Bacquerette woke up early. She made breakfast for her 2-year-old daughter, left the child with her neighbor and started the long walk to the village of Ambohitsara. Bacquerette wanted to make sure she was one of the first people in line for a one-day-only family planning clinic.
She walked almost two hours on footpaths that snake along the sandy bank of the Canal des Pangalanes in eastern Madagascar. And she managed to arrive at the event just after it started.
The 33-year-old single mother had come to get an IUD.
"Life is hard," Bacquerette says, explaining why she wants an IUD. "It's very hard to have very many children." Bacquerette, who like many people in this part of Madagascar goes by just one name, would like to have more children ... but not right now.
This clinic might be her last chance to get an IUD or any other long-lasting contraceptive for the foreseeable future, mainly because of the changing political landscape 9,000 miles away in Washington, D.C.
One of the first acts of the Trump administration in January was to reinstate an abortion-related litmus test for foreign aid known as the "Mexico City policy."
Under the policy, foreign aid groups are barred from getting U.S. funding if they perform or actively support abortion anywhere in the world.
The Trump administration broadened the policy to apply not just to grants for family planning but to billions of dollars in global health assistance given to groups that offer everything from malaria prevention to HIV treatment.
The newly expanded policy is being felt throughout the developing world.
In Madagascar the change is forcing dramatic cutbacks by the largest provider of long-term contraception in the country, the British nonprofit Marie Stopes International. Nearly half of Marie Stopes funding in Madagascar, millions of dollars a year, had been coming from USAID.
In Madagascar, Marie Stopes does not provide abortions because abortion is illegal in the country. But the parent organization in London refuses to renounce abortion as part of reproductive health services in some of its operations in other parts of the world.
The loss of USAID funding has forced Marie Stopes to shut down a voucher program in Madagascar that allowed low-income women to get contraceptives for free at private clinics. And by the end of the year, it's planning to wind down 21 of its 22 mobile contraception clinics, which were funded entirely by USAID.
By Jeep, Train And Hovercraft
As part of the group's services, local nurses travel to incredibly remote parts of Madagascar in four-wheel- drive Land Cruisers, trains, boats and even hovercraft to run family planning clinics.
There's a saying in Ambohitsara that a married woman should bear at least 7 children for her husband. Some do, but many women now want fewer kids. And at the start of the contraception clinic event, that's abundantly clear.
More than 100 women and girls are packed in to the sandy courtyard of the health clinic. They range in age from 14 to their early 40s.
One of the nurses from Marie Stopes, Olivia Haingoniaina, is holding up a blue plastic replica of a penis and demonstrating how to use a condom. The crowd erupts in laughter when she jokes about how a condom is much easier to take off than put on.
Haingoniaina and her fellow nurse, Valeria Zafisoa, explain various ways to prevent pregnancy, including the rhythm method.
They remind the crowd that birth control pills and condoms are available through clinics by the national health ministry. If the women want long term contraception primarily implants or IUDs, Marie Stopes is offering them at this clinic for free
All of this has been funded by grants from the U.S. Agency for International Development.
In one room of the clinic, Zafisoa screens the women. Then next door Haingoniaina inserts the implant or IUD.
A Chief On A Mission
Among the visitors to the contraception clinic that day is Nirivelo, a chief from an adjacent village. He wants to make sure several teenage girls from his village get contraceptive implants.
Nirivelo says in the past having a large family was viewed as a sign of wealth and prosperity here. And girls would often start having children in their mid-teens.
He says families are now having fewer children, which means fewer mouths to feed. He adds that it's also easier to work the rice fields if you don't have a kid hanging off each hip. And delaying pregnancy also makes it more likely that girls will finish high school.
Nirivelo says that recently one girl from his village, a student at the secondary school in Ambohitsara, got pregnant. And it's been a big problem. Her parents are upset. They want the father of her child to marry her. But the boy's parents can't afford to pay a dowry, he says. It's caused a little war in the village.
To make sure this kind of situation doesn't come up again, he's telling the other students to come to this contraception clinic. That attitude reflects Madagascar's goals for family planning. In 2015 the government set an ambitious goal of boosting its rate of contraception use from 30 percent to 50 percent.
But that soon may no longer be possible. Lalaina Razafinasoa, the country director of Marie Stopes Madagascar, says her group has already shut down some of its family planning work in the country and plans to stop the mobile contraception clinics in a matter of months unless they can find other source of revenue.
"It's really unbelievable to have to have this happen," she says.
Despite its reputation as an exotic Indian Ocean destination, Madagascar remains an incredibly poor country. More than 75 percent of the population lives in poverty.
Razafinasoa says the loss of U.S. funding means that hundreds of thousands of women in this country of 25 million people will lose access to contraception. And they will also lose the care that the group provides for women who defy the law and have illegal abortions. "We are providing post-abortion care," she says. "We are providing post-abortion family planning."
Razafinasoa pauses. She shakes her head as if she still can't really believe these cuts are happening.
"It will be a disaster," she says.
SCOTT SIMON, HOST:
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. Transcript provided by NPR, Copyright NPR.