Republican administrations dating back to the Reagan era have sought to reduce the number of abortions around the world by requiring that overseas family planning groups refrain from performing or promoting the procedure as a condition for receiving U.S. aid.
One of President Trump's first acts in office this week was to bring back the ban, but the effect might not be what was intended. When the policy was last in effect, abortion rates increased in some sub-Saharan African nations, researchers found.
Then, as now, some of the biggest providers of reproductive healthcare around the world — groups such as the International Planned Parenthood Federation and Marie Stopes International — decided to forego U.S. funding rather than limit the services they provide and risk exposing more women to unsafe abortions.
That meant cutting staff, scaling back services and shutting down clinics that had provided some of the only access to modern contraception in remote corners of the globe. The result: more unintended pregnancies and more abortions.
"Attempts to stop abortion through restrictive laws — or by withholding family planning aid — will never work, because they do not eliminate women's need for abortion," Marjorie Newman-Williams, who directs Marie Stopes International's international operations, said in a statement. "This policy only exacerbates the already significant challenge of ensuring that people in the developing world who want to time and space their children can obtain the contraception they need to do so."
Some abortion opponents, however, take issue with the argument that the policy denies women access to family planning services.
"The money is there," said Carol Tobias, president of the National Right to Life Committee in Washington. "It will just go to organizations that agree to limit their abortion activities."
She applauded Trump for "putting an end to taxpayer funding of groups that promote the killing of unborn children in developing nations."
Even without the policy, U.S. law does not permit federal aid dollars to be used for abortion services under most circumstances. But Tobias said that U.S. grants for non-abortion-related programs allow family planning groups to execute a "bookkeeping" maneuver and allocate more of their non-U.S. money for abortion.
The ban first introduced by the Reagan administration in 1984 was an attempt to overcome that, requiring that international aid groups certify that they will not use money from any other source to perform or "actively promote" abortion as a family planning method.
In the past, this has been interpreted broadly to include counseling or providing referrals to women who are considering the procedure. Exceptions were made in cases of rape, incest or when a mother's life was in danger.
Known officially as the Mexico City policy, after the city where it was announced, it has become a political football, rescinded by Democratic presidents and restored by Republican ones. Critics refer to it as the global gag rule.
Its return has alarmed public health experts in a number of African nations, where thousands of women die every year as a result of complications from unsafe abortions.
"You don't reduce abortions by not making them accessible," said Rachel Dukes, of the South African Medical Research Council. "You make women sick and make women die from the consequences of backyard abortions."
Researchers at Stanford University found that abortion rates rose sharply in 20 sub-Saharan African countries that had previously relied heavily on U.S. family planning support after President George W. Bush reinstated the Mexico City policy in 2001. Elsewhere, they remained relatively stable.
The authors of the study, published in the Bulletin of the World Health Organization in 2011, did not draw any "definitive conclusions." But they said, "If women consider abortion as a way to prevent unwanted births, then policies curtailing the activities of organizations that provide modern contraceptives may inadvertently lead to an increase in the abortion rate."
Officials at Population Action International, which studied the effects of the policy in six African and Asian countries, said their findings support that conclusion.
The U.S. is the world's largest provider of bilateral assistance for family planning, and providers who were cut off after 2001 struggled to find alternative funding, said Jonathan Rucks, director of advocacy for the group, which campaigns for reproductive rights.
In Kenya, the two leading reproductive healthcare organizations, Marie Stopes Kenya and the Family Planning Assn. of Kenya, had to close eight clinics. Those facilities were often the only local sources for reproductive healthcare and also acted as an entry point for a wide range of primary care services, the study found.
The Family Planning Assn. of Nepal laid off 60 staff members and lost access to the $400,000 worth of contraceptives normally funded by the U.S. Agency for International Development.
Activists worry that Trump's version of the policy could be even more far-reaching, jeopardizing programs that combat child and maternal deaths as well as diseases such as malaria and Zika.
The previous iterations applied only to family planning support, currently worth about $575 million, according to an analysis by Population Action International.
Trump's memorandum extends the policy to all global health assistance provided by the U.S. government, "to the extent allowable by law."
Although the details have not been spelled out, Population Action International estimates that it could apply to as much as $9.5 billion in funding.
The government in the Netherlands has said it will set up a fund to help fill the gap, but will need help from other donors.
The wording of Trump's memorandum is so broad that some public health experts are wondering whether it might also apply to programs operated by multi-national corporations and foreign governments that offer abortions through their public health systems.
That could be devastating for a country like South Africa, which has received more than $5 billion in assistance from the U.S. over the last 11 years for its HIV programs.
"In some provinces, most of the training of health workers and most of the monitoring and information is all carried out by USAID-funded programs," said Dr. Eddie Mhlanga, a gynecological specialist with the Mpumalanga provincial department of health who serves as the country co-lead for Global Doctors for Choice.
A particular problem exists with HIV patients who take anti-retroviral drugs, because the medicines can reduce the effectiveness of some contraception methods, he said.
"Those people might say, 'I'm not looking forward to another baby,'" Mhlanga said. "In this situation, these people cannot be given advice or cannot even be referred for services."
Times staff writers Zavis reported from Los Angeles and Dixon from Johannesburg, South Africa.