Sara E. Casey

Introduction: In January 2025, the Trump Administration announced a 90-day freeze on all US government (USG) foreign aid, which subsequently became a permanent shutdown of the US Agency for International Development in July 2025. The sudden withdrawal of USG financing disrupted health and humanitarian systems worldwide, with disproportionate impacts on women, girls and other marginalised populations. This study documents impacts of the funding freeze during its early months (February–March 2025) on global health programmes. Methods: This rapid mixed-methods assessment combined a global online survey with qualitative case studies in Nepal, Kenya and Colombia. The survey was distributed via email through networks and relevant listservs. Semistructured key informant interviews (KIIs) (n=53) were conducted with non-governmental organisation leaders, clinicians, community health workers, government officials and humanitarian actors, all purposively selected based on their direct or indirect involvement in USG-funded health programmes. Interview transcripts were thematically analysed and triangulated with quantitative findings. Results: Survey respondents reported initial impacts of the USG funding cuts across health sectors and functions, including humanitarian and emergency response/preparedness, gender-based violence and mental health and psychosocial support. Five key themes arose from the KIIs with stakeholders in three case study countries: disruptions to sexual and reproductive health and rights (SRHR) services, HIV service interruptions and treatment access, the collapse of referral networks and service ecosystems, a mental health crisis among clients and health workers and the rising vulnerability of marginalised populations. Both survey and interview data highlighted growing inequities and anticipated reversals in longstanding health gains. Conclusions: The 2025 US foreign aid freeze generated immediate and widespread disruptions across health and humanitarian systems, revealing systems-level vulnerabilities. These early findings point to the need for more diversified and reliable financing, stronger domestic preparedness and policy approaches that centre SRHR and marginalised populations.

South Sudan has one of the highest maternal mortality ratios (MMR) in the world. The MMR has declined from 1687 to 1223 maternal deaths per 100,000 live births since 2000,1 largely due to the incre...

Background: Chad has one of the highest maternal mortality ratios in the world, and low modern contraceptive prevalence. Understanding the barriers and influences on women's decision-making around contraceptive use is critical to reducing the unmet contraceptive need, and thus maternal mortality.Methods: A mixed-methods study was conducted in three districts of Guéra province, Chad, including a longitudinal survey of women, focus group discussions with male and female users and non-users of modern contraceptives, and in-depth interviews with midwives, community health workers, and community leaders.Results: Survey participants showed increased knowledge of modern contraceptive methods, and 20.5% reported current modern contraceptive use at endline. Participants described multiple reasons for contraceptive non-use, including that it contradicts with their religious beliefs, community stigma and widespread misconceptions, particularly around long-acting reversible contraceptives. Husbands played a large role in a couple's contraceptive decision-making, as either a major facilitator or barrier depending on the individual.Discussion: Overall, the study's findings suggest that participant awareness of modern contraceptive methods increased. Contraceptive use was more than twice as high as the provincial rate. Given the dominance of injectables within our sample, programs should explore introducing and scaling up community-based distribution of the self-injectable contraceptive (DMPA-SC). The findings highlight the need for more diverse and tailored stigma reduction interventions in the community to promote awareness and reduce misconceptions of modern contraceptives among key groups of people, including men, couples, and religious and other community leaders. Values clarification and attitude training should be considered for all cadres of providers to promote non-discrimination and equity in contraceptive service provision.

In humanitarian settings, refugee girls’ vulnerability to negative sexual and reproductive health (SRH) outcomes and the barriers they face to access to SRH services increase. Despite global guidelines on adolescent sexual and reproductive health and rights (SRHR) in humanitarian settings, evidence on the diverse knowledge, attitudes, and behaviors of refugee adolescents are limited. This mixed methods study used a cross-sectional survey and participatory research activities to explore the knowledge, attitudes, and behaviors of 12–19 year old refugee girls from Darfur living in two refugee camps in Wadi-Fira, Chad. Focus group discussions with parents of adolescents and in-depth interviews with health workers were conducted to better understand community attitudes toward adolescent SRHR and barriers to accessing services. Overall, SRH knowledge, including of contraceptive methods, was mixed, but older girls had better knowledge than younger girls. Despite stigma around adolescent sexual activity expressed in this community, 20.9% of girls had already had sex. The majority of girls believed that health workers would maintain confidentiality if they sought contraception. Among girls who had ever had sex, 18.0% were currently using a modern contraceptive. None were using a long-acting method, but most obtained their method at the camp health center. Parents and health workers described how social stigma toward premarital sex and unintended pregnancy impeded adolescent access to SRHR information and services, although the midwives described helping girls to seek contraception. Despite community stigma towards premarital sex and contraception for adolescents, some girls in the camps successfully managed to receive a contraceptive method, demonstrating both their interest in and need for contraception. Although midwives were largely supportive of adolescent access, expanding contraceptive service delivery channels and making services more adolescent-responsive would further increase adolescent access. Gender transformative programming engaging girls and boys, should be expanded to improve adolescent knowledge and self-efficacy with respect to SRHR. These efforts must also engage parents and community members to create an enabling environment for adolescent SRHR and reduce stigma.

Background: Globally, mistreatment of women during labor and delivery is a common human rights violation. Person-centered maternity care (PCMC), a critical component of quality of care, is respectful and responsive to an individual’s needs and preferences. Factors related to poor PCMC are often exacerbated in humanitarian settings. Methods: We conducted a qualitative study to understand Sudanese refugee women’s experiences, including their perceptions of quality of care, during labor and delivery at the maternities in two refugee camps in eastern Chad, as well as maternity health workers’ perceptions of PCMC and how they could be better supported to provide this. In-depth interviews were conducted individually with 22 women who delivered in the camp maternities and five trained midwives working in the two maternities; and in six dyads with a total of 11 Sudanese refugee traditional birth attendants and one assistant midwife. In addition, facility assessments were conducted at each maternity to determine their capacity to provide PCMC. Results: Overall, women reported positive experiences in the camp maternities during labor and delivery. Providers overwhelmingly defined respectful care as patient-centered and respect as being something fundamental to their role as health workers. While very few reported incidents of disrespect between providers and patients in the maternity, resource constraints, including overwork of the providers and overcrowding, resulted in some women feeling neglected. Conclusions: Despite providers’ commitment to offering person-centered care and women’s generally positive experiences in this study, one of few that explored PCMC in a refugee camp, conflict and displacement exacerbates the conditions that contribute to mistreatment during labor and delivery. Good PCMC requires organizational emphasis and support, including adequate working conditions and ensuring suitable resources so health workers can effectively perform.

Background: Countries affected by armed conflict have higher maternal mortality than stable settings. South Sudan has one of the highest maternal mortality ratios in the world, with an estimated 789 maternal deaths per 100,000 live births. Long-term socio-political instability has contributed to significant challenges in its health system. To reduce maternal and newborn morbidity and mortality, South Sudan must increase the number of skilled midwives.Methods: A cross-sectional mixed methods study was conducted in 2022 to assess the midwifery education program at three schools receiving support from International Medical Corps in South Sudan, including in-depth interviews with 15 midwifery school graduates currently working as midwives, their supervisors, 16 school faculty (in dyads), and two Ministry of Health officials; and nine focus group discussions with women clients of graduate midwives.Results: Participants identified strengths of the schools, including being well equipped with trained and competent teaching staff, competency-based curriculum, including practical training which prepared graduate midwives to apply their skills in practice. Weaknesses of the program included its dependence on donor funding, inadequate mentorship and number of tutors, and insufficient practice for some services due to low client load at clinical sites. Additionally, participants identified challenges affecting midwives' ability to provide good quality care, including lack of equipment and supplies, low client load, low salaries, and insecurity due to conflict. Nevertheless, women in the community appreciated the immense work that midwives do. Midwives were respected by the community at large, and graduates expressed pride and satisfaction in their job, as well as the positive impact they have had in providing critical services to communities.Discussion: Overall, the quality of the midwifery education program appears to be strong, however gaps in the program and the provision of quality care remain. The findings highlight the need to ensure sustained funding for midwifery education, as well as health system strengthening to ensure midwives can practice their skills. Continued investment in midwifery education and training is critical to reduce high maternal mortality and morbidity in South Sudan.

As governments impose restrictive policies to contain infectious disease outbreaks, pre-existing gender-based inequalities are often exacerbated, increasing the risk of gender-based violence (GBV). Despite international guidance on the need for continued provision of GBV services during emergencies, governments often de-prioritise GBV services and programmes. We conducted a rapid assessment in South Africa, Kenya, Uganda, and Nigeria to examine the impact of COVID-19 policies on the availability of GBV prevention and response services. The study team interviewed 80 stakeholders representing different GBV services in the four countries. The interviews revealed strikingly similar government mis-steps that disrupted the availability of comprehensive GBV services. In all four countries, the government’s failure to exempt the provision of multi-sectoral GBV services from initial lockdown restrictions led to confusion and disrupted the provision of critical GBV services such as clinical management of rape, legal and judicial services, psychosocial services, availability of shelters, and community-based prevention activities. The government’s imposition of curfews, stay-at-home orders, and transportation restrictions further diminished access to services. Governments must strengthen currently available GBV prevention and response services and be better prepared for future pandemics. Following international guidelines, governments should deem GBV services as essential from the beginning with clear implementation plans. Governments must invest in community-based solutions and the expansion of digital tools to ensure everyone, especially those likely to be structurally excluded, have access to critical services during an emergency.

Since 1984, Republican administrations in the US have enacted the global gag rule (GGR), which prohibits non-US-based non-governmental organisations (NGOs) from providing, referring for, or counselling on abortion as a method of family planning, or advocating for the liberalisation of abortion laws, as a condition for receiving certain categories of US Global Health Assistance. Versions of the GGR implemented before 2017 applied to US Family Planning Assistance only, but the Trump administration expanded the policy’s reach by applying it to nearly all types of Global Health Assistance. Documentation of the policy’s harms in the peer-reviewed and grey literature has grown considerably in recent years, however few cross-country analyses exist. This paper presents a qualitative analysis of the GGR’s impacts across three countries with distinct abortion laws: Kenya, Madagascar and Nepal. We conducted 479 in-depth qualitative interviews between August 2018 and March 2020. Participants included representatives of Ministries of Health and NGOs that did and did not certify the GGR, providers of sexual and reproductive health (SRH) services at public and private facilities, community health workers, and contraceptive clients. We observed greater breakdown of NGO coordination and chilling effects in countries where abortion is legal and there is a sizeable community of non-US-based NGOs working on SRH. However, we found that the GGR fractured SRH service delivery in all countries, irrespective of the legal status of abortion. Contraceptive service availability, accessibility and training for providers were particularly damaged. Further, this analysis makes clear that the GGR has substantial and deleterious effects on public sector infrastructure for SRH in addition to NGOs.

Background: Unsafe abortion is a leading cause of maternal mortality. In Afghanistan, which has experienced decades of armed conflict and where abortion is highly restricted, maternal mortality is high at 638 maternal deaths per 100,000 live births. Post-abortion care (PAC) is a lifesaving package of interventions to reduce morbidity and mortality related to induced or spontaneous abortion, but is rarely provided and often of poor quality, particularly in humanitarian settings. In July 2018, we conducted a study to identify the factors that influence access to and use of PAC services at Sharana Provincial Hospital. Methods: In-depth interviews (IDIs) were conducted with ten women who had received PAC services at Sharana Hospital, and eight focus group discussions (FGDs) were conducted with 40 married women and 40 married men aged 18–45 from four villages surrounding Sharana Hospital. Results: PAC clients and community participants discussed similar barriers to seeking PAC, including cost, distance to the health facility, the need for male accompaniment to seek care, perceived and actual quality of care, stigma and shame. Despite the mentioned stigma around abortion, community members expressed willingness to help women to receive PAC. Conclusions: Our results suggest that while some barriers are not unique to PAC, others, especially those related to stigma around abortion, may be specific to PAC. It is important for the Ministry of Public Health and its partners to prioritize addressing these barriers to ensure that women have access to this critical life-saving care.