A blue, burgundy and white patterned wrapper hides the swell of Joanna Banda’s belly. At 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.
In remote villages in Malawi, pregnant women like 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 had started to cut the number of women dying in childbirth.
Momentum Tikweze Umoyo, a $28m, five-year programme aimed at cutting maternal and infant mortality rates in five of Malawi’s 28 districts, was meant to last until August 2027. It is just one of the casualties of US president 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 week, Trump said he would not be spending $4.9bn in aid already approved by Congress.
Kafulatira, where Banda lives, is a scattered mud and straw-walled village of 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 in December 2024.
A mobile clinic used to come every month or two to the community, providing a private space for women to get screening for cervical and other cancers, HIV testing 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 been fine, as she has a contraceptive implant that lasts for three years, but that others weren’t 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, children playing around them.
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 a per capita income of just $508, according to the World Bank. It is incredibly vulnerable to the climate crisis: 80% of the population works 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, was equivalent 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 US health spending was more than double that of the Malawian government.
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.”
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% in 2025, leading to a 1% decrease in Malawi’s gross domestic product.
The government has little means to make up the shortfall. Malawi’s fiscal deficit (the gap between what the government spends and its revenues) was 10.1% in the year to 31 March. It is also under intense political pressure, with presidential and parliamentary elections on 16 September.
Funding healthcare in Malawi “is indeed the duty of the government, but … the government doesn’t have the resources,” says Hester Nyasulu, Malawi country director for Amref Health Africa, a Kenyan NGO that was one of seven delivering 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. More women received family planning services and first-trimester antenatal care, while teenage pregnancies fell.
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 ministry of health, with fuel and staff lunches paid for by USAID.
At the health centre in Makion, a small market town about 34 miles from the district capital, breastfeeding guides painted on the wall were branded: “USAID: from the American people”.
Staff there bemoan pregnant women having later antenatal appointments or none at all, a drop in cervical cancer screenings and two women aged 18 and 20 having unsafe abortions because they live 17 miles from the clinic (they are fine now, the staff say).
“It’s increased the workload in the [health] facilities, hence poor quality of services being provided,” says Yohane Billiat, the district family planning coordinator. “We are failing to give them services in their places,” says Samuel Chawaka, the Makion health centre manager.
Even in Malawi’s cities the quality of healthcare is falling. In the capital Lilongwe, the US previously funded the training of health workers to find and manage tuberculosis (TB) cases. 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 … and drug-resistant TB can also flourish,” he says. “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 down to between 8,000 and 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.”
