It is under-fives week at Zambia’s Nyangwena health centre and, outside in the morning sunshine, women are taking turns to weigh their babies. A noisy toddler wriggles as his mum places him into the harness of a set of scales. Measurements are taken and, afterwards, ice lollies handed out to children.

Reaching families in the surrounding rural communities is a major challenge for staff at the centre, and, after outreach services were stripped back, things are getting worse.

It is one year since devastating cuts to family planning services, imposed by Donald Trump, took effect. Already, Esther Zulu, clinical officer at Nyangwena, worries staff are seeing more young mothers. The number of teenage pregnancies recorded at the centre has doubled, from eight in 2017 to 16 in 2018.

Meanwhile, the number of people taking tests for sexually transmitted infections and HIV has slumped. “People will only come if they are not feeling well,” says Zulu.

Until November 2017, a project run by Planned Parenthood Association of Zambia (PPAZ) would offer HIV testing in homes, distribute condoms in the community, and give family planning information to teenagers in schools.

Such work was halted by the Mexico City policy, or “global gag rule”, signed two years ago by Trump, which blocked US funds to any organisations involved in abortion advice and care overseas. The policy has been imposed by Republican presidents since Ronald Reagan in 1984, but Trump’s measure was more wide-reaching than ever before. Campaigners estimated that 15 times more funding would be affected. Women’s rights groups and health experts warned that progress on family planning, population growth and reproductive rights would be swept away.

Rural areas such as Nyangwena, which were once prioritised by US aid, are thought to have been hardest hit. Here in Rufunsa district, and across Chongwe and Livingstone, projects tackling teenage pregnancies and HIV, run by PPAZ, were all cut. The organisation, which is a member of the International Planned Parenthood Federation, lost almost half of its annual operating budget in 2017, with access to a $3.8m (£3m) fund cut off.

More than 70 community members – who, in exchange for a small monthly stipend, provided a range of outreach care – were let go. Seventeen staff members lost their jobs. Salome Sichali, programme office at PPAZ, cried when she told the community. “There were 70-plus people whose lives were shattered, and abruptly.”

Community leaders asked how people would be able to access services or condoms, which PPAZ had been making available at collection points in shops and near to bars. Today, the entire district of Rufunsa, home to 68,000 people, receives government packages of up to seven boxes, each containing 144 condoms every month. These are shared between 23 health facilities.

Promises that services would be taken over by alternative partners haven’t been kept. Of the 16 sites operated by PPAZ, only three are now running. “Even today people call and ask what is happening. We just say I’m not sure,” says Sichali.

The same pattern is seen elsewhere, campaigners warn. “There is this narrative from the US government that when providers they have been partnering with are cut out, other partners can come in and fill that void. That’s just not something we’re seeing,” says Jonathan Rucks, senior director of advocacy at PAI, an advocacy group.

Sichali fears progress made in parts of Zambia – where teenage pregnancy rates stand at 29% and nearly a third of girls are married before the age of 18 – is at risk of going backwards.

In the past, organisations affected by the global gag rule were mostly focused on family planning. Today, services are much more integrated – which means everything from HIV treatment to child and maternal health can be affected by funding cuts.

Nyangwena health centre has just two community workers delivering HIV care, and one overseeing tuberculosis cases. For a facility serving 3,270 people over a vast rural area, it isn’t enough.

“People will end up dying in the community because we are not following them,” says Brenda Simakuni, who works as a counsellor for Chiyota health post, also in Rufunsa.

Already, reports in Rufunsa are gravely concerning. “Last month we lost a boy aged 20,” says Simakuni. “He started taking medication and all of a sudden he just stopped. He told parents that he was tired of taking the drugs.” Health workers had tried to counsel him during follow-up visits, she adds, but he had struggled to accept that he was HIV positive. There aren’t enough resources to do comprehensive follow-ups for all patients.

Simakuni is especially worried about the effect that service cuts will have on girls, whose health, safety and education is at stake. She was previously a community counsellor with PPAZ, but is now unpaid. At a local school, where she has taught about family planning, seven of the students in grade nine – where children are as young as 15 – were sitting their end-of-term exams in November while pregnant.

Not far from Nyangwena health centre, Juliet Banda, 16, is sitting outside the house where she lives with her grandmothers. Three years ago, she dropped out of school because her family couldn’t afford the fees. She began a relationship with a 22-year-old man who promised he would marry her and pay for her education. When she became pregnant five months later, he disappeared.

Facebook Twitter Pinterest Two grandmothers crush stones outside their home to support their teenage granddaughter and her baby. Photograph: Cynthia R Matonhodze/The Guardian

“I’m supposed to be at school,” she says through a translator, as her 18-month-old baby sleeps indoors. “Science was [my] favourite subject. I was learning a lot about human beings.” Juliet would like to be a nurse, specialising in midwifery. She isn’t working, and depends on the income her grandmothers make through crushing stones.

Young women in Zambia are among those most vulnerable to HIV. Entering into “sugar daddy” relationships with older men, who are often the least likely to go to a clinic and get tested, heightens the risk. PPAZ introduced savings groups for young women who could become involved in transactional relationships, though now that services have been cut, some of the groups have become dormant.

“The concern is that these young girls could be susceptible to contracting the virus,” says Sichali. “They don’t have access to income generating activities.”

Zambian students are taught sex education in schools, which includes age appropriate information about sex and issues such as gender-based violence. Such efforts are hampered, however, by the variability in teaching quality. And while PPAZ previously sent peer educators into schools, this work is now much more sporadic.

There are also strict rules preventing children under 16 from accessing condoms without parental consent. Even if children are able to seek their family’s permission to get them, many will only be able to access contraceptives at facilities that could require a three-hour journey on foot. “If you look at the vastness of our areas, the health services are few. These long distances are a challenge,” says Muleya Hateya, adolescent health focal point for Rufunsa district. “Some [areas] will get cut off during rainy season.”

Across Rufunsa, changes to the way statistics are collected makes it hard to judge whether or not teen pregnancies are increasing. The number of pregnancies among 19-year-olds are now included and there are greater efforts to report. But the figures are worrying. During the first three-quarters of 2018, 629 teen pregnancies were recorded, compared with 227 during the whole of 2017.

While statistics for teenage pregnancies are limited, even less is known about how service cuts may have affected the number of unsafe abortions, which are routinely unreported.

The wider impact of the global gag rule will be impossible to measure according to Elizabeth Sully, a senior research scientist at the Guttmacher Institute, who is investigating the effect of the funding cut. Where replacement funding is found, it is not known where that money would have been going otherwise in the healthcare system, she says. Nor is it possible to quantify the loss of trust in communities where services have suddenly stopped.

“We are in the times of saying no one gets left behind in terms of healthcare,” says Sichali. “We had planned activities and we were monitoring what was working and what wasn’t along the way. We made progress but we needed to finish.”