KAUGAMA, Nigeria—Saki Samuno hissed at the darkening skies. The women around her wore the same irritated look as they pointed upwards, anticipating a torrential downpour.
After months without access to family planning services, 28-year-old Samuno trudged along the dirt paths leading to the only clinic for some 80 miles serving her rural village of Kaugama, a remote farming area in northeast Jigawa, Nigeria’s third most impoverished state.
The facility itself—a rundown, government-owned bungalow with sloping ceilings, wall cracks wide enough for fat lizards to slip through and no regular staff—did not discourage the women from their hours-long trek. The women sought the female medical workers in crisp white uniforms who came every few months, or longer, bearing medication and medical expertise.
The nurses, employed by the organization Marie Stopes Nigeria, provide free family planning counseling, pregnancy testing, contraceptives and, when necessary, post-abortion care to women in underserved and remote areas across the West African country. The organization, which often works with the Nigerian government, also advocates for more relaxed abortion laws in a country where the procedure is both criminalized and common (potentially as many as 2.7 million abortions are carried out annually in Nigeria, most of them unsafe, according to Johns Hopkins University research).
“We have been waiting for this,” said Samuno, a trader and mother of six children who was married at 14. She can barely afford to feed her children, Samuno says, and she doesn’t want to become pregnant again and give birth to a seventh child. Instead, she says: “I want to rest.”
For poor and rural Nigerian women like Samuno, struggling to support her family in a country with one of the world’s worst maternal mortality rates and highest fertility rates, the November U.S. presidential election—and the possible repeal of controversial Trump administration policies—could mean the difference between life and death. With abortion in the United States now central to this year’s political debate, access to sexual and reproductive care is also on the ballot, possibly affecting millions of women around the world. The United States is the world’s largest global health funder, and U.S. policies that place broad restrictions on billions of dollars of funding have the power to drastically limit access to life-saving services, from Nigeria to Nepal and beyond.
In January 2017, President Donald Trump reinstated the Mexico City Policy, also known as the global gag rule by critics and women’s rights advocates. The policy, first introduced by President Ronald Reagan and implemented by every Republican president since, cuts funding to global health providers receiving U.S. financial aid that “perform or actively promote abortion as a method of family planning,” according to USAID.
Later that year, Trump further expanded the 1984 policy, renaming it “Protecting Life in Global Health Assistance,” to include not only family planning and reproductive health providers, but also those working on issues related to global health security, HIV and AIDS, maternal and child health and infectious diseases.
Should Democratic presidential nominee Joe Biden win the November election, he could rescind the Mexico City Policy, just as both former Democratic presidents Bill Clinton and Barack Obama have done before him, which could increase access to health services and support for millions of women worldwide.
The financial shortfall created by the cut in U.S. funding means Marie Stopes Nigeria—which refused to sign the Mexico City Policy in order to continue pressing for safe abortion access and laws—has had to limit their family planning services, halt plans to expand, and stop partnerships with other organizations who signed up to the policy to receive U.S. aid, according to the organization.
As a woman, if you don’t have plenty of children, you don’t have a voice.”Blessing Agbo, Head nurse of Marie Stopes’ mobile nursing team
Since 2017, Marie Stopes Nigeria says at least two programs focused on training family planning service providers, much like the mobile nurses in Kaugama have been halted. The organization’s 23 remote outreach teams serve a population of more than 200 million. While Marie Stopes Nigeria trained 2,600 service providers and supported other key initiatives with $14 million in U.S. funding in the five years prior to Trump’s expansion of the Mexico City Policy, the organization says it has only been able to train 1,010 additional providers since then. Marie Stopes Nigeria, says they have also been blocked from receiving hundreds of millions of dollars in funding that could have helped expand its walk-in and mobile support services across the West African country.
The Mexico City Policy has “massively shrunk the work that can be done,” says Effiom Effiom,Marie Stopes Nigeria’s country director. Many women opt for abortion because they do not know about family planning, he says, and so cutting off funding providing those services in a bid to halt abortion is unfair. “The whole concept of family planning is an emergency business, it’s a necessity,” he said by phone.
Trump’s April 2017 defunding of the United Nations Population Fund (UNFPA) has also led to immense funding shortages in the country. In 2016, the year prior to the funding cut, UNFPA contributed around $18.5 million in reproductive healthcare funding to support family planning, maternal health and HIV assistance across Nigeria. The next year, that number dropped to roughly $10 million.
For many Nigerian women, particularly those in remote parts of the country, the difficulties imposed by U.S. foreign policy on the search for contraception and family planning services are compounded by the local conservative and religious resistance to contraception and abortion, and now, the crippling COVID-19 health crisis that has further limited access to sexual and reproductive health care globally.
Samuno often has to wait for months to get contraceptive and family planning counseling, and, like the other women who gathered on floor mats inside the Marie Stopes clinic, can neither afford the $3 contraceptive cost in hospitals some 80 or so miles away in Dutse, the capital of Jigawa state, nor can they easily travel the distance without the permission from their husbands. Most of the Nigerian women who come to Marie Stopes have specific requests: birth control pills and injectable contraceptives (some that prevent pregnancy for months and others, like a small plastic rod injected into the arm that dispenses the hormone progestin which halts production of a monthly egg], for years). Some women who see the nurses need critical care after having sought out dangerous unregulated abortions, desperate to end pregnancies in a country where abortions are illegal, except in cases when a woman might die without one.
Social stigma around contraceptives and abortion remains high
The vast majority of Nigerian women do not use contraceptives, particularly in low-literacy rural areas where misinformation spreads rampantly by word of mouth, some of it stating without medical basis that contraceptives cause infertility. In the country’s conservative north where Sharia law, or Islamic law, is practiced, religious and traditional norms do not encourage child spacing, meaning many women who lack decision-making power in their families abstain or are barred from using contraceptives.
In Jigawa, the average fertility rate was 8.5 live births per woman in 2016, according to Nigeria’s National Bureau of Statistics—one of the highest rates in Nigeria and far surpassing the global average of around 2.5 live births per woman, according to the United Nations.
Women like Samuno are outliers in their communities: Her husband is friends with the village head, who works closely with Marie Stopes’ health workers and allows Samuno to hike to the clinic for birth control. Maternal mortality rates are higher in northeast Nigeria where the ongoing war with the extremist Boko Haram has led to decimated health infrastructure.
Nigerian government efforts to expand family planning services and awareness have seen some impact. The number of Nigerian women using modern contraceptive methods rose from 6 percent in 1990 to 18 percent in 2018, according to a 2018 health survey conducted by the Nigerian government. But Nigeria also has one of the most restrictive abortion laws in the world, although post-abortion care is not illegal, which allows Marie Stopes to treat women who have undergone unsafe abortions.
Social stigma attached to abortion is high across the country, particularly in the Muslim-majority north, also home to Nigeria’s poorest households. In May 2019, Nigerian police, raided a Marie Stopes clinic in Lagos, the country’s economic capital on the southernmost coast, harassing staff and confiscating confidential client information, with one officer allegedly claiming that birth control was abortion.
“People see giving birth as their strength here,” says Blessing Agbo, the head nurse of the mobile nursing team, as she paused briefly to call in another patient for a contraceptive implant. “As a woman, if you don’t have plenty of children, you don’t have a voice.”
Despite the stigma, research in Nigeria points to rising abortion rates. In cases of unintended pregnancies, women often opt for roadside doctors, some of whom use wildly unsafe methods such as drinking dissolved eyeliner.
The pandemic puts a new strain on health facilities
Meanwhile, COVID-19 has made the situation even more dire. A months-long national lockdown in Nigeria meant a doubling of calls to health facilities requesting family planning services as well as gender-based violence treatment and post-abortion care, according to Marie Stopes and Ipas, another reproductive health organization in Nigeria.
Jigawa State saw some of the highest numbers of sexual abuse cases reported in recent months, according to Lucky Palmer, country director for Ipas, which advocates for increased global access to safe abortions and educates women on sexual and reproductive health in Nigeria. Ipas has also spoken out against the terms of the Mexico City Policy.
With global COVID-19 shutdowns limiting medicine supplies, women who cannot access free care are now paying much more to get the care they need—or going without it, risking potentially deadly results.
Samuno says the countrywide lockdown meant husbands in Kaugama, who would normally go off to work in the more prosperous southern Nigeria, were stuck at home. It also meant more unintended pregnancies, according to local women, a situation the women at the Marie Stopes clinic say they are determined to avoid. Habiba, a 30-year-old woman who has given birth to 10 babies, six of whom have survived, says she’s particularly at risk for unplanned pregnancies because she doesn’t leave the house to trade or farm like other women. “I’m a housewife and this is important for me because I want to rest before I can think of giving birth again,” she said, minutes after a nurse implanted a plastic birth control insert into her arm.
The white-clad nurses said they were also the first health workers to relay the danger of COVID-19, on the same day that they arrived at the government-owned bungalow in Kaugama. They stressed the importance of hand washing, sanitization, and social distancing before turning their attention to family planning.
Minutes before noon, just as the rain started to trickle from the sky, Samuno got her turn to select what contraceptive method she wanted. She chose a plastic rod to be inserted in her arm. It would help her prevent pregnancy for up to five years.
The women who left before their turns, fearful of the torrential rains, would have to wait for the next time the nurses showed up. It could be three months, or it could be 10.
Those who stayed behind, sitting on the mats waiting beside Samuno—teen girls and middle-aged women alike, with babies strapped to their backs under long flowing hijabs of green, red, and black—would likely be the butt of gossip, or worse, if neighbors found out about their trip to see the nurses. But Samuno shrugged, dauntless. She’s done getting pregnant.
“Shikena,” Samuno said, in the local Hausa language. Finished.