President Donald Trump reinstated — and massively expanded — an executive order Monday barring US foreign aid from going to any nongovernmental organization (NGO) that either provides abortion services, or even discusses abortion with its patients as an option for family planning.

Trump has promised to take sweeping actions against abortion, including appointing Supreme Court justices who would overturn Roe v. Wade. Reinstating and expanding the global gag rule is the first indication of how serious he is.

The global gag rule has become something of a political seesaw since Ronald Reagan first implemented it in 1984 at a United Nations population conference in Mexico City (which is why it’s also called the “Mexico City policy”). Bill Clinton repealed it immediately when he took office. George W. Bush immediately reinstated it when he took office. Then Barack Obama immediately repealed.

But Trump did more than just reinstate the Reagan-era policy — he expanded it to an unprecedented degree. The gag rule will apply to 15 times more funding than normal because it applies to all global health funding, not just family planning funding through USAID (United States Agency for International Development) or the State Department.

Trump’s version of the gag rule will apply to roughly $9.5 billion dollars in global health funding, as opposed to roughly $575 million in family planning and reproductive health funding, according to Population Action International (PAI), a global family planning advocacy organization.

“Trump’s Global Gag Rule is cruel and unusual in that it massively expands an already harmful policy,” said a statement from PAI. “This grotesque expansion targets the most effective health organizations in 60 low and middle income countries.”

The funding cuts will go far beyond abortion, and even beyond contraception. They will likely prevent many global health organizations from offering HIV prevention and treatment services, maternal health care, and Zika virus prevention.

The effects of reinstating and expanding the gag rule now — especially after eight years of the Obama administration, which supported sexual and reproductive health in foreign aid — will be very messy, advocates say. The ripple effects and unintended consequences will have devastating effects on the health of women and girls around the globe. And while it will export the US abortion wars overseas, only foreign women will be the casualties.

“Trump’s global gag rule will obstruct and destroy the work of health care providers who are often women’s main — and sometimes only — source for reproductive health care, and their entry point for receiving a wide range of primary health care services,” said Suzanne Ehlers, president and CEO of PAI, in a statement.

The gag rule does wide-ranging damage to women’s health abroad

The global gag rule goes much further than simply banning US foreign aid from paying for abortions directly — which is already the law, and which has its own detrimental consequences for women.

Instead, the gag rule tries to control how international organizations use their own funds, raised from other sources.

Just like Republican efforts to defund Planned Parenthood in the United States, it’s an attempt to stop abortion from happening by forcing organizations that provide it to make a choice: stop providing or promoting abortion, or lose the large amounts of funding that you get from the US government to support your other medical services.

But large global family planning organizations, like the International Planned Parenthood Federation and Marie Stopes International, aren’t simply going to stop offering abortion care or counseling worldwide — and so they will lose funding.

In a statement, the International Planned Parenthood Federation/Western Hemisphere Region (IPPF/WHR) confirmed that they will not sign on to the gag rule’s conditions: “As a rights-based health organization that seeks to protect and enhance the lives of women, men and young people throughout the Americas and Caribbean, IPPF/WHR will not sign a policy that denies human rights and puts the lives of women at risk.”

Marie Stopes International also released a statement in response to the executive order, asserting that the organization “knows that safe abortion is a vital component of women’s reproductive healthcare, and therefore we cannot agree to these conditions.”

The reality is simple and brutal. Reinstating the global gag rule will not reduce abortions. Sub-Saharan Africa, for instance, had higher abortion rates after George W. Bush reinstated the gag rule, because it reduced women’s access to contraception and caused more unwanted pregnancies, which women then chose to terminate.

SSA countries more reliant on USAID for reproductive health saw big rise in abortions after 2001 global gag rule https://t.co/6Z11jfVKx1 pic.twitter.com/VprcKGzXsY — Charles Kenny (@charlesjkenny) January 23, 2017

The gag rule will, however, lead to more women dying across the developing world. Marie Stopes International estimates that without alternative funding, the loss of its services alone will cause 6.5 million unintended pregnancies, 2.2 million abortions, 2.1 million unsafe abortions, and 21,700 maternal deaths just in Trump’s first term, from 2017 to 2020. The organization says it will also be prevented from reaching 1.5 million women with contraception every year.

Studies conducted by PAI have shown that every time the global gag rule returns, more women in developing countries bear unwanted pregnancies, die or become disabled due to unsafe abortions, or lose crucial medical care.

After Obama lifted the gag rule in 2009, PAI director of advocacy Jonathan Rucks told Vox, large international family planning organizations like Marie Stopes International and the International Planned Parenthood Federation were able to bring crucial contraceptive services to areas like West Africa that were poorly served before. But with the gag rule back in effect, large geographic areas may simply lose services, including birth control.

The gag rule hurts not just abortion access, not just contraception access, but other forms of health care as well, Rucks said. In many developing countries, women get reproductive health care at the same place they get all of their other care. So when health care providers lose funds due to the gag rule, it slashes funding and causes nurses to be laid off for all health care services the provider offers.

And the rule has both direct and indirect consequences, Rucks told Vox. Because the Obama administration had such supportive sexual and reproductive health policies, the United States was able to partner with other donor governments, like the United Kingdom and Sweden, that also support reproductive freedom. But those governments “won't be as likely to want to pool funds with us” for international aid if the Trump administration implements such negative and harmful policies, Rucks said.

The gag rule isn’t the only US policy that has this overall effect. But it has earned a reputation among human rights advocates as a particularly cruel, draconian measure that exists for one purpose only: appeasing far-right opponents of legal abortion in the United States.