1 The White House

Presidential Memorandum Regarding the Mexico City Policy. On Jan 23, 2017, on his fourth day in office, President Donald Trump signed an executive order imposing the global gag rule,an anti-abortion policy that under other conservative presidential administrations has caused serious disruptions to US overseas family planning efforts. Alarmingly, Trump's order goes even further than in the past, with potentially devastating effect.

2 Barot S

Cohen SA The global gag rule, also known as the Mexico City policy, was devised in 1984 by the administration of Ronald Reagan to impose a draconian set of anti-abortion rules on US overseas family planning programmes.This policy banned US family planning funds from going to foreign non-governmental organisations (NGOs) that provide abortion services, counselling, or referrals, or advocate for liberalisation of their country's abortion laws—even if they use non-US government funds for these activities. In 1984, and every time the global gag rule has been imposed since then, foreign governments were exempt for diplomatic reasons, as were US-based NGOs on constitutional grounds.

3 USAID

USAID'S family planning guiding principles and U.S. legislative and policy requirements. To be clear, legislation was already in place in 1984, and is still in place now, that bans the use of US funds under the Foreign Assistance Act from paying “for the performance of abortion as a method of family planning”.But for anti-abortion activists this Helms Amendment, passed in 1973, did not go far enough; they wanted to limit any activity that could possibly enable or promote abortion. Hence, the global gag rule.

4 Kaiser Family Foundation

US funding for international family planning and reproductive health. 1 The White House

Presidential Memorandum Regarding the Mexico City Policy. 5 PAI

Trump's global gag rule dramatically expands harmful health impacts. 6 Kaiser Family Foundation

The US Government and global health. Under Trump's order, the gag rule now applies not only to US bilateral family planning assistance (US$575 million for fiscal year 2016),but also to all “global health assistance furnished by all departments or agencies”—encompassing an estimated $9·5 billion in foreign aid.Foreign NGOs that receive US funding to work on a broad range of health programmes in about 60 low-income and middle-income countries—including on HIV/AIDS, the Zika virus, malaria, tuberculosis, nutrition, and maternal and child health, among others—will potentially be subject to the same ideological restrictions that have hampered family planning aid at points in the past.Thus, President Trump's version of the global gag rule represents a wider attack on global health aid writ large.

2 Barot S

Cohen SA 7 Kaiser Family Foundation

The US Government engagement in global health: a primer. Adding to the widespread concern among US government agencies, global health NGOs, and advocates is the Trump administration's failure to provide any guidance on the interpretation or application of the new policy. Those details may emerge in the coming weeks and months. But we already know that, when last in effect, the gag rule crippled family planning programmes. Many foreign NGOs, as a matter of principle and out of dedication to the patients they serve, refused to let the US Government muzzle their abortion advocacy efforts or dictate what services or counselling they provided using their non-US funds. These health providers were forced to reduce staff and services, or even shut clinics.As a result, many thousands of women no longer had access to family planning and reproductive health services from these clinics—sometimes the only provider of such services in the local community. Various actors, including the governments of Canada and the Netherlands, are mobilising to compensate for at least some of the damage that will be done by the gag rule. But the US is the largest funder of global health programmes worldwide,and the disruption this aid effort will suffer is massive.

8 Bendavid E

Avila P

Miller G United States aid policy and induced abortion in sub-Saharan Africa. 9 Jones KM Contraceptive supply and fertility outcomes: evidence from Ghana. Moreover, there is no evidence that the global gag rule has ever resulted in its stated aim of reducing abortion. The first study to measure the effect of the gag rule showed that this policy could actually have resulted in an increase in abortions.Another study assessed the gag rule in Ghana and found that because of declines in the availability of contraceptive services, both fertility and abortion rates were higher during the gag rule years than during non-gag rule years in rural and poor populations.This is consistent with anecdotal data that the gag rule's main effect has been to reduce women's access to quality contraceptive services, thereby increasing the probability of unintended pregnancy and making recourse to abortion more likely.

But the harmful effects of Trump's order are likely be even greater. NGOs in low-income settings often provide integrated health services; for instance, they offer patients contraceptive care, HIV prevention or treatment, maternal health screenings, immunisations, and information on safe abortion care all under one roof. By expanding the gag rule to the full scope of US global health aid, hundreds more national and local NGOs will be forced to choose between drastic funding cuts (if they decline to sign the gag rule) or denying their patients the information and services that are their right (if they sign, and can no longer provide or discuss abortion). Millions of women living in low-resource settings may now be unable to obtain the care they need, when they need it.

10 Hasstedt K Why we cannot afford to undercut the Title X national family planning program. Guttmacher Institute. , 11 Hasstedt K Understanding Planned Parenthood's critical role in the nation's family planning safety net. Guttmacher Institute. The unprecedented scope of the Trump global gag rule validates the fears of many observers: reproductive health and rights worldwide will face a sustained attack in the next 4 years of the Trump Administration. This assault will almost certainly include defunding the United Nations Population Fund (UNFPA), as well as potentially drastic cuts to US overseas family planning aid. It will be mirrored domestically by efforts to restrict abortion access—for instance, by banning all private and public insurance coverage of abortion or prohibiting the most commonly used method for second-trimester procedures—and to shred the nation's family planning safety net, including by defunding Planned Parenthood.

It is becoming clearer with each Trump executive order that not only reproductive health but also global health programmes and overall foreign assistance supported by the US Government are in grave jeopardy, as indicated by President Trump's repeated promises to “put America first”. The social conservatives driving this agenda—who now control the US Presidency and both Houses of Congress—are showing complete disregard for the millions of women, men, and children who will suffer the consequences, intended or not, of these regressive policies.

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I am President and CEO of the Guttmacher Institute, a research and policy organisation committed to advancing sexual and reproductive health and rights in the USA and globally.

Article Info Publication History Identification DOI: https://doi.org/10.1016/S0140-6736(17)30270-2 Copyright © 2017 Elsevier Ltd. All rights reserved. ScienceDirect Access this article on ScienceDirect