Under President Donald Trump, a decades-old Republican policy on global family planning just got a whole lot more aggressive. Just one day after the largest demonstration for women’s rights in American history, the Trump administration went further than any administration ever before in muzzling women’s and family health care providers around the globe.

The Mexico City policy — or the global gag rule, as it’s popularly known — essentially allows US presidents to fight the county’s domestic abortion wars abroad. And while the politics are entirely domestic, it’s foreign women and families who suffer the consequences.

Created by President Ronald Reagan in 1984, the original rule made US aid money to family planning providers contingent on a pledge not to “perform or actively promote abortion as a method of family planning,” even when those activities are funded by other countries or private foundations.

The policy thus limits the ability of global family planning providers to provide women and families comprehensive care if, in any aspect of their work, they recommend, discuss, or even mention abortions to clients, let alone provide abortion services.

Hence the “global gag rule.”

Trump’s reinstatement of the policy on Monday was not unexpected. Indeed, since Reagan, every Republican president has reinstated the rule when he comes into office, and every Democrat has rescinded it. But what was a shock was Trump’s radical expansion of the policy to include not just family planning organizations but all global health organizations that receive US government funding.

This means organizations that address everything from malaria, tuberculosis, and HIV/AIDS to tropical diseases and vaccinations — the list goes on — will now risk losing funding if they even mention abortion.

“It is not only chilling effect on family planning,” Dr. Mengistu Asnake, the Ethiopia country representative for Pathfinder International, a global family planning organization, tells me via Skype from Addis Ababa. “It will create a chilling effect on every health program.”

“This is really an extreme executive order,” says Lori Adelman, director of global communications at Planned Parenthood, “perhaps the most extreme executive order ever issued in the global health space. It is more extreme than under any other Republican administration.”

Adelman continues, “We know, based on what we have seen over 40 years of global health work, that this will mean thousands of global health organizations will shut down, including ones that deal with Zika, HIV, and maternal health.”

“It is not,” she adds, “an exaggeration to call this catastrophic.”

The new muzzle

Since the passage of the 1973 Helms Amendment, the United States has not allowed taxpayer money to fund abortion services overseas. The gag rule controls how foreign organizations and partners working on family planning policies use money they receive from other sources.

Traditionally, the gag rule, when in place, has banned all international nongovernmental organizations (NGOs) that receive USAID family planning funding from mentioning abortion to patients, as well as curtailed their ability to use outside funding to provide abortions.

Now, with the Trump administration’s change, experts say the gag rule will apply to 15 times more funding than it used to.

According to the Kaiser Family Foundation, a nonprofit organization focused on health issues, the policy will now apply to aid money coming not just from the US Agency for International Development (USAID), as before, but also from the Centers for Disease Control and Prevention (CDC), the Department of Health and Human Services, the National Institutes of Health (NIH), the Food and Drug Administration (FDA), and even to Peace Corps volunteers working on family planning in the field.

The United States in 2016 allocated $608 million for family planning world wide and about $9.5 billion for organizations administering global health, Suzanne Ehlers, the President and CEO of PAI, a global family planning advocacy organization, told me.* She explains that in the past, only the smaller budget was targeted by the global gag rule.

But under Trump’s executive order, it’s the $9.5 billion budget that comes under the rule. Additionally, Ehlers said, while some 40 countries receive US aid for family planning, some 60 countries receive aid for general global health, expanding the reach of the rule still further.

What it means

The global health world is reeling, and it’s still unclear how this will all play out. But the implications could potentially be enormous.

If organizations don’t agree to sign the pledge saying they won’t discuss abortion, says Ehlers, “they stand to lose massive funding from the US government. If they do choose to sign, their whole patient load will be impacted.”

That’s in no small part because many countries, she said, do not have the “luxury of freestanding family planning clinics.” Rural areas, especially, often offer integrated health — a one-stop shop for birth control, immunization, and, say, anti-diarrheal medication.

“The administrative and bureaucratic burden” of separating reproductive health out of those operations “is staggering,” Ehlers says, noting that monitoring and complying will lead to a dramatic chilling effect on reproductive health because groups will be afraid of missteps. The “perception of noncompliance” is scary, so organizations will start to back away. No one is quite sure yet how deep the changes will go. “That uncertainty has its own set of consequence and impacts,” she says.

And it is not uncommon for organizations that refuse to sign the pledge to have to shut down entirely or dramatically reduce public health services.

According to a PAI report, when the Planned Parenthood Association of Ghana rejected the pledge in 2003, 67 staff members were fired, nursing staff was reduced by 44 percent, and “1,327 communities were affected by the cuts.” And that was with a loss of just $200,000 in USAID money.

Marie Stopes International, a leading global health organization, initially estimated that a stop on USAID funding alone would have an immediate impact on its services. “In 2017, USAID funding would have helped us reach 1.5 million women in some of the poorest, most underserved countries in the world,” the organization said in a statement.

“We estimate that without alternative funding, the loss of our services during Trump’s first term, between 2017 and 2020, could result in: 6.5 million unintended pregnancies, 2.2 million abortions, 2.1 million unsafe abortions and 21,700 maternal deaths.”

For Dr. Asnake, the Pathfinder country leader in Ethiopia, the practical consequences are both immediate and long term, economic and possibly fatal.

Resources that could be used for family health programs will now be diverted to monitoring for compliance with the American executive order. Next, clinics and organizations that lose funding will start to fire staff, he says, and decrease their programming.

And in Africa, he points out, a worker in a clinic is not just working for him or herself — that staffer may be supporting many people on that salary, and often even more than one family. All of those people will now be poorer as a result of the new gag rule expansion.

And for the immediate term, Dr. Asnake notes that losing American funding means losing American technical support. Women will be left stranded while country organizers scramble to fill in the gaps.

“Even stopping for a day or two when thousands of women are waiting for services,” he says, has a “huge” impact. In the past, the developing world has looked to Europe to help fill in for lost funding.

But, he notes, “there was no refugee crisis in 2002. In 2016-2017 there is a huge refugee crisis. Will Europeans be willing to donate when they have [their own] refugee crisis on their doorsteps?”

Abortion increases under the gag rule — and women die

Beyond the new administrative burdens, though, are the very real consequences to women’s health and safety that the regular gag order rules already cause. Under the gag rule, regular access to contraceptives becomes patchy, and the number of unwanted pregnancies increases, leading to more unsafe abortions and more women dying.

According to Marie Stopes International, USAID is the “largest bilateral donor in family planning” and has expanded access to contraception enormously across the world. The United States is the largest donor of funds for contraception globally.

But part of that access comes by partnering with organizations that help distribute contraception to rural areas and teach women and families about reproductive health. Those partner organizations that refuse to sign the gag rule — Marie Stopes, for one, and the International Planned Parenthood Federation for another — will no longer be able to work with USAID at all.

Clinics and health groups that rely on the funding and infrastructure the US provides may simply fold.

Because abortions don’t stop happening just because we stop discussing them, the incidence of women seeking abortion under the gag rule usually increases, often with deadly consequences: In 2011, the World Health Organization published a report drawing a link between the global gag rule and a rise in abortions in sub-Saharan Africa.

A 2015 study conducted by the Guttmacher Institute, a nonprofit research organization supportive of legal abortion, found that some seven million women are treated annually for complications due to unsafe abortions.

It is estimated some 22,000 women die each year from unsafe abortions annually, with many thousands more left disabled. But in the last year of the Bush administration’s gag rule, that number was estimated as closer to 68,000, according to a 2008 World Bank report. It’s a number that can only be lowered by better access to education and contraception.

The Trump administration’s choice to extend the gag rule “sends a message,” says Planned Parenthood’s Adelman. “About how little regard they actually have for not only women’s health and lives but the health and lives of children and vulnerable communities around the world.”

“This, essentially, is limiting the free speech of people in other countries, if you want to talk about American values,” she adds. “This is anti–free speech and anti–human rights.”

Correction: An earlier version of this story misidentified the title of Suzanne Ehlers. She is president and CEO of PAI, not executive director. We regret the error.