EPWORTH, Zimbabwe (AP) -- Carrying her infant daughter, 19-year-old Sithulisiwe Moyo waited two hours to get birth-control pills from a tent pitched in a poor settlement on the outskirts of Zimbabwe's capital, Harare.
The outreach clinic in Epworth provides Moyo with her best shot at achieving her dream of returning to school. "I am too young to be a baby-making machine," she said. "At least this clinic helps me avoid another pregnancy."
But the free service funded by the U.S. government, the world's largest health donor, might soon be unavailable.
As he did in his first term, U.S President-elect Donald Trump is likely in January to invoke the so-called global gag rule, a policy that bars U.S. foreign aid from being used to perform abortions or provide abortion information. The policy cuts off American government funding for services that women around the world rely on to avoid pregnancy or to space out their children, as well as for heath care unrelated to abortion.
Four decades of on-again, off-again restrictions
The gag rule has a 40-year history of being applied by Republican presidents and rescinded by Democratic presidents. Every GOP president since the mid-1980s has invoked the rule, which is known as the Mexico City Policy for the city where it was first announced.
As one of his first acts as president in 2017, Trump expanded the rule to the extent that foreign NGOs were cut off from about $600 million in U.S. family planning funds and more than $11 billion in U.S. global health aid between 2017 and 2018 alone, according to the U.S. Government Accountability Office, the investigative arm of Congress.
The money -- much of it intended for Africa -- covered efforts such as preventing malaria and tuberculosis, providing water and sanitation, and distributing health information and contraception, which might also have repercussions for HIV prevention.
Women's health advocates are "uneasy" following Trump's victory, said Pester Siraha, director of Population Services Zimbabwe, an affiliate of MSI Reproductive Choices, an NGO that supports abortion rights in 36 countries.
The policy stipulates that foreign NGOs that receive U.S government funding must agree to stop abortion-related activities, including discussing it as a family planning option -- even when they are using non-U.S. government funds for such activities. During Trump's first term, MSI did not agree to those conditions, effectively making it ineligible for U.S government funding.
Siraha said that a blueprint offered to Trump by the conservative-leaning Heritage Foundation in its plan known as Project 2025 indicates that the new administration could enact "a more comprehensive global gag rule."
Even NGOs in countries that outlaw abortion, such as Zimbabwe, are affected. Population Services Zimbabwe, for instance, closed its outreach clinics during Trump's first term after losing funding due to its association with MSI Reproductive Choices. Such outreach clinics are often the only health care option for rural people with limited access to hospitals due to poverty or distance.
"It leaves women with no place to turn for help, even for information," said Whitney Chinogwenya, global marketing manager at MSI Reproductive Choices.
Some NGOs in other African countries such as Uganda, Ghana, Ethiopia, Kenya and South Africa rolled back services, including clinics, contraception, training and support for government and community health workers, as well as programs for young people, sex workers and LGBTIQ+ communities.
Other services shut down entirely. The risk of unplanned pregnancies, unsafe abortions and related deaths increased in many of the affected countries, according to the U.S.-based Guttmacher Institute, which supports abortion rights.
Chinogwenya, the MSI Reproductive Choices marketing manager, said her organization's donor income dropped by $120 million during Trump's first term. The money would have provided 8 million women globally with family planning help, preventing 6 million unintended pregnancies, 1.8 million unsafe abortions and 20,000 pregnancy-related deaths, she said.
The gag-rule policy "leads to more unintended, unwanted, unsupportable pregnancies and therefore an increase in abortion," said Catriona Macleod, a professor of psychology at South Africa's Rhodes University.
"This legislation does not protect life ... it's been called America's deadly export," said Macleod, who heads the university's studies in sexuality and reproduction.
Trump's transition team did not respond to a request for comment from The Associated Press.
Damage isn't always easy to repair
President Joe Biden rescinded the gag-rule policy in 2021, resulting in Population Services Zimbabwe receiving $9 million, about 50% of its donor funding, from USAID in 2023. "But we haven't regained all the loss we suffered," said Siraha, the organization's director.
"You need a minimum of five years to have an impact. If we then have another gap of five years, it means we are reversing all the gains," she said.
Her organization estimates that 1.3 million women could lose out on the care they need in Zimbabwe, leading to an additional 461,000 unintended pregnancies and 1,400 maternal deaths if the gag rule is reinstated.
Overseas aid budget cuts by other Western governments will make it harder to find alternative funding, Siraha said.
Forced into difficult choices
MSI Reproductive Choices is lobbying world leaders and alternative donors to fight for abortion rights.
"Trump's reelection may embolden the anti-choice movement, but the fight for women's reproductive rights is nonnegotiable," Chinogwenya said.
However, agencies that rely heavily or entirely on U.S funding might have little choice but "to quiet their guidelines on access to abortion" to qualify for funding, said Denise Horn, an international relations and civil society expert at Bryant University in Rhode Island.
In South Africa, where abortion is mostly legal, some NGOs, especially those without alternative funding, stopped openly discussing abortion as an option or changed their guidelines and the information they share publicly, according to an assessment by South Africa's Rhodes University and the International Women's Health Coalition, a New York-based NGO.
"Organizations thus have to evaluate what is most important: the non-abortion work they will still be able to do or the principle of pro-choice," read part of the 2019 assessment report. "Ultimately, these organizations will have to make this difficult decision."
The long lines of women at the outreach clinic in Zimbabwe's Epworth settlement underline the dire need for family planning services in impoverished communities.
Engeline Mukanya, 30, said she is already struggling to support her three children with the $100 she earns monthly from plaiting women's hair. Nurses inserted a birth-control implant in her left arm to protect her from pregnancy for the next five years.
Like many here, she cannot afford private providers who charge $20 to $60.
"It's unfortunate that we are so far away from America yet we are being caught in the crossfire of its politics," she said. "All we want is the freedom to space our births."