UNFPA and the human fallout of US aid cuts: A $335 million gap

  Sitting on a bench at a reproductive health clinic in one of the poorest parts of Madagascar’s capital city of Antananarivo were two nervous, pregnant 16-year-old girls. No longer in school, unsure how their lives were about to unfold, and preparing for the toll childbirth would have on their small bodies — thrust into premature adulthood when they’re still just kids. They each walked about 40 minutes to the clinic — it’s the only free, one-of-its-kind clinic within a three-mile radius. They couldn't afford to pay for services at a clinic closer to their homes. For Finoana, who is six months pregnant, she’s in many ways alone on this journey. The father is a married man who denies that the child is his. Tina, who is eight months pregnant, moved in with her 22-year-old boyfriend, who sells food for a living. The 24-7 clinic provides people in the surrounding communities with free contraceptives, childbirth delivery, inpatient overnight stays, prenatal and postnatal care, vaccines, and post-abortion care. The patients are mostly females between 13 to 40 years old. The health workers are also trained to care for suvivors of abuse, such as rape. The clinic doesn’t perform abortions, but it receives about eight to 10 patients with complications from unsafe abortions per month. While abortions are illegal in Madagascar, they still happen in unsafe ways in the communities, without the guidance of health care professionals. The clinic’s services work to avert this — educating people on contraceptives — but also saving the lives of those who perform abortions on their own. This clinic is part of a global network of programs and health facilities that the United Nations Population Fund, or UNFPA, supports — working to reach some of the people living in the lowest-resource settings with reproductive care. This includes clinics similar to this one, but also services for displaced populations, including tents that serve as safe spaces for those who are escaping the sexual violence of war, efforts to rally communities against female genital mutilation, among other programs. But the U.S. foreign aid funding cuts are compromising the ability of this U.N. agency to do this work around the globe. The U.S. government terminated 44 of its grants to UNFPA, totaling $335 million. And the future could be even more bleak. Trump’s budget request for fiscal year 2026 eliminates family planning funding entirely, saying these programs do “not make Americans safer.” The White House is also asking the U.S. Congress to claw back funds previously approved by Congress for fiscal years 2024 and 2025. This includes eliminating funding for UNFPA. “This devastating decision will force thousands of health clinics to close. Women in crisis zones will be forced to give birth without medicines, midwives or equipment, putting their lives and their babies’ lives in jeopardy,” the organization wrote after the initial onslaught of cuts in February. “Rape survivors will be denied counselling and medical care. Midwives delivering babies in the world’s worst humanitarian crises will lose their ability to function. Shipments of life-saving medical supplies to refugee camps will be disrupted.” Abrupt cuts In 2024, the U.S. provided $255.9 million in co-financing and $30.5 million in core funding, making up over 17% of UNFPA’s overall budget — and around 42% of UNFPA’s entire humanitarian budget. As such, the U.S. cuts to UNFPA have largely hit humanitarian and lifesaving programs. This includes programs in Afghanistan, Bangladesh, Cameroon, Central African Republic, Chad, Colombia, Democratic Republic of the Congo, Dominican Republic, Ecuador, Egypt, Ethiopia, Iraq, Mali, Pakistan, Palestine, Yemen, Somalia, South Sudan, Sudan, Ukraine, and Venezuela. There were also grants terminated where the agency was responding to regional crises in Syria, Latin America, the Pacific, and to support refugees from Ukraine across Europe. Terminated grants also previously supported global humanitarian response coordination in areas such as supplies, data, and human rights, as well as a joint programme with the United Nations Development Programme in Georgia, among others. In recent months, the cutting of U.S. foreign aid programs, more broadly, has been chaotic. The Trump administration has terminated programs and then reinstated them — which left organizations unclear on the ultimate fate of which of their programs had survived. For UNFPA, humanitarian programs that were cut and then reinstated included a $2.5 million grant in Haiti, $900,000 in Madagascar, $2.5 million in Nigeria, and $11 million in Sudan. And development programs that were cut and then reinstated included $247,500 for Papua New Guinea and a $1.2 million grant for Jordan — but they’ve still not received money in their accounts for this award. UNFPA said the U.S.’ decision to deny future funding to it is based on a triggering of the Kemp-Kasten amendment, first enacted in 1985, which says funding can’t go to organizations or programs that support “coercive abortion or involuntary sterilization.” “This decision is based on unfounded claims about UNFPA’s work in China that have long been disproved — including by the US Government itself,” wrote the organization in May. U.S. Republicans have argued that by having programming in China, UNFPA has supported the strict, coercive population control policies in the country, but the U.S. government has already investigated this and found no evidence that UNFPA is in violation of the Kemp-Kasten amendment. For this particular U.N. agency, U.S. funding is like a game of pingpong — every Republican president since Ronald Reagan has stopped funding to the agency, while Democratic presidents have restored it. But this time was different. Since January, awards have been turned off and on several times, ultimately landing with most awards being terminated without warning, and stop work orders issued. In previous situations, under previous Republican administrations, awards were allowed to finish, and the organization was granted a grace period to mitigate against avoidable harms to those it serves. ‘If it’s not free, they will not come’ Misa is a midwife at the clinic in Antananarivo where the teenagers Finoana and Tina have received prenatal care. When she was growing up, Misa wanted to be a teacher. But her father, who was a doctor, steered her towards medicine. During her medical internship, when she held the first baby she helped deliver, she knew it was the right choice. To be the first person in the world to touch a new human is such a gift, she said. And now she gets to do a little bit of both. Teaching adolescents about contraceptives is a critical part of her role — and helps prevent them from coming to her clinic in the middle of the night after a botched abortion. If these teenagers don’t learn about reproductive health at her clinic, there’s a good chance they won’t learn about it elsewhere. Her clinic has seen a great increase in the regular use of people using free family planning services. Misa asked to go by a pseudonym because providing post-abortion care has caused her tensions with the government. They’ve misinterpreted this as her clinic providing the actual abortions illegally. But she said, despite the problems it’s caused her, she can’t stop. She won’t turn someone away when she’s bleeding out or who has a fever spiking because of infection. Most of 16-year-old Tina’s friends have already given birth — all unwanted pregnancies. She didn’t know about contraceptives when she became pregnant, but she learned about them at the clinic, and said she will use them after her baby is born. She’d like to return to school someday to ultimately become a teacher, but she’s not sure she’ll have the resources. Each day, Misa’s small clinic delivers about five babies and juggles more than 100 patients. The three midwives rotate 24-hour shifts, and there are also two doctors and five interns. UNFPA provides this clinic with free contraceptives and medicines for services such as childbirth. Given that the small clinic was serving such a large community, UNFPA helped rehabilitate the clinic and expand it — also buying beds and mattresses so patients can stay overnight. Misa and her colleagues were trained by UNFPA on the use of long-acting, injectable contraceptives and the management of hemorrhages during childbirth. For Misa, providing free reproductive health services to this community is critical. “If it’s not free, they will not come. There will be a big increase in childbirths here,” she said. “There will be a big increase of abortions, mothers’ deaths, and teenage pregnancies.” The U.S. funding cuts aren't expected to impact this particular clinic right now — it receives funding from another donor. But it’s an example of the type of work UNFPA does globally, and in many cases, now can’t continue. And there are concerns that the availability of health commodities could decrease in the long run due to the U.S. cuts, so that health centers like this might not be able to serve the same number of people. And reproductive services, more broadly, will be hard hit in Madagascar. According to MSI Reproductive Choices, the country is grappling with $6 million in U.S. cuts that were previously funneled toward family planning and reproductive health: $4 million from the U.S. Agency for International Development and $2 million for UNFPA. MSI also estimated that nearly half a million people won't be reached with sexual and reproductive health care, 1 million sexual partners won’t have protection over the course of a year, and nearly half a million unintended pregnancies won’t be prevented. Nearly 150,000 unsafe abortions won’t be averted, and 1,300 lives won’t be saved. An estimated $31.1 million in direct health care costs that could have been prevented will be lost. A UNFPA spokesperson also said the cuts will halt gender-based violence prevention and response services for a quarter of a million people across Madagascar, including for people living with disabilities.