggested other U.S. foreign policy programs may be compounding the effects of the Mexico City Policy, and further reducing access to SRHR support. An outcome that this study hopes will provoke further exploration of the collective effect U.S. foreign policy has on SRHR access, and what the scale of the negative repercussions of this may be for women worldwide.

1 Acknowledgements

I would like to express my sincere gratitude to Professor Shanker Satyanath for his guidance, support, and feedback, without which this research project would not have been possible. I would also like to thank Nejla Asimovic for continually providing vital technical assistance and advice that helped shape this project in to what it is today. Finally my thanks go to everyone at Friends of UNFPA for constantly reminding me why I embarked upon this thesis topic, and to all those who have supported me throughout this process for helping me see it through to the end.

2 Contents

1 Introduction 4 1.1 Key Concepts ...... 5

2 Background 6 2.1 The History of the Mexico City Policy ...... 6 2.2 Signiﬁcance Today ...... 8

3 Literature Review 9

4 Hypotheses 13

5 Data Description 15

6 Methodology 20

7 Results and Analysis 22

8 Future Implications 29

9 Conclusion 30

Appendices 36

A Figures 36 A.1 Parallel Trends Confirmations: Maternal Mortality Ratio ...... 36 A.2 Parallel Trends Confirmations: Skilled Birth Attendant ...... 36 A.3 Parallel Trends Confirmations: Adolescent Fertility Rate ...... 37 A.4 Regional Coefficient Plots ...... 38

3 1 Introduction

This thesis seeks to explore the relationship between U.S. partisan politics, the internationally focused federal policies that partisanship has brought to life, and the repercussions that these policies have had on a global scale. Specifically, this thesis concerns the Mexico City Policy, also known as the Global Gag Rule. Conceived by President Reagan’s Republi- can administration, the Mexico City Policy has been enacted by every Republican president since its creation, and rescinded by every Democratic president in turn. Designed to appeal to domestic Republican supporters, the Mexico City Policy imposes a key debate of U.S. domestic politics, abortion rights and pro-choice vs. pro-life sentiments, on federal funding to non-governmental organizations operating internationally. When enacted by a U.S. executive, the Mexico City Policy sanctions the removal of all U.S. reproductive health governmental funding from any foreign non-governmental organization working internationally that practices or “promotes” abortion services through activities such as abortion counselling, referrals and education.1 While it is clear that the Mexico City Policy intends to affect the availability of abortion services internationally, this thesis considers the unintended effect that the policy has on access to other sexual and reproductive health and rights services internationally. In order to explore this relationship, this thesis makes the critical assumption that sexual and reproductive health and rights access can be measured through indicators of women’s health and family planning activities, and that a significant relationship between these indicators and the enactment of this Mexico City Policy, reflects the policy having a significant effect on sexual health and reproductive health services and access for women internationally. Specifi- cally, this thesis operationalizes Maternal Mortality Ratio (MMR), contraceptive prevalence rate, the percentage of births with a Skilled Birth Attendant present, and the adolescent fertility rate in a country to see the effect the policy’s enactment has on the treatment nations in this study. The results of this study suggest that there is in fact a significant relationship

1"The Mexico City Policy: An Explainer,” The Henry J. Kaiser Family Foundation, October 3, 2019, https://www.kﬀ.org/global-health-policy/fact-sheet/mexico-city-policy-explainer/

4 between the Mexico City Policy’s enactment and both Maternal Mortality Ratio and the presence of a Skilled Birth Attendant during delivery. Interestingly this significance is not present in the case of both contraceptive prevalence and adolescent fertility rate, an outcome to be explored more deeply in Section 7: Results and Analysis. In its exploration of the relationship between the Mexico City Policy and access to sexual and reproductive health and rights services, aside from abortion, this thesis will first intro- duce the key concept of sexual and reproductive health and rights. Following this, contextual information on the history of the Mexico City Policy, and its significance today will be provided. An extensive review of existing literature that relates to the key thesis question will take place, considering how this study will contribute to the existing analysis of the Mexico City Policy and the role that U.S. domestic and foreign policy plays in the field of women’s health and rights, after which our empirical analysis will begin. Each key hypothesis will be provided, as will each variable and data source. From this the methodology of our study and the results of the analysis will be explored. Ultimately, reaching the conclusion that the Mexico City Policy does have an unintended effect on access to sexual and reproductive health and rights services internationally, a finding that warrants further exploration in the future.

1.1 Key Concepts

Sexual and Reproductive Health and Rights With the exploration of this thesis focusing on the effect that the Mexico City Policy has on various indicators of access to sexual and reproductive health and rights services, it is important to define what this umbrella term, sexual and reproductive health and rights, often abbreviated to SRHR, encompasses. First introduced at the 1994 United Nations International Conference on Population and Development (ICPD) in Cairo, the term ‘sexual and reproductive health and rights’, is defined by the World Health Organization as a state of complete physical, mental and

5 social well-being in all matters relating to reproductive function.2 The debut of this term in 1994 established a new, comprehensive, approach to women’s health that looked both at physical concerns such as maternal health, sexually transmitted infections and gender-based violence, but also social well-being through sexual health education, family planning services and post-natal support.3 McIntosh and Finkle (1995) mark this as a turning point in the global attitude towards population policy, “giving prominence to reproductive health and the empowerment of women” rather than simply controlling population growth.4 While the Mexico City Policy seeks to impact just one strand of the myriad of services oﬀered under sexual and reproductive health and rights care, abortion, this thesis considers the other physical, mental and social support services, including maternal mortality, sexual education and family planning support, it may be infringing upon in addition.

2 Background

2.1 The History of the Mexico City Policy

Named after the city in which it was announced, the Mexico City Policy was ﬁrst introduced at the United Nations International Conference on Population and Development in Mexico City in 1984. Originally enacted under the presidency of Ronald Reagan, the policy restricts the use of U.S. federal funds (most commonly issued by USAID) by foreign non-governmental organizations who oﬀer services relating to abortion provision and promotion.5 In order to remain eligible for U.S. funding, upon which many organizations are reliant, non-governmental organizations are required to agree to these terms, which suppress not only abortion practice but also the referral of women to abortion clinics, counselling on abortion

2“What is SRHR,” Women Win, January 1, 2019, https://guides.womenwin.org/srhr/what-is-srhr 3UNFPA (2019). Supplement to Background Paper on Sexual and Reproductive Health and Rights: An Essential Element of Universal Health Coverage. United Nations Fund for Population Activity. 4C. Alison McIntosh and Jason L. Finkle. 1995. "The Cairo Conference on Population and Development: A New Paradigm?" Population and Development Review 21, 223. 5United Nations International Conference on Population. 1984. Policy Statement of the United States of America. Mexico City, August 6-13, 1984.

6 options and advocating for the legalization of abortion. It is important to note that the Mexico City Policy was not the first piece of U.S. foreign policy to target abortion activities by non-governmental organizations around the world. The Helms Amendment to the U.S. Foreign Assistance Act, introduced by Senator Jesse Helms in 1973, in response to the Supreme Court’s ruling in the case of Roe v. Wade, began the tradition of U.S. foreign policy appeasing pro-life attitudes in the United States, as it stipulates that “no foreign aid from the United States shall be used to fund abortions”.6 What separates the Mexico City Policy from the Helms Amendment is that, while the Helms Amendment places restrictions on how U.S. funding can be used, the Mexico City Pol- icy prevents non-governmental organizations from allocating any of their own organizational funds, U.S. donated or otherwise, towards abortion services.7 It is these greatly expanded restrictions of the Mexico City Policy that inspired its alternate name, the Global Gag Rule, and what makes it such a contentious piece of U.S. foreign policy. As a consequence of this, while the Helms Amendment has remained in place since its establishment in 1973, the Mexico City Policy has had wildly differing levels of support, divided along political party lines. From its initial enactment by President Ronald Reagan in 1984, the Mexico City Policy remained in effect through the presidency of George H.W. Bush, until 1993 when President Bill Clinton rescinded the policy. In 2001, President George W. Bush re-enacted the policy, and then in 2009, it was rescinded once more by President Barack Obama. If this were not evidence enough for the divided view of the Mexico City Policy, perhaps what highlights it most is the urgency with which Presidents have acted to enact or rescind said policy, with President Clinton, President George W. Bush and President Obama all making the change within the first three days of their presidencies.

6"Challenging the Rhetorical Gag and Trap: Reproductive Capacities, Rights, and the Helms Amend- ment.". Northwestern University Law Review, 1427. 7"The Mexico City Policy: An Explainer,” The Henry J. Kaiser Family Foundation, October 3, 2019, https://www.kﬀ.org/global-health-policy/fact-sheet/mexico-city-policy-explainer/

7 2.2 Signiﬁcance Today

Following the example of the administrations that have come before it, on January 23, 2017, the third day of his presidency, President Donald Trump once again enacted the Mexico City Policy. However, for the first time in the history of the policy, President Trump not only enacted it but “dramatically expanded” the restrictions it places upon foreign non-governmental recipients of U.S. funding for sexual and reproductive health and rights.8 Previously, the restrictions of the Mexico City Policy have applied solely to the provision of U.S. family planning funds to recipient nations, equal to approximately $575 million.9 The new iteration of the policy enacted under Trump, however, applies restrictions to all U.S. global health assistance funding, equivalent to approximately $8.8 billion.10 Close to 70% of the newly implicated funding comes from AIDs relief programs, with childhood nutrition programs, the President’s Malaria Initiative and even sanitation and hygiene programs also now being incorporated under the Mexico City Policy’s rules.11 12 Given that this thesis concludes that the Mexico City Policy has had unintended effects on sexual and reproductive health and rights services aside from its primary target of abortions, the significance of this finding may only be amplified now that all U.S. global health assistance funding is subject to the same ruling – potentially putting at risk the health of millions around the world. This is not only alarming in the sense that it demonstrates the active choice of a U.S. president to enforce a policy that endangers women and children around the world, but, in the fact that this choice acts in opposition to the globally agreed upon goals for the future, the United Nations Sustainable Development Goals (SDGs). Created by the U.N. General Assembly as a vision for the year 2030, the SDGs call for reduced maternal mortality

8“Trump’s ’Mexico City Policy’ or ’Global Gag Rule’,” Human Rights Watch, February 14, 2018, https://www.hrw.org/news/2018/02/14/trumps-mexico-city-policy-or-global-gag-rule 9Ibid. 10"Impact of Mexico City Policy on PEPFAR", AMFAR, July 2019, https://www.amfar.org/issue-brief- the-eﬀect-of-the-expanded-mexico-city-policy/ 11Ibid. 12“Trump’s ’Mexico City Policy’ or ’Global Gag Rule’,” Human Rights Watch, February 14, 2018, https://www.hrw.org/news/2018/02/14/trumps-mexico-city-policy-or-global-gag-rule

8 (Goal 3.1), reduced preventable deaths of newborns (Goal 3.2) and universal access to sexual health and reproductive services (Goal 3.7) – goals this thesis ﬁnds previous iterations of the Mexico City Policy to be in direct deﬁance of, and which one can therefore assume, will be further derailed by President Trump’s expansion of the policy, signifying the United States intentional dissension from formally established global goals.

3 Literature Review

Despite the controversial nature of the Mexico City Policy, which has inspired a high level of public scrutiny directed towards the policy’s onerous restrictions on non-governmental organizations providing family planning services, there is a surprising lack of rigorous quantitative study on the subject. The work of Jakubowski and Bendavid (2019) found that U.S. global health financing and aid, including reproductive health aid, functions as a hugely influential ‘soft power’ tool for American presidential administrations. Finding “a positive association between US health investments and the probability of very favorable opinion of the United States”, an association that is not present between opinion and U.S. disbursements to other sectors, Jakubowski and Bendavid posit that health diplomacy and funding, unlike other aid donations, bolster the United States’ ability to shape their image abroad, and “influence international policy through noncoercive means”.13 With this finding in mind, the Mexico City Policy can be seen as a powerful example of exactly what Jakubowski and Bendavid are referring to, a health policy acting to shape policy abroad. Backed by a conservative single issue voting bloc, the Mexico City Policy was designed by the U.S. domestic religious right to “institutionalize the stigmatization of abortion in U.S. foreign assistance”, and influence international attitudes towards abortion in a nature that was in line with the religious right’s ideal U.S. ‘image’, one in which pro-life

13Jakubowski, Aleksandra Don Mai, Steven M. Asch, Eran Bendavid, “Impact of Health Aid Investments on Public Opinion of the United States: Analysis of Global Attitude Surveys From 45 Countries, 2002–2016”, American Journal of Public Health 109, no. 7 (July 1, 2019), 1035.

9 attitudes reigned.14 Much qualitative analysis of this suppression of abortion access worldwide has been carried out, with Camp (1987), and Law and Rackner (1987), all producing early theories on the Mexico City Policy’s denial of women’s control over their reproductive rights, concluding that restricting the right of women around the world to utilize abortion services signaled U.S. foreign policy as a “regressive force” of soft power, acting against gender equality, in favor of conservative ideals.15 16 However, interestingly, Crane and Dunsenberry’s (2004) study for Reproductive Health Matters Journal found that actually “with a high degree of certainty, it can be said that the Gag Rule has not achieved an overall reduction in abortions”.17 An extremely interesting outcome, given that it reveals that the policy is failing to achieve the conservative driven goal of reducing abortions. This study was also the first of its kind to consider whether, as well as acting to influence abortion policy internationally, the Mexico City Policy was yielding any further ‘soft power’ in the realm of sexual and reproductive health and rights, providing enlightening anecdotal evidence of further unintended consequences of the policy’s existence, including family planning clinic closures, reduced sexual health services and the termination of U.S. contraceptive shipments to 29 countries following President George W. Bush’s enactment of the Mexico City Policy.18 These studies provide a backbone for this thesis, which aims to quantitatively expand on these concerns of to what extent the Mexico City Policy is acting, on the part of conservative U.S. congressmen, against women’s control over their reproductive lives around the world, by establishing if, and how significantly, the policy has unintended consequences on other

14Crane, Barbara B. and Jennifer Dusenberry. 2004. "Power and Politics in International Funding for Reproductive Health: The US Global Gag Rule." Reproductive Health Matters 12 (24): 125 15Law, Sylvia A. and Lisa F. Rackner. 1987. "Gender Equality and the Mexico City Policy." New York University Journal of International Law and Politics 20 (1): 228 16Camp, Sharon. 1987. "The Impact of the Mexico City Policy on Women and Health Care in Developing Countries." New York University Journal of International Law and Politics 20 (1): 35 17Crane, Barbara B. and Jennifer Dusenberry. 2004. "Power and Politics in International Funding for Reproductive Health: The US Global Gag Rule." Reproductive Health Matters 12 (24): 128 18Ibid., 132

10 aspects of sexual and reproductive health and rights. While Crane and Dunsenberry (2004) qualitatively note suspicions that unintended, or unexpressed, damaging outcomes to sexual health provisions were stemming from the Mexico City Policy’s enactment, it was a 2011 quantitative study by Bendavid, Avila and Miller in the World Health Organization Bulletin that cemented the need for this thesis to explore these concerns further. Like much of the qualitative content on the subject, Bendavid et al look at the Mexico City Policy’s effect on induced abortion rates, specifically in sub-Saharan Africa. Dividing nations in to those with high and low exposure to the Mexico City Policy, based on the level of U.S. donations to reproductive health in said country during periods when the Mexico City Policy is not in place, the study finds that high-exposure countries saw an increase in induced abortions when the Mexico City Policy was re-introduced in 2001 by President George W. Bush.19 This raised concerns for Bendavid et al that the funding restrictions imposed by the Mexico City Policy may lead to a reduction of general family planning and contraceptive provisions, and thus, women are opting for abortions as a replacement to the diminished family planning services. Bendavid et al conclude by questioning whether this signals the existence of unintended consequences catalyzed by the enactment of the Mexico City Policy.20 Bendavid et al themselves do not rigorously evaluate the possibility of the existence of unintended consequences of the Mexico City Policy, yet much evidence exists that drives this thesis’ desire to explore these concerns. Referring back to the umbrella term of sexual and reproductive health and rights, we know that as well as abortion provisions, the provision of adequate family planning services, sexual education, maternal healthcare and other social support services factor in to reproductive health, and thus are all services Bendavid et al highlight as potentially being at risk in periods when the Mexico City Policy is in place. This is alarming, given the wealth of literature that

19Bendavid, Eran, Patrick Avila, and Grant Miller. 2011. "United States Aid Policy and Induced Abortion in Sub-Saharan Africa." Bulletin of the World Health Organization 89 (12): 875 20Ibid., 878

11 identifies stable reproductive health as key to the education, empowerment and economic engagement of women as members of society. Goldin and Katz (2002) find a “novel causal pathway linking reliable contraception to college completion” concluding that “the pill enabled women to plan their college education and careers and not live in a world of uncertainty of unplanned pregnancies”.21 With Koropeckyj et al (2017) finding that college completion leads to “increased earnings and productivity, expanding the economy in the long run through higher wages, employment and GDP”, it is therefore clear to see that protecting contraceptive provision is key, as it allows women to participate economically and further economic growth.22 Herrera and Sahn’s (2015) findings highlight how crucial the ability for women to plan their pregnancies can be, as they find that in the case that women can not plan their reproductive futures, and teenage pregnancy occurs, there was an “increased likelihood of dropping out of school and a reduction to women’s cognitive skills”.23 Summarized by Finlay and Lee’s (2018) work, it can be seen that “improvements in reproductive health lead to improvements in women’s economic empowerment. Contraceptive use improves women’s agency, education and labor force participation; higher maternal age at first birth increases the likely hood of school completion and participation in the formal labor market and having fewer children increases labor market participation”.24 If Bendavid et al’s concerns are well founded, and reproductive health in general is being put at risk during periods of the Mexico City Policy’s enactment, these previous studies demonstrate that women’s economic empowerment and participation in the work force are fundamentally in danger too. Thus far, no study has, on a global scale, attempted to examine whether wide spread damage is indeed being done to sexual and reproductive health and

21Goldin, Claudia and Lawrence F. Katz. 2002. The power of the pill: Oral contraceptives and women’s career and marriage decisions. Journal of Political Economy 110(4): 760 22Koropeckyj, Sophia, Chris Lafakis, and Adam Ozimek. 2017. The Economic Impact of Increasing College Completion. Cambridge, MA: American Academy of Arts and Sciences. 23Herrera, Catalina and Sahn, David E., The Impact of Early Childbearing on Schooling and Cognitive Skills Among Young Women in Madagascar. IZA Discussion Paper No. 9362. 24Finlay, J.E. and Lee, M.A. (2018), Identifying Causal Eﬀects of Reproductive Health Improvements on Women’s Economic Empowerment Through the Population Poverty Research Initiative. The Milbank Quarterly, 96: 320.

12 rights services, aside from abortion services, in periods of the Mexico City Policy’s enactment, and given the extensive ramiﬁcations for both women’s health and empowerment, this is the question this thesis seeks to resolve.

4 Hypotheses

The repetitive enactment and revocation of the Mexico City Policy provides an opportu- nity for a natural experiment that can isolate the effects of the policy on outcomes of interest. This thesis seeks to evaluate a collection of hypotheses regarding the policy’s effect on sexual and reproductive health and rights, across a period within which the policy changes from being in place, to being removed, thus looking at what effect the removal of the Mexico City Policy has on the chosen indicators. The choice to study the Mexico City Policy’s relationship to indicators of sexual and reproductive health aside from abortion, is guided by the intuition that many of the non- governmental organizations providing abortions internationally, and thus being defunded during the Mexico City Policy’s enactment, also provide a plethora of other sexual and reproductive health services such as family planning, maternal/antenatal care, sexual education and so on. This is supported by an investigation of the work practices of groups such as International Planned Parenthood and Marie Stopes International, which confirms this intuition that one organization provides multiple strands of services considered under the SRHR umbrella. The analysis of this thesis concerns whether these activities, though not directly targeted by the Mexico City Policy, are significantly affected by the policy’s enactment. The key overarching hypothesis of this study is that the Mexico City Policy has an unintended, significant, effect on access to sexual and reproductive health and rights services, aside from abortion services, internationally. To test this, this thesis operationalizes four indicators of sexual health and reproductive rights to represent the various health provisions incorporated under this term, specifically, Maternal Mortality Ratio, contraceptive preva-

13 lence rate, the presence of a Skilled Birth Attendant at the delivery of a child, and adolescent fertility rate.

Hypothesis 1: Removal of the Mexico City Policy will lead to a reduced Maternal Mortality Ratio (MMR). Maternal Mortality Ratio is deﬁned by the World Health Organization as the number of maternal deaths per 100,000 live births, therefore a reduction in this will be demonstrated by a negative, signiﬁcant relationship between the policy’s removal and the MMR of a nation.25

Hypothesis 2: Removal of the Mexico City Policy will lead to an increased contraceptive prevalence rate. Contraceptive prevalence is deﬁned by the World Health Organization as the percentage of women who are currently using at least one method of contraception.26

Hypothesis 3: Removal of the Mexico City Policy will lead to an increase in the percentage of births at which a Skilled Birth Attendant is present. A Skilled Birth Attendant is any skilled healthcare professional, including doctors, nurses and midwives who can assist in the delivery of a child.27

Hypothesis 4: Removal of the Mexico City Policy will lead to a reduction in the adolescent fertility rate. The World Health Organization deﬁnes the adolescent fertility rate as the number of births per 1000 women aged between 15 and 19 years old.28

25“Maternal Mortality Ratio (per 100 000 Live Births),” World Health Organization (World Health Orga- nization, March 11, 2014), https://www.who.int/healthinfo/statistics/indmaternalmortality/en/ 26"Contraceptive Prevalence,” World Health Organization (World Health Organization, March 11, 2014), https://www.who.int/reproductivehealth/topics/family_planning/contraceptive_prevalence/en/ 27“Skilled Birth Attendant,” World Health Organization (World Health Organization, March 11, 2014), https://www.who.int/reproductivehealth/topics/mdgs/skilled_birth_attendant/en/ 28“Adolescent Fertlity Rate,” World Health Organization (World Health Organization, March 11, 2014), https://www.who.int/gho/maternalhealth/reproductivehealth/adolescentf ertility/en/

14 5 Data Description

Independent Variable The independent variable in this thesis is the enactment of the Mexico City Policy, measured on a yearly basis. For this variable I have created a dataset which records, for all 112 countries included in this study, the years in which the Mexico City Policy had been enacted by a U.S. president, and the years in which it was not. The dataset is coded as a binary with 0 signalling the absence of the Mexico City Policy, and 1 signalling years in which the Mexico City Policy was in place. This data was obtained through reviewing Presidential Memorandums, released by the White House on every occasion that a president has enacted, or rescinded the Mexico City Policy.29

Dependent Variable The dependent variable in this study is the access to, and provision of, sexual and reproductive health and rights services, which for the purposes of our empirical analysis will be operationalized through four indicators, drawn from the World Health Organizations Devel- opment indicators, designed to represent different facets of the umbrella term of sexual and reproductive health and rights. The first operationalization, utilized to represent maternal health, is the indicator Ma- ternal Mortality Ratio (MMR). Maternal Mortality Ratio measures the number of maternal deaths, defined as death of a woman while pregnant or within 42 days of termination of pregnancy, per 100,000 live births. For this indicator this thesis uses country-level annual data published in the dataset World Health Organization Maternal Mortality Ratio Trends (1995-2015). The second operationalization is of contraceptive prevalence rate, an indicator of family planning and sexual health service provisions. Contraceptive prevalence is measured as the

29Presidential Memorandum regarding the Mexico City Policy. 2017. Washington: Federal Information & News Dispatch, Inc.

15 percentage of women who are currently using, or whose sexual partner is currently using, at least one method of contraception. This thesis uses a survey-based database published by the United Nations Department of Economic and Social Affairs – Population Division. From the database World Contraceptive Use 2019, this thesis specifically utilizes annual, country-level data. To represent antenatal care services, this thesis operationalizes the indicator of the presence of a Skilled Birth Attendant. This is measured as the percentage of live births attended by a skilled healthcare professional e.g. doctor, nurse or midwife trained in life-saving ob- stetric care. This thesis uses joint UNICEF and World Health Organization data published annually at a country level. Finally, to represent sexual health education this thesis employs the indicator of adolescent fertility rate, which is measured as the number of births per 1000 women aged 15-19. This indicator can be affected by many things, including income level, prevalence of child marriage, religiosity and more. However, it has previously been employed in scientific studies to measure the effectiveness of sexual education programs, with sexual education being found to cause a reduction in the adolescent fertility rate, which motivated the choice to include this as one of the four operationalized indicators in this study.30 This data was attained from the United Nations Population Division, World Population Prospects data. This is published annually at the country level.

Control Variables This study includes ﬁve control variables at the country level: annual per capita donations made by OECD donor countries and organizations other than the United States towards reproductive health, GDP, Population, Percentage of Population living in Urban Areas, Secondary School Enrollment and Percentage of Female Labor Participation. The decision to control for annual per capita donations made to countries included in

30Linda H Bearinger, Renee E Sieving, Jane Ferguson, Vinit Sharma. 2007.“Global perspectives on the sexual and reproductive health of adolescents: patterns, prevention, and potential”. The Lancet, Volume 369, Issue 9568, page 1228.

16 this study by OECD donors other than the United States is a replication of Bendavid et al’s (2011) study, which does the same to account for the fact that when the Mexico City Policy is enacted, other developed countries may increase their donations towards reproductive health programs in developing countries affected by the Mexico City Policy. An example of this phenomena can be seen in the United Kingdom’s creation of the ‘Global Safe Abortion Fund’ in 2006, in response to President George W. Bush’s continuing support for the Mexico City Policy.31 This therefore controls for any compensations being made by other nations against the restrictions of the Mexico City Policy and allows us to isolate the effect of the Mexico City Policy. This variable uses data from the OECD Creditor Reporting System. It is crucial to control for GDP and population, given that a country’s size and wealth directly affects its level of development, and by consequence, its level of gender equality, female empowerment and ability to provide domestic funding of family planning services.32 Along the same lines, the Percentage of Population living in Urban Areas, Secondary School Enrollment and Percentage of Female Labor Participation are also controlled for to adjust for the fact that higher levels of urban population, education and female involvement in the labor force suggested higher levels of development. Controlling for this eliminates the potential bias this could have on the effects of the Mexico City Policy’s existence on sexual and reproductive health and rights services. This thesis uses the World Bank Development Indicators (1960-2019) dataset for all four of these control variables. While research initially motivated the inclusion of the aforementioned control variables, this choice was cemented by the statistical significance between this thesis’ treatment and control countries for each variable, as seen in Table 2 below. This significance indicated a need to control for the effects of these variables, in order to avoid them biasing the thesis’ final results. While this high-level of significance is present for the differences between treatment and control countries for OECD donations, Urban Population percentage, Percentage

31United States. Congress. House. Committee on Foreign Aﬀairs. 2008. The Mexico City Policy/Global Gag Rule : Its Impact on Family Planning and Reproductive Health : Hearing before the Committee on Foreign Aﬀairs, House of Representatives, One Hundred Tenth Congress, First Session, October 31, 2007. United States:., 17. 32Klasen, Stephen: ‘Does Gender Inequality Reduce Growth and Development? Evidence from Cross- Country Regressions’, Sonderforschungsbereich 386, Paper 212 (2000).

17 of Secondary Enrollment and Percentage of Female Labor Participation, it is not for GDP. However, in order to be conservative with our investigation, it is included as a ﬁfth control variable.

Table 1: Descriptive Statistics

Variable Mean (SD) Min Max

OECD Donations (millions) 51.703 0.00 1177.05 (112.094)

Urban Population (%) 45.158 8.46 91.63 (18.970)

GDP 136.4 billion 75,951,128 11,140 billion (669.0 billion)

Population 47,397,999 98,487 1.379 billion (170 million)

Female Labor Participation (%) 51.835 6.08 87.75 (17.828)

Secondary Enrollment (%) 64.197 5.93 125.82 (27.409)

18 Table 2: Balance Table

Control Treatment t-test Variable Mean/SE Mean/SE (1)-(2)

OECD Donations (millions) 16.285 161.479 -145.194*** [0.660] [8.958]

Urban Population (%) 48.133 35.8 12.333*** [0.520] [0.721]

GDP 147 billion 103 billion 44.1 billion [26 billion] [13.8 billion]

Total Population 35 million 86.3 million -51.3 million*** [3.96 million] [10.9 million]

Female Labor Participation (%) 50.259 57 -6.741*** [0.461] [0.955]

Secondary Enrollment (%) 66.819 53.965 12.854*** [0.880] [1.615]

Standard errors in parentheses. *** p<0.01, ** p<0.05, * p<0.1

19 6 Methodology

In order to empirically examine the relationship between the Mexico City Policy’s enactment and access to indicators of sexual and reproductive health and rights internationally, this thesis draws much inspiration from Bendavid et al’s (2011) research design, on the basis that this paper was the first of its kind to successfully look at the policy through a quantitative lens. In their study of the Mexico City Policy’s effect on induced abortion rates in sub-Saharan Africa, Bendavid et al divide their countries into treatment and control groups based on each countries relative ‘exposure’ to the Mexico City Policy.33 A nation’s exposure to the Mexico City Policy was assigned by whether, during a period when the Mexico City Policy was not enacted, a country received an amount of family planning funding assistance from the United States that was above or below the mean value of family planning assistance provided by the U.S. to recipient countries during that time. Countries with a high level of exposure to the Mexico City Policy are those who received a higher than average per capita level of funding for family planning assistance during the period the policy was not in place, and those with low exposure had, conversely, received below the mean value.34 This was calculated using data obtained from the OECD Creditor Reporting system. Highly exposed countries were considered the treatment group in Bendavid et al’s study, given that they would be most affected by the restrictions the Mexico City Policy places on funding for family planning and reproductive health services. Low exposure countries acted as the control in this study. Bendavid et al then applied a difference in difference empirical design to analyze the differential changes in induced abortion rates between high and low exposure countries in sub-Saharan Africa at the time of the reinstatement of the Mexico City Policy. In a similar vein, this study divides the 112 countries included in the analysis of the Mexico City Policy’s unintended consequences on sexual and reproductive health access in to a high exposure treatment group and low exposure control group. Utilizing the same

33Bendavid, Eran, Patrick Avila, and Grant Miller. 2011. "United States Aid Policy and Induced Abortion in Sub-Saharan Africa." Bulletin of the World Health Organization 89 (12): 873. 34Ibid., 874

20 OECD Creditor Reporting system, high exposure countries were identified as those who, in the period of 1993 to 2001, when the Mexico City Policy was not in place, received a per capita level of funding for family planning and reproductive health services above the mean value of per capita assistance provided by the U.S. over this period. Low exposure countries, who represent the control group in this study, are those who received below the mean value of per capita U.S. funding for family planning and reproductive health assistance from 1993 to 2001. One key difference between the application of the difference in difference empirical design in this paper, to most, including the Bendavid et al study, is that while traditionally a difference in difference is applied to analyze differential changes between a treatment and control group following the introduction, or reinstatement of a policy, this study applies the method to analyze the significance of the Mexico City Policy’s removal. As the enactment of the Mexico City Policy acts as a natural, cyclical experiment, there are multiple time periods one can observe to capture its enactment and removal, however when obtaining data for all countries and variables within this study, it became clear that the optimal time period to observe, to have the most robust dataset possible, was from 2001 to 2016. In this time period the Mexico City Policy was in place from 2001 to 2008 and was then rescinded by President Obama in 2009 until the end of his term in 2016. It is the effect that this removal of the Mexico City Policy, in 2009, had on indicators of access to reproductive and sexual health services internationally that this thesis, and the difference in difference design, will be measuring. Therefore, 2001 to 2008 serves as the control period, and 2009 to 2016 as the treatment. A confirmation of parallel trends between the control and treatment groups of countries was carried out to ensure that a difference in difference method was a viable analysis approach for this study, a graphical representation of which can be found in Appendices A1-3. This difference in difference was applied first to observe the policy’s affect on the chosen indicators, and then replicated with the addition of country and year fixed effects to account for external shocks that may have taken place across the many years and countries included

21 in this analysis.

7 Results and Analysis

Overall, this study finds that the removal of the Mexico City Policy has a significant effect on certain indicators of sexual and reproductive health and rights, while not significantly affecting others, specifically contraceptive prevalence and adolescent fertility rate. Thus, partially upholding our overarching hypothesis that the Mexico City Policy has an unintended effect on access to sexual and reproductive health services, aside from abortion, internationally. This outcome is maintained even in the case of the addition of fixed effects to the regression, as demonstrated in Tables 3 and 4 included below. A detailed analysis of these results, by indicator and hypothesis, will follow.

22 Table 3: Original Regression Results

VARIABLES Maternal Mortality Maternal Mortality Contraceptive Prevalence Contraceptive Prevalence Skilled Birth Attendants Skilled Birth Attendants Adolescent Fertility Adolescent Fertility Ratio Ratio + Controls +Controls + Controls + Controls Mexico City Policy Removed -66.96*** 23.20** 1.44 -2.909 3.113* -2.127 -8.652*** 2.335 (17.830) (11.530) (2.566) (2.101) (1.871) (1.370) (2.424) (2.092)

Treatment Country 151.3*** 56.22*** -4.128 -4.307 -22.86*** -6.923*** 13.49*** 1.088 (-24.81) (18.270) (3.353) (3.225) (2.890) (2.350) (3.491) (3.402)

Diﬀerence in Diﬀerence -50.25 -68.52*** 3.596 3.37 3.421 6.853** -2.02 -1.621 (36.32) (25.18) (4.648) (4.239) (4.14) (3.218) (4.937) (-4.554)

OECD Donations (millions) 0.208*** -0.00731 -0.0208** 0.0305*** (0.0574) (0.00965) (0.00858) (0.0104)

Urban Population (%) -1.541*** 0.0288 0.258*** 0.228*** (0.334) (0.0635) (0.0412) (0.0603)

GDP 0** 0** 0 0** (0) (0) (0) (0)

Total Population -2.16e-07*** 1.34e-08* 9.52e-09* -4.98e-08*** (0.000) (0.000) (0.000) (0.000)

23 Female Labor Participation 2.030*** 0.0941* 0.036 0.440*** (%) (0.31) (0.0549) (0.0423) (0.0563)

Secondary Enrollment (%) -7.670*** 0.491*** 0.642*** -1.092*** (0.232) (0.0452) (0.0303) (0.0421)

Constant 326.5*** 727.9*** 36.98*** 1.373 83.76*** 21.40*** 78.63*** 110.4*** (12.18) (27.23) (1.884) (4.767) (1.291) (3.521) (1.714) (4.936)

Observations 1680 1107 405 287 750 531 1792 1173

R-squared 0.044 0.687 0.007 0.521 0.129 0.676 0.024 0.508

Standard errors in parentheses. *** p<0.01, ** p<0.05, * p<0.1 Table 4: Regression with Fixed Eﬀects Results

VARIABLES Maternal Mortality Contraceptive Prevalence Skilled Birth Attendants Adolescent Fertility Ratio + Controls + Controls + Controls + Controls Mexico City Policy Removed -115.9*** 13.26*** 9.575*** -17.07*** (-10.20) (4.41) (4.05) (-15.23)

Treatment Country 173.6*** -3.107 -5.601 43.17*** (4.90) (-0.47) (-0.84) (12.94)

Diﬀerence in Diﬀerence -40.20*** 1.587 5.585*** 0.744 (-4.45) (0.90) (3.49) (0.87)

OECD Donations (millions) -0.107*** 0.00356 0.00146 -0.00200 (-4.17) (0.61) (0.22) (-0.82)

Urban Population (%) 3.284** -0.593** -0.198 0.0877 (2.89) (-2.65) (-1.03) (0.85)

GDP 3.99e-11*** -5.51e-12 -3.69e-12** 4.54e-12*** (3.77) (-1.44) (-2.69) (4.44)

Total Population -0.000000211 -1.83e-08 0.000000183*** -0.000000155*** (-0.95) (-0.35) (3.48) (-7.74)

Female Labor Participation 3.034*** -0.120 -0.0607 -0.0399 (%) (3.78) (-0.76) (-0.44) (-0.54)

Secondary Enrollment (%) -2.176*** 0.104 0.208*** -0.0628* (-7.22) (1.72) (4.17) (-2.27)

Constant 452.7*** 27.67*** 24.52*** 87.12*** (12.28) (3.62) (3.99) (25.87)

Observations 1107 287 531 1173

Fixed Eﬀects XXXX

Standard errors in parentheses. *** p<0.01, ** p<0.05, * p<0.1

Hypothesis 1: Removal of the Mexico City Policy will lead to a reduced Maternal Mor- tality Ratio (MMR). In Table 4, Column 1, one can see that the removal of the Mexico City Policy is associ- ated with a statistically significant negative effect on Maternal Mortality Ratio in treatment countries, when controlling for demographic and economic factors, with a p-value of less than 0.01. The removal of the policy inducing a -40.20 change in Maternal Mortality Ratio in treatment countries supports Hypothesis 1, confirming that when the Mexico City Policy is

24 not in place, maternal mortality is significantly reduced in highly exposed nations, signalling better maternal care availability when there is no restriction on U.S. funding for sexual and reproductive health and rights internationally. This aligns with our intuition that when the Mexico City Policy is in place, maternal mortality is at greater risk than when the Mexico City Policy is removed. With funding being restricted by the Mexico City Policy, monetary support for the systems that protect mothers, such as regular pre-natal check-ups and advis- ing, the employment of community health workers and the availability of sanitary delivery suites, is reduced.35 What this result likely captures is that with the removal of the Mexico City Policy during our treatment period, restrictions on U.S. funding being lifted is allowing funds to be channelled in to the aforementioned vital services, reducing the likelihood of maternal death through enhanced reproductive care, reflected in the significant negative effect we see on Maternal Mortality Ratio.

Hypothesis 2: Removal of the Mexico City Policy will lead to increased contraceptive prevalence rate. Table 4, Column 2 provides the results of the analysis of the removal of the Mexico City Policy and its effects on contraceptive prevalence in the treatment countries in this study. The results of this analysis do not support Hypothesis 2, as there is no statistical significance to the increase in contraceptive prevalence in treatment countries following the removal of the Mexico City Policy in 2009, both when controlling for demographic and economic factors, and when not. To understand why we do not see the expected result of the removal of the Mexico City Policy having a significant positive effect on contraceptive prevalence rate we must understand what externally may have been occurring during our treatment period that could have affected contraceptive availability. This led to an examination of the wider U.S. foreign policy portfolio, specifically reproductive and sexual health focused programming, that was in place during our treatment time. In doing this, one policy stood out as a

35United States. Congress. House. Committee on Foreign Aﬀairs. 2008. The Mexico City Policy/Global Gag Rule : Its Impact on Family Planning and Reproductive Health : Hearing before the Committee on Foreign Aﬀairs, House of Representatives, One Hundred Tenth Congress, First Session, October 31, 2007. United States:., 108.

25 possible explanation for why Hypothesis 2 is not supported, this policy being the President’s Emergency Plan for AIDS Relief, otherwise known as PEPFAR. Introduced by President George W. Bush in 2003, PEPFAR was, and still is, the largest effort by a single nation to provide funding towards tackling HIV/AIDS.36 While this study examines the effect of the removal of the Mexico City Policy by Obama in 2009, PEPFAR has remained in place since its creation, existing under both Presidents Bush and Obama, and therefore, across both this study’s treatment and control periods, a fact that could influence the results of this thesis. Similarly to the Mexico City Policy, PEPFAR is strongly influenced by the religious right, using the ‘ABC method’ – Abstinence, Be Faithful, and Condoms to promote HIV/AIDs prevention. The ordering of these stratergies – Abstienence, Be Faithful and then Condoms, is unsurprisingly, when considered in the conservative context in which this policy was defined, intentional. The U.S., through PEPFAR, is “promoting abstinence and fidelity in marriage” above and beyond contraceptive methods such as condoms.37 While this initiative is heralded as being one of the most successful in the reduction of HIV/AIDs, the needs of women and those seeking family planning support have been found to be negatively affected. There is reduced condom availability and funding is channelled almost exclusively towards “abstinence until marriage programs”.38 This has been manufactured by U.S. policy decisions which mean “abstinence programs, run through PEPFAR, are not required to discuss condoms”, condoms can be distributed solely in areas used by sex-workers, rather than distributed towards the general public and, therefore, allows “condom users to become stigmatized as promiscuous and irresponsibly pro-sex”.39 Being a globally influential program, these PEPFAR policies are one way to begin to

36Published: Nov 25, 2019. “The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR).” The Henry J. Kaiser Family Foundation, November 25, 2019. https://www.kff.org/global-health-policy/fact-sheet/the- u-s-presidents-emergency-plan-for/. 37Schonangerer, Bernadette. 2013. "Abstinence, Fidelity, and Morality in HIV/AIDS Prevention: The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in the Context of International Discussions about Sexual Rights." Journal Fur Entwicklungspolitik, 29. 38“The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR),” The Henry J. Kaiser Family Founda- tion, November 25, 2019, https://www.kff.org/global-health-policy/fact-sheet/the-u-s-presidents-emergency- plan-for/) 39Dietrich, John W. "The politics of PEPFAR: the President’s Emergency Plan for AIDS Relief." Ethics International Affairs 21, no. 3 (2007): 277-292.

26 explain and understand why, that despite the removal of the Mexico City Policy and its restrictive funding practices towards sexual and reproductive health services, we do not see a significant increase in contraceptive prevalence during our treatment time. The continuation of PEPFAR at this time likely counteracted any significant positive effect one would expect to see from the removal of the Mexico City Policy on contraceptive distribution and prevalence as the ongoing implementation of ABC-centric programming, which works to delegitimize and stigmatize contraceptive use, specifically the use of condoms, would hinder the possibility of there being a significant, positive increase in contraceptive prevalence at that time.

Hypothesis 3: Removal of the Mexico City Policy will lead to an increase in the percentage of births at which a Skilled Birth Attendant is present. In Table 4, Column 3 the results of the analysis demonstrate a statistically significant, positive effect on the presence of a Skilled Birth Attendant when the Mexico City Policy is removed. With a high level of significance, given its p-value below 0.01, the percentage of live births with a Skilled Birth Attendant present increases by 5.585 in our treatment countries, when the Mexico City Policy is removed. A similar story to that discussed in the analysis of Hypothesis 1, can be applied here too to understand the causal story behind this result. Anecdotally, stories of Skilled Birth Attendants, such as clinicians and hospital staff being laid-off in periods in which the Mex- ico City Policy is in place, have been documented, a logical outcome of the reduced funding abortion providing healthcare NGOs face during the policy’s enactment.40 Therefore it is reasonable to suggest then that when funding restrictions are removed in the treatment period, the possibility of skilled obstetrics staff being able to be employed will increase again. Thus, explaining why we would see a significant increase on the percentage of live births with a Skilled Birth Attendant present during the treatment period of the Mexico City Policy’s being removed.

40United States. Congress. House. Committee on Foreign Aﬀairs. 2008. The Mexico City Policy/Global Gag Rule : Its Impact on Family Planning and Reproductive Health : Hearing before the Committee on Foreign Aﬀairs, House of Representatives, One Hundred Tenth Congress, First Session, October 31, 2007. United States:., 32

27 Hypothesis 4: Removal of the Mexico City Policy will lead to a reduction in the adolescent fertility rate. In Table 4, Column 4 the results of the analysis show that, the removal of the Mexico City Policy did not have a significant effect of the Adolescent Fertility Rate during our treatment period. Furthermore, with the addition of fixed effects, we see that surprisingly, the direction of the effect, which was expected to be negative, is in fact positive, an outcome that does not support Hypothesis 4’s expectations. In order to understand this result, in a similar vein to the analysis of Hypothesis 2, consideration must be made for what outside factors may have been influencing the Adolescent Fertility Rate from 2009-2016. Interestingly, this process once again led to an analysis of the PEPFAR program, and how it could, in addition to influencing contraceptive prevalence, be affecting teenage pregnancy rates too. Interestingly, this analysis of PEPFAR, with its effect on adolescent fertility rate in mind, connects back to the earlier discussion on its effect on contraceptive prevalence and condom distribution. Santelli, Speizer and Edelstein (2013) find that PEPFAR specifically targets the adolescent use of condoms, banning “the education on or provision of condoms in school-settings” and that condoms and other modern contraceptives cannot be discussed with “in-school youth”.41 As a result of this, PEPFAR is not providing young people around the world with comprehensive sexual education, which is a choice, known, as a fact, to have “high rates of adverse outcomes, including unplanned adolescent pregnancy”.42 While it was expected that adolescent fertility would reduce in our treatment period, an expectation that can be attributed to the logic that the removal of the Mexico City Policy would allowing funding for sexual education services, in organizations such as International Planned Parenthood Federation to increase, we can however assume that the ongoing existence of PEPFAR, and its negative effects on access to contraceptives and sexual education

41Santelli, John S., Ilene S. Speizer Zoe R. Edelstein (2013) Abstinence promotion under PEP- FAR: The shifting focus of HIV prevention for youth, Global Public Health, 8:1, 1-12, DOI: 10.1080/17441692.2012.759609 42Center for Health and Gender Equity, Debunking the Myths in the U.S. Global AIDS Strategy: An Evidence-Based Analysis, March 2004, p. 8

28 in school, overrode this anticipated eﬀect, and any signiﬁcance the Mexico City Policy’s removal may have had on adolescent fertility rates, negating the prediction of Hypothesis 4.

8 Future Implications

The results of this study certainly signal a need for further empirical analysis of the U.S. government, its policies, and their relationship to access to sexual and reproductive health services worldwide. Not only does this study yield a significant effect between the removal of the Mexico City Policy and improved maternal and antenatal care, a result which sug- gests the policy’s enactment puts mothers’ health and access to safe, fully staffed birthing environments, at risk, but an analysis of this study’s statistically insignificant findings un- covered further interesting outcomes. Our exploration in to the lack of significance for both contraceptive prevalence and adolescent fertility rate in our treatment countries, during our treatment period, found that another U.S. program relating to sexual health and reproductive rights, PEPFAR, may too be having damaging effects on women’s health, through the diminishing of contraceptive provision and education, potentially leading to unplanned adolescent pregnancies. What is of value to note is that through PEPFAR the suppression of contraceptive prevalence, potentially leading to heightened adolescent fertility, is a seem- ingly intentionally integrated in to PEPFAR’s programmatic mission, specifically through its abstinence forward ‘ABC’ HIV/AIDs prevention approach. These results should motivate further study in to the interplay of the multiple U.S. policies targeting sexual health and reproductive rights, how they play in to each other, and the potentially extremely harmful overarching effect this portfolio of conservative influenced polices, possibly intentionally, may be inflicting on women’s health worldwide. However, in this study’s own attempt to begin to deepen this analysis, by looking at the Mexico City Policy’s effect on access to sexual and reproductive health services at a regional level, in addition to the international level the study is currently looking at, limitations appeared. Specifically, the limited amount of data in some regions, and the fact that in

29 some regions all countries fall under either the treatment or control delineation this study uses – the level of U.S. funding the country receives for reproductive health programs. As one can see in Figure A4, found in the appendices, this means some regions are only contributing to our global information, having no individual, continental, results to review. This leads to an underpowered analysis on the regional level, that may be missing key stories due to a lack of data. While this study can draw some interesting conclusions, such as how signiﬁcance for the indicators changes for Asia, Sub-Saharan Africa and Europe, improved data collection and future studies that focus on regional level information are highly recommended as the next step for continuing this thesis’ study of U.S. partisan politics, foreign policy and its eﬀect on access to sexual and reproductive health internationally.

9 Conclusion

Overall, the empirical assessment completed in this study supports the original overarching hypothesis that the Mexico City Policy does negatively effect access to sexual and reproductive health and rights services, aside from its target of abortion services, internationally. As one of the first quantitative studies to look at this question with a global lens, this study’s findings that both maternal health and the presence of obstetrics trained healthcare staff improve in periods when the Mexico City Policy is not in place, are worrying, and suggest that the continued enactment of the Mexico City Policy by republican administrations could be detrimental to women’s health and reproductive rights as time goes on. These findings encourage further quantitative study of the unintended consequences of the Mexico City Policy, and other U.S. policies effecting women’s health’s worldwide. This is especially pressing given the Trump Administration’s greatly expanded iteration of the Mexico City Policy that remains in place at the time of writing. Access to reproductive and sexual health services plays a fundamental role not only in women’s’ physical health, but mental well-being and economic empowerment too. Protecting

30 these valuable services should be at the forefront of donor nations like, the United States’, minds, above and beyond appeasing concerns of the domestic electorate. One hopes that the results of the study will spur others on to continue to evaluate the damage policies like the Mexico City Policy are causing for women’s rights around the world, and encourage a continued ﬁght for robust policy change, to protect the individuals around the world who’s lives could be changed by the removal of the Mexico City Policy from U.S. foreign policy decision making, and the termination of the ‘unintended’ consequences that come with it.

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A Figures

A.1 Parallel Trends Conﬁrmations: Maternal Mortality Ratio

A.2 Parallel Trends Confirmations: Skilled Birth Attendant A.3 Parallel Trends Confirmations: Adolescent Fertility Rate A.4 Regional Coefficient Plots