During a period of unusually heavy rain in Chad last year in the late summer and early fall, parts of the country were inundated with flooding so bad that houses began to collapse. Yewande Odia heads the United Nations Population Fund (UNFPA) office in Chad, which is responsible for reproductive and maternal health. She recalls being told of a pregnant woman who ran out of her flooded house and soon thereafter went into labor.
"Babies don't tell you what time they're coming," says Odia. "And she's stuck in horrible, dirty, stinky sewage water and she's giving birth."
She fled her home and managed to get herself to a higher, drier location where one of the 300 midwives that Odia's office employs had set up a tent. The midwife had something called a "reproductive health kit." It's filled with drugs and equipment that Odia says "allows us in the middle of nowhere to give safe, clean, sanitary delivery services."
The result was that this woman — who moments earlier was at risk of potentially life-threatening complications had she delivered in an unclean setting — was able to give birth safely.
"This is critical life saving work that [the midwives] do," says Odia.
That work, funded in part by the U.S. Agency for International Development, is now under threat as one of thousands of programs that the U.S. State Department has said it is canceling. The challenge facing countries like Chad that are affected by the USAID cutbacks is figuring out whether they can continue some of this lifesaving work.
Midwives mean more women and babies survive
Thousands of women die during childbirth each year in Chad. The World Health Organization and United Nations say the country has the second highest maternal mortality rate in the world. That's due in large part to Chad's fragile health system and is compounded by the many Chadian women who don't have access to a safe and sterile place to deliver. On top of that, the country is now home to hundreds of thousands of refugees, most of whom are women and children, who have fled the violence in neighboring Sudan.
The midwives play a vital role in getting pregnant women to a health center or mobile clinic. "When they give birth at home," says midwife Ernestine Nedjoumbaye, "there are more risks of infections and bleeding out, and more women die in childbirth." But in a sanitary setting, the mothers and their babies usually survive.
Last year, Odia says U.S. funds provided prenatal care to 100,000 pregnant women in Chad and safe deliveries to 26,000.
Now, Secretary of State Marco Rubio has announced the official cancellation of 5,200 USAID contracts worldwide, amounting to 83% of the agency's programs. That includes the program that Odia was relying on to pay about half of her midwives.
"Losing the U.S. funding is huge," she says. "The lack of midwives to support these women, to support these children means that women will die in childbirth. That's the immediate impact."
Odia says she is actively looking for alternative sources of funding to manage the shortfall. But she expects she'll have to make some tough choices soon. Money to pay the midwives' salaries runs out at the end of March.
"We will have to prioritize," Odia says. "Some things will have to go and some things we'll have to do less of."
A crisis as big as a continent
The midwife program in Chad is just one of hundreds of programs across Africa that have been impacted by the deep and unprecedented cuts in U.S. foreign assistance. There are HIV treatment programs that have shuttered, tuberculosis screenings that have stopped and food assistance for malnourished children that has been discontinued
Before Trump began his second term, programs based in sub-Saharan Africa had been receiving more than a quarter of the U.S. foreign assistance budget, amounting to some $5.7 billion in 2024 for health programs in particular.
Last week, in Kigali, Rwanda, at the Africa Health Agenda International Conference, this new reality of a world with only a trickle of U.S. assistance was a pressing topic of discussion.
"The overriding message is that we must never waste a crisis," says Dr. Githinji Gitahi who runs Amref Health Africa, a continent-wide African NGO and the organizer of the conference.
Gitahi says Africans have been talking about the need for self-reliance for years, but now there's a sense of urgency to achieve it — and to rethink the way money is spent on health systems. "This is not to take away from the lives saved by USAID," he says. But historically, a lot of foreign aid spent on global health (from both governmental and philanthropic sources) has targeted specific diseases such as malaria, polio, tuberculosis and HIV. Gitahi argues that previous funding hasn't considered taking care of multiple diseases at once nor the full sweep of health problems in a particular place.
He says now is the time to prioritize prevention and investment into primary health care and public health more broadly. There have already been workshops in Kenya, Uganda and Zambia to talk about such a shift, says Gitahi. At these meetings, government officials are discussing how to handle the funding gaps by altering projects or jettisoning them altogether. Some of this effort was already underway, Gitahi says, because a fundamental change to USAID has been anticipated for some time.
"So it is catastrophic, unprecedented but not unexpected," explains Gitahi. "If there was actually a plan for transition, then we would not say it's a bad thing. What is a bad thing is actually the sudden, unplanned nature."
This is what's left so many governments and health care providers in Africa and elsewhere scrambling. Some have called the evisceration of USAID a wakeup call.
Dr. Jean Kaseya, director general of Africa CDC, agrees with Gitahi on the importance of seizing this moment.
"You have to find a way to survive," he says. "Yes, we are suffering, but it's also an opportunity for us to rethink how African countries must take the lead and the ownership of their health program."
To do that, Kaseya says these nations will need to find a way to contribute more of their own funds to support the programs and personnel that have, until recently, relied primarily on external funding.
For instance, Nigeria has already committed an additional $200 million to its health budget.
"This is the kind of movement we want to see in Africa," he says. "We don't say we are covering the gap, but we are mitigating the impact of the cut."
For Ernestine Nedjoumbaye in Chad, the funding cuts come at a time when she and her fellow midwives still need help with the basics: birthing beds, medicines, clothing — all while she and the others aren't sure if they'll have a job in a couple weeks. Nedjoumbaye says they're left with one overriding emotion.
"We're worried."
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