Health-care workers in Madagascar and dozens of other countries have faced new obstacles since Trump signed an order tying U.S. aid to antiabortion rules.

Nana thought for a second, and then shook her head. Donald Trump? No, never heard of him.

Her humble, earthen home and field of cassava are about as far from Washington as it gets. She lives in Madagascar, an impoverished island hundreds of miles off the coast of Africa — and tiny Betsingilo is a week-long trip by bus from the country’s capital.

ASIA AFRICA Detail Antananarivo Indian Betsingilo Ocean 100 MILES

The distance has not stopped Trump’s foreign policy from affecting people’s lives here.

Madagascar is one of dozens of countries where health providers are facing cutbacks or other disruptions after a dramatic change to foreign aid by the Trump administration. Little noticed by many Americans, the shift could have profound consequences in rural communities like Nana’s.

The policy change was one of Trump’s first acts as president. On Jan. 23, 2017, he signed an executive order that denied U.S. assistance to any foreign-based organization that performs, promotes or offers information on abortion.

A similar plan, known as the Mexico City policy, was in effect under past Republican presidents. But Trump expanded it exponentially to apply not just to around $600 million in overseas family-planning funds, but to the entire $8.8 billion in annual U.S. global health aid.

It will take years to gauge the full impact of the policy, which will affect aid groups as they renew grants or seek new U.S. funding. In many of the more than 60 countries that receive U.S. health assistance, the impact could be minimal. But the change has resulted in tens of millions of dollars in funding cuts to two of the developing world’s biggest providers of women’s health care, including Marie Stopes International — which runs a mobile family-planning clinic serving Nana’s village.

More broadly, the policy has created a wave of uncertainty in aid-dependent countries. For the first time, groups that treat HIV, malaria and other illnesses will also have to pledge to have no role in promoting abortion — or forgo American aid. Many organizations will face a dilemma, advocates say, since abortion-related services are often integrated into general health care in poor nations. Disentangling them can be difficult.

“This is now a massive, potentially devastating experiment with people’s lives,” said Asia Russell, executive director of Health GAP, a global AIDS and human-rights advocacy group, who is based in Uganda.

The Post’s Max Bearak visited a remote village in Madagascar to see how President Trump’s antiabortion policy might make it difficult for women there to access family planning services. (Carolyn Van Houten,Max Bearak,Joyce Lee/The Washington Post)

American officials say they don’t believe the new policy will ultimately reduce the availability of health care. “We are not changing funding amounts by one dollar,” said Alma Golden, a deputy assistant administrator for USAID, the government’s foreign-aid agency. Funds denied to some organizations will be redirected to others that provide similar services and promise to follow the new policy, officials say.

But it can take weeks or months for that to happen. In some remote areas, there are few, if any, other health groups that could readily step in. Madagascar is especially vulnerable because it has relatively few foreign donors.

“There are still many women in Madagascar who want contraception but don’t have it,” said Marie Georgette Ravoniarisoa, director of the family health division of Madagascar’s health ministry. “Marie Stopes was beginning to reach more of them, but it looks like the Trump administration will make things go backwards.”

In Betsingilo, Marie Stopes is the only provider of family-planning services — something Nana felt she desperately needed.

Nana, who like many Madagascar residents goes by one name, is a 24-year-old single mother of two. She already struggles to grow enough cassava and maize to feed her children. Having another child, she says, could prove disastrous. So when Marie Stopes’s mobile clinic reached a nearby village last year, Nana walked eight miles and became the first woman from Betsingilo to get long-term contraception — a hormonal implant in her arm that can last three years. “I was trembling,” she later recalled. But she was determined to have the procedure. What she didn’t know was that the political earthquake that had occurred earlier that year, thousands of miles away, might spell the end of that clinic and others, potentially leaving her and many other poor women with few options for treatment.

Trump’s aid policy reflects a larger administration push to defund groups that provide abortions, referrals or information on the procedure. Overseas, a key component of that is the Mexico City policy, named for the city in which it was drafted in 1984. President Ronald Reagan brought it into law, and each Democrat in the office after him rescinded it, while each Republican reinstated it.

Congress has long prohibited the use of U.S. foreign aid for abortions. But under Democratic presidents, foreign groups could still qualify for family-planning funds as long as they used non-U.S. funds for abortions. Under the Mexico City policy, groups have to forswear not just performing abortions but promoting them in any way. Critics call it the “global gag rule.”

Antiabortion advocates say the policy will save the lives of the unborn.

“This is a welcome step toward restoring and enforcing important federal policies that respect the most fundamental human right — the right to life,” said Cardinal Timothy M. Dolan, head of the U.S. Conference of Catholic Bishops’ Committee on Pro-Life Activities, when Trump reinstated the policy.

Academics have questioned whether the Mexico City policy effectively decreases abortions. A 2011 study by Stanford University researchers suggested the policy has actually been “associated with increases in abortion rates in sub-Saharan African countries.” One possible reason for that: Some organizations that had provided contraceptives lost funding, which may have led to more unwanted pregnancies, the researchers wrote.

Since Trump’s expanded policy took effect in May 2017, most foreign health groups have committed to following the new rules. But a small group refused to sign, including the International Planned Parenthood Federation and Marie Stopes, a London-based aid group named for an early 20th-century family-planning pioneer. They, in turn, have hundreds of local partners.

International Planned Parenthood says it has had to make reductions in clinics, staffing, services or health supplies in 29 countries.

Marie Stopes, which works in 37 countries, says it lost around $30 million in U.S. aid in 2017. That was equivalent to 17 percent of its donor grants, and 7 percent of its total income.

Although the group eventually got funding from other donors, it has still had to cut services in countries like Madagascar, Uganda and Zimbabwe to conserve its funds for leaner years ahead.

“It was painful, but at the end of the day, it was a no-brainer not to sign,” said Marjorie Newman-Williams, president of Marie Stopes’s U.S. branch. “The right to safe abortion is core to our mission. To sign it would’ve been walking away from who we are.”

In addition to family-planning funds, the policy — as expanded under Trump — applies to programs that fight diseases like AIDS and malaria. In rural areas in the developing world, such programs might be run from the same clinic that provides family planning, with the aid intermingled.

Asked why the administration chose to broaden the Mexico City policy, the White House said in a statement the move recognized that “when we design programs to end malaria or HIV/AIDS or maternal mortality, we don’t intend to fund the abortion industry.”

Most groups are expected to sign the policy, officials said.

Golden, of USAID, said the U.S. government remained committed to expanding family planning. “We recognize the timing and spacing of children is critical to women’s health and the health of their children,” she said.

The roughly $3.5 million that USAID was giving annually to Marie Stopes in Madagascar was redistributed to organizations like Population Services International that agreed to comply with the new policy. USAID remains the biggest supplier of family-planning methods such as condoms in the country, but Madagascar’s government had come to rely on Marie Stopes to provide services in certain areas.

“The ministry can’t cover everywhere on its own,” said Ravoniarisoa, the health ministry official.

Countries affected by the expanded Mexico City policy are home to some of the world’s most vulnerable people. They tend to be places with fragile governments and rudimentary health care, struggling to cope with rapidly growing populations. Madagascar is a case in point. While beautiful, it is poor and beset by periodic coups, endemic diseases, droughts and cyclones. Women in rural southern Madagascar, where Nana is from, have the shortest average number of months — 24 — between pregnancies nationwide, and they typically start giving birth in their teens, according to official data. Government surveys in Madagascar show that most women want to use contraception to plan their pregnancies. Tema Razanavahony, 29, lives in a village near Betsingilo. “My boy was just 8 months old, and I was already pregnant again,” she said. Like Nana, she got a three-year implant. “Because of this, I am strong.”

Marie Stopes doesn’t provide abortions in Madagascar, as they are illegal in most cases. But it does advocate for the legalization of abortion. The end of USAID funding for at least the next three years has hit the group hard. Its administrative staff in Madagascar is taking a mandatory five days unpaid leave per month. A voucher program that provided free contraception to 170,000 women and girls was eliminated.

Marie Stopes is especially concerned it might have to suspend its 21 mobile clinics, which rove Madagascar by truck, boat and sometimes even hovercraft. They used to be fully funded by USAID and are now running on shoestring budgets. Where a team of four health professionals once went to a village, now it’s often two, and the number of operations performed has declined by half, the group says. An additional mobile clinic has already been eliminated.

The group estimates there are 350,000 women in Madagascar who can only get family-planning services like implants and tubal ligatures from its mobile clinics.

Jean Rangomana, a surgeon for Marie Stopes whose clinic packs up neatly into a Toyota Land Cruiser, said some women had already received hormonal implants or IUDs, and “they have been promised checkups in case anything goes wrong.”

When Rangomana’s clinic visited a village near Betsingilo in April, six women, assured by Nana that the procedures wouldn’t hurt, walked for miles with their children in tow to get there. Four decided to get some form of long-term contraception. “There’s nothing to worry about,” Nana told the women. Rangomana chose not to tell them that it was possible he might not return. “I tell them, ‘This is simple. It is about having a better life,’ ” Rangomana said. “I also tell them, ‘You can always change your mind. We’ll come back and take it out.’ I hope that I have not lied to them.”

Organizations that advocate for access to abortion have always known that U.S. government funding is insecure. But under Trump’s expanded policy, groups that were once far removed from America’s abortion politics are facing that same uncertainty.

Among them are recipients of funding from PEPFAR, the President’s Emergency Plan for AIDS Relief, which was started under President George W. Bush and is considered a U.S. success story.

Many health facilities in the developing world, particularly in rural areas, offer a broad range of services — everything from tuberculosis treatment to HIV testing to family planning — under one roof. In part, that’s because of a lack of resources. But AIDS researchers have long argued that integrating health services is vital in stemming the spread of the virus.

“The idea is, if pregnancy prevention gets them in, let’s get all their needs there,” said Chloe Cooney, director of global advocacy at Planned Parenthood Federation of America. “If you disqualify them in that space, there’s a massive ripple effect.”

Some local organizations are already feeling the impact of the policy on HIV and AIDS treatment.

In Mozambique, a southeast African country heavily dependent on aid for its health care, a Planned Parenthood affiliate called Amodefa lost 60 percent of its funding, though some of its work can be transferred to other groups, said Santos Simione, its executive director.

The group has closed clinics across the country that were funded through PEPFAR, many in rural areas with a high prevalence of HIV where it was the primary provider of care, he said. It has laid off a third of its staff.

“The U.S. government and Planned Parenthood helped us build capacity for almost a decade. We became the organization people in our communities could trust to get information and care,” Simione said in an interview.

He said that he has offered to help train new organizations that did sign on to the Mexico City policy, but they have declined for fear their funding could be jeopardized. “It will take years and years before some places in Mozambique get the same quality of care we gave,” he said.

Another illustration of the Trump policy’s far-reaching impact is how it affected an international charity, WaterAid, focused on sanitation, hygiene and drinking water.

In some countries where it operates, women face the risk of sexual assault as they walk to fetch drinking water. If its staff referred them to a clinic, “the chances of it being a Planned Parenthood or Marie Stopes clinic were really quite high,” said Lisa Schechtman, director of policy and advocacy for the group. It didn’t sign the policy and lost the opportunity to apply for USAID funds for health and nutrition programs in six countries, she said.

The U.S. State Department has been studying the expanded policy’s impact, but Deborah L. Birx, the U.S. global AIDS coordinator, said there is not yet sufficient data to say whether concerns raised by public health advocates were warranted.

Claudia Rasolomamy, a community health worker in the town of Besakoa, enters the consultation room between patient appointments to talk to Jean Rangomana, a surgeon for Marie Stopes International, which runs a mobile family-planning clinic.

In the 21 months since Trump took office, private donors as well as governments in Europe and elsewhere have increased their assistance to family-planning groups that became ineligible for U.S. aid. Last year, four European nations — Sweden, Belgium, Denmark and the Netherlands — launched the SheDecides initiative to raise money for sexual and reproductive health programs, in reaction to Trump’s policies.

But some organizations have faced months of turbulence as they try to nail down new funding.

In Madagascar, Rangomana and the other doctors have relied on stopgap aid to operate their mobile clinics. There is no guarantee, however, that Marie Stopes can support them beyond this fall.

“Our staff are losing focus on their work because they are worried about their futures,” Lalaina Razafinirinasoa, Marie Stopes’s director in Madagascar, said in late August.

She was cautiously optimistic that the group would find the needed money. But she has drawn up termination letters in case she’s wrong.