PLGHA (expanded Global Gag Rule) was associated with impaired abortion law reform, prevention of safe post-abortion care, and reinforced abortion stigma in Malawi, and participants felt these impacts endured even after the policy's revocation in January 2021.
Key Findings
Results
While PLGHA was in effect, participants observed the stalling of a liberalised abortion bill in Parliament in Malawi.
17 semi-structured qualitative interviews were conducted between July and August 2021
Participants included current and past recipients of US global health assistance and civil society organisations working in SRHR in Malawi
Participants associated PLGHA enforcement specifically with impaired abortion law reform at the national legislative level
The stalling of the abortion bill was described as a direct observable outcome linked to PLGHA's enforcement period
Results
PLGHA was associated with enhancement of anti-abortion attitudes and hindrance of national sovereignty in Malawi.
Participants reported that enforcement of the policy reinforced abortion stigma within Malawi
The policy was perceived as hindering Malawi's national sovereignty in determining its own SRHR policies
Anti-abortion sentiment emboldened during PLGHA enforcement did not reverse following Biden's revocation of the policy in January 2021
These findings emerged from qualitative interviews with 17 SRHR stakeholders conducted in July–August 2021
Results
In some cases, over-implementation of PLGHA restricted legal access to post-abortion care and contraceptive care.
Participants reported that organisations went beyond the policy's stated requirements in restricting services
This over-implementation affected access to post-abortion care, which can be legally provided under Malawian law
Contraceptive care access was also reportedly hindered through over-implementation
This finding suggests that the policy's chilling effect extended beyond its formal legal requirements
Results
The threat of PLGHA being reinstated by a future US president was associated with hesitation among participants to invest in public health programmes and advocacy efforts.
Interviews were conducted in July–August 2021, approximately six months after Biden's revocation of PLGHA
Despite the revocation, participants expressed reluctance to fully commit to SRHR programming due to policy uncertainty
This chilling effect on investment persisted even in the absence of active enforcement
Participants felt that only a permanent repeal of the GGR would allow organisations and the Malawi government to fully invest in public health interventions promoting SRHR
Results
The Biden administration's revocation of PLGHA in January 2021 was perceived as symbolically supportive of SRHR globally but did not reverse anti-abortion sentiment emboldened by prior enforcement.
Revocation was seen as exemplifying support of SRHR globally among participants
However, participants reported that the negative impacts on abortion stigma and law reform endured after revocation
Interviews captured perceptions approximately six months post-revocation (July–August 2021)
Participants felt the harms associated with PLGHA's enforcement persisted into the post-revocation period
Methods
The study used a qualitative design with semi-structured interviews to examine PLGHA's influence on Malawi's SRHR landscape during enforcement and after revocation.
17 interviews were conducted with current and past recipients of US global health assistance and civil society organisations working in SRHR in Malawi
Interviews were conducted between July and August 2021
The study setting was Malawi, a country described as dependent on US global health assistance
The study addressed a gap identified by authors: 'Limited research explores the expanded GGR's influence when revoked in countries dependent on US global health assistance'
What This Means
This research examined how a US foreign policy called the Global Gag Rule (GGR) — which prohibits organizations receiving US family planning funds from providing or discussing abortion services — affected sexual and reproductive health in Malawi. The expanded version of this policy, known as PLGHA, was in place from 2017 to 2021 under President Trump and applied to all US global health funding, not just family planning money. Researchers interviewed 17 people working in sexual and reproductive health in Malawi in mid-2021, shortly after President Biden revoked the policy.
Participants reported that while the policy was active, it appeared to stall the passage of a more liberal abortion law in Malawi's Parliament, strengthened anti-abortion attitudes in the country, and in some cases led organizations to go even further than required by the policy — restricting legal services like post-abortion care and contraception. Even after the policy was revoked, participants said these negative effects persisted: abortion stigma remained heightened, the legislative momentum for reform had not recovered, and organizations were hesitant to invest in reproductive health programs because the policy could be reinstated by a future US president.
This research suggests that US foreign policy decisions can have lasting effects on health and policy environments in countries that depend heavily on US aid, even after such policies are formally reversed. The findings indicate that temporary policy changes may not be sufficient to undo the damage done, and that a permanent legislative repeal of the Global Gag Rule — rather than executive-order reversals that can be undone by the next administration — may be necessary for countries like Malawi to fully pursue their own reproductive health goals.
Iyer A, Luffy S, Newton-Levinson A, Rochat R, Cooper B. (2025). The influence of the expanded Global Gag Rule on Malawi's sexual and reproductive health and rights landscape: a qualitative study.. BMJ global health. https://doi.org/10.1136/bmjgh-2023-013639