When he returns to the White House, President-elect Trump is widely expected to slash funding for women’s health organizations around the world, and people on the left and the right alike are focused on what that means for abortions.
But the impact of any Trump cuts would go far, far beyond abortions, and would probably be devastating to millions of women and girls worldwide. Trump’s approach would reduce the availability of contraception and likely increase maternal mortality and cervical cancer.
When he was president in 2017, Trump framed similar cuts as “protecting life in global health.” But a study published by The National Academy of Sciences estimated that over Trump’s four years in office, this policy led to 108,000 deaths of children and mothers in poor countries.
So I wish Trump could meet some of the women and girls who will be collateral damage. They are people like a 16-year-old girl sitting forlornly on a hospital bed I met in Ambovombe, in the remote and impoverished south of Madagascar. The girl, Sambiasie (who has only one name), told me she and her boyfriend relied on an injectable contraceptive, costing her 40 cents every three months — and then she ran out of money.
“I didn’t have the money, so I missed an appointment,” she told me. For want of 40 cents, she became pregnant. Her boyfriend then dumped her. She had to drop out of school. Then she had a miscarriage.
You may be thinking: She was irresponsible to have sex if she couldn’t afford a contraceptive. True, of course. But were you ever young? It’s hard to see how less availability of contraception won’t mean more pregnancies, more girls dropping out of school, and probably more abortions as well.
Republicans once were champions of family planning: President George H.W. Bush was so devoted to the cause that his colleagues nicknamed him Rubbers. But increasingly the G.O.P. has sought to eviscerate the United Nations Population Fund, the largest provider of contraceptives in poor countries.
After taking office, Trump is expected to end all American funding for the U.N. Population Fund, as he did in 2017. (President Biden restored it.) Trump is also likely once again to impose an expansive form of what critics call the “global gag rule,” ending all support for global health organizations that do not oppose abortion. (Biden rescinded the gag rule.)
All this will be hotly debated by men in suits in Washington, but it will play out in the lives of exhausted women in places like Madagascar.
In a slum in the capital, Antananarivo, I visited a mobile clinic that provides free contraception, cervical cancer screenings and treatment for sexually transmitted infections. The clinic is a lifeline for women like Linah Ravaosoloarimalala, 25, who has three children and wants to stop there. She is homeless, living in a market and has neither the money to pay for contraception nor the ability to stop procreating.
“When my husband is drunk, he comes to me and forces me to have sex,” she said quietly. “If I say I want family planning, he beats me.”
The advantage of contraceptive shots is that a violent partner doesn’t have to know about them, and she was able to get one in the mobile clinic. But that option may not be possible after Trump takes office.
The mobile clinic is one of four that were operated in the capital by MSI Reproductive Choices, a global women’s health nonprofit. But Trump cut all funding for MSI in 2017 under the global gag rule, so two of the clinics were taken out of service. The U.N. Population Fund has paid for the remaining two clinics, including the one where Ravaosoloarimalala received her injectable contraceptive, but its existence will be in doubt if the Population Fund loses American funding.
Claims from conservatives that their efforts are about “protecting life” are a red herring. Madagascar already bans all abortions, even to save the life of a mother, and in any case, American law has long prevented aid from going to pay for abortions.
That said, without access to contraception, women and girls will get pregnant — and some will find under-the-table ways to terminate pregnancies. Indian-made misoprostol, an ulcer medication that also induces abortions, is widely available in poor countries; I found that even at a rural pharmacy in Madagascar, it’s easy to buy without a prescription, no questions asked, for 50 cents a pill.
One study by three Stanford scholars found that in the past the global gag rule was associated with increases in abortions. “Reduced financial support for family planning may have led women to substitute abortion for contraception,” the scholars concluded.
After Trump cut American funding for the U.N. Population Fund in 2017, the result in Madagascar was that condoms, injectables, I.U.D.s and implants became hard to find for a time, health workers say. There’s no data, but somehow I doubt that people stopped having sex.
In America, we sometimes take family planning for granted. In much of the world, access is transformational.
“I’ve wanted family planning a long time,” said Annick Harenasoa, 18, a high school senior who came to a Population Fund-supported clinic for her first injectable contraceptive. “If this clinic didn’t exist, I think I would get pregnant. I wouldn’t achieve my dreams.”
Five of her classmates had already become pregnant and dropped out of school, she said.
I’m on my annual win-a-trip journey, for which I choose a university student to travel with me to cover neglected global issues. I wanted the winner, Trisha Mukherjee, to observe the gap between how Americans see issues and what actually unfolds in places like Madagascar.
The American right is concerned that the Population Fund is complicit in abortions, but after decades of covering global health, I can flatly say that is wrong. Indeed, by providing contraception, the fund has hugely reduced unplanned pregnancies, and thus reduced abortions.
And let’s be clear: “Reproductive health” is not the same as abortions. Too many people equate the two, but the Population Fund saves women’s lives in childbirth. It fights taboos about menstruation that, as Mukherjee noted in an article from this trip, keep millions of girls out of school. It opposes child marriage and female genital mutilation. It tackles AIDS. It repairs obstetric fistulas. It combats violence against women. It provides screenings for cervical cancer.
Is it sometimes an unwieldy bureaucracy? Of course! It’s the United Nations. But it’s also lifesaving.
“If this clinic didn’t exist, I would have just waited to die,” Lydia Vavitiana, 28, a cervical cancer survivor, told me at the Population Fund-supported clinic in Ambovombe. “It saved my life.”
Cervical cancer isn’t controversial like abortion, and so rarely gets discussed — which means it also doesn’t get addressed. It kills some 350,000 women a year worldwide, overwhelmingly in poor countries; in three dozen countries, it kills more women than any other cancer. It’s an excruciating and humiliating disease, sometimes diagnosed in part by the stench of rotting flesh.
So thank goodness for groups like the U.N. Population Fund and MSI, for taking on reproductive health in a way that isn’t performative or ideological but actually saves lives.
Reproductive health is, in fact, an area of huge global success. In Madagascar, women averaged seven children each until the mid-1970s and now, partly because they can control when they become pregnant, average just three or four. Maternal mortality worldwide has halved over the last 35 years. AIDS is no longer a death sentence.
Whether that progress can be sustained is now less clear. MSI says that the Trump administration’s gag rule in 2017 cost it $120 million, enough to prevent six million unintended pregnancies and 20,000 maternal deaths. In Madagascar, MSI had to cut its staff from 539 health workers to 139.
I realize that Washington gets caught up in its own political fevers and deliriums. But I hope that administration officials will understand that if they cut off funding for the U.N. Population Fund and for women’s health organizations like MSI, this will not be an ideological triumph of one American political faction but the death knell for women and girls just like their own mothers, sisters, wives and daughters.
