Domestic political alliances with conservative forces in the US is costing women their health at home and abroad

The Trump administration’s ideological commitment to the domestic anti-abortion lobby is endangering women across the Americas, say Hani Serag et al

The history of the “Global Gag Rule” is one of tragic irony and misguided energy from conservative foreign policy elements within the United States. The Global Gag Rule, also known as the Mexico City Policy, restricts the activities of non-governmental organizations (NGOs) in developing countries that receive USAID family planning from engaging in abortion-related activities, including advocacy, regardless of the funding source for these activities. It is even more ironic that abortion rates increase where the Global Gag Rule disrupts family planning services. [1] Inability to access safe abortions does little to prevent women from seeking unsafe abortions which harm the wellbeing of women. [2] Although this is well-documented, one of the first things that Donald Trump did when he became President was to sign an executive order reinstating the Global Gag Rule. In March 2019, the Trump administration expanded the rule. Previously it only applied to family planning assistance ($575 million in FY2016) but the expanded law includes all “global health assistance furnished by all departments or agencies”⁠— an estimated $9.5 billion or 16-fold increase in restricted funding. [3] A recent report shows the impact of this rule and the detrimental effect that it is having on women and girls. 

United States domestic policy is similarly misguided when dealing with women’s health. Despite the continuous improvement in gender-specific health indicators, especially those dependent on advances in medical technology and specialized care, like mortality rates from breast cancer, [4] the US is witnessing several alarming trends in women’s health. The pregnancy-related mortality ratio has been steadily increasing from 7.2 deaths per 100,000 live births in 1978 to 18 per thousand deaths in 2014. From 2011-2014, the ratio was three times worse for black women than white women (40 vs 12.4 per 100,000 live births, respectively). [5] Rates of sexually transmitted diseases (STDs) are increasing. In 2016, the Centres for Disease Prevention and Control (CDC) reported more than 2 million cases of chlamydia, gonorrhoea, and syphilis. Half of all sexually transmitted infections occur among young people between 15-24 years, disproportionately affecting women. [6] Women continue to use their rights to safe induced abortion. Nearly 15% of pregnancies ended by induced abortion in 2017 due to a variety of reasons around unintended pregnancy. [7]

Instead of advancing health and non-health policies to address the structural determinants of these trends, the current US administration continues to take positions that may exacerbate these alarming trends and deny women autonomy of their bodies. Abortion bans across a number of US states show how quickly hard fought reproductive rights can be rolled back. The expansion of the Global Gag rule in March 2019 will prevent organisations that provide abortion services or abortion referrals from participating in federal family planning funds. The rule will reduce the funding for Planned Parenthood by $60 million. [8,9] 

The impact of these changes is being felt on the global stage. In September 2018, during the 56th session of the Directing Council of the Pan American Health Organization (PAHO), the US delegation requested a roll-call vote on the “Plan of Action for Women’s, Children’s, and Adolescents’ Health 2018-2030.” Twenty-four member states voted in favour of passing the plan, three abstained, and only the US rejected it. The US delegate stated that “regrettably” they “must vote no.” She explained that the US, under the Trump Administration, could not accept the mention of “comprehensive sexuality education,” “sexual and reproductive health and rights,” and “sexual and reproductive health services,” as they could be presumed to support the promotion of, or provisions for, abortion. Other member states have emphasized the importance of these notions for women’s empowerment and the reduction of violence and pregnancy among adolescents in particular. The US also opposed (again, against a strong consensus) any reference to “sexual and reproductive health” in the “Plan of Action for Cervical Cancer Prevention and Control 2018-2030.” Another vote was avoided when the US delegation decided to endorse the plan with a documented reservation on one paragraph. 

The “Plan of Action for Women’s, Children’s, and Adolescents’ Health 2018-2030” recognizes that women of all age groups continue to face structural barriers that undermine health, and access to information and services. It addresses persistent inequities and uneven improvements in the health outcomes of women, adolescents, and children within and between nations across the Americas. It paves the road to achieving health goals of the 2030 development agenda by providing a roadmap for multi-level action to address systematic weaknesses in: equitable access to quality health services; promotive and preventive measures; active community participation of women, adolescents, and children; information-driven policies; and a coordinated cross-sector response to improve the health of women, adolescents, and children. [10,11,12,13] 

The Plan of Action for Cervical Cancer 2018-2030 is likewise aimed at improving women’s health with a focus on the prevention, screening, and treatment of cervical cancer. The plan recognises that screening alone is insufficient to prevent illness and therefore integrates goals and targets for sexual and reproductive health. While discussing the plan, the U.S. delegate requested a more narrow focus on the prevention of sexually-transmitted diseases instead of the use of “comprehensive sexuality education.” We see this as a significantly inappropriate disease-centric approach, especially as last year the world celebrated the 40th anniversary of the Alma Ata Declaration

We congratulate the twenty-four member states who voted in favour of the plan. We hope that this will discourage states from taking conservative ideological stands that question fundamental rights while leaving women to die from preventable illnesses because of the lack of comprehensive sex education and services. Indeed, political ideologies such as these are a form of structural violence, given that they obstruct policy efforts to improve health and reduce inequities among women. 

This issue comes at a very important time for women’s reproductive rights in the US and globally. Earlier this summer, a number of US States signed “abortion ban bills” to severely restrict women’s access to abortion. In Autumn 2018, the election of Brett Kavanaugh to the Supreme Court despite allegations of sexual assault brought greater public attention to longstanding concerns about women’s rights and equality. These broader social and structural barriers underscore the importance of adopting a comprehensive health approach, rather than a disease-centric focus, if the US is serious about improving women’s health and achieving greater equity. 

Hani Serag, MD, MPH, University of Texas Medical Branch (UTMB), Galveston, Texas, USA
Competing interests: None declared

Brenda K. Wilson, PhD, University of Texas Medical Branch (UTMB), Galveston, Texas, USA
Competing interests: None declared

Cusi Ferradas, DVM, MPH, La Universidad Peruana Cayetano Heredia (UPCH), Peru
Competing interests: None declared

Michael Goodman, MPH, DrPH, University of Texas Medical Branch (UTMB), Galveston, Texas, USA
Competing interests: None declared

Ben G. Raimer, MD, MA, FAA, University of Texas Medical Branch (UTMB), Galveston, Texas, USA
Competing interests: None declared



[1] Crane, B. B., & Dusenberry, J. (2004). Power and politics in international funding for reproductive health: the US Global Gag Rule. Reproductive health matters12(24), 128-137.
[2] Grimes, D. A., Benson, J., Singh, S., Romero, M., Ganatra, B., Okonofua, F. E., & Shah, I. H. (2006). Unsafe abortion: the preventable pandemic. The lancet368(9550), 1908-1919.
[3] Starrs, A. M. (2017). The Trump global gag rule: an attack on US family planning and global health aid. The Lancet389(10068), 485-486.
[4] National Institute of Health – National Cancer Institute (2019). Cancer statistics – Cancer Stat Facts: Female Breast Cancer. Available from
[5] Centres for Disease Control, and Prevention (2018). Reproductive health: Pregnancy Mortality Surveillance System. [cited 2019 March 20]. Available at
[6] Centres for Disease Control, and Prevention (2017). Sexually-Transmitted Disease Surveillance 2016. [cited 2019 March 20]. Available at
[7] (2019) U.S. Abortion statistics: Facts and figures relating to frequency of abortion in the United States. [cited 2019 March 20]. Available at
[8] The Washington Post (2019) Trump administration bars clinics that provide abortions or abortion referrals from federal funding. Available from
[9] Arwa Mahdawi (2019. The Gardian. [cited 2019 March 20] Available at
[10] Pan American Health Organization (2018). Plan of Action for Women’s, Children’s, and Adolescents’ Health 2018-2030. Passed during the 56th session of the Directing Council, September 23-27, Washington DC, USA.
[11] UNAIDS, UNFPA, UNICEF, UN Women, World Health Organization (2018). International technical guidance on sexuality education: An evidence-informed approach. United Nations Educational, Scientific and Cultural Organization (UNESCO).
[12] United Nation (2015). The Global Strategy for Women’s, Children and Adolescents’ Health (2016-2030).
[13] World Health Organization. Committing to implementation of the Global Strategy for Women’s, Children’s and Adolescents”. Sixty-Ninth World Health Assembly, Agenda item 13.3; 28 May 2018; Geneva, WHO; 2018 (Document WHA69.2) [cited 2018 June 30]. Available at: