The patient-provider relationship is inherently one of unequal power: The patient is seeking expertise, in many cases, from a person with the power to act as a gatekeeper. That power imbalance is often intensified by class, health literacy, race, sexual orientation and gender identity differences between providers and patients—with potentially catastrophic consequences.
The successful patient-provider relationship relies on trust: in state and federal regulations, in accrediting organizations and in the provider acting in partnership with the patient. The president’s new domestic gag rule destroys that fragile balance between power and trust.
The federal Title X program, passed by Congress in 1970 and signed into law by President Richard Nixon, provides birth control and sexual health services—like cervical cancer screening, breast exams and STI screening and treatment—for low-income, low-access communities across the United States.
On Friday, the Trump administration reinstated the Reagan-era domestic gag rule—barring providers who are able to provide essential services through Title X from counseling, referring or performing abortion services.
Trump’s domestic gag rule forces providers into an impossible choice: Will we care for the pregnant person in front of us and make a requested referral for abortion related services, or will we accept funds allowing us to care for thousands of others? The new rule also imposes cumbersome physical and financial demands on abortion providers who receive Title X funds, which further limit access to abortion care.
This rule is not about “paying for abortion”—rather, if directly asked for an abortion referral, providers would have to respond that as a Title X grantee, we cannot refer them, and we would be limited instead to providing a resource list of comprehensive providers without specifying whether they offer abortion services. But this rule does mean that we cannot support our patients to make the best decision for themselves and their lives.
As midwives, nurses, physicians and public health practitioners, and as patients ourselves, we cannot accept a gag rule which inserts politics into the patient-provider relationship.
Title X was established and maintained because sexual and reproductive health care is health care. Every dollar spent on family planning saves five to seven dollars in later healthcare and service costs. Though the World Health Organization considers access to family planning, including safe abortion, to be a human right, the U.S. only allows the use of federal funds for abortion care in very limited circumstances. Denying our patients —who are disproportionately poor, young and people of color—access by refusing them referrals to providers reinforces existing disparities in sexual and reproductive health.
This also isn’t change without consequence. Globally, we know that when denied access to safe legal abortion, pregnant people will still have abortions. This policy change worsens an already fraught situation for patients, especially those most in need.
In the U.S., Black women die at three to four times the rate of white women during the childbearing year—even when controlling for income and education. Pregnancy carries risks, and those risks need to be considered in context. A recent report released by the non-partisan National Academies of Science, Engineering, and Medicine affirmed the safety and quality of care of abortion in the United States, re-established the well-known fact that abortion is a safer option than pregnancy for many people in this country—and explicitly states that barriers to access, such as non-evidence-based regulations like those in Trump’s domestic gag rule, actually decrease safety and increase risk.
The domestic gag rule, like the global gag rule re-instituted and expanded by Trump in 2017, is an act of violence against poor women and women of color—because they are the easiest targets for an administration determined to prioritize fetuses over the people who carry them.
As midwives, nurses, physicians and public health practitioners, we are charged to care holistically for our patients—to advocate for their interests, educate them and make mutual decisions about their care. Our patients depend on us to do so. They trust us to do so. And we gladly accept the honor and responsibility of that trust, regardless of the income, insurance or politics of our patients.
We will not accept the shattering of that hard-won trust. We will not enter into a deal-with-the-devil to de-prioritize the wellbeing of patients seeking to end their pregnancies in order to continue providing contraception to others. Our patients deserve the very best evidence-based care—provided without the interference of political whims and dogma.
