Introduction

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          In 1958, as part of a move to improve family planning in international health in the context of global concern for overpopulation in high-growth areas[1], Sweden began providing aid to other countries for assistance in family planning and maternal health[2]. Their aid intended to reduce instances of unsafe pregnancy that contributed to maternal mortality and increase autonomy in some respects by improving sexual education. This represented the first instance of a country offering contraceptives to another under a foreign aid model. Shortly thereafter, in 1965, the US initiated its own policy on international family planning. This policy fell under the U.S. Agency for International Development (USAID). When it came to family planning and reproductive health (FP/RH)*, USAID focused on providing information, contraceptive supplies, birthing spaces, STD screening, and other health services to countries[3]. Since 2009, the US has contributed between 0.4 and 0.5 billion dollars to FP/RH aid that went to approximately 35 countries over the years[4]. The US has maintained this commitment to international reproductive safety, being one of the largest purchasers and distributors of contraceptives internationally [5]. Contraceptives as foreign aid has meant a lot to recipient countries where persistent barriers of poverty, coordination, and health care inhibit access to necessary care. The US has made tangible progress toward its goal of improving contraceptive access. Contraceptive prevalence is defined by the percentage of women of reproductive age who currently use at least one method of contraception, by themselves or by a sexual partner[6]. As a result of USAID, contraceptive prevalence has grown in recipient countries from less than 10% in 1965 to 34% in 2023 on account of expanding access to voluntary family planning and programs meant to inform women about birth spacing. Additionally, in 2024, the aid offered the opportunity of contraception to 24.2 million women, which was linked to the prevention of 14,000 maternal deaths and 8.1 million unintended pregnancies[7]. While an increase in the proportion of women on contraceptives alone may not offer nuanced insight into reproductive autonomy or health, this expansion is indicative of an increased opportunity for choice when it comes to pregnancy. This aid provides individuals with greater autonomy over whether or when to have children by improving sex education, programming, and access to contraceptive services. There are also other benefits of limiting the number of high-risk, unplanned pregnancies, reducing sexually transmitted diseases, and preventing child mortality. This paper finds that recent cuts to US foreign aid, particularly the dismantling of USAID and UNFPA contributions, threaten decades of progress on reproductive autonomy and sexual and reproductive health (SRH), especially in regions like sub-Saharan Africa.

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          The US also contributes to international FP/RH efforts by appropriating funds to the UN Population Fund (UNFPA). The US was a critical partner in the creation of UNFPA in 1969 and has since been a significant contributor. The UNFPA is contextualized by one of the major global health initiatives laid out by the UN. A Sustainable Development Goal set by the United Nations as of 2015 is “universal access to sexual and reproductive health-care services, including family planning”[8]. A Guttmacher Institute study estimated that in 2024, there were 139 million women with an unmet need for any modern contraceptive method, meaning they wished to avoid pregnancy but were not using a modern method. Among those 139 million, 78 million reported being open to the use of contraception in the future, while 61 million did not intend to ever use contraception[9]. In 2024, the UNFPA helped connect over 14 million women to primary healthcare services that holistically integrated sexual and reproductive health[10]. The UNFPA also distributed contraception in the form of over 1 billion condoms, 10 million contraceptive implants, and 67 million oral contraceptives. In the same year, the monetary contributions by the US to the organization were directly linked to the prevention of 6,800 maternal deaths, 3,103,100 unintended pregnancies, and 1,191,600 fewer sexually transmitted diseases worldwide[11]. Through financial assistance and coordination of programs across multilateral entities, the US has historically led the effort towards an internationally coordinated FP/RH policy that centers information and access to contraception and care for over 150 countries[12]. The relative success of these systems raises the question of how international reproductive health will be shaped by current policy shifts and disruptions of aid.

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       Trump’s first term

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          In his first term, President Trump reduced US involvement in international FP/RH efforts. Initially, the administration withdrew core funding from the UNFPA, amounting to a $32.5 million reduction in 2017[13]. During the rest of his term, Trump promised no additional dollars to the UNFPA. Since the US was previously a top contributor to the UN organization and international contraceptive purchases, this withdrawal was devastating. The State Department justified its move with the erroneous claim that “China's family planning policies still involve the use of coercive abortion and involuntary sterilisation, and UNFPA partners on family planning activities with the Chinese government agency responsible for these coercive policies”[14]. In addition to cuts to funding, Trump also reinstated the Mexico City Policy early in his first term. The Mexico City Policy was first implemented by Ronald Reagan in 1984. It requires that foreign NGOs that receive funding from the US may not “perform or actively promote abortion as a method of family planning,” even with dollars not tied to the US[15].

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 President Trump holding up his Executive Order reinstating the Mexico City Policy in 2017[16].

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          While the UNFPA does not perform or support abortions as a method of family planning, the US, in its withdrawal from the UNFPA and reinstatement of the Mexico City Policy, degraded the organization’s efforts, creating consequences for those receiving UNFPA services. As the US targeted abortions abroad, the totality of family planning efforts took a hit. A range of studies document the quantifiable impact of instances when the Mexico City Policy was implemented, both during Trump’s first term and from previous Republican administrations. Brooks et al., in a study from eight countries in sub-Saharan Africa, observed that women used fewer contraceptives when the Mexico City Policy was in place between 2014 and 2019. They quantified a 13% reduction in contraceptive prevalence associated with the policy[17]. A study by Kavakli and Rotondi further indicated that, from a set of 134 countries that received global health funding from a US source, women were more likely to report having less access to modern contraception and information on family planning after the Mexico City Policy. The 30 low and middle-income countries in the study, which were dependent on US aid for family planning, were most susceptible to the consequences of the policy. Women in these 30 countries were more likely to report that they had an undesired pregnancy during the years of the policy’s implementation[18]. These outcomes are part of a larger “chilling effect” that occurs globally when the US alters its policy on reproductive health and foreign aid. Planned Parenthood indicates that the “chilling effect” extends from immediate healthcare to civil society dialogue and national policy agendas. This “chilling effect” takes two main forms in FP/RH civil society efforts. First, organizations are incentivized to end education and information services on abortion to comply with the regulation on promoting abortion. Second, they frequently “over-implement” restrictions on contraceptive access and health services, reducing delivery and collaboration with different organizations[19]. Since many of the programs for FP/RH rely on collaborations with NGOs and civil society groups, new rules guiding these networks implicate these important partnerships. During Trump’s first term, fragmentation and mistrust plagued networks, which was the case in places like Ethiopia, Kenya, Senegal, and South Africa[20]. Many providers took on a cautionary stance, cutting even services that were beyond the scope of the stipulation. The policy represents a barrier to sustainability. It seems that when implementing this policy, the priority of the administration was to root out and punish violators rather than support compliance and create clear, aligned frameworks for health and progress. While the Trump administration did cut core UNFPA funding during his first term, most of the shift in contraceptive policy internationally came as a result of the reinstated Mexico City Policy. This prompts consideration of how much more devastating global consequences could be if the US actively obstructed the supply and distribution of contraception.

 

       Today

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          Recent U.S. political decisions have implicated global access to contraception. This section explores the tension between domestic policy and foreign assistance and the shifts that are expected to occur as a result of current disruptions in aid. In shaping international contraceptive prevalence during his second term, Trump continued with many of the same measures from his first term. He re-implemented the Mexico City Policy in January of 2025 and zeroed out US contributions to UNFPA bilateral family planning in the 2026 budget[21][22]. However, something unique to Trump’s second term has also been the dismantling of USAID. In January of 2025, Trump signed an executive order (EO 14169) putting foreign aid on hold for 90 days. Shortly after, a stop-work order was initiated that froze nearly all US global health funding. The FY 2026 budget encapsulated a $6.2 billion cut to global health programs, zeroing out funding for FP/RH programs[23]. Additionally, the Recissions Act of 2025 rescinded funding previously allocated to foreign aid, a total of $9.4 billion from the Department of State and the U.S. Agency for International Development (USAID), including significant contributions to Global Health Programs[24]. The administration has also cut funding to other global health programs related to sexual health and reproduction, including the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Centers for Disease Control and Prevention (CDC)’s Maternal and Child Health Branch and Global Health Center. These programs have been crucial historically to tracking and preventing HIV infections and impacting maternal and newborn health[25].

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          There will be deep consequences to the dual cuts to the UNFPA and USAID. The Guttmacher Institute finds that, “Each time the United States has withheld funds from UNFPA for political purposes, it has caused significant disruption to UNFPA’s critical services and programs, including gender-based violence prevention and response to humanitarian crises"[26] With the added layer of the termination of USAID contracts for FP/RH, we can expect severe impacts internationally. Further, the OECD projects that, in addition to cuts to US assistance, total international assistance for SRH is expected to decline from donors such as the Netherlands, the UK, and Canada. If the US were to follow through with its proposed budget for 2026 family planning, it would require that other donor governments nearly double their funding to maintain current levels[27].

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          The United States has been involved in global FP/RH efforts for nearly 60 years and has been the largest international donor to FP/RH in the world[28]. This means that the USAID disruption on service distribution will be far-reaching. As a result of the cuts, it is estimated that $27 million worth of family planning products are presently stalled in transit, with no programs or workers left to unload or distribute them[29]. Long-term supply-chain issues and lags in the distribution of contraception will be devastating on their own, and Trump’s response has only worsened the issue. 

In one particular example, as of August 1, 2025, contraceptive products (IUDs, injectables, and pills) worth $9.7 million that were intended for distribution in low-income countries remained in a warehouse in Belgium. 

 

 

 

 

 

 

 

 

 

 

Warehouse outside Antwerp, Belgium where a contraceptive stockpile is located[30]. 

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          If distributed, this stockpile would make pregnancy a choice for over 650,000 individuals for up to one year and for 950,000 individuals for three to 10 years. The contraceptive stockpile in Belgium was intended to reach more than 40 countries, with 77% of the supplies designated for the Democratic Republic of the Congo (DRC), Kenya, Tanzania, Zambia, and Mali[31]. Although NGOs offered to purchase and distribute these family planning supplies, the Trump administration ordered that the stockpile be destroyed[32]. In 2024, the Guttmacher Institute calculated the consequences of a $10 million cut to USAID FP/RH funding[33]. The Reproductive Health Supplies Coalition uses this analysis to conclude that the destruction of the Belgian contraceptive stockpile would specifically contribute to 362,000 unintended pregnancies, 161,000 unplanned births, and 718 preventable maternal deaths[34][35]. Therefore, the dismantling of international networks for reproductive health sabotages the systems that provide contraceptive supplies as well as other forms of healthcare training to low-income countries and underprivileged individuals seeking healthcare in these countries. In the next years of the Trump policy, the impacts on distribution networks will be significant. Without the US’s annual contribution, Guttmacher Institute finds that 34,000 pregnant people could die each year from preventable deaths[36].

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       US Justification

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          Given that the US is directly curtailing global availability of contraception and reproductive healthcare, not only with its dismantling of USAID, but also with cuts to AIDS relief and CDC programs, as well as an order to destroy contraceptives, how is it addressing concerns about the consequences of its actions on global health? In the second Trump Administration, the State Department justified such actions by claiming incorrectly that USAID was planning to send “$50 million worth of condoms to Gaza—and, under later embellishments, $100 million worth of condoms to Hamas”[37]. To critique the distribution of health resources by USAID, members of the Trump administration have also begun equating contraception with abortion. The State Department has categorized contraceptive methods as “abortifacients,” or methods to terminate, rather than prevent, pregnancy[38]. The result has been a widespread reductive interpretation of contraception and a growing demonization of reproductive health. The US has also shifted its stance on contraception policy by arguing that contraception, by nature, is not “lifesaving”[39]. This categorization is the reason funds for international FP/RH were promptly cut under Trump’s Executive Order 14169, and have minimal potential of being reinstated. The fact that the administration does not view reproductive health resources as “lifesaving” indicates how it overlooks maternal and menstrual health, sexually transmitted diseases, and newborn health. 

 

       Case Study: Sub-Saharan Africa and the DRC

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          Most of the countries affected by the current state of contraceptive aid are in Africa. Between 2018 and 2020, obligations in Africa made up approximately half of US FP/RH funding[40]. As of 2023, around 67% of contraceptives supplied through USAID were distributed to Africa[41]. Nations that are dependent on USAID and supplies from contraceptive stockpiles are already facing contraceptive shortages, one of them being the Democratic Republic of the Congo (DRC)[42]. Looking at the DRC in particular can offer insight into how countries dependent on the US for family planning and reproductive health funding will be impacted by the current shifts in foreign aid policy.

 

          The DRC already had very limited SRH services due to its endemic conflict. Fighting between Congolese armed forces and various groups in the North Kivu province since 1996 has resulted in a compromised health system and created a shortage of sexual and reproductive health services in the area[43]. In 2023, the maternal mortality rate of the DRC was 427 deaths per 100,000 live births, representing the 12th highest maternal mortality ratio in the world[44]. The country also had an unmet need for contraception of 30.8% in the same year, a rate that has remained relatively unchanged over the years of the survey. Because of this unmet need, the rate of unwanted pregnancies in the DRC remains high. The Family Planning Estimation Tool, which forecasts modern contraceptive use and unmet need for contraception, quantifies that in 2024, there were 2,480,000 unwanted pregnancies in the DRC[45]. It also explains that only 17.9% of women used modern contraception in 2024, leaving millions with an unmet need vulnerable to unintended pregnancy and health complications.

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          Before the funding cuts, US aid was essential to sustaining SRH in the DRC. Historically, the United States has been the largest provider of humanitarian assistance and health sector support in the DRC[46]. Within the DRC, US-sponsored initiatives like the IHP program and PROSANI accounted for contraceptive supplies, training programs, and awareness campaigns. In total, the United States funded 44 organizations in the DRC that worked to integrate reproductive services into healthcare. The USAID IHP information campaign on contraception, menstrual hygiene, and STIs began in 2018 and lasted for six years. In a study that interviewed women within the DRC about the IHP program, 95.7% of women interviewed recalled noticing the information campaign, and 89.3% reported that the campaign motivated their decisions concerning SRH and pregnancy. Community-based outreach like this improves contraceptive awareness and reproductive health, especially for rural communities[47]. Nevertheless, the gap between information and accessible health services is still prevalent in the DRC.

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Humanitarian midwife trained by UNFPA in the DRC[48].

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          One of the other programs dependent on US aid in the DRC was PROSANI, which brought maternal, newborn, and reproductive health access to underserved regions. After 7 years in operation, beginning in 2018, PROSANI helped connect over 9 million individuals to contraceptives, supported 10 million pregnant people in attending prenatal care, and conducted 9 million births with trained attendants[49].

 

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   Staff at a medical facility supported by PROSANI[50].​

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          Unfortunately, global reductions in USAID and UNFPA complicate the ongoing funding of these programs. According to a 2025 UNFPA study on the impacts of US funding cuts on SRH services, it was found that 50% of organizations in the North and South Kivu provinces reported cutting family planning staff by half or more, while 63% reported having no capacity to continue providing contraceptives. In terms of maternal health services, 55% of organizations conveyed that they no longer had the medicine and equipment needed to offer these services[51]. The report already notes that the closure of SRH clinics and the drastic reductions in human resources and financial capacity severely impact the quality and quantity of SRH services in the DRC. 

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         Before the cuts, US-funded programs had connected millions of Congolese individuals to contraceptives and trained professionals in SRH. As a result of the sharp decline in US assistance, there have already been significant reductions in access to these services. Relief Web quantifies that in the first quarter of 2025, only 7% of the targeted beneficiaries for SRH services were reached[52]. The compounded effect of drastic funding cuts and unstable healthcare structures within the DRC is projected to contribute to resurgences in unintended pregnancies, STIs, unsafe abortions, and infant mortality.

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       Conclusion

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          US provision of contraception as a form of foreign aid has allowed recipients increased autonomy in family planning decisions and greater access to sexual and reproductive health. But access to contraception, testing, emergency care, prenatal and postnatal health, and service training, all have been impacted by Trump’s funding cuts. The unprecedented cuts to USAID by the administration are responsible for NGOs’ significant losses in capacity to offer lifesaving SRH services in countries like the Democratic Republic of the Congo. Shifts in the US contraceptive policy have implications for unintended pregnancies, unsafe abortions, maternal deaths, HIV/STI rates, and more. Even if the US reversed the Mexico City Policy and cuts to SRH funding through USAID and other programs, capacity would have to be rebuilt. The loss of trained personnel and equipment has shuttered NGOs, and distributive and information systems have broken down. Meanwhile, individuals who are deprived of services will have experienced unwanted pregnancies, unsafe abortions, HIV/STIs, and even death.

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