Originally published in The Lancet Public Health.

As one of his first actions as president, Donald Trump imposed and expanded the global gag rule, a sweeping policy that will cripple highly successful US family planning programmes in developing countries and seriously damage broader US global health efforts. This callous policy—ostensibly meant to counter abortion—might shock observers abroad, but is only the opening salvo in what is expected to be a broad-based assault on sexual and reproductive health and rights. President Trump has vowed to “put America first”; however, his policies would put the health of women last, around the world and most certainly in the USA.

US social conservatives opposed to women’s health, rights, and autonomy have powerful levers at their disposal. These levers include the presidency, both houses of the US Congress, federal agencies’ regulatory powers, and control over a majority of governorships and legislatures in the 50 states. Even as the specifics are still emerging, abortion rights and birth control access will come under withering attacks that could roll back decades’ worth of progress.

One major angle of attack already underway is to undo, entirely or in part, the health reform law championed by President Obama, often referred to as Obamacare. Under the law, over 20 million previously uninsured Americans gained health coverage, and the proportion of reproductive-age women who were uninsured dropped by more than a third. The law also substantially boosted access to birth control, requiring most insurance plans to cover 18 different contraceptive methods without any out-of-pocket costs. Before the law, these costs, even for women with insurance, could run into hundreds of dollars annually, putting highly effective methods with high upfront costs, such as the intrauterine device, out of reach for some women. These gains are now threatened.

But the peril to high-quality, affordable contraceptive care does not end there. Social conservatives have also long sought to undermine the network of publicly supported family planning providers that offer lowcost or no-cost care to women in need. Congressional leaders have their sights set on crucial family planning programmes such as the grant programme known as Title X, the only federal programme dedicated to providing family planning services. In particular, conservative policy makers are determined to deny federal funding to health centres affiliated with Planned Parenthood because, in addition to providing contraceptive and closely related care, such as testing and treatment of sexually transmitted infections, Planned Parenthood centres might also offer abortion care with non-federal funds.

Defunding Planned Parenthood, which would certainly diminish access to care, is a dangerous proposition, not least because (counter to claims from those pushing for this step) other providers do not offer as comprehensive a package of care. Planned Parenthood health centres consistently perform better than other types of publicly funded family planning providers on a range of key indicators. For instance, they are much more likely to offer a full range of birth control methods and sameday insertion of intrauterine devices or implants, and are also more likely to offer convenient evening or weekend appointments. Moreover, it is unlikely that other types of providers would be able to absorb an influx of new clients. Planned Parenthood health centres see a higher volume of contraceptive clients and, in many communities, are the sole source of publicly funded contraceptive care.

Another area that will see a host of legislative attacks is abortion access—already the target of a recent statelevel onslaught, with states enacting 338 abortion restrictions between 2011 and 2016. Some of these laws make abortion care more difficult and expensive to obtain, especially for young and poor women. Others have made it harder for providers to offer the procedure or otherwise seek to reduce the availability of services. Collectively, these measures further stigmatise abortion and continue to isolate it from other health services. These restrictions have a profound effect on the landscape facing women seeking to access abortion care: in 2016, almost six in ten (57%) US women of reproductive age lived in a state the Guttmacher Institute classifies as either hostile or extremely hostile to abortion rights.

At the federal level, legislation that is expected or already introduced includes restrictions on later abortion, such as a ban at week 20 after fertilisation or a ban on certain abortion methods—eg, dilation and evacuation, a safe and common procedure used in the second trimester. Anti-abortion policy makers are also expected to push for additional restrictions on insurance coverage of abortion, a policy that would fall hardest on low-income women who rely on public insurance for their care.

Taken together, this hostility to reproductive health care threatens a massive rollback of US women’s health, rights, and autonomy. Reproductive health and rights advocates, for their part, will fight this regressive agenda at every turn. We will insist—as we always have—that policies be grounded in voluntarism and informed consent, and that they must support women’s right to make their own decisions to access high-quality contraceptive services, obtain safe and timely abortion care when needed, and achieve healthy pregnancies and raise their children with dignity.

Full text with references for this Comment is available at The Lancet Public Health.