Danielle Solomon: The global gag rule is only one of many barriers to contraceptive access

The first week of Donald Trump’s presidency was bookended by two definitive and controversial actions. The first, on 23 January, was the reinstatement and expansion of the “Mexico City policy”—a piece of legislation that prevents NGOs that receive federal funding from providing abortion counselling. There has been a lot of debate, particularly in global health circles, about the impact of this policy, but it is important not to view it in isolation.

Despite seeming at first glance to be largely related to international development, the Mexico City policy actually represents just one part of a network of legislation, which aims to block access to sexual and reproductive health education and services, both in the US and abroad. One particular target of much of this legislation is the reproductive health organisation Planned Parenthood.

Although critics of Planned Parenthood largely focus on its provision of abortion services, many supporters are concerned that any defunding of Planned Parenthood would prevent a large percentage of Americans (low income women in particular) from accessing healthcare services, such as sexual health screening, cancer screening, and contraception. There is, however, another group of people that already suffer from limited access to these services—a group that, as a result of another of Trump’s executive orders, could potentially be banned from entering the US. Refugees.

The past few years have seen a number of academic and political bodies aim to investigate the quality of reproductive and sexual health services that are available to victims of forced migration. The results so far are dispiriting.

A 2016 analysis of United Nations High Commissioner For Refugees data from 10 countries found that refugee women are much more likely to die in childbirth than the general population; in Chad, refugee maternal deaths outstripped those of the native population by 881 per 100 000. During a 2015 study of pregnant Syrian refugees living in Lebanon, it was discovered that less than half of the 420 women surveyed desired their current pregnancy, and over 75% of the women would seek to prevent getting pregnant in the future, but that all were facing financial and structural barriers to contraceptive access.

Reports on refugee camps across Europe have revealed shortages of basic services, such as emergency contraception and post-exposure prophylaxis (PEP) for HIV prevention, despite the risk of rape and sexual coercion that both male and female refugees face at every stage of their arduous journey.

An examination of the Mexico City policy’s 30 year history gives us a good indication of its likely effects: an increase in abortion rates, globally, and the loss of thousands of lives. The Trump administration’s simultaneous opening salvos against immigration and reproductive rights will only serve to compound this inevitability.

When looking at reproductive and sexual healthcare services for refugees, however, it becomes clear that there are significant funding issues that predate the Trump administration. Over the past 15 years, reproductive and sexual health funding has consistently and disproportionately been directed away from countries affected by conflict.

International funding bodies seem to forget that when a war breaks out, as we scramble to create a structure within which those who are affected can live, we are working with people whose day to day lives are not dissimilar from our own. People who may live as refugees for decades are normal human beings; human beings who become pregnant, who are sexually active, who are victims of rape, who should not die prematurely due to preventable and screenable diseases.

The next four years are going to be exceptionally difficult for anyone affected by conflict, and people of all nationalities who provide emergency services will be faced with insurmountable challenges. However, I hope that the fight against these challenges does not stop all of us from continuing the ongoing and necessary discussion about the perceptions, preconceptions, and blind spots that we bring to the table when thinking about healthcare, policy, and our obligations as global citizens.

Danielle Solomon is a specialist registrar in genitourinary medicine and HIV at the Mortimer Market Centre in London. She previously studied at the Harvard TH Chan School of Public Health, and has worked on sexual and reproductive health policy at Pathfinder International and the Fenway Institute, Boston.

Competing interests: None declared.