When news from the US develops so fast and unexpectedly that TV political dramas struggle to compete, it might be premature to comment on its health policy, given President Donald Trump's propensity for controversy and subsequent re-evaluation. Yet this is the international issue of British Journal of Midwifery and, as no other country has such influence on world health-care, it would be impossible not to mention Trump's plans to overturn the Affordable Care Act (ACA, nicknamed ‘Obamacare’) and revive the so-called ‘Global Gag Rule’.
To ‘repeal and replace’ the ACA with the American Health Care Act (AHCA) was a key campaign message, but has been tough to deliver. It proposes allowing insurers to charge higher premiums for ‘pre-existing conditions’, including pregnancy and caesarean section (Aggarwal, 2017), and drastically reducing Medicaid funding. Medicaid, which finances Planned Parenthood, a non-profit family planning organisation, is estimated to cover 51% of all births in the US, and is a lifeline for the vulnerable, most notably poor women and ethnic minorities (Sonfeld and Kost, 2017). The limits imposed by the AHCA threaten to deny thousands of women access to services that are vital to preventing unwanted pregnancy, sexually transmitted infections and illicit abortions (Aggarwal, 2017).
These restrictions go far beyond the US. One of Trump's first decisions was the reinstatement of the Mexico City Policy, otherwise known as the ‘Global Gag Rule’, which cut federal funding for all organisations providing abortion referral or counselling services (Solomon, 2017). This has repercussions for the organisations as well as countries such as the UK that will have to decide whether to plug the gap.
The US's global influence is undeniable, but should be seriously questioned when it comes to reproductive health. The maternal mortality rate in the US is the highest of any high-resource country (21 per 100 000) (Aggarwal, 2017) and yet Trump proposes to risk women's lives by limiting the control they have over their bodies. To midwives who fight tirelessly for women to give birth only when they are prepared, informed and safe, these reductive policies are simply insulting—more so if we consider midwives reducing mortality rates in countries with far fewer resources.
The UK is lucky to have the NHS and several family planning organisations that can give women education and autonomy. Yet it cannot be forgotten that the NHS has been under prolonged strain; its future debated in the general election. While no party is proposing Trump-style cuts, we should nevertheless be aware of the effect that further reductions in funding may have on midwife recruitment, and birth outcomes. Health systems may always be pressured to reduce spending, but we should not allow cuts to undermine midwives' work or to make birth less safe for women.