AMPAHO, MADAGASCAR—Ampaho feels like the edge of the world, somewhere most people, even in Madagascar, will never go.

The community of 240 small bamboo huts sits along a slow-moving waterway not far from the shore of the Indian Ocean on Madagascar’s east coast. The trip from the capital, Antananarivo, to Ampaho takes two days by car along the country’s winding roads followed by a meandering voyage on a rustic boat through the Panagalane canal.

On a rainy night five years ago, Marigrety Razafindramiarana’s daughter Marthe ran into trouble giving birth to her eighth child. The family had few options.

The nearest medical clinic, a centre without electricity staffed only by a nurse, was a six-hour walk away; the nearest real hospital would be a six- or seven-hour boat ride. The family managed to get Marthe into a canoe to begin the journey to get help, but only the baby survived. Marthe died on the shore of a nearby community, leaving behind eight children and her elderly mother.

In Madagascar, 10 women a day die in complications from pregnancy and childbirth, according to the United Nations Population Fund (UNFPA), compared to fewer than 25 a year in Canada. Nirivelo, the village chief of Ampaho, says his own mother died this way. That’s why he encourages the women in his village to use contraception, the main kinds being intrauterine devices and contraceptive implants. He is aware that family planning in this community can save lives — he has already seen 10 women in the community of 650 lost in childbirth in the five years he has been the chief.

But contraception is not easy to find in a village like Ampaho, where the public health service doesn’t reach. People are extremely poor, and even if they had money to buy contraceptives, there is no pharmacy. The women in Ampaho have relied solely on teams from Marie Stopes International (MSI) to deliver free long-term methods of contraception, which allows them to delay and space pregnancies and care for the children they already have.

This outreach done by MSI Madagascar to places like Ampaho and other remote areas of the country was until recently almost entirely financed by the United States Agency for International Development (USAID). But that funding has ended.

The reason: a Reagan-era policy that has been enacted every time a Republican administration has been in office since, signed by U.S. President Donald Trump three days into his presidency.

The Mexico City policy, also referred to by critics as the global gag rule, bans U.S. federal funding from going to any foreign non-governmental organization that performs or actively promotes abortion as a method of family planning.

Abortion is illegal in Madagascar, and MSI does not perform or promote abortion there. Nevertheless, as a result of the policy the organization has lost its USAID funding in Madagascar and will be losing it in 15 other countries because of the organization’s commitment to choice globally.

Sarah Shaw, MSI’s head of advocacy, said there was never any question of that the organization would reject the new requirements. “MSI’s absolute core, fundamental belief is we defend a woman’s right to choose to access abortion services if that is what she decides,” said Shaw.

While the choice for the organization was simple, the outcomes have been hard to watch as projects in some of the world’s poorest countries are scaled back and closed down.

Haingoniaina Andrianirina is a nurse who visits Ampaho and other remote communities in Madagascar. She said she now fears for her own safety while doing outreach work. The vehicles the teams used to travel to remote communities were taken back by USAID. The team now worries about travelling in unmarked vehicles in a country where hijackings on the roads are common. The MSI branding helped protect them.

But the nurse’s bigger concern is for the women living in poverty that she serves. UNICEF estimates around 82 per cent of Madagascar’s population of 25 million lives below the international poverty line of $1.90 (U.S.) a day. Andrianirina said without access to the long-term contraceptive methods MSI brings here, there will be consequences. “The poverty will go up,” said Andrianirina. “Now they have three or four children. Some of them don’t have clothes, others don’t have anything to eat. They just go to sleep without eating at night.”

While U.S. support for outreach services has ended in Madagascar, outreach work is continuing with stopgap funding until the end of December. After that the organization is not sure how they will pay for this work. Other projects, such as a voucher plan that provided contraception to poor and young women in urban centres and areas that surround them, have already ended.

As USAID funding agreements end, similar effects may be felt by Marie Stopes International programs around the world if the organization cannot replace the $30 million (U.S.) in funding that has been lost as a result of the Mexico City policy.

And Marie Stopes is not alone. While USAID has declined to release information on how many previously funded organizations have refused to sign on to the new terms, opponents of the policy say this is its harshest implementation ever.

“This policy is massively expanded from anything we have seen in the past,” said Jonathan Rucks, director of advocacy for PAI.

PAI, an organization that works on advancing access to contraception, has been studying the effects of the Mexico City policy. Previous versions the policy applied only to family planning foreign aid, while the current policy applies to all global health funding: about $9 billion (U.S.) under what is now called Protecting Life in Global Health Assistance.

When the reinstatement of the Mexico City policy was announced, MSI estimated the loss in funding could lead to 1.6 million unintended pregnancies globally, 530,000 abortions (505,000 of them unsafe) and 5,265 maternal deaths each year between 2017 and 2020. At this point the organization is seeking other sources of funding, but it’s working with a great deal of insecurity.

“It means our programs are currently having to make really hard decisions on what services they can afford to maintain,” said Shaw.

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Proponents of the policy want to prevent U.S. tax dollars from funding abortion worldwide. Yet studies of past implementations of the policy show a correlation with an increase in abortion when the Mexico City policy has been in effect. For example, PAI reports that “the Planned Parenthood Association of Ghana saw 50 per cent more women come to their clinics for post-abortion care the year after the Gag Rule was reinstated by the (George W.) Bush administration.”

Dr. Hery Tiana Rabarizafay thinks this will be the case in Madagascar. Every day at her small clinic in Antananarivo, she helps women who are in danger after botched procedures from backstreet providers or from using traditional herbs or medication to try to end unwanted pregnancies. “They want to find a solution for their problems,” said Rabarizafay.

There are no reliable statistics on deaths due to unsafe abortions in Madagascar but recent data from the World Health Organization found there are about 25 million unsafe abortions a year worldwide and the WHO believes that 4.7 per cent to 13.2 per cent of all maternal deaths worldwide can be attributed to unsafe abortion.

The recent WHO report called for increased access to safe abortion and contraception, yet globally, reproductive health services are being hit on two levels by the U.S. government. Apart from the defunding of foreign NGOs through the Mexico City policy, a separate move has withdrawn funding from the United Nations Population Fund, which also provides family planning services globally.

Constant-Serge Bounda, the representative for the population fund in Madagascar, said this retraction of support is coming at a critical time. “With the cutting of this important U.S. funding the impact will be considerable, mainly for young girls,” said Bounda.

The U.S. agency said, however, that it will redirect the funds that are no longer going to organizations as a result of the conditions of Protecting Life in Global Health Assistance. “As the world’s largest bilateral donor to global health programs, the United States remains committed to helping women and their children thrive,” said an official from the U.S. development agency in an email.

In Madagascar, Population Services International (PSI) has confirmed that it will be taking over some of the programming previously provided by MSI.

However, critics say this reprogramming does not replace what is being lost. “During previous iterations of the policy — even as funding was reprogrammed — entire communities were cut out because there was no one else to fill the gap,” said Rucks. “This contributed to the resultant decrease in contraceptive access and increase in unintended pregnancies and unsafe abortions.”

In March, Ottawa announced $650 million from its foreign affairs budget to reproductive health programming, this was not new spending but rather a reallocation from other parts of the aid budget.

According to a report by Global Canada, an initiative to support Canadian global leadership, Canada’s current level of foreign aid as a share of national income is close to historically low levels. Robert Greenhill, executive chairman of that group, said the move to fund reproductive health is significant.

“If there was a silver bullet for development that would be it, and Canada has that right at a time when the Americans have gotten it deeply wrong.”

In March, following the reinstatement of the Mexico City policy, Canada also contributed $20 million specifically to organizations losing funding as a result of the policy, including Marie Stopes International.

According to information released under the Access to Information Act, at least four organizations have requested support from the Canadian government after losing funding as a result of the Mexico City Policy.

In Ampaho, Nirivelo worries about his community losing MSI’s services. He has seen the changes they have made in women’s lives in the village.

He has also seen the potential of contraception to empower the next generation of women. “It’s different now because they can continue their study, not get pregnant and stop there.”

Annie Burns-Pieper is a Gordon Sinclair Foundation Reporting Fellow.Twitter: @aburnspieper