Views And Reviews Personal View

The global gag rule and what to do about it

BMJ 2017; 356 doi: (Published 01 February 2017) Cite this as: BMJ 2017;356:j511
  1. Scott L Greer, associate professor of global health1,
  2. Sarah D Rominski, research assistant professor2
  1. 1Department of Health Management and Policy, University of Michigan School of Public Health
  2. 2Department of Obstetrics and Gynecology, University of Michigan Medical School

Since Ronald Reagan was president, banning and unbanning the use of US aid to support agencies that discuss abortion or refer patients to abortion services has been a partisan tradition. Republican presidents make a point of ordering the ban in their first days in office, and Democrats make a point of rescinding it. In this, as in many other ways, Donald Trump is an ordinary Republican. On his third day in office he signed his new version of the executive order.1

The order is known as the “Mexico City policy,” after its first enunciation in 1984 in Mexico City, or as the “global gag rule,” because it effectively blocks US support to any organisation that even discusses abortion as a form of family planning. US support for organisations that provide abortion has been illegal by statute since 1973. Trump reinstated the policy as it stood under George W Bush but added a new and alarming expansion of his own. The policy is now expanded to “global health assistance furnished by all departments and agencies.”

In other words, it doesn’t just affect the $600m (£480m; €560m) spent by the US Agency for International Development on family planning but also the $6bn spent by all US agencies, from the Centers of Disease Control (CDC) to the National Institutes of Health, the Food and Drug Administration (FDA), and various agencies of the United Nations. This expansion also affects not just the forty or so countries that receive US family planning aid, but approximately another sixty that receive assistance from any of these programmes. The administrative burdens of implementing this rule, on both US agencies and aid recipients, could be very large. Such rules are likely to prevent the US from effectively tackling a problem like the Zika virus.

The consequences of this action can be expected to be widespread and contrary to the stated intent of the rule. If the goal of this policy is to reduce the number of abortions worldwide, then it will fail. Countries exposed to the gag rule show a rise in abortion rates when the rule is in effect and a reduction when it is not.2 Policies that curtail investments into comprehensive family planning programmes reduce the outreach of these programmes to the rural areas where the majority of people in sub-Saharan Africa live.

By limiting women’s access to modern contraception, the rate of unwanted pregnancies rises. In this situation women will often turn to abortion.

Reducing access to abortion and contraception results in shorter birth intervals, which negatively impact the health of women and their children and result in higher levels of child malnutrition.3 Rather than improving the health of women and children in the world’s poorest countries, the global gag order increases maternal and child morbidity and mortality.

American advocates of public health and reproductive rights clearly have much work to do, including intervening in the detailed process of working out the implications of this order for agencies such as the CDC or FDA. The consequences for birth control and other policies, including the administrative costs, are still to be determined and can still be affected by political and administrative action.

Trump’s action gives European and other governments a clear opportunity to show global leadership. The Netherlands has already proposed a fund to make up the $600m that Trump’s action will cost the global family planning sector, and more than twenty governments are reportedly interested in contributing.4 Advocates of public health and gender equality outside the US must hold their governments to their promises. The history of foreign aid shows that governments fail to meet their general aid targets, or even fulfil specific, popular commitments, unless they are put under serious political pressure. Making sure that governments make and fulfil their commitments will be crucial. Furthermore, replacing the $600m compensates for George W Bush’s version of the order, not Trump’s. Governments and donors will have to expend both thought and money on ways to compensate for the scale of Trump’s expansion of the order.


  • Competing interests: We have read and understood BMJ policy on conflict of interests and have no relevant interests to declare.


View Abstract

Sign in

Log in through your institution

Free trial

Register for a free trial to to receive unlimited access to all content on for 14 days.
Sign up for a free trial