On his ninth day in office, President Biden repealed a Republican policy that barred millions of women and girls from life-saving healthcare and led to increased rates of abortion, unplanned pregnancy, and risk of maternal death. With the swoop of his pen, he dramatically shifted US policy on reproductive health and rights, at home and abroad. But analysts say it could take years to overcome the damage inflicted under four years of the former Trump administration’s policy.

“There’s a lot more work to do,” says Seema Jalan, executive director of the Universal Access Project and Policy at the United Nations Foundation. 

First implemented under President Reagan, the Global Gag Rule (also known as the Mexico City Policy) banned US funding for international organizations that perform abortion services, counseling or referrals. Every Democratic president since has repealed it; every Republican has reinstated it.

“What is really clear about the global gag rule is that it doesn’t reduce the number of abortions. In fact, perversely, it increases the number of abortions in countries that are impacted by it,” says Shannon Kowalski, International Women’s Health Coalition director of advocacy and policy. Pre-Trump gag rules led to a 40 percent increase in abortions, a 12 percent increase in pregnancies, and critical risks of maternal mortality in the countries most affected, according to a 2019 study published in The Lancet. “And so, despite this policy being put in place by people who are trying to protect life, it actually has the opposite impact,” Kowalski adds.

Yet Trump took gag rule restrictions to new heights. While previous iterations applied only to family planning funding, he expanded the policy to affect almost all US foreign health aid—more than $7 billion in 2020 alone, hitting programs in everything from child nutrition to HIV/AIDS and malaria prevention. 

The gag rule is “a weapon that kills many women,” says Abebe Shibru, country director for Marie Stopes Ethiopia, part of a global network of reproductive health providers that refused to comply with the gag rule and consequently lost significant US funding. Shibru ran the organization’s Zimbabwe program when Trump’s gag rule went into effect, and the group had to cut its healthcare sites in half, from 1,200 to 600—mostly in rural areas where many women have no other access to healthcare. 

The pandemic exacerbated everything.“COVID is another gag rule,” Shibru continues. In many places, lockdowns have prevented women from traveling to clinics. In Ethiopia, women have delayed necessary care because they fear getting the virus. Contraceptives—mostly manufactured overseas—have run short in many parts of Africa. Trump’s gag rule worsened the toll. 

All told, MSI Reproductive Choices (the Marie Stopes parent group), estimates that continued US funding could have helped prevent 6 million unintended pregnancies, 1.8 million unsafe abortions, and 20,000 maternal deaths. 

Further, fatalities can occur through self-induced abortions among women—or young girls—who don’t have access to care. “They’ve done this using knitting needles, sticks, coat hangers, medicines—I mean, I could go on. It’s incredibly harrowing,” says Sophie Hodder, Marie Stopes Kenya country director. “Infections or hemorrhaging can kill. It’s heartbreaking.” 

At home and abroad, Trump’s policies fueled distrust among many who wonder, “What has happened to the ethical compass of the United States?” says Dr. Jeanne Conry, International Federation of Gynecology and Obstetrics president-elect. “I feel like there’s been a loss of faith.” 

The gag rule wasn’t the only method Trump implemented to attack reproductive healthcare. In the US, he implemented strict new rules for organizations receiving funding under Title X, the only federal grant program dedicated to reproductive health services—including cervical and breast cancer screenings—for low-income patients. This “domestic gag rule” jeopardized care for 1.6 million patients nationwide, according to the Guttmacher Institute, a reproductive policy research group. Trump also withdrew the US from the World Health Organization (Biden rejoined) and halted US funding for the United Nations Population Fund (President Biden committed to reviewing and restoring it.) 

This on-again, off-again approach to federal policy wreaks havoc with long-term budgets and plans. “Every time we get a new president in the US, all the progress that has been made around integrating services is torn apart. So we need a permanent fix,” says Terry McGovern, professor and chair of Columbia University’s Heilbrunn Department of Population and Family Health.

That could come in the form of the Global Health, Empowerment, and Rights (HER) Act, which would prohibit all future versions of the Global Gag Rule. Introduced in 2019 by Sen. Jeanne Shaheen (D-NH) and Rep. Nita Lowey (D-NY), it’s sitting with the House Committee on Foreign Affairs. Advocates are hoping for cooperation across aisles under the new administration. 

Reframing the issues may help. For example, research shows that restrictions on reproductive health services contribute to maternal mortality. Every day, more than 800 women die preventable deaths in pregnancy and childbirth-related causes, according to the World Health Organization. As Conry puts it, that’s “the equivalent of a couple of jumbo jets crashing, filled with pregnant women, every single day.” The Global Gag Rule and policies like it contribute to those deaths. Viewed that way, “I have to believe that some of the thinking Republicans would support a permanent fix,” McGovern says.

She also calls for money—now. “Just revoking the policy and not providing any kind of funding or support to fix the damage is kind of only doing a quarter of the job,” McGovern adds. President Biden ordered that “all steps necessary” be taken to implement the administration’s commitment to reproductive health, but there’s a lag between words and action, and “the clock is already ticking,” Jalan says.

When women and girls can’t access healthcare, entire countries suffer. When 14- and 15-year-old girls become pregnant, “that’s the end of their education. They don’t take six months off and come back. That’s it, they’re done,” adds Hodder.  Overwhelming evidence points to the economic benefits of women in the workforce and leadership roles, but “you can’t get to leadership in a country if you’ve had to drop out of school at 15 because you’re pregnant.”

Many of the UN’s Sustainable Development Goals—reducing poverty and hunger, fostering good health, education, and gender equity—rely on sufficient reproductive healthcare. “Without family planning, it is unthinkable to accomplish or to meet the sustainable development goals,” adds Shibru. Like so many health workers around the world, he pins his hopes on the new US president to support the full potential of women and girls. 

“With the Biden administration, we know what needs to get done,” Jalan continues. “This is the moment for this administration to make historic changes in how we conduct our foreign policy in a way that’s better for everyone living on the planet.”

About the author: Karen Coates is an independent journalist and author in New Mexico who covers food, environment, health, and human rights globally. She’s an International Women’s Media Foundation fellow, a contributing editor for Archaeology Magazine, and an editor/producer on the forthcoming film, Eternal Harvest, which documents the lasting effects of the US bombing campaign in Laos.