The Trump administration’s reinstatement and expansion of the “global gag rule” (GGR) has been the most “extreme and sweeping” iteration of the policy yet and “threatens to derail decades of progress” in improving health care, according to a report released Tuesday by the Center for Health and Gender Equity (CHANGE). 

“When the GGR is in effect, it creates and exploits inefficiencies in health care delivery and causes harm to beneficiaries, who may not be aware that their fate is being determined by what is essentially a political football in Washington, D.C.,” the report’s authors concluded.

The GGR, also known as the “Mexico City Policy,” prohibits foreign nongovernmental organizations (NGOs) receiving U.S. family planning aid from providing abortion care or information about the medical procedure.

The anti-choice restriction was first instituted by President Ronald Reagan in 1984, revoked by President Bill Clinton in 1993, reinstated by President George W. Bush in 2001, and revoked again by President Barack Obama in 2009.

President Donald Trump reinstated the policy on January 23, 2017,  delivering on a campaign promise to the religious right. While previous Republican administrations applied the restrictions to about $575 million in U.S. family planning aid, Trump expanded the policy to include an estimated $8.8 billion in U.S. global health assistance, according to Human Rights Watch.

The expanded GGR, implemented through the Protecting Life in Global Health Assistance plan, restricts funding for family planning, maternal and child health, HIV/AIDS, infectious diseases, and water and sanitation.

The CHANGE report, “Prescribing Chaos in Global Health,” details the GGR’s impact on a range of issues including abortion and contraception access. The report predicts that the expanded policy will not reduce abortions but only increase the stigma of abortion and the number of unsafe illegal abortions.

There is some evidence that unsafe illegal abortions have been increasing in countries affected by the GGR.

“The U.S. government is sending a message to the world that abortion is something disfavorable or shameful, that it’s not health care, that it’s not anything that the U.S. government is going to support and it doesn’t want anybody else to support either,” said Lourdes Rivera, senior vice president of U.S. programs at the Center for Reproductive Rights, according to the CHANGE report. “That’s a huge message, and it stigmatizes abortion.”

CHANGE spoke to officials from government agencies and NGOs who worry that “the chaos that has accompanied each iteration of the GGR has now been magnified by Trump’s expanded version.” 

As CHANGE discovered, the expanded gag rule has created confusion for both NGOs attempting to comply with the policy and for the government officials tasked with implementing it.

The expanded policy applies to agencies such as the Office of Water, which is overseen by the USAID’s Bureau for Economic Growth, Education, and Environment and seeks to save lives by improving water supply, sanitation, and hygiene.

An official who spoke to CHANGE expressed surprise that the GGR applied to funding through the Water Office: “My colleagues at the Water Office were not even informed that the gag rule was attached to their program …. It’s like the farthest thing from abortion—you’re digging a toilet.”

The Trump administration’s GGR will have a significant impact on reproductive health in the coming years. Marie Stopes International (MSI) estimates that from 2017 to 2020 the cuts to its programs will result in 6.5 million unintended pregnancies, 2.2 million abortions, 2.1 million unsafe abortions, and 21,700 maternal deaths.

Lillian Mworeko, executive director of International Community of Women Living with HIV Eastern Africa (ICWEA), told CHANGE that while abortion is illegal in her country of Uganda, the GGR has limited access to reproductive health information and services.

“[MSI is] the biggest family planning service provider in the country, and that means quite a lot in terms of access to information, access to services .… And the impact does not stop at the organizational level; it translates to the service beneficiaries, the majority of whom are women, but also importantly, young people,” Mworeko said.

“Trump’s global and domestic gag rules show no matter what side of the U.S. border you reside, no one is outside the reach of this administration’s brutal attacks on health and rights,” Serra Sippel, president of CHANGE, said in a statement. “Evidence shows that the global gag rule is a failed and deadly policy—and under President Trump it’s downright catastrophic for global health. It’s time for Congress to act now to end this policy once and for all.”