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A number of countries have felt the effects of an executive order signed by President Trump soon after he entered office. The administration reinstated and expanded a policy that bars international aid groups from getting U.S. funding if they perform or actively support abortion anywhere in the world. In Madagascar, that's meant significant cutbacks as the largest provider of long-term contraception in the country. NPR's Jason Beaubien takes us there.
UNIDENTIFIED MAN #1: (Foreign language spoken).
JASON BEAUBIAN, BYLINE: Nurses from the British nonprofit Marie Stopes International run family planning clinics in some of the most remote parts of this island nation off Africa's southeast coast. This team of two nurses and three outreach workers is currently plying the Canal des Pangalanes, a 400-mile-long inland waterway in eastern Madagascar. They move from village to village in a narrow, 45-foot long boat powered by an old truck engine.
On this day, the boat is tied up in the village of Ambohitsara. Dugout canoes loaded with green bananas, fish and sacks of rice are lined up next to them. The crew from Marie Stopes has set up a mobile contraception clinic in the village's three-room health center. The team was expecting to see 40 to 50 women on this day. But more than a hundred turned up before the event even started. One of the nurses, Olivia Haingoniaina, is holding up a blue plastic replica of a penis and demonstrating how to use a condom.
BEAUBIAN: The crowd erupts in laughter when she jokes about how they're much easier to take off than put on. Haingoniaina and her fellow nurse explain various ways to prevent pregnancy, including the rhythm method. Birth control pills and condoms are widely available in Madagascar. But long-term methods like implants or IUDs aren't. And that's what the Marie Stopes team is offering on this day.
(SOUNDBITE OF TAKING BLOOD PRESSURE)
BEAUBIAN: In one room of the clinic, the first nurse screens the women, checks their blood pressure, weight, temperature. Then next door, Haingoniaina inserts the implant or IUD. One of the women who's come to this clinic is a 33-year-old single mother named Bacquerette. She walked more than four miles to get here. Bacquerette uses just one name, which is common in this part of Madagascar.
BACQUERETTE: (Foreign language spoken).
BEAUBIAN: She says she wants an IUD for peace of mind. She already has one child. She's not married. And she says having more children right now would make her life very difficult. A chief from an adjacent village, Nirivelo, has also come to the contraception clinic. He's there to make sure that several teenage students from his village get contraceptive implants.
NIRIVELO: (Foreign language spoken).
BEAUBIAN: He explains that one of the girls from his village got pregnant, and it's been a big problem. Her parents are upset. The boy's parents can't afford to pay a dowry. It's caused a little war in his village, he says. So to avoid these troubles, he's telling the other students to come to this contraception clinic. These clinics have been funded by the U.S. Agency for International Development, but that funding is being suspended by the Trump administration.
To public health experts, family planning is the foundation for maternal and child health not just in poor countries but in any country. If a woman can control when and how frequently she's pregnant, her health and the health of her children improve dramatically. Madagascar has made strides in these areas. The fertility rate has dropped from seven births per woman 30 years ago to just over 4 per woman now. But the country still has a long way to go.
Childhood mortality rates in Madagascar are worse than in Bangladesh. And Malagasy women are about as likely to die in childbirth as mothers in Haiti. And now Lalaina Razafinasoa, the country director for Marie Stopes Madagascar, says her group is losing millions of dollars in USAID funding.
LALAINA RAZAFINASOA: It's really unbelievable to have this happen.
BEAUBIAN: Madagascar had been trying to reach an ambitious goal of boosting its rate of contraception use from 30 percent to 50 percent. But with U.S. funding drying up, she says that probably isn't achievable anytime soon. The ironic thing is that Marie Stopes is losing U.S. funding as part of a policy shift related to abortion. Yet the organization isn't involved with abortion services here because the procedure is illegal in Madagascar. The funding cut is because Marie Stopes's parent organization in London refuses to renounce abortion as a family planning method. It does provide abortion services in other parts of the world. The loss of U.S. funding, Razafinasoa says, means that hundreds of thousands of women in Madagascar will lose access to reproductive health services.
RAZAFINASOA: So it will be a disaster.
BEAUBIAN: And this policy isn't just going into effect in Madagascar. It's affecting billions of dollars in U.S. global health grants in some of the poorest countries on Earth.
UNIDENTIFIED MAN #2: (Foreign language spoken).
BEAUBIAN: Back in Ambohitsara at the Marie Stopes contraception clinic, the staff called in woman after woman from 8 in the morning until just after sundown. The nurses held 135 personal consultations over the course of the day. Fifty-five women got new implants. Twelve got IUDs. Some just had questions. Some were follow-up visits. Haingoniaina, the nurse, says the large turnout at this clinic is similar to what they've been seeing recently up and down the 400-mile waterway. Everywhere they go, she says, she hears from women that they want smaller families.
HAINGONIAINA: (Through interpreter) In their minds, it's easier to do their everyday work if they don't have so many children. It's difficult to go fishing with a child. It's difficult to work their land with children. Life is simpler if they have fewer children.
BEAUBIAN: She says that her work is more than just a job. In a way, it's patriotic, the 27-year-old says. It's about improving her country.
HAINGONIAINA: (Through interpreter) It's very important for Madagascar because, currently, there are families that have eight or nine children. The kids don't have enough to eat. They don't go to school. They're very, very poor. So it's not good for Madagascar.
BEAUBIAN: But unless Marie Stopes finds new money to replace the funding that's being suspended by the Trump administration, Haingoniaina could soon be forced to look for a new line of work. Jason Beaubien, NPR News, Ambohitsara, Madagascar.
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