海角大神

As the U.S. presidential election approaches, Lalaina Razafinirinasoa cannot shake a frightening thought. If Donald Trump wins, he will likely impose policies that could lead to the deaths of women she knows.聽

After all, it has happened before.

One of Mr. Trump鈥檚 first acts when he became president in 2017 was to sign an executive order cutting off all American health aid to organizations that 鈥減erform [or] actively promote abortion.鈥�

The ban was not intended to stop U.S. money from being used on abortions; that has been forbidden for 50 years. Rather, it was meant to keep American aid dollars out of the hands of pro-abortion-rights groups more generally. That鈥檚 whether they planned to use the money to fund birth control, give HIV tests, or treat malaria 鈥� a vastly expanded version of a policy enacted by every Republican administration since Ronald Reagan.

Ms. Razafinirinasoa runs the Madagascar branch of MSI Reproductive Choices (formerly Marie Stopes International), a family planning charity that chose to give up $30 million a year in U.S. funding rather than accept the new conditions.

That forced Ms. Razafinirinasoa鈥檚 team to cut outreach programs that brought birth control to the island鈥檚 poorest and most remote corners, a decision that still haunts her.

鈥淲e鈥檒l never know exactly how many women we lost,鈥� Ms. Razafinirinasoa says. Globally, one peer-reviewed study estimated the U.S. policy led to the deaths of more than 10,000 women and nearly 100,000 children, primarily as a result of decreases in the quality of their medical care.

So now, as Ms. Razafinirinasoa and other global family planning advocates watch the election approach from thousands of miles away, it feels close and urgent.

鈥淲e are trying not to panic, because what can we do?鈥� says Jedidah Maina, the executive director of the Trust for Indigenous Culture and Health, a Kenyan health nonprofit. 鈥淚t could change our lives, but we don鈥檛 even have a vote.鈥�

The luxury of choice

When Ms. Razafinirinasoa became the director of Marie Stopes Madagascar in 2015, she often found herself brushing up against the lives she could have lived.

Visiting remote, rural villages like the ones where her parents grew up, she met pregnant 11-year-olds and hungry women struggling to feed a half-dozen emaciated children, all of them far too small for their age. 鈥淚鈥檓 just tired of giving birth,鈥� she remembers one mother of seven quietly confessing.

Ms. Razafinirinasoa knew that only a razor-thin line separated her life from theirs. In Madagascar, whose international image is of white sand beaches and wide-eyed lemurs, the average woman is a mother of five, and a third of girls give birth before the age of 19. Nearly half the population is chronically hungry.

鈥淣ot many people have the luck I did,鈥� she says. Her parents moved to a city and sent her to school. But another fundamental part of that 鈥渓uck鈥� was also that she got to decide if and when she had children. Everyone 鈥渟hould at least be able to make their own choice on their reproductive life,鈥� she says.

The World Health Organization agrees. When women control their fertility, it concludes, they are healthier, more educated, and more economically independent. And so are their children.

Over the past four decades, the number of women worldwide using modern contraceptives has doubled. In many places, American aid has played a major role in this story. But the help comes with strings attached.

Since the 1980s, American funding for family planning has been deeply politicized. Each time a Republican becomes president, they instate the Mexico City Policy, an executive order barring American funding for foreign organizations that do abortion-related work. Each time a Democrat takes office, they repeal it.

Historically, the Mexico City Policy, which critics call the 鈥済ag rule,鈥� applied only to funding earmarked for family planning. But in 2017, Mr. Trump announced he was expanding it to all American global health aid, then around $9 billion annually.

Suddenly, recipients had to choose between providing legal abortions and getting funding for things like malaria tests, HIV medications, and child nutrition. 鈥淲hen we design programs鈥� for these services, 鈥渨e don鈥檛 intend to fund the abortion industry,鈥� explained the White House in a statement to The Washington Post at the time.

Meanwhile, in countries like Madagascar, where abortions are not allowed even when they are needed to save the mother鈥檚 life, groups still lost funding if their parent organization supported or provided them elsewhere.

鈥淚 don鈥檛 know that people are always aware that this policy has enormous impact even where abortion is highly restricted,鈥� says Sara Casey, an assistant professor of population and family health at Columbia University.

Counterintuitive consequences

At the end of Mr. Trump鈥檚 presidency, Dr. Casey led a study of the policy鈥檚 impact in Kenya, Madagascar, and Nepal. In all three countries, her research concluded that the policy made it harder for women and girls to access family planning. Organizations receiving American funding also often aggressively self-policed, overapplying the policy out of worry that they might accidentally overstep an unseen line.

In Madagascar, the researchers found the policy鈥檚 effects were especially far-reaching, in part because the United States provided nearly 90% of all family planning aid. That meant that when MSI Reproductive Choices and other organizations cut their programs, many women lost their only access to free birth control.

One woman described scrambling to find ways to pay $0.65 for an injectable contraceptive at a private pharmacy, until one day she couldn鈥檛 anymore. 鈥淎nd now I鈥檓 pregnant when I didn鈥檛 want to be,鈥� she said.

Globally, experts estimate that despite the policy鈥檚 purported aims, it actually increased the number of abortions being performed in many countries. A study published in the journal Lancet estimated that abortions increased by 40% during the Trump and Bush administrations in counties that relied heavily on U.S. family planning aid, including Madagascar. Although the study did not analyze the causes of this increase, the authors posited it could be because the policy restricts access to contraceptives, leading to more unwanted pregnancies.

Ms. Razafinirinasoa says the effects of those years still reverberate. Though Marie Stopes Madagascar eventually made up some of its lost funding, the scope of its work remains narrower than in 2016. Another Trump administration would likely mean more cuts, with a possible further extension of the Mexico City Policy to include emergency humanitarian aid.

Ms. Razafinirinasoa knows who would suffer most from those policies. 鈥淭his is about equity,鈥� she says. When aid goes away, 鈥淭he poorest people are always the first ones who will die.鈥�