How a Rule Imposed by Trump Shapes Abortion Access Around the World

Patients line up for test results at a maternal and child health center in India’s Tamil Nadu state.
17:18 JST, January 26, 2025
President Donald Trump on Friday reinstated a policy known by its critics as the “global gag rule,” which affects who has access to safe abortions – not in the United States, but in countries that rely on U.S.-funded programs.
Since Ronald Reagan’s presidency, Democrats have reversed the rule upon taking the White House, while Republican administrations have reimposed it.
The move came hours after Trump addressed the antiabortion March for Life rally in Washington, emphasizing his antiabortion record but avoiding any promises about new restrictions, and amid a broader turn away from international aid.
The global health community, including nongovernmental organizations and national health-care systems in developing countries, were already braced for the whiplash. For millions of women, access to safe abortion care and contraception could be interrupted.
The U.S. president has an outsize impact on global abortion access
That’s because of the global gag rule – also known as the Mexico City policy, after the place where an initial version was announced in 1984.
Regardless of who is in office, the United States does not fund abortions abroad, as stipulated by a law, the Helms Amendment, which has been in effect for more than 50 years. The Mexico City policy takes those restrictions much further: It forbids organizations that take U.S. global health funding, with limited exceptions, from performing abortions, counseling or providing information about the option of abortions or advocating for the liberalization of abortion rights – regardless of what funds, from any source, they use to provide those services.
Advocates for abortion rights call the policy a weaponization of U.S. foreign assistance. The United States is by far the largest governmental donor for family planning, and its rules are agenda-setting. The policy, in effect, means that “a single dollar of U.S. money taints an entire organization’s operating budget from all sources,” in terms of ability to even proactively mention abortion, the Guttmacher Institute, a national nonprofit that supports abortion rights, said in a report in 2020.
Trump expanded the policy in his first term to apply not only to foreign organizations receiving family planning funding, but also those receiving global health assistance from any department or agency. What once applied to about $500 million in U.S. foreign assistance, under Trump affected around $8.8 billion, including funds to organizations working on nutrition, malaria and HIV/AIDS.
The State Department said that in the last cycle under Trump, only four of 733 “prime” partner awards – organizations that have a direct agreement with the U.S. government – declined to sign the policy.
Among those was the International Planned Parenthood Federation, the largest nongovernmental provider of contraception. It said at the time that to continue its work, it had to forgo around $100 million in U.S. funding for operations supporting family planning and HIV programs across the world, which it estimated could have prevented some 20,000 maternal deaths, 4.8 million unintended pregnancies and 1.7 million unsafe abortions. The most affected areas were sub-Saharan Africa, South Asia, Latin America and the Caribbean.
“Whenever the policy has been enacted,” Dilly Severin, executive director of the U.N. Foundation’s Universal Access Project, which advocates for access to reproductive health care, said in a statement Friday, “health care clinics in many countries have been forces to close and outreach services for the hardest to reach populations have been eliminated.”
Global health organizations say the rule’s full impact is hard to measure
Part of the reason the policy is so wide-reaching is that “we don’t provide health care in silos,” said Elizabeth Sully, a principal research scientist at the Guttmacher Institute. While the rule targets abortion, family planning services more broadly end up taking a hit, she said.
Organizations are left with a tough choice: halting activities central to provision of care or leaving behind that funding and cutting other services, Sully said. The rule also creates a chilling effect with providers confused, fearful and extra cautious not to be accused of violating it, by discontinuing services, refraining from initiating partnerships or self-censoring.
In some countries, especially less developed ones, NGOs are often among the most accessible and effective – or only – providers of these services. They’re often enmeshed with national governments and public health systems. “The poor woman we were trying to serve is the one to suffer most,” said Pester Siraha, Zimbabwe country director for MSI Reproductive Choices, which provides contraception and safe abortions in dozens of countries.
The U.K.-based MSI Reproductive Choices said that it “has never, and will never” sign the global gag rule. Instead, it opts to take the funding hit whenever the rule is in place. In 2017 under Trump, that meant the organization’s annual donor income was reduced by 17 percent, or about $30 million.
MSI’s program in Zimbabwe is one of the country’s primary providers of contraceptive services and reproductive health care, including by operating mobile clinics that travel to rural, hard-to-reach areas across the country’s 10 provinces. Some 40 percent of its funding support for contraceptive services comes from the United States, Siraha said. And some 545,000 people in Zimbabwe used an MSI-provided method of contraception as of last year. When funding was cut, the program reduced its coverage by around half, she said. The 11 mobile teams were reduced to five.
Trust suffers in addition to access, said Anna Mackay, senior director of global programs and philanthropy at MSI Reproductive Choices. Connections with communities, partners and the health system “really takes years to build up,” she said. “That trust that communities have, that they know these providers, trust these services, know that you’re going to be coming back,” she said.
Some contraceptive services include implants and intrauterine devices that can be removed. When services were slashed, women weren’t able to easily access implant removal. “Now, those women really struggled when we finally went back into those communities,” Siraha said about the situation in Zimbabwe. “That was the first complaint, that lack of trust: You come here, you provide this service, and we want to have it removed. And then you are no longer there.”
There are major complications that come with reduced access: Unplanned pregnancies, which can also lead to unsafe abortions, she said. Teenage pregnancies can lead to maternal mortality. “So it’s a complicated cycle where you’re stopping one service of contraception alone, but it has a negative effect on other indicators of health.”
Democrats have not managed a permanent repeal
In September, a bill making its way through Congress, the Global Health, Empowerment, and Rights Act, to permanently repeal the Mexico City policy, drew 172 co-sponsors in the House and 50 in the Senate. As a senator, former vice president and Democratic presidential candidate Kamala Harris co-sponsored an earlier version of the proposal in 2017.
“This bill is about more than health: It is a guarantee that American foreign assistance dollars will never be weaponized as a tool of oppression,” said Rep. Barbara Lee (D-California) in 2023 while reintroducing the act.
Such legislation has not gathered enough support to become law.
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