A blue, burgundy and white patterned wrapper hides the swell of Joanna Banda’s belly. Eight months pregnant, she has had just three of the five antenatal appointments she should have had. She is unlikely to attend her final three either, as she still has to save 3,000 kwacha (£1.28) for a bicycle to take her six miles on rutted dirt tracks to the nearest health centre when she goes into labour.
Joanna Banda, left, who is eight months pregnant, with Jennifer Matangadzira, a health worker, in Kafulatira. Photograph: Amos Gumulira/The Guardian
In remote villages in Malawi, pregnant women such as 22-year-old Banda, who has one child after losing her first soon after giving birth, are struggling to get the medical care they need.
In January, US aid cuts abruptly ended a rural healthcare outreach programme that was starting to reduce the number of local women dying in childbirth.
Momentum Tikweze Umoyo, a five-year $28m (£20m) programme aimed at cutting maternal and infant mortality rates in five of Malawi’s 28 districts, was meant to last until 2027.
It is just one of the many casualties of Donald Trump’s decision to suspend foreign aid just hours after taking office in January, risking the lives of some of the world’s poorest, most vulnerable people. In July, Congress approved $9bn in cuts to aid and public broadcasting. Last month, the US president said he would be cancelling $4.9bn in aid already approved by Congress.
Kafulatira, where Banda lives, is a village of scattered mud huts with almost 1,000 people in Salima district, east of the capital, Lilongwe. There is no piped water or electricity, and a bridge across the steep-banked river that divides it from the nearest health centre was washed away last December.
Kafulatira was once regularly visited by a mobile clinic, but villagers now have to walk 11 miles to the nearest health centre. Photograph: Amos Gumulira/The Guardian
A mobile clinic used to visit the community every month or so, providing a private space for women to get screening for cervical and other cancers, HIV tests and treatment, and vaccinations for children. It also provided antenatal checkups and family-planning services, including contraception.
“The outreach clinics were helping a lot, because we could access services right here in the village,” Mulirani Gerard says through a translator. “Since last year, we had been waiting for the team to come, so we were just wondering what had happened.” No one told villagers why their healthcare had been cut.
Gerard says she has not been too badly affected, as she has a contraceptive implant that lasts for three years, but that others were not so lucky. “It’s a challenge, because this has led to unintended pregnancies,” the 25-year-old says, pointing to her friend Banda, as they sit in the shade with other mothers as children play around them.
Jennifer Matangadzira, left, and Flora Kamowa, a health coordinator, visit a pregnant woman in Kafulatira. Photograph: Amos Gumulira/The Guardian
Juliette Kannda, a 31-year-old mother of three, had been receiving bi-monthly contraceptive injections. Now, she says, she is saving up 10,000 kwacha for the 25-mile round trip to another health centre. “I am looking forward to getting the [contraceptive] implant, considering the distances I travel to access services,” she says.
Malawi is one of the world’s poorest countries. In 2024, the landlocked southern African country had an income of just $508 per person, according to the World Bank. It is incredibly vulnerable to the climate crisis: 80% of the population work in agriculture and it has been battered by repeated cyclones and droughts in recent years. The country, of about 22 million people, is also highly dependent on aid.
Aid from the US, both grants and low-interest loans, amounted to 2% of the country’s GDP in 2024, according to the International Monetary Fund. That compares with an average of 0.5% across sub-Saharan Africa.
In 2023, the US accounted for a quarter of all aid sent to Malawi, according to the International Food Policy Research Institute (IFPRI). The year before that, the Center for Global Development found that US health spending was more than double that of the Malawian government.
Pregnant women are often having antenatal appointments late or not at all, according to staff at the Makioni health centre. Photograph: Amos Gumulira/The Guardian
Malawi’s economy was already in a parlous state before the US aid cuts. For the past three years, inflation has been above 20%, the economy has grown more slowly than the population, and a scarcity of foreign exchange has led to shortages of fuel, fertiliser and medicine. An IFPRI study in April estimated that US aid will fall 59% this year, cutting 1% off Malawi’s GDP.
The government had little means to make up the shortfall. Malawi’s fiscal deficit (the gap between government expenditure and revenue) was 10.1% in the year to 31 March. In any case, its attempts to win back voters with election-year spending failed, with Lazarus Chakwera losing to Peter Mutharika in elections on September 16.
Funding healthcare in Malawi “is indeed the duty of the government, but … the government doesn’t have the resources,” says Hester Nyasulu, Malawi director for Amref Health Africa, a Kenyan organisation that was one of seven backing the Momentum Tikweze Umoyo project.
The funding cuts should have been a “transitional process”, he says, adding: “We were starting to reap the benefits of the investment … The termination of the USAID [funds] … will definitely lead to more deaths of pregnant and lactating women and also newborns.”
Between January 2022 and December 2024, maternal mortality rates in clinics and hospitals had fallen in three of the five districts covered by the project, according to data provided by Nyasulu. More children were vaccinated, treated for malaria and had their nutrition monitored, and more women received family planning services and first-trimester antenatal care, while teenage pregnancies fell.
skip past newsletter promotion
Sign up to Global Dispatch
Get a different world view with a roundup of the best news, features and pictures, curated by our global development team
Privacy Notice: Newsletters may contain information about charities, online ads, and content funded by outside parties. If you do not have an account, we will create a guest account for you on theguardian.com to send you this newsletter. You can complete full registration at any time. For more information about how we use your data see our Privacy Policy. We use Google reCaptcha to protect our website and the Google Privacy Policy and Terms of Service apply.
after newsletter promotion
A mural at Makioni health centre, which used to benefit from US aid funds. Photograph: Amos Gumulira/The Guardian
In Salima district, outreach clinics were held at 87 sites surrounding seven health centres, reaching between three and 10 communities every weekday. The vehicles and staff were provided by the health ministry, with fuel and staff lunches paid for by USAID.
At the health centre in Makioni, a small market town about 34 miles from the district capital, breastfeeding guides painted on the wall were branded: “USAID: from the American people”.
Yohane Billiat (right) and Samuel Chawaka, who work at the Makioni centre, say the level of service at health facilities is poor. Photograph: Amos Gumulira/The Guardian
Staff there lament how pregnant women are having antenatal appointments later or not at all and the drop in screenings for cervical cancer. Two women aged 18 and 20 survived unsafe abortions, which they had undergone because they lived 17 miles from the clinic, staff say.
“It’s increased the workload in the [health] facilities, hence the poor quality of services being provided,” says Yohane Billiat, district family-planning coordinator.
Samuel Chawaka, the Makioni health centre manager, says: “We are failing to give them services in their place.”
A US state department spokesperson said: “The US government supports life-saving assistance in Malawi, including approximately $160m to support efforts to address HIV, TB, malaria and other critical health risks.
“America continues to be the most generous nation in the world. It is imperative to remember that the American taxpayer was never meant to bear the full burden of taking care of every person on Earth – whether that be with food, medicine or otherwise.”
However, even in Malawi’s cities the quality of healthcare is falling. In Lilongwe, the US previously funded the training of health workers to find and manage cases of tuberculosis (TB). There has subsequently been a fall in the number of cases detected and referred for treatment, says Thoms Chigeda, the district TB coordinator.
“If people are not being diagnosed early enough, it will be difficult for them to get cured,” he says, “and drug-resistant TB can also flourish. We had made some strides in the TB fight in the district, but because of this I think we might be losing the battle.”
Before the US aid cuts, 11,000 babies were immunised every month, says Maclean Nkhoma, the city’s immunisation coordinator. Now it is less than 9,000, and the infant immunisation rate has fallen from 98% to 85%, he says.
“They [the US] have been supporting us; they have to continue. Because otherwise whatever happens in Malawi or in Africa, like outbreaks, will also affect them,” Nkhoma says. “If Africa is protected, that means the whole world is protected.”
