What will a second Trump presidency mean for abortion care in the US? Bette Browne reports
Donald Trump’s first term as US President laid the groundwork for seismic changes in reproductive healthcare when the Supreme Court ended the constitutional right to abortion. Judicial appointments made by Mr Trump helped to form the court’s majority verdict overturning the 1973 Roe v Wade decision. The ruling in June 2022 was the biggest sea-change in US healthcare in half a century.
Now, as he embarks on a second term, many health policy experts believe Mr Trump aims to cement even more profound changes. They say his tenure is likely to herald tighter restrictions on reproductive rights and exacerbate health inequalities. It could also impact reproductive healthcare for women in developing countries receiving US aid.
Immediate impact
Following the Supreme Court ruling, President Joe Biden signed two executive orders that aimed to protect reproductive healthcare. The second order, which was signed in August 2022, stated that the continued advancement of “restrictive abortion laws” in states across the country had created legal uncertainty and disparate access to reproductive healthcare services depending on where a person lived. This was putting patients and providers “at risk” and fuelling “confusion” for hospitals and healthcare providers, including pharmacies.
“There have been numerous reports of women denied health- and life-saving emergency care, as providers fearful of legal reprisal delay necessary treatment for patients until their conditions worsen to dangerous levels,” it stated.
“There are also reports of women of reproductive age being denied prescription medication at pharmacies – including medication that is used to treat stomach ulcers, lupus, arthritis, and cancer – due to concerns that these medications, some of which can be used in medication abortions, could be used to terminate a pregnancy. Reportedly, a healthcare provider, citing a state law restricting abortion, even temporarily stopped providing emergency contraception.”
The executive order had several aims including to support patients travelling out of state for reproductive healthcare services.
Executive orders, which do not need congressional approval, can be overturned by a new president. It was predicted that Mr Trump would use executive powers during his second term to further restrict abortion rights, but this was before the extent of his victory became clear. His Republican party achieved small majorities in the Senate and the House of Representatives, in addition to the governorships of a number of states.
Current situation
As of December 2024, abortion is illegal (with few exceptions) in 13 out of 50 US states. Twenty-eight others restrict access based on various gestational limits.
In the November elections, state ballot measures to protect or expand abortion rights were adopted in seven states: Arizona, Missouri, Maryland, Montana, Nevada, New York, and Colorado. However abortion-rights measures were rejected in Florida, South Dakota, and Nebraska.
With the ending of the federal right to abortion, Mr Trump has said he wants restrictions to be left to the states. During the election campaign, he moderated his comments on abortion against a background of voter disquiet about highly restrictive state laws enacted following the overturning of Roe v Wade.
In October, Mr Trump indicated he would veto a federal abortion ban although in March he suggested he was likely to support a 15-week federal ban, with exceptions for rape, incest and life-threatening emergencies.
On 17 December, Mr Robert F Kennedy, the man tapped by Mr Trump to lead the Department of Health and Human Services, was reported in The Hill as saying he had “come to an agreement with President-elect Trump on the issue of abortion, concluding the matter will be left to the states to decide”.
State laws
Prior to the Supreme Court’s decision in 2022, some states had been working on legal mechanisms around the federal right to abortion. In September 2021, for example, the ‘Texas heartbeat Act’ came into effect. It prohibited abortion after detection of a ‘foetal heartbeat’, which is usually detectable at around six weeks of pregnancy (when many women do not know they are pregnant).
The law included an exemption for certain emergency situations restricted to “a life‐threatening physical condition aggravated by, caused by, or arising from a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed”. Texas was the first state to introduce such a restriction.
The law withstood challenges in state and federal courts primarily due to the way it was drafted. It relied solely on enforcement by private individuals through civil lawsuits.
A ‘trigger law’ took effect in Texas following the 2022 Supreme Court decision. Currently, abortion is completely banned in Texas with very narrow exceptions. An exception applies to medical emergencies, but many doctors have cited ambiguities that are leading to delayed care. There are no exemptions in cases of rape and incest.
Doctors who provide an abortion, which was not deemed a medical emergency, could face life in prison, a $100,000 civil penalty for each unlawful abortion, and loss of their medical license.
The nature of the strict abortion ban in Texas does not allow us
as medical professionals to do our jobs
‘Devastating’
“Under a Trump presidency, there’s no question that the already devastating abortion access crisis will likely get worse,” according to Ms Amy Friedrich-Karnik, Director of Federal Policy at the Guttmacher Institute, a US-based research and policy organisation committed to advancing sexual and reproductive rights worldwide.
In an email response to the Medical Independent (MI), she stated: “There are currently 13 states enforcing total bans on abortion, with more restricting abortion throughout pregnancy and these bans have real consequences.”
She said women have died as they were unable to access the required abortion or miscarriage care within their own state or to travel to another state.
Last year, investigative news outlet ProPublica published extensive reports on the deaths of women following delays receiving abortion and miscarriage care due to abortion law. ProPublica highlighted, for example, the reluctance of some doctors to perform dilation and curettage following incomplete medical abortion and miscarriage due to legal concerns.
In response to reporting by ProPublica on the cases of two women in Texas who had a miscarriage and died after medical staff delayed emergency care, 111 obstetricians/gynaecologists wrote to the state’s lawmakers calling for urgent legal change.
“As reported by ProPublica, the evidence is clear. The nature of the strict abortion ban in Texas does not allow us as medical professionals to do our jobs,” the doctors wrote.
“The law does not allow Texas women to get the lifesaving care they need and threatens physicians with life imprisonment and loss of licensure for doing what is often medically necessary for the patient’s health and future fertility.”
Medications
Reproductive rights advocates hoped that drugs commonly used for medical termination of pregnancy (misoprostol and mifepristone) might be an option for women in the states that ban or restrict abortion. However, they now fear that access will be tightly restricted under Mr Trump’s presidency.
Some have suggested Mr Trump could withdraw the Food and Drug Administration’s authorisation for the drugs or enforce the Comstock Act of 1873. This law bans the mailing of drugs used for abortion, but there are different interpretations of how it could be applied (in 2022, the Office of Legal Counsel in the Department of Justice concluded the Act does not prohibit the mailing or delivery of abortion medications unless the sender intends that the drugs will be used unlawfully).
“In Trump’s first few months in office, we’re going to be paying special attention to what actions the administration takes to further restrict medication abortion,” Ms Friedrich-Karnik told MI.
“Expanded access to medication abortion has been a huge reason why more people have been able to access abortion care post-Roe [Supreme Court ruling], and we know that is a major target for anti-abortion policymakers.
“The Trump-Vance administration could immediately signal – through statements or official guidance from the US Department of Justice – that it will enforce a radical and legally unsound interpretation of the Comstock Act. This would likely target medication abortion, but could go so far as to effectively ban all abortion nationwide. Even the threat of enforcement would create a chilling effect for providers, who might halt provision if faced with potential criminalisation.”
The Guttmacher Institute is also concerned that the Trump administration could stop enforcing the Emergency Medical Treatment and Labor Act, which requires hospitals to provide emergency abortion care to any patient that needs it. The administration could also direct the Department of Justice to withdraw from litigation defending access to emergency care for abortion in states that otherwise ban access.
‘Reproductive healthcare crisis’
“The unnecessary and cruel harm caused by the first Trump administration includes a reproductive healthcare crisis in vast swathes of the United States,” the CEO of the US Centre for Reproductive Rights, Ms Nancy Northup, told MI in an email response.
“President Trump has boasted about appointing three Supreme Court Justices who ultimately overturned Roe v Wade and in the wake of that ruling, abortion care is nearly or completely banned in 17 states. In vast swathes of the south and mid-west, patients are forced to cross multiple state lines to get care, but many lack the means to do so. Obstetricians are fleeing states where abortion is banned because they cannot properly care for their patients, including those experiencing severe pregnancy complications. Obstetricians and medical school residents don’t want to work in these states, creating maternal health deserts.”
Ms Northup believes these harms may significantly worsen during a second Trump presidency. “A second Trump administration will compound these harms with new, potentially far worse ones. It will seek to stop the availability of medication abortion by mail, which has been a lifeline in post-Roe America. It will attempt to gag all organisations, including US-based ones, from advocating for abortion law reform or providing abortion care abroad.
“Such attacks at the federal level will reverberate in the states, undoubtedly leading to more prosecutions, investigations, and lawsuits against providers, patients, and their loved ones.”
However, she also noted that “the election again confirmed that Americans support reproductive rights with voters passing ballot initiatives in seven states adding protections for abortion rights into their state constitutions”.
Women’s health
Reproductive rights do not solely relate to abortion. Maternal healthcare, miscarriage care, fertility treatments like IVF, and access to contraception, are other key components of women’s healthcare. Affordable health insurance is also vital, not least because of soaring drug costs.
The US has one of the highest rates of maternal mortality of any wealthy nation. Maternal mortality rates have nearly doubled from 17.4 per 100,000 live births in 2018 to 32.9 in 2021, according to the American Journal of Obstetrics and Gynaecology.
The 2021 mortality rate for black women was almost 70 per 100,000 live births, according to the Centres for Disease Control and Prevention. By contrast, several European countries including Ireland have rates in the single digits.
While there are a number of factors contributing to the high maternal mortality rates (including lack of access to healthcare, racism, a rise in multimorbidity, etc) experts fear that the strict abortion laws are increasingly becoming yet another driver.
There are also concerns that access to contraception could be threatened if the Trump administration revives efforts to repeal or undermine the Affordable Care Act. This legislation, introduced by President Barack Obama over 14 years ago, made health insurance more affordable for millions of people and guarantees contraceptive coverage. The administration could return to a situation that would allow employers and educational institutions to avoid offering coverage in their employees’ or students’ health plans by claiming moral and religious exemptions.
The unnecessary and cruel harm caused by the first Trump administration includes a reproductive healthcare crisis in vast swathes of the United States
Global
Planned Parenthood has suggested Mr Trump’s presidency will adversely impact reproductive health and rights globally. The organisation operates over 600 health clinics in the US and partners with organisations in 12 countries around the world.
According to a statement it issued after Mr Trump’s election: “A return to Trump’s policies and the potential implementation of Project 2025 will cause millions of people to lose access to contraception, abortion, and other critical healthcare services, both in the US and around the world.”
[Project 2025 is a policy document devised by right-wing think-tank The Heritage Foundation. It sets out an ultra-conservative vision for Mr Trump’s second presidency and includes contributions by advisors from his first term. During the campaign, Mr Trump distanced himself from the document, but a number of his recent appointees were involved in Project 2025].
“President Trump will reinstate the ‘global gag rule’, which causes significant and specific harm to IPPF [International Planned Parenthood Federation] and will amount to an approximate loss of $60 million in USAID funding,” stated Planned Parenthood.
The Mexico City policy – also known as the ‘global gag rule’ – denies US funding to organisations (incorporated outside the US) if they use their own non-US funds to provide abortion services, counselling, or referrals. The policy was established under President Ronald Reagan in 1984. It has since been revoked by every Democratic president and reinstated by every Republican president.
The US does not fund abortions abroad as stipulated by the 1973 Helms Amendment. However, the ‘global gag rule’ takes restrictions further. The version initiated during Mr Trump’s first term from 2017 to 2021 forbade non-US organisations that received US global health funding from any abortion-related activities regardless of the source of funds they use to provide those services.
In effect, this places non-US non-governmental organisations in the position of losing critical funds that support a range of health services, or accepting the funding, but not being able to provide the full range of lawful sexual and reproductive health services and information.
International Planned Parenthood operates in countries including Cameroon, Ethiopia, Malawi, Mauritania, and Togo. It is also involved in a multi-country USAID project in West Africa, which started in 2023 and is planned to continue until 2028. It is expected to reach nearly 1.2 million contraceptive users.
“Abruptly cutting this work short will have tragic consequences for the local population, clinics, outreach, and community services and programmes. Under Project 2025, Trump’s policy advisors have proposed an extreme new expansion of the gag rule to include all foreign assistance to US and non-US organisations, including humanitarian funding,” the organisation said.
Planned Parenthood clinics within the US may also come under pressure, according to the Guttmacher Institute. “These clinics receive reimbursement from Medicaid, Title X, and other publicly funded programmes for providing such care as contraception, STI screenings and treatments, and cancer screenings. The Trump-Vance administration would likely encourage states to ‘defund’ Planned Parenthood by making its affiliates ineligible to receive reimbursement from Medicaid and other publicly funded family planning programmes.”
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