A mother and her newborn baby at the Maternal and Child Health Training Institute for medically needy in Dhaka. UN Photo/Kibae Park

Will President Donald Trump eliminate access to healthcare for some of the poorest women on the planet?

One of the first foreign policy moves of President elect Donald Trump may be to eliminate access to healthcare for some of the poorest women on the planet.

If past is precedent, with the stroke of a pen on January 22 he will re-instate what is known as the Mexico City Policy, or by opponents as the “Global Gag Rule.” This is a restriction that bans NGOs from receiving funding from the American government if those NGOs provide abortion services, counsel patients that abortion is a family planning option, or advocate for the legalization of abortion in their countries. Even if the dollars used to do these things do not come the USA, the entire organization is nonetheless banned from receiving US funding.

This policy has been a political football in domestic American politics for the past 30 years, with Republicans enacting it and Democrats rescinding it, usually on their first day in office. It was was first enacted by President Reagan in 1984 then rescinded by President Clinton in 1993. It was enacted again by President Bush in 2001, and once again rescinded by President Obama in 2009.

Caught in this back-and-forth are millions of women around the world who visit health clinics supported by the United States government, often through grants administered by the United States Agency for International Development.

30 Years Is Enough: End the Global Gag Rule from PAI on Vimeo.

US policy from the early 1970s, known as the Helms Amendment, already bans US funding for “the performance of abortion as a method of family planning.” But that the global gag rule takes that a step further by prohibiting all funding for an organization even if it suggests to patients that abortion is an option–or lobbies its government on abortion related issues.

Global health organizations note that during years in which the gag rule is enforced, the number of abortions (often unsafe) has increased. That’s because the organizations that are affected by the gag rule tend to also be important providers of contraceptives to poor women in the developing world. When access to contraception decreases, the number of women seeking abortion increases. From the Guttmacher Institute 

After President George W. Bush reimposed the gag rule in 2001, a consortium of NGOs led by Population Action International organized a study to assess the policy’s effects. Between 2002 and 2006, the research teams made site visits to the Dominican Republic, Ethiopia, Ghana, Kenya, Nepal, Tanzania, Zambia and Zimbabwe. They found that in Kenya, for example, the gag rule led to the termination of critical activities run by the Family Planning Association of Kenya and Marie Stopes International (MSI) Kenya—the leading providers of health care to people living in poor and rural communities in the country. In addition, enforcement of the policy drastically curtailed community-based outreach activities and the flow and availability of contraceptive supplies. Government clinics, exempt from the gag rule, were never able to pick up the slack nor regain the trust of women turned away by the NGOs.

The NGO investigators found that the U.S. Agency for International Development (USAID) had to cut off shipments of contraceptives—already in short supply—to 16 countries in Sub-Saharan Africa, Asia and the Middle East. The Lesotho Planned Parenthood Association, for example, had received 426,000 condoms from USAID over two years during the Clinton administration. Once the gag rule went back into effect, USAID had to end condom shipments to Lesotho entirely because the association was the only available conduit for condoms in that country. At that time, one in four women in Lesotho was infected with HIV. Under the Obama administration, funding for international family planning assistance has increased and partnerships with organizations implementing reproductive health programs abroad have expanded, which has allowed U.S. aid to reach underserved or never-served populations. MSI, for example, first received USAID funding in 2010 to scale up delivery of free or highly subsidized family planning services in Madagascar to rural and hard-to-reach areas. Since 2010, U.S.-funded work has enabled 436,000 women and men to receive voluntary family planning services; about 40% of all women using a modern family planning method in Madagascar have received their method from the U.S.-supported MSI-Madagascar program. Given that the United States is one of the largest government donors of MSI’s work in developing countries, many of these critical health services could be put at risk if the Mexico City policy were reinstated.

Access to contraception and modern family planning methods is already a profound challenge in the developing world. According to Guttmacher, about a quarter of married women in 24 poor countries want access to family planning services, but cannot get it. This leads to high birth rates. There are 16 countries in the world (all but one of which, Afghanistan, is in Africa, with average fertility rates of more than than 5 children per woman.  Alas, if past is precedent the next President of the United States may make access to contraception more difficult for the women who want it the most.