That Donald Trump's presidency would steamroll over the healthcare and reproductive rights of American women was obvious, but within three days of his inauguration, Trump also made it clear that the lives of women around the world are under siege as well. On Monday January 23, Trump signed an executive action that reinstated the global gag rule, just as Republican presidents have done for the past 30 years. However Trump took it a step—or rather, a flying leap—further by massively expanding the scope of the rule, and the impact will be catastrophic. Reproductive health advocates warn that millions of women could suffer and die as a result.
The global gag rule, also known as the "Mexico City Policy," was first put into effect by Ronald Reagan in 1984. It requires foreign NGOs that receive family planning assistance from the US to certify that they will not "perform or actively promote abortion as a method of family planning" with any of their funds—even money that does not come from America. Organizations that take family planning funding from the US are gagged (hence the name) from offering any information, referrals, counseling, legal services, medical advice, training, education, or lobbying that mentions abortion.
The global gag rule has been in place for 17 out of the past 32 years. It's a bad and harmful policy, but one that foreign NGOs are accustomed to dealing with. But Trump's executive action widens its scope significantly: Instead of just applying to the $607 million pool of family planning funding impacted by past iterations of the global gag rule, it applies to "all global health assistance furnished by all departments or agencies." That's $10.3 billion that funds programs—including AIDS prevention, infectious disease, maternal health, malaria, tuberculosis, nutrition and more.
"We have never seen something like this before," said Elisha Dunn Georgiou, the vice president of programs at PAI. "Trump's global gag rule is a cruel and unusual version of an already grotesque policy and will target the most effective health organizations in 60 low and middle income countries, punishing women in places where they are already struggling."
The global gag rule is not just a prohibition on funding abortion—it's a prohibition on talking about it. Since 1973, the Helms Amendment has prohibited NGOs that receive federal funds from using those funds "to pay for the performance of abortions as a method of family planning." Due to Helms, the US government has maintained a de facto ban on funding abortion care with foreign assistance dollars for over forty years. Apparently this wasn't sufficiently restrictive for conservative politicians, who found it necessary to police words as well. It's worth noting that American NGOs are not required to make the same certifications because the policy violates the constitutional right to free speech. Foreign NGOs, on the other hand, are considered fair game.
In essence, this policy forces NGOs delivering healthcare in underserved areas to adhere to an anti-abortion agenda. If they need US aid, then they cannot talk about abortion with their patients. And given that the US is the world's largest provider of foreign aid, and that USAID provides nearly half of all global funding for women's contraception, it puts many organizations in an untenable position.
Trump's global gag rule is a cruel and unusual version of an already grotesque policy.
"Organizations are presented with the choice to either give up talking about abortion or lose all of their US funding," said Akila Radhakrishnan, the vice president and legal director of the Global Justice Center. "There are not a lot of organizations that have the ability to refuse US aid."
The negative impact of the Global Gag Rule is thoroughly researched and far-reaching. Counterproductively, or perhaps ironically, it has been shown to increase the rate of abortion. A 20-country study from Stanford examining the Global Gag Rule in sub-Saharan Africa found that countries with "high exposure" to the policy experienced a relative decline in the use of modern contraceptives and an increase in the induced abortion rate.
Maaike van Min is the director of the Department for International Development at Marie Stopes International (MSI), an international NGO that provides contraception and safe abortion services in 37 countries. She said MSI expects the policy to cause an additional 2.2 million abortions a year, because history shows that the global gag rule spikes the incidence of unplanned and unwanted pregnancies, which increases the number of women who seek abortions.
"We know that women who do not have access to safe abortion will put their lives and health in danger if they have a pregnancy they cannot keep," van Min said. "Women that have absolutely nothing to do with US politics are the ones who will suffer."
The vast majority of abortions are sought by women in the world's poorest countries. According to the World Health Organization, of the 36 million induced abortions a year, 21.6 million are unsafe, and 18.5 of unsafe abortions occur in developing countries. Seven thousand women die from complications of unsafe abortion each year, and deaths due to unsafe abortion constitute 13 percent of all maternal deaths. Agreeing to the global gag rule means that foreign NGOs cannot talk to women about their safe and legal options, at the expense of their health and safety.
Nearly 140 organizations, including MSI and the International Planned Parenthood Federation (IPPF), have said they oppose the global gag rule. Van Min said MSI will not agree to abide by the policy because abortion-related services are central to its mission, but this means the organization will lose the USAID funding it has received for the past eight years, representing $30 million and 20 percent of its annual budget. MSI serves 1.5 million women a year with this funding, and the impact will be devastating.
"If you estimate the number of women we could have served if we had USAID funding until 2020, who now we can't, we estimate that we could have saved 14 lives a day," she said. "Or to put it another way, that's 14 more maternal deaths a day."
This concern is particularly acute in countries with sky-high maternal mortality rates, which tend to be the same places where NGOs are the dominant, best, and perhaps only source of healthcare. If foreign NGOs agree to the policy, their health centers are likely to see patients with more complicated pregnancies and deliveries, which puts a strain on their already limited resources. If they do not agree, reduced funding can lead to cuts in nursing staff and clinic closures, leaving rural and impoverished areas without any access to healthcare and family planning. Exacerbating matters, the budget cuts that come with refusing to comply with the global gag rule limit NGO's capacity to make contraceptives available—increasing the demand for abortion and the likelihood that women will resort to unsafe, illegal methods of terminating their pregnancies.
The Guttmacher Institute estimates that 225 million women who want to avoid a pregnancy are not using an effective contraceptive method. By limiting access to contraceptives, the global gag rule could set off a number of public health disasters. For example, research from the International Food Policy Research Institute analyzed the impact of the policy in Ghana and found that the lack of contraceptives likely caused a 12 percent increase in rural pregnancies, which led to an additional 200,000 abortions and between 500,000 and 750,000 additional unintended births.
Rather than reducing abortion, this policy increased pregnancy, abortion, and unintended births.
"I find that these additional unwanted children have significantly reduced height and weight for age, relative to their siblings," wrote the report's author Kelly M. Jones. "Rather than reducing abortion, this policy increased pregnancy, abortion, and unintended births, resulting in more than a half-million children of significantly reduced nutritional status."
The global gag rule also inhibits the treatment and curbing of STIs, including HIV. More than one billion people on earth have an STI, and 1.7 million die from them a year. When George W. Bush reinstated the policy in 2001, a consortium of NGO investigators found that USAID had to cut off shipments of contraceptives to 16 sub-Saharan, Asian, and Middle Eastern countries. This included Lesotho, where Planned Parenthood was the only organization distributing condoms in a country where one in four women was infected with HIV.
And then there is the "chilling effect," whereby NGOs are so concerned about violating the policy that they overcompensate. For example, they might stop providing emergency contraception, post-abortion care, or even treating patients who have miscarried. "This policy makes NGOs so concerned about going afoul of the regulations that they go above and beyond," said Caroline Crosbie, acting CEO of Pathfinder International. "And historically even when this policy or rule is rescinded, the effect lasts years beyond because people are not sure what the next US administration will do."
The global gag rule not only raises conflicts between physicians and patients, but also between foreign NGOs and the countries in which they work. Since 1984, dozens of countries around the world have liberalized their abortion laws and worked to integrate abortion into their healthcare system. This means that a foreign NGO that takes US money could not tell a woman in, say, South Africa (where the procedure is legal) that abortion is an option for her. It also means that advocates working in countries with restrictive laws cannot lobby for or testify about abortion—even a doctor who has witnessed firsthand the damage that unsafe abortion can cause.
The impact of the silence under Trump's global gag rule will be greater than it was under Bush.
"The world is a lot different now than it was in 2001, when Bush implemented the gag rule," said Patty Skuster, policy advisor at IPAS, a global nonprofit dedicated to ending death and injury from unsafe abortion. "Governments have made major progress in making sure women can access to abortion and organizations were starting to speak out about abortion. The impact of the silence under Trump's global gag rule will be greater than it was under Bush."
The global gag rule is a political volleyball that gets tossed back and forth between administrations, but even if the Democrats take back the White House in 2020 and repeal it, change doesn't happen overnight. The infrastructure and capacity is far easier to tear down than it is to build back up. Clinics won't immediately be able to re-open, and it will take time for organizations that have stripped their programming of abortion-related resources to reintegrate them.
In the meantime, millions of women and children around the world will find their bodily autonomy and capacity to make decisions about their lives, not to mention their physical health, curtailed by the US government in a way that is neither reasonable, productive, nor just.
"There is so much arrogance involved," said Skuster. "I've been in this field for the better part of the last decade, and whenever I go to Africa and do training, everyone knows someone who has had an unsafe abortion and died or needed to get treatment. Unsafe abortion is a pervasive part of life for women in the developing world, and that is something that lawmakers in the US have no understanding of."