This year's election between President Joe Biden and his Republican opponent Donald Trump threatens to upend abortion access and reproductive health services far beyond the United States.
Anti-abortion advocates are already drawing up plans for Trump to reinstate and expand funding restrictions on overseas groups that critics say disrupted reproductive health services like access to contraception in countries from Kenya to Nepal during the former president's four-year term.
A return to the policies, coupled with the U.S. Supreme Court's 2022 ruling that overturned a decades-long constitutional right to abortion, could embolden other nations to restrict access, researchers and abortion rights advocates say.
A Trump re-election would send "a chilling message to all reproductive health providers," said Evelyne Opondo, Africa regional director of the International Center for Research on Women (ICRW), a research and advocacy group.
"(It) would certainly make the environment very difficult for us and we must get ready for that possibility."
Victory in November would likely see him swiftly reinstate a ban on funding for overseas groups that perform or promote abortions that has been installed by Republican administrations, and repealed by Democratic ones, since the 1980s.
Trump went further than previous presidents on what is known as the global gag rule or Mexico City Policy, however, by expanding the pool of money subject to the restrictions from about $600 million in family planning funding to the entire pot of U.S. global health assistance money – an estimated $12 billion or so.
In 2019, he also expanded the policy beyond what previous administrations had done to include sub-grantees and subcontractors of affected non-governmental organizations (NGOs).
"You could start, day one, of another Trump administration with the worst of that policy in place from the beginning," said Amy Friedrich-Karnik with the Guttmacher Institute, an abortion rights research group.
"And then, who knows? They can apply this rule to all foreign assistance, to humanitarian assistance," she said.
Friedrich-Karnik co-authored a study released last month examining the effects of the global gag rule in Ethiopia and Uganda – two countries heavily reliant on U.S. foreign aid.
Though Ethiopia has significantly fewer abortion restrictions, both countries saw negative impacts that included a decrease in mobile outreach visits to provide family planning in public facilities in Ethiopia, the research found.
The rule also led to cuts in the number of community health workers in Uganda, less support to local health facilities, and curtailed contraception access, Opondo said.
It caused "a lot of self-censorship by organizations because of the fear of losing U.S. funding and potentially damaging relations with the U.S.," she said.
Other studies have also documented negative health consequences that coincided with the expansion of the global gag rule in countries that vary widely in how restrictive their abortion laws are.
Beyond NGOs that would be directly affected by the funding restrictions, the policy disrupted contraceptive and abortion service delivery supply chains in countries such as Kenya, Nepal and Madagascar, found a 2022 study published in BMJ Global Health.
The on-again, off-again nature of the restrictions also makes it difficult for organizations to plan long-term and establish partnerships even when they are allowed to do so, said Sara Casey of Columbia University, one of the report's authors.
"You could have a two-year gap in service delivery because this policy is requiring these shifts," Casey said. "It's very insidious in that sense – it's not just a matter of taking the money from Peter to give to Paul."
Anti-abortion advocates say they hope Trump will at the very least restore his version of the funding restrictions.
"We were grateful for Trump's expansion of the Mexico City Policy," said Jor-El Godsey, president of Heartbeat International, an anti-abortion advocacy group.
Godsey, though, wondered if Trump would stock a would-be next administration with personnel that was sufficiently conservative on the issue.
"At this point, we're not really sure what a Trump administration's going to do," he said.
The Trump campaign did not respond directly when asked if he plans to reinstate and expand the rules, emphasizing his support for states' rights on the issue and reiterating that he would not sign a federal abortion ban.
"President Trump has long been consistent in supporting the rights of states to make decisions on abortion, and he has repeatedly said he will not sign a federal abortion ban," said campaign spokesperson Karoline Leavitt.
The new, more restrictive landscape both at home and abroad could even affect how other countries approach the issue – to say nothing of NGOs or groups at direct risk of losing funding, Casey said.
"I think countries do see what's happening in the U.S. and then think, oh, we don't want to lose our foreign aid so we're certainly not going to even mention the word abortion anymore – even though the global gag rule technically does not apply to countries and governments," she said.
