Among a flurry of executive orders during his first weeks in office was President Donald Trump’s reinstatement of the Global Gag Rule on January 23.

The Mexico City Policy, more commonly known as the Global Gag Rule, prohibits foreign nongovernmental organizations (NGOs) that receive U.S. family planning assistance funds to “perform or actively promote abortion as a method of family planning” with non-U.S. funds.

As the policy has a decades-old track record of repeal and reinstatement, gauging its present-day implications can be aided by looking at its history.

History and Breadth of the Policy

The Gag Rule was first introduced by the Reagan administration at the Second International Conference on Population in Mexico City in August of 1984, and took effect the following year. The policy remained in effect under Reagan, as well as under President George H. W. Bush. Since then, despite the public health imperative for women’s health care, it has been been repealed and reinstated along party lines, with Democratic presidents Bill Clinton and Barack Obama repealing the rule via executive action, and Republican presidents George W. Bush and most recently, Donald Trump, reinstating it.

The only exception to this pattern was a temporary one-year legislative imposition of the policy that came about when the United States owed almost $1 billion in dues to the United Nations. In exchange for Republican support for paying said dues, the Clinton administration yielded on reproductive rights in reaching the Smith Amendment, which mandated foreign NGOs acted in compliance with Gag Rule restrictions.

The Gag Rule builds on another U.S. foreign policy, the 1973 Helms Amendment, which restricts U.S. foreign assistance funds from paying for abortions, or the coercement there of. Despite repealing the Gag Rule during their terms and general usage of progressive rhetoric surrounding reproductive rights, neither the Clinton nor Obama administrations moved to challenge the Helms Amendment during their terms.

Though both the Gag Rule and the Helms Amendment prohibit funds being used toward the performance of abortion, this has not historically applied to cases of rape, incest, or life endangerment, though provisions are vague.

The Global Gag Rule also specifically prohibits foreign NGOs from providing advice about abortion procedures and/or abortion referrals, conducting information campaigns about abortion as a means of family planning, and lobbying to change country laws to liberalize or decriminalize abortion. Abortion-related research and distribution of emergency contraception, which is not a form of abortion, are not prohibited by the policy; though research has shown that NGOs often cease such related operations out of fear for losing their U.S. funding.

Breach of Autonomy and International Human Rights Law

“The Gag Rule is a radical intrusion on the rights and autonomy of recipients of U.S. funding,” wrote Barbara B. Crane and Jennifer Dusenberry in Reproductive Health Matters. Indeed, the policy applies to countries no matter if abortion is legal there. (See Pew and the Center for Reproductive Rights’ maps on worldwide abortion laws.)

Critics of the Gag Rule say that it is a clear violation of human rights. Beyond limiting health access, they argue the policy clearly violates the affected populations’ rights to speak and to give and receive information—which are all tenets of human rights law guaranteed by the Universal Declaration of Human Rights, the Covenant on Civil and Political Rights, and of course, the United States’ own Constitution.

In many countries receiving U.S. aid, there have been NGO-led movements that have worked to successfully change the dialogue, practices, and laws surrounding abortion. The Global Gag Rule directly rebukes and inhibits their progress.

Implications of Reinstatement

When the Gag Rule was announced in 1984, the International Planned Parenthood Federation (IPPF) and Marie Stopes International—two of the largest international family planning providers—refused to adhere to its provisions and were stripped of U.S. funding. The termination of funding to these providers, as well as many others, has been detrimental to their livelihood as organizations and the lives of their clients.

During the Reagan administration, a PAI study found that the rule was already inhibiting progress on reproductive rights and reducing access to safe care in its early stages. In Turkey—where abortion was already legal—NGOs strapped for funding were “forced to curtail critical training for doctors on safe abortion techniques because the programs had been partially funded by the U.S.,” and in India, many family planning and health care organizations promptly closed down.

Following the reinstatement of the policy by George W. Bush, the Global Gag Rule Impact Project—comprised of a group of nonprofits in the family planning and health services sphere—conducted a 2002 study focused on the Gag Rule’s implications in Kenya, Ethiopia, Romania, and Zambia. They found:

Some of these organisations were forced to close clinics, terminate staff and cut both family planning and prevention and treatment services for STIs and HIV/AIDS, maternal health and well-baby care, sexual health education, and youth outreach programmes. The Gag Rule also led to the termination of all US contraceptive supply shipments to leading family planning organisations in 29 countries. In the absence of alternatives, women who relied on these services must certainly have suffered more unwanted pregnancies and more unsafe abortions.

Beyond hurting these NGOs, stripping many women and their families of basic health care and prevention services (even basic shipments of contraceptive methods, like condoms), and revoking USAID family planning technical and leadership expertise, the Gag Rule has only enhanced the number of induced abortions generally—as was proven by a 2011 Stanford University study focusing on countries in Sub-Saharan Africa that lost U.S. aid under the policy.

The rule has also severely impacted the safety of abortion procedures, as unregulated abortions directly correlate to unsafe abortions. Restricting access forces women to undergo unsafe procedures in the shadows, including attempting to induce their own abortions by methods ranging from taking drugs like Misoprostol to getting punched in the abdomen—as the United States saw on a domestic level with Texan women following severe legislative abortion restrictions and barriers to care that were imposed in 2013.

Previous iterations of the policy have withheld U.S. family planning assistance funds from the U.S. Department of State or the U.S. Agency for International Development (USAID) from foreign NGOs that refuse to comply with the Gag Rule’s terms, but as the Center for Health and Gender Equity: CHANGE noted, “Trump’s Global Gag Rule is a dramatic expansion in the number and type of foreign assistance programs that are subject to the restrictions, and targets all global health assistance.”

Experts have varying predictions as to just how devastating the rule’s reinstatement could be.

CHANGE estimated that it will contribute to at least 6.5 million unintended pregnancies, 2.1 million unsafe abortions, and 21,700 maternal deaths—statistics Marie Stopes International largely agrees with. CHANGE also warned that the Gag Rule will prevent introduction and distribution of effective contraceptive methods, strip over 600 ministry of health sites from providing family planning services, and end health consultations for young people—including those living with HIV/AIDs.

The Center for American Progress estimated that the reinstatement could cause a total of 8.4 million women to be at risk of serious illness or injury due to an unsafe abortion, the maternal death rate to spike by as much as 289,000 women, and up to 75 percent of sexually active teenagers in developing countries could lose access to contraceptives.

International Response

The international response to Trump’s decision and potential expansion of the rule has been swift: the Netherlands pledged in January to set up a global abortion fund. Dutch official Lilianne Ploumen said rule will lead to “dangerous backroom procedures and higher maternal mortality,” and that “Banning abortion does not reduce the number of abortions.” She continued, “We have to make up as much as possible for this financial blow, with a broad-based fund that governments, companies and civil society organizations can donate to… So that women can continue to make their own decisions about their own bodies.”