There is a familiarity about this photo, and it could have been taken in many boardrooms around the world – men gathered around a table making plans and cutting deals.

But the lack of women here, among a group of conservative Republicans discussing their healthcare bill with the president and vice-president, struck a particular nerve.

That’s because one of the points under discussion was whether the new bill should mandate that health insurance plans provide “essential benefits” including maternity services.

In January, the White House came in for some flak when President Trump signed an abortion bill surrounded by men.

So the reaction was swift when Vice-President Mike Pence tweeted the photo, with the words: “Appreciated joining @POTUS for meeting with the Freedom Caucus again today This is it. #PassTheBill”

Democratic Senator Pat Murray was one of the first to respond, making an ironic observation.

But it wasn’t just women who were upset about it.

Democratic Congressman Jim McGovern described it as an outrage.

Others gave a numeric illustration to make their point.

The president has been keen to include women in the photographs of him signing executive orders, ever since the White House was heavily crticised for an all-male photo of him legislating on abortions, on his first day in the job.

Why are people talking about this photo?

And Dan Scavino, President Trump’s social media director, was quick to respond to the criticism on Thursday by tweeting a female-friendly photo of the president and his vice-president negotiating the healthcare bill with a group of moderate Republicans.

Less than a fifth of Republicans in the House of Representatives are women, but gender representation is not just a Republican problem – the US Congress as a whole is still dominated by men.

With 20% female, the US ranks alongside Bangladesh in global terms. In Sweden it’s 44%.

The US is not the only country to have an all-male photograph from the corridors of power sparking debate.

Last week, an inaugural girls’ council in al-Qassim province in Saudi Arabia was condemned when the first pictures showed 13 men on stage, but no women.

The disquiet over the Mike Pence photo has put the spotlight on the concessions that President Trump is offering to the conservative wing of his party, namely to strip the new health bill of “essential benefits”.

Conservatives have long wanted to reverse an Obamacare requirement that all health plans include 10 key benefits, including emergency services, drug use treatment and maternity care.

It has led some people to question why they are paying for services they say they do not need – like pediatric care for people who have no intention of having children.

Republican Senator Pat Roberts expressed that view on Thursday, when asked about the negotiations, saying: “I wouldn’t want to lose my mammograms.”

He later tweeted an apology: “I deeply regret my comments on a very important topic. Mammograms are essential to women’s health & I never intended to indicate otherwise.”

More on the healthcare story

• What are the Republicans proposing?
• Trump health bill: Winners and losers
• Is Obamacare more popular than ever?
• A bumpy 24 hours for Trump health bill