With one devastating flourish of the presidential pen, worldwide progress on family planning, population growth and reproductive rights was swept away. Now some of the world’s poorest women must count the cost

Six months ago, one powerful white man in the White House, watched by seven more, signed a piece of paper that will prevent millions of women around the world from deciding what they can and can’t do with their own bodies.

In that moment, on his very first Monday morning in office, Donald Trump effectively signed the death warrants of thousands of women. He reversed global progress on contraception, family planning, unsustainable population growth and reproductive rights. His executive order even has implications for the battle against HIV, tuberculosis and malaria.

Rarely can the presidential pen have been flourished to such devastating effect. The policy it reintroduced will shut health clinics in Uganda and HIV programmes in Mozambique; it will compel women from Nepal to Namibia to seek out deadly back-street abortions.

“It is an unprecedented attack on women’s rights – it goes much deeper than abortion,” said Ulla Müller, president and CEO of EngenderHealth, a leading advocacy organisation.

What is the 'global gag rule'? The rule, otherwise known as the Mexico City policy, requires NGOs to certify that they will not perform or promote abortions anywhere in the world as a condition for receiving US family planning funds. Every Republican president since 1985 has implemented it. But Donald Trump has adopted a stringent version of the rule, under which NGOs that refuse to sign will be refused all health assistance, including for HIV, primary care, nutrition, tuberculosis and malaria programs. As much as $8bn in US funding could be affected – money that developing world health budgets can ill afford to do without.









“Girls are kicked out of school if they get pregnant. They are very often forced to marry the fathers. Very often they have to live in their in-laws’ house, where they have to do unpaid labour. It is a violation of women’s rights. We need to see this as a gender issue and very much as a power issue.”



Tewodros Melesse, director general of the the International Planned Parenthood Federation (IPPF), which stands to lose as much as $100m, said the US move “seeks to restrict the rights of millions of women. It asks us as a health provider, to stop providing services which are entirely legal in countries through our members – where some of the most poorest women, depend on them.

“The human cost of the gag rule will have a long and fatal legacy.”



Like so many far-reaching American policies, Trump’s executive order is enshrouded in complexity to the point where it seems almost designed to confuse.



The order reinstated the Mexico City policy (so called because it was first signed at the International Conference of Population in Mexico City, in 1984). Under this policy, any NGO outside the US seeking American funding for family planning has to pledge it will not carry out abortions anywhere in the world, even with its own money. Such organisations must agree not to talk to women about a termination, nor lobby governments to liberalise their policy on abortion.

US aid has never been used to fund abortion services (it is forbidden, by law). This is a ban on speaking about abortion – a restriction on free speech which the First Amendment does not permit within the US. For this reason, the rule became known as the global gag.

Trump’s version of the policy has massively expanded its reach. It is no longer just international family planning organisations that must agree not to “perform or actively promote abortion”. Every global health organisation that accepts US funding now has to sign the same clause. Anyone working to fight HIV, get vaccines or vitamins to children, or prevent Zika or malaria is facing a stark and unprecedented choice: sign, or lose all funding from the biggest aid donor in the world.

I believe that President Trump doesn’t give a hoot about any of these issues Jon O'Brien, president, Catholics for Choice

As much as $10bn (£7.7bn) of global health funding hangs in the balance. Among those who will lose money if they refuse to sign up to the anti-abortion orthodoxy are the two big international family planning organisations, Marie Stopes International (MSI) and the IPPF. But for the first time, global NGOs such as Save the Children, WaterAid and the International HIV/Aids Alliance are also targeted.

The effects will be felt most keenly in the tiny, frontline clinics run by small NGOs struggling to help women and children in crowded townships, refugee camps and remote rural villages. There are no abortion doctors in such places (in most African countries, abortion is banned unless the woman’s life is in danger). These clinics instead offer contraceptive injections and condoms for those who would struggle to feed numerous children. But they also treat children for malaria and malnutrition and their mothers for HIV. This integrated care is now under threat.

But that’s not all. Trump has also decided to stop funding the UN Population Fund, which does hard and heroic work, reaching some of the most oppressed women in the world in refugee camps and war zones, as well as getting contraception to the remotest parts of the planet. In 2016, the US gave the organisation $69m in core funds and for its humanitarian response work.

And deep budget cuts to foreign aid under Trump include a proposal to axe every cent for overseas family planning, currently $600m a year.

The triple blow is already being felt by some of the world’s poorest women.

Take Nigeria, a country with one of the world’s fastest growing populations. The average woman there has more than five children. MSI predicts that because of Trump’s “global gag rule”, there will be an additional 660,000 abortions in Nigeria over the next four years, with 10,000 women dying as a result.

“This is going to be really huge,” said MSI country head Effiom Effiom of the US decision to pull funding. “They’ve been key in strengthening healthcare. It’s their funding that allowed us to reach 500,000 women in the past three years. Who will bridge that gap?” he asks.

It’s a question that bothers Sakina Sani as well. She has two children already and knows she cannot afford many more. She is grateful to a family planning clinic in northern Nigeria for furnishing her with a contraceptive implant that will enable her to plan out her family for the next four years. But after that, she’ll be on her own.

Facebook Twitter Pinterest Sakina Sani, a mother of two, has a contraceptive implant – known informally among young Nigerians as a ‘tattoo’ – placed in her arm. Photograph: Ruth Maclean/The Guardian

“I’d have to have more children,” she admits. “All I could do is pray harder for God to help feed them.”

Across the continent, in Uganda, her experience is replicated by Dausi Mukwana, 26, who had the first of her four children at the age of 14. An injectable contraceptive called Sayana Press and a tireless healthworker called Aisha Mugoya have belatedly given her control over family planning. But Mugoya’s work promoting family planning is now in jeopardy: funding will dry up in the coming weeks.

“The number of maternal deaths will increase as the number of pregnancies increases, and the number of abortions is going to increase,” said Dr Moses Okilipa of Reproductive Health Uganda, a branch of the IPPF, which refuses to sign up to the Mexico City policy.

Facebook Twitter Pinterest Dausi Mukwana, 26, a rural Ugandan, receives a contraceptive called Sayana Press. Photograph: Juozas Cernius/for The Guardian

The glaring paradox is that the global gag policy doesn’t even work. “The gag rule contributes to the very thing it purportedly seeks to reduce: the frequency of abortion,” said a report in June from the Guttmacher Institute, a US research organisation focused on sexual and reproductive health and rights. Evidence shows that when the gag is imposed, unwanted pregnancies and abortions go up.

Banning abortions and forcing NGOs not to offer any counselling or advice about them drives desperate women to the back-street abortionists and witch doctors.



Hardline opponents of abortion don’t understand this; they don’t believe it or don’t care. At Trump’s right elbow when he signed the order was Mike Pence, a born again Christian. Trump is not religious, but some of his most influential advisers are – and the choice of Pence as his running mate brought on board the religious right. The new, improved global gag is their reward.

“I believe that President Trump doesn’t give a hoot about any of these issues one way or the other,” said Jon O’Brien, president of Catholics for Choice. He pointed out that Trump’s closest advisers include a significant number of ultraconservative Catholics. Kellyanne Conway has been a prominent anti-choice campaigner for decades, he said, claiming in interviews that “unborn babies can feel pain at 20 weeks” (a view that the evidence does not support). Steve Bannon, chief strategist and Sean Spicer, White House press secretary, are both conservative Catholics. Katy Talento, a health policy aide on the Domestic Policy Council, recently published an article alleging that “chemical birth control causes abortions and often has terrible side effects, including deliberate miscarriage”, a claim about the pill that is not supported by scientists.

And then there is Pence. At the Republican National Convention in Ohio last July, he called himself “a Christian, a conservative and a Republican, in that order”. Born into an Irish Catholic Democrat-voting family in Indiana, he found God at a Christian music festival in Kentucky in 1978. He was still a Democrat in 1980, when he voted for Jimmy Carter, but his views started to shift to the right at college and he became a big admirer of Ronald Reagan’s “common sense conservatism”. By 1988 he was running for Congress as a Republican. He lost but won a seat in the House of Representatives for Indiana in 2000.

In his 2000 Congressional campaign, he urged that the Ryan White Act, which provides funds for HIV treatment for the poor, should only be renewed if the money was “directed toward those institutions which provide assistance to those seeking to change their sexual behaviour”.

As governor of Indiana in 2015 he made national headlines when he signed into law a bill that was interpreted as permitting discrimination against LGBT people in the state. Under the Religious Freedom Restoration Act, restaurants, hotels or shops would be able to cite a religious objection to serving gay customers. Pence was photographed signing the bill into law in March 2015 surrounded by monks and nuns in habits. A number of large businesses spoke out against the law, including Apple CEO Tim Cook and in the face of an outcry, Pence made revisions.

Facebook Twitter Pinterest Opponents of the anti-abortion law signed by Mike Pence protest outside the Indiana State House last July. Photograph: Mykal McEldowney/AP

His opposition to abortion has been solid. In October 2015, he awarded $3.5m of Indiana state funds to a charity called Real Alternatives, which promotes sexual abstinence and counsels pregnant women wanting an abortion to have the baby. Then, in March 2016, Pence brought in one of the toughest state abortion laws in the US. Abortion on the grounds of foetal abnormality, including Down’s syndrome, would be banned. All women wanting an abortion would be required to have an ultrasound examination, where they would see the foetus on the monitor, at least 18 hours before the termination. The harsher aspects of this law were stayed by the courts, but the US by now understood Pence was willing to fight the most controversial battles on behalf of the religious right. As Rolling Stone put it in January: “When Trump needed a VP nominee with a career-long reputation for being virulently pro-life to balance his own abortion flip-flops, Mike Pence was the answer to all his political prayers.”

The day after the inauguration, 500,000 people attended the Women’s March on Washington on 21 January, to voice disgust at Trump’s past sexual behaviour and fear for the future of women’s reproductive rights. Days later, Pence became the first vice-president in history to attend the annual anti-abortion March for Life, held for the past 44 years on or near the anniversary of the historic judgement of Roe v Wade. Thousands of anti-abortion activists were bussed to the National Mall in Washington DC, some holding pictures of the foetus in the womb, others waving banners. “Trump loves the bump” was one. “We voted to make America pro-life again”, said another. A third read: “We hear your silent cries”.

“It is no coincidence that the first right cited in the US Declaration of Independence is the right to life,” Conway told the crowd, to cheers. But it was Pence who made the real impact. Trump had sent him to address this gathering, he said. Life, Pence said, “is winning again in America”.

Fighting back

The most devastating impact of the policy is on the big providers of family planning, IPPF and MSI, whose clinics all over the world will be stripped of US funds because they offer abortions in countries where it is legal to do so (in the UK, Marie Stopes provides terminations on behalf of the NHS). In developing countries, they partner with local NGOs, funding clinics where women may go for a contraceptive implant or injection but often for other healthcare too, such as an HIV test or cervical cancer smear. All of this is at risk.

MSI received $30m from USAid last year, which was 17% of its total funding. It is working to raise funds from other sources, but the gap will be hard to fill. Hardest hit will be services in Madagascar, Zimbabwe, Uganda, Ethiopia, Nigeria and the Sahel. These are places where MSI has been running substantial programmes with USAid funding. In Madagascar, 40% of women get their contraception from MSI.

IPPF has about $100m annually in US funds but, after the last global gag, it deliberately invested nearly half the money in HIV services, decreasing its exposure in case another Republican president came in. Trump’s extension of the Mexico City policy to all forms of healthcare means they stand to lose the lot. Among programmes under threat unless alternative sources of funding can be found are HIV treatment in the Caribbean, clinics testing for Zika across Latin America, and help for displaced people in Colombia.

“We have become much more of an integrated service provider. We’re trying to be a one-stop shop that takes you from the start of life to the end of life,” said Matthew Lindley of IPPF, who support fragile health systems in impoverished and war-torn countries.

“If we had USAid funding, we would have expected to avert 6m unintended pregnancies,” said Megan Elliott, vice-president for strategy and development at MSI. “Because we can’t avert them, we believe there will be an additional 2m abortions. Because they are in restricted environments, the majority of those women will be getting a backstreet abortion where they won’t be properly cared for and certainly won’t get proper contraception to prevent a further unwanted pregnancy.”

Facebook Twitter Pinterest In a picture widely seen as a parody of Trump signing the global gag order, Isabella Lövin, Sweden’s deputy prime minister, is flanked by female colleagues as she signs a bill. Photograph: Johan Schiff/EPA

Last time the gag rule was in force, between 2001 and 2008, USAid stopped supplying contraceptives to NGOs in 16 developing countries in Africa, Asia and the Middle East, many of which had very high rates of HIV. Guttmacher cites Lesotho, where one in four women were HIV-positive, and which got no US support at all for family planning or contraceptive supplies under George W Bush. In 13 other countries, USAid cut off support to the leading family planning organisation. The Planned Parenthood Association of Zambia suffered a 24% budget cut and had to reduce its services.

The fightback began in March. She Decides was the idea of the Dutch trade and development minister Lilianne Ploumen, who was backed by the Belgian, Swedish and Danish governments. A fundraising conference attracted representatives from 50 governments and raised €181m.

That’s a drop in the ocean, they acknowledge, but the campaign to persuade more governments, philanthropists and the private sector to step up with cash continues. Earlier this month, the Bill and Melinda Gates Foundation (which also funds work at the Guardian) announced it would increase its funding for family planning by 60%, with an extra $375m over the next four years.

Chris Hohn, a hedge fund manager, started the Children’s Investment Fund Foundation, which makes grants for projects to improve children’s health in poor countries. Concerned about the harmful effects of pregnancy on so many adolescent girls, which can result in a baby suffering from stunting and malnutrition, his Fund is giving MSI $10m.

Millions of women have been given control over their bodies and their futures. Millions of girls have been able to stay in school and have hopes of a career. But the edicts of the Trump administration, rooted in an ideology that says the lives of women count for less than the life of a foetus, have set the world back years.

The gag meanwhile extends far beyond the world of NGOs. Western officials who don’t want to fall out with the Trump White House are silent. Those who work at the Department for International Development do not want to criticise their colleagues at USAid, who themselves are privately wringing their hands over a policy that will undo much of their good work on behalf of women and girls.

Further afield, the 30-year-old woman with 10 children she can’t feed or send to school, and the 14-year-old made pregnant by her uncle, can’t be gagged.

They have no voice at all.



Ruth Maclean in Maiduguri, Nigeria, and Liz Ford in Mbale, Uganda, contributed to this report