In the aftermath of the US election, much focus has been on the consequences for abortion rights across the US, and whether this will affect state-led initiatives to roll back restrictive legislation.
What has received much less attention is what will happen next to abortion services, sexual and reproductive health, and health more widely across many parts of the world, as a direct result of a decision President Trump is likely to take on his first day in office.
The US is by far the largest donor of aid for global health, providing US$15.8 billion (£7.8 billion) in 2022, compared to the next three largest donors Germany (US$4.4 billion), Japan ($3.2 billion) and the UK (US$2 billion). That means restrictions and reductions on that aid can have enormous consequences around the world.
In 1984, President Reagan implemented the Mexico City Policy (which became widely known as the global gag rule), under which any organisation providing abortion services (defined widely from actual abortion provision to basic advice) was banned from receiving US aid – even if that funding was not being spent on abortion services. Since then, Democratic administrations have removed this rule, only for succeeding Republican presidents to reinstate it.
Based on his track record in his first presidency, Trump is likely to bring back this kind of restriction on aid when he returns to the White House. His first administration reintroduced this policy and vastly expanded the scope of its focus well beyond family planning services to include HIV/AIDS treatment, sanitation and public health more widely.
The amount of funding affected by these rules rose from around $600 million under Bush-era workings of the global gag rule to around US$12 billion. The ruling will apply not just to the organisations directly receiving USAID funding, but to any organisation they work with, even if using non-USAID funds for that work.
The potential impact of these restrictions on how countries can use their public health funding is significant; the performance of the previous Trump administration suggests health organisations are right to be worried about what may be coming.
Research over decades shows that when the global gag rule is in place the health of women and children in particular are put at risk.
A study in Kenya, for example, found sexual and reproductive health services (which may include abortion services, but also offer critically important services for pregnant and new mothers, infants and children) were closed. Stocks of contraceptives also declined as a consequence of these restrictions on how aid was spent. In Uganda, organisations reportedly stopped providing services designed to reduce death from unsafe abortions, worried even this might fall into the vague definitions of “abortion services”.
Leading international reproductive health charity MSI Reproductive Choices saw its overall funding fall by 17% in 2017 during Trump’s first term, over its refusal to agree to the terms of the global gag rule. In some countries abortion rates rose by up to 40%, with many expected to be unsafe, as US funding for safe abortion facilities disappeared.
There’s likely to be an increase in maternal and child mortality. The death rate from safe abortions is very small (around 1 per 100,000 births). Unsafe abortions, by contrast, are incredibly dangerous, with a death ratio of 200 per 100,000 abortions.
This type of restriction on how US aid can be spent doesn’t just affect abortion services. It also undermines wider sexual and reproductive health services, including family planning access and information. The result is that unwanted pregnancy rates increase at the same time as abortion service provision is reduced, with the inevitable consequence of pushing many women into dangerous unsafe abortion procedures. One study suggested an additional 30,000 maternal and child deaths occurred annually as a direct result.
A review of research findings on the impact of these public health restrictions carried out by policy organisation KFF, showed declines in usage of modern contraception, increases in pregnancies and rates of unsafe abortions.
The affect on advice on and availability of modern contraception, especially condoms, also brings with it additional health challenges. Best practice has long suggested integrating sexual health services with other health services including HIV testing and treatment, screening for some cancers and antenatal care, can improve health outcomes.
Undermining one aspect of these services has a knock-on effect on all of them. A 2022 study suggested that across highly US-aid dependent countries, there have been an additional 90,000 new HIV infections every year when the global gag rule has been in force.
Reduced access to contraception
Nepal, which enshrined the right to abortion and requires all government health facilities to offer free abortion services in its 2018 Safe Motherhood and Reproductive Health Rights Act, is one country that could be particularly badly affected. The US is the largest bilateral donor for health in Nepal and has provided more than three-fifths of aid for family planning and reproductive health under President Biden. One study found maternal and child health services in Nepal as a whole worsened under Trump’s last term, not just those parts linked to abortion services.
Contraception services declined and stocks frequently ran out, increasing risks of unwanted pregnancies. Organisations working on abortion were also often excluded from ministry of public health consultations, despite abortion being legal in the country, over government fears of the consequences for US aid flows.
When these kind of restrictions are in place the number of abortions has increased. And much of that increase is happening in unregulated, dangerous places, adding to the risk of death for pregnant women.
What might happen next?
Under previous US presidents, other donors have increased their commitments in order to try and protect sexual and reproductive health services and wider public health from the devastating impact of US policy.
It is critical that donors, especially those in Europe (including the UK), announce their plans now for how they will step up their support to protect women’s health and access to safe abortions, in order to prevent the closure of these vital services. Not just for the next four years but for the longer term.
These restrictions create the precise opposite of what they set out to achieve, resulting in more abortions and more deaths. But more than that, they are deeply harmful and dangerous to women who have no say over a policy that presents a danger to their lives.