Getty Images

For millions of women, life is about to get more brutal, and potentially shorter, because of a president they didn’t elect in a country they’ve never been.

Much attention has been paid to the potential impact of a Donald Trump presidency on American women and minority groups in the United States — the threat posed to female citizens by a president who brags about sexual assault and suggests women should be punished for abortion, the potential infringements on the rights of Muslims and immigrants. But it’s not just people within U.S. borders who have reason to worry. For women around the world, a Donald Trump/Mike Pence administration spells a policy of active hostility to reproductive rights and using U.S. dollars to hold other countries hostage to American abortion politics. For women who aren’t American and who had no say in this election, Trump and Pence are going to have an awful lot of influence over their futures — and it’s not going to be good. Some of them likely won’t live through it.

“The Trump/Pence administration really represents one of the greatest threats we’ve seen to health and rights of women and girls globally,” said Serra Sippel, the president of CHANGE, a global organization promoting sexual and reproductive health and the rights of women and girls.

There are a lot of unpredictable ways that threat may metastasize, but the easiest, and most likely, is through American foreign aid. USAID, the international agency that works to alleviate poverty and improve global health, has a $22.7 billion budget, of which $2.9 billion goes to improving health, mostly in developing countries — things like reducing maternal and child deaths, combating HIV/AIDS and tuberculosis, preventing and treating malaria, and vaccinating children. The United States government remains the world’s largest donor to, and implementer of, global health programs.

Kenya, where I live, is a prime example of the influence of U.S. funds: According to USAID, “USAID/Kenya’s health and HIV/AIDS budget is equal to approximately 50% of the budget for the entire [Kenyan] Ministry of Health.”

This generosity, though, comes with strings — especially when it comes to abortion rights. And under Trump, those strings are about to get pulled a lot tighter. One of the first agenda items on his list is likely the Global Gag Rule, a Reagan-era law that is essentially a gag order on any organization receiving U.S. family-planning funding from even talking about abortion. U.S. dollars can’t fund elective abortions abroad anyway, due to a law called the Helms Amendment, but the Gag Rule takes that further, saying that NGOs will lose all of their U.S. family-planning money if they so much as tell a woman abortion is a legal option in her country or advocate for abortion rights with their own resources.

The Gag Rule reliably has been implemented by Republicans and rescinded by Democrats, and no one doubts that Trump will put it back in place, likely in his first few days of office. The impacts of the rule under President George W. Bush were dramatic. In 20 developing countries, the United States stopped providing badly needed contraceptives to organizations it said violated the Gag Rule. Many groups were forced to slash services or even shutter because they lost U.S. funding for talking about abortion. Women saw their access to maternal health care and treatment for HIV and malaria curtailed.

The Gag Rule manipulated other countries’ ability to legalize abortion too — if health-care providers can’t talk about abortion without losing their funding, then they can’t testify to the harms they see from illegal and often unsafe abortion every day, or lobby their governments for legal change. Tens of thousands of women around the world die from unsafe abortions every year; millions more are injured. Some are jailed. Unsafe abortion remains one of the leading causes of maternal mortality. The overwhelming majority of these deaths and injuries occur in places where abortion is outlawed. But because abortion is domestically controversial, the United States prefers to treat it as a political issue rather than a matter of basic health care, even overseas — and that costs women’s lives. Whatever your opinion on the morality of abortion, the reality of abortion is that without access to safe procedures, women are injured or killed, and that’s a pressing public health concern.

Even without the Gag Rule, U.S. policy toward safe abortion services abroad is remarkably conservative — even under a technically pro-choice Obama administration. Under the Helms Amendment, the funds can only pay to end pregnancies for rape and incest survivors, or women whose lives or health are threatened by a pregnancy, but because U.S. policy constricts or relaxes with every new president, and because abortion is so stigmatized, USAID and many recipients of USAID funds tend to interpret the law in the most restrictive terms.

Kenya, again, is an illustrative example: In a major victory for Kenyan feminists and health advocates, the 2010 Kenyan Constitution liberalized abortion, allowing it in cases of rape, emergency, or threat to the pregnant woman’s health or life. But because of conservative interpretations of the Helms Amendment, Kenyans haven’t been able to fully implement their own laws.

Lucy Minayho Lugalia, who lives in Kenya and works for the Ipas Africa Alliance, a reproductive rights group, told me that when her organization studied the impact of Helms on Kenyans, they found that “the reality is that Helms is being implemented as a complete ban on abortion.” Health-care providers reported being barred from ordering what’s called an MVA machine — a manual vacuum aspirator, which is used for abortions as well as to treat incomplete miscarriages — or drugs that induce abortion and help complete miscarriage, even though these tools are standard for medical care other than abortion. This is an endemic problem across developing nations dependent on USAID money. In Malawi, for example, one nurse midwife told Ipas researchers, “We ran out of [an essential MVA equipment part] last week. A woman came here bleeding after inserting a cassava stick in her uterus. Because we couldn’t treat her, she had to walk eight hours to the nearest hospital.”

USAID funding sometimes leads government agencies, which depend on the money, to place the moral imperatives of U.S. politicians over the health of their own citizens. According to Minayho Lugalia and her colleagues, the Kenyan Ministry of Health issued a memo reminding all health-care providers they can’t offer abortion services — despite the fact that under both U.S. and Kenyan laws, they should be able to, at least under certain circumstances. The outcome: When women come in seeking abortion services for allowable reasons — rape, for example, which is especially endemic in the humanitarian crisis zones that dot much of the developing world — they may not be able to access them. And when women come in for emergency abortion services — if they tried to self-induce, for example — advocates say doctors sometimes hesitate to provide care, even where they’re legally allowed to, because they are so worried of running afoul of the law.

“There’s this memo from the Ministry of Health that abortion services should not be provided. And there’s a woman who’s bleeding,” explained Erick Yegon, a senior research evaluation adviser with Ipas. “[Hospitals] have to look at which provider will be willing to provide the service, knowing that at the top of their heads there’s this memo, that if anything goes wrong, they will be seen to have breeched the directive of the Ministry of Health. So it really affects how they provide the service. And by the time they provide the service, there’s a lot of delay — you have to determine whether you want to provide it or not, and if you’re going to get in trouble, instead of just treating the woman who is bleeding.”

When women come in seeking abortions, health-care providers often find that their hands are tied — and, according to Minayho Lugalia, some end up incentivizing dangerous choices.

“When a patient presents [seeking an abortion], they tell them they can’t give them the service,” Minayho Lugalia said. “They won’t tell them to do an induced abortion, but they will tell them the only way they can do it is if they’re coming for an emergency. So of course that’s taken as, ‘Let me go take a drug or start it, and come back to the facility for a complete procedure.’ The dangers of that are quite significant.”

And this, mind you, is the landscape under a Democratic president, without the Global Gag Rule in place.

While abortion has never been an animating issue for President-elect Trump, it is a big one for his VP. Pence signed laws — currently stayed and not in effect — barring abortions for fetuses with abnormalities, and requiring women to seek funeral services after abortions or miscarriages. A Trump/Pence administration, Pence has said, means the legal guarantee of abortion rights in the U.S. will be “consigned to the ash heap of history.” For women overseas who are already at risk, the next four years could be even worse.

“Is it going to be the Global Gag Rule on steroids given Pence’s anti-abortion extremisms?” CHANGE’s Sippel said. What that might look like, according to Sippel: It could apply to all U.S. foreign aid (under the previous administrations, it applied only to family-planning funding), so any organization that receives U.S. aid money for any purpose could find itself gagged from telling women about their legal rights or trying to make abortion safer in their own country. The exceptions for rape, health, and life endangerment could also be done away with, so even women who face life-threatening pregnancies or who are rape survivors could not be given abortion care at any facility receiving USAID family-planning dollars.

For reproductive health advocates, the scariest thing about the incoming administration is how volatile it is, and how little Trump seems to care about established norms or people who might be hurt by his policies. We know that historically, Republican presidents have not been particularly helpful for women’s rights abroad, especially in the realm of reproductive health. But they’ve been reined in, however nominally, by Democrats and the need to play nice with other nations. A Republican majority in both houses of Congress coupled with a president who seems ignorant, uninterested, or both in basic statesmanship means all bets are off.

“There is the sense that we need to expect the unexpected,” Sippel said. “I don’t know what they’re going to conjure up that we haven’t even thought of. But we’ll be on the watch.”

Follow Jill on Twitter.

Jill Filipovic senior political writer Jill Filipovic is a contributing writer for cosmopolitan.com.

This content is created and maintained by a third party, and imported onto this page to help users provide their email addresses. You may be able to find more information about this and similar content at piano.io