The Global Gag Rule Is Back, With a Vengeance.

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On January 23, 2017, President Trump, on his first day in office, signed an executive order reinstating the Mexico City Policy, also known as the “global gag rule.” This policy prohibits foreign NGOs that perform or promote abortion from receiving US government family planning funds. The NGOs are also prohibited from using private funds to engage in abortion activities. The policy also restricts referrals for abortion—where legal—as part of the full range of family planning options; promoting changes in a country’s laws or policies related to abortion; and conducting public information campaigns about abortion as a method of family planning. Foreign NGOs are consequently forced to choose between one of two options: accept US federal funds and be prohibited from providing abortion counseling, referrals, or advocacy efforts; or refuse US funds and attempt to secure alternative sources of funding.

The Mexico City Policy first took effect in 1985 during President Reagan’s administration; since then, it has been reinstated or rescinded strictly along party lines. In the past, organizations that refused to comply with the global gag rule lost US funds and ended up with fewer resources to support family planning and reproductive health services such as family planning counseling, contraceptive commodities, condoms, and reproductive cancer screenings. Family planning clinics were closed in Ethiopia, Ghana, and Nepal. The Family Planning Association of Kenya (FPAK), a leading reproductive health (RH) services provider for rural communities, closed 15 clinics from 2001 to 2005. Healthcare referral systems collapsed, key staff members (e.g. nurses) lost their jobs, and reproductive health commodities were in short supply. Meantime, organizations that accepted US funding were not able to provide accurate information to patients, leading to mistrust of health providers by women.

But disturbingly, President Trump’s gag rule goes further than any previous administration. It restricts funding for other global health projects that were exempted by the Bush administration, calling for “a plan to extend the requirements of the reinstated Memorandum to global health assistance furnished by all departments or agencies.” This includes program funding for maternal and child health, nutrition, HIV/AIDS (including PEPFAR, established by then-President Bush), infectious diseases, malaria, tuberculosis, and neglected tropical diseases. All are crucial public health programs necessary to prevent disease and improve the health status of populations in the developing world.

Most of my work as a nurse midwife and public health practitioner is in developing countries where health resources are limited and health systems are unable to support the population’s demands for health services. The majority of women affected by the Mexico City Policy live in these countries, where access to reproductive health services is already a challenge. An estimated 225 million women in developing countries who wish to avoid future pregnancies are not using family planning methods. Of the 74 million pregnancies that occur globally each year, 28 million end in unplanned births and 36 million in abortions, of which 21 million are performed under unsafe conditions. About 13 percent of all pregnancy-related global maternal deaths are due to unsafe abortion. In Sub-Saharan Africa, more than 95 percent of abortions are unsafe.

For some of the women who will be directly affected by this reinstated and expanded policy, the first contact they have with a health system is when seeking care for an abortion complication, such as severe bleeding or infection, both life-threatening conditions. During some of my work in South Sudan, Angola, and Kenya, I saw firsthand as women died due to abortion complications even after they reached a health facility, most often due to lack of appropriate resources and/or qualified personnel. NGOs in these countries usually fill the resource gap and provide women with comprehensive reproductive health services, including family planning and referral, which is not only lifesaving but also necessary to avoid the cycle of repeat unintended pregnancies and unsafe abortion.

Although the public health community has yet to understand the full extent of Trump’s gag rule, the anticipation should be that the expansion of this outdated policy will further deny women their basic fundamental reproductive rights to information and access to life-saving, comprehensive sexual and reproductive health services. Moreover, we can anticipate that other populations affected by HIV/AIDS and other diseases, both infectious and non-infectious, will also become vulnerable under Trump’s policy. As public health actioners, we need to make the case for how severe the consequences will be, and how best they can be offset. The health of millions depends on it.

Monica Adhiambo Onyango is a clinical assistant professor of global health.