The Trump administration’s expanded ban on U.S. aid to groups that counsel or make referrals for abortions to women overseas has not affected most grants but in some countries has disrupted or delayed health care when an alternative provider could not be found, according to a State Department review released Tuesday.

The review aims to address concerns that the provision could also force the closure of health clinics that do not provide abortion services but refer patients to other clinics or advocate for legalized abortion.

But according to the report, only eight of 1,360 primary recipients of government grants and 47 smaller, local organizations that receive funds from the larger groups declined to sign the U.S. policy, officially called “Protecting Life in Global Health Assistance.” Most of those are in sub-Saharan Africa and received aid from the U.S. Agency for International Development.

The policy, initially projected to affect as much as $9 billion in U.S. foreign aid for health programs, has been around since the Reagan administration, known as the Mexico City policy because it was announced in a population conference held there. Since then, it has been adopted as U.S. policy during Republican administrations and waived in Democratic ones. Critics call it the “global gag rule.”

Secretary of State Mike Pompeo noted in a statement the “small number of awards affected” since President Trump imposed it and added that the U.S. government “is committed to protecting life, the unborn, and the dignity of the human person.”

John Barsa, the acting USAID administrator, said essential care is more important than ever during the covid-19 pandemic.

“Implementing the policy has not changed USAID’s global health assistance funding levels by even one dollar,” he said in a statement.

But some health-care-focused groups expressed concern about the impact of the policy on programs that have nothing to do with abortion, including those addressing HIV/AIDS, malaria, voluntary family planning and reproductive health, tuberculosis, and children’s nutrition.

The report acknowledges that the policy has caused some clinics to experience a “gap or disruption in delivery” or “extra costs” and “delayed implementation of activities for several months.”

In Liberia and Togo, for example, no alternatives could be found for family planning services provided in mobile health clinics to rural areas.

The report said more time is needed in countries including Ethiopia, Tanzania, Mali, Madagascar and Senegal to offer replacement family planning for poor and rural populations that had been served by Marie Stopes International, one of the two major organizations that refused to commit to the policy.

“The global gag rule is bad public policy, on every level,” said Zara Ahmed, associate director for federal issues at the Guttmacher Institute, which advocates for reproductive health care.

“It is driven solely by ideology, effectively weaponizing U.S. foreign assistance to attack sexual and reproductive health and rights. While numerous studies have documented the policy’s harms, there is no evidence — none — that the global gag rule has had any positive impacts.”

A Guttmacher study completed early this year said that in Uganda, the policy had caused a reduction in the number of community health workers. It warned that could lead to lower contraceptive use and an increase in unintended pregnancies.

But others said the report suggests the policy’s impact is much less sweeping than originally expected.

“The report shows that there is no diminishing of services, and that’s encouraging,” said Tony Perkins, president of the Family Research Council, an antiabortion group. “No one wants the services provided to be restricted or to be diminished. But this is in keeping with the policies of this administration to advance a view of sanctity of human life.”

The State Department’s report comes more than a year and a half after a follow-up was promised to an initial six-month review. The reason for the delay was unclear.

The report did not provide the names of groups that declined to sign the policy. At the six-month mark, only three primary providers did not agree to go along with it, including Marie Stopes and the International Planned Parenthood Federation.

The report said no disruptions in health care or significant delays have occurred since the programs that did not agree to go along with the U.S. policy lost their funding.

But it acknowledged that USAID does not generally collect information on the smaller organizations that receive U.S. grants through the larger groups. It does not even know how many there are, making it difficult to fully assess the program’s impact.