A White House official on Thursday clarified a new policy that renews abortion-related restrictions on global health funding, suggesting that the new version may be even more restrictive than previously understood.

President Donald Trump signed the latest version of the Mexico City policy on Monday, returning a common Republican funding restriction but significantly expanding its reach.

Also known as the "global gag rule," the policy prohibits any foreign organization that takes US aid money from using any of its other money on abortion-related services, including information or medical referrals, even in countries where abortion is legal.

The previous version of the policy exempted hospitals or clinics that don't offer abortion. It also carved out an exemption that allowed health facilities to treat women with complications from illegal or unsafe abortions without putting the facilities' US funding at risk.

White House deputy press secretary Sarah Sanders said the Trump administration has not decided on similar exemptions yet.

"The [George W.] Bush regulations implementing this policy excluded hospitals," she wrote in an email responding to questions on the policy from BuzzFeed News. "We will be issuing regulations as well, and may very well address the issue of hospitals there."

Sanders' statement is significant. It's the first time a Trump administration official has suggested that hospitals may have to agree to the so-called gag rule as a condition to receive global health assistance. It's also the administration's first clear indication that it may depart from the ground rules laid out last time the policy was enacted.

But the clarification also raises more questions. The Bush-era ground rules stipulated that the policy applied to "foreign nongovernmental organizations" and that foreign governments were specifically exempted. Trump's language omits the word "nongovernmental," and Sanders didn't mention exemptions for foreign governments. She did not reply on Thursday to an email requesting more details.

Reproductive health experts reacted with frustration to the possibility that hospitals may have to sign on to the policy as a condition of funding.



"They’re weighing in on what sort of services should be provided by a hospital that’s adhering to their own, in-country laws," Jonathan Rucks, advocacy director for the reproductive health organization PAI, based in Washington, DC, told BuzzFeed News.

"it would essentially obstruct a country from implementing its own laws and its own health strategies," said Serra Sippel, president of the Center for Health and Gender Equity in Washington, DC. "In countries like Ethiopia and Nepal, where abortion is legal, what we would see happen in the hospitals receiving US global health assistance is, they would be forced to turn women away who are seeking to legally terminate a pregnancy. We know what happens to those women: They will seek unsafe abortions, and they will put their lives at risk if they don't have access to safe abortions in the hospitals."



The World Health Organization attributes 13% of maternal deaths annually to complications from unsafe abortion.

Two previous versions of the rule — under former presidents George W. Bush and Ronald Reagan, who initiated the policy in 1984 — restricted only US money spent on family planning programs. Trump's version of the rule restricts all global health funding.

In her email, Sanders described the rationale behind the expansion.

"Family planning was the giant pot back then. Today, family planning programs are joined by major investments in global health programs for HIV/AIDS, tuberculosis and malaria, and many other specific initiatives. This Memorandum reflects the current state of foreign assistance," Sanders wrote.



But the broad language worries public health experts who say that HIV/AIDS treatment and prevention, some gender-based violence initiatives, vaccination programs, and other health interventions could be put at risk by the policy.

Most health groups, including the WHO, said it was too soon to know exactly how the expanded policy would affect their work.

Sanders also clarified the reasoning behind the administration's expansion of the policy.



"The foreign abortion industry has followed the money and moved into other activities," she wrote. "Money is fungible and we do not want our compassionate disease treatment and maternal mortality prevention programs to unintentionally free up the resources of the abortion industry to perform more abortions."



White House press secretary Sean Spicer on Tuesday erroneously suggested that US aid dollars had in the past funded abortions, which the 1973 Helms Amendment prohibits. Unlike that law, the Mexico City policy is a presidential directive, which can change with a new administration. Democratic presidents have consistently rescinded the policy; Republican presidents have consistently replaced it.

"The concern about fungibility is only raised when [conservatives] have an objection as to what is being done with that private funding," said Rucks, of PAI. He pointed out that faith-based organizations are global health partners of USAID. "They win government contracts and grants and provide services the grant outlines, and at the same time with their own private funding, they may be working against" stated government goals like increased family planning reach, Rucks said.

Bush also carved out an exception to the Mexico City policy for the President's Emergency Plan for AIDS Relief (PEPFAR) in 2003, the same year he initiated the fund, and for multilateral organizations. In its first four years alone, Stanford University researchers estimated the program saved 740,000 lives in nine countries.

It's still unclear whether Trump's implementation of the policy will also exempt those institutions. A draft of another executive order curtailing multilateral funding, seen by BuzzFeed News, specifically prohibits US funding for any international organization that "directly or indirectly" supports the performance of abortion.

Kate Nocera contributed reporting.