While we will be celebrating the 50th anniversary of International Women's Day on 8th March, political changes in the USA mean that women all over the world will again lose access to essential health services.
Photo: Einar Nilsen
Only a few weeks into his second term as president, Donald Trump has managed to shake up most of the systems that underpin American involvement with health-promoting work in the USA and beyond: He has given notice that the USA will be withdrawing from the WHO and has restricted the activities of the US infection control authorities and health research institutes, censored researchers and threatened to close down the largest aid organisation in the USA – USAID (1) . Just to mention a few of his initiatives. Perhaps some of the most extreme of these will be stopped in court. Perhaps his strategy is to direct attention to seemingly outrageous measures, so that other changes can be introduced away from the limelight.
Aid workers felt gagged because they were unable to talk about or refer patients to abortion care services
For example, only four days into his presidential term, Trump reactivated the Mexico City policy (2) . This policy bans the use of publicly funded aid in support of organisations that offer abortion, or that refer patients to abortion services. This policy was first introduced as early as in 1984 by the then President Ronald Reagan at a meeting in Mexico City. The ban applies even when the abortion is not funded by the US public purse (which is prohibited under different legislation). Consequently, the policy came to be known as The Global Gag Rule : Aid workers felt gagged because they were unable to talk about or refer patients to abortion care services (2, 3) . Since then, Democratic presidents have regularly revoked the policy on taking office while Republican presidents have re-introduced it (3) . But in Trump's first presidential term, he extended the policy. It used to apply only to family planning organisations that were funded by (the now threatened) USAID. Since 2017, all American aid organisations have been included, no matter how they are funded, and no matter the nature of their primary objective. Funded organisations were no longer permitted even to co-operate with people or institutions that offered abortions. Consequently, the policy also affected assistance that was primarily directed at AIDS, tuberculosis, malaria or childhood vaccination (3) . The total amount of aid funding affected by these restrictions increased from USD 600 million over one Republican presidential term before Trump last took office, to approximately USD 7.2 billion during his previous term (3, 4) .
The problem is that the policy leads to more abortions, that ambiguities and constant changes give rise to confusion and that the regulations are interpreted more stringently than strictly necessary
It is not uncommon for aid funding to be subject to conditions. This is the case in Norway too: We demand a guarantee that projects we support will not contribute to corruption, that they comply with Human Rights principles and that they support equal opportunities and bolster women's rights (5) . This is uncontroversial to us. Trump's presidential orders about the Mexico City policy mention both abortion and coercive sterilisation (6) . Of course, the latter has not received negative attention. For some, abortion can be as ethically troubling as involuntary sterilisation. However, the problem is that the policy leads to more abortions, that ambiguities and constant changes give rise to confusion and that the regulations are interpreted more stringently than strictly necessary.
Even before Trump became President in 2017, a study showed a higher incidence of abortion in several sub-Saharan countries in periods during which the Mexico City policy was activated. These countries are particularly affected by the policy. The researchers also found a decline in the use of modern contraception, probably due to the withdrawal of aid funding (7) . Later studies from several different countries have shown the same trend (4) . At the same time, the Mexico City policy is given an overly strict interpretation. Many aid organisations are so worried about losing their funding that those who work for them dare not answer patients who ask for abortion. Nor do they dare to refer patients for abortion if the pregnancy is the result of rape or incest or provide necessary health services to women who already have had an abortion. All of these things are permitted even when the Mexico City policy is activated (8) .
One in every three women lives in a country affected by the Mexico City policy
Some organisations have chosen to decline aid funding that is subject to the Mexico City policy. The leader of the African organisation MSI Reproductive Choic es, Dr Carole Sekimpi, has written in the BMJ about the ways that this stance has affected healthcare in Madagascar. Clinics have had to close down, and services have been curtailed. The organisation estimates that up to 20,000 women have died who could otherwise have been saved (8) .
Globally, one in every three women lives in a country affected by the Mexico City policy (8) .
Sekimpi writes that in the time ahead, aid organisations will have to make themselves less dependent on US funding (8) . This means that other countries, like Norway, will need to give more. The last time Trump reactivated the rule, we gave USD 10 million to an international initiative – SheDecides – that was intended to reduce the impact of the discontinued funding streams (9) . There is much to suggest that we may need to give considerably more support in the time ahead.