Nairobi, Kenya - Health worker Elizabeth Wanjiru was walking through the narrow streets of Kenya's largest slum earlier this year when she came across two schoolboys pointing at something in a muddy ditch. As she drew closer she saw it was the remains of an aborted fetus.
Dumped elsewhere in Kibera, the fetus had washed up in a narrow alleyway after a night of rainfall. It's something Wanjiru hasn't seen for years.
Wanjiru and other health workers in Kenya told CNN that the number of backstreet abortions have increased since the United States cut aid to family planning programs that provide abortion services, in addition to contraception, in the world's least developed countries.
Ushered in by President Donald Trump's administration, the Mexico City policy, or global gag rule, was supposed to reduce the number of abortions, but healthcare workers in Kenya say it's doing the opposite. The cuts, which left thousands of women in Kenya without contraception, have forced many to resort to risky, backstreet abortions as a form of birth control.
Trump is also eyeing funding changes in the US. Last week, his administration proposed a new rule that would bar abortions or advice on abortion at facilities receiving federal family planning funds. While there are already laws in place that prevent federal money from directly funding abortions, the new rule would mean family planning programs would have to perform abortion services or provide abortion counseling and referrals in a different place, and by different employees, for the facility to continue receiving federal family planning dollars. It's been described as a domestic version of the global gag policy by abortion rights activists.
Reliant on international donors for support, communities like Kibera are where the Mexico City policy has been felt the most and, so far, the national government says it has been unable to make up the shortfall.
For five years Khadijah Dija visited a family health clinic in the slum every three months to get a free contraceptive injection until Trump's funding cuts came into effect.
The single mother-of-two says she relied on the family-planning method to avoid having another child she couldn't afford. Her daily earnings from selling porridge, equivalent to 50 cents, are barely enough to buy food for her family, or pay rent on their one-room house.
When the nongovernmental organization Family Health Options Kenya (FHOK) informed Dija last August that it no longer had funds to provide her with free contraception she said she was devastated.
The three-month injectable contraceptives she had previously received for free would now cost her $4, according to FHOK.
Sitting on the bottom bunk of her children's bed, their toys scattered around her, Dija told CNN that she had considered getting injections from a local pharmacy, where they sell for about $2 to $3. But she said they're often expired, or unsafe, and she couldn't afford them anyway.
Injectables are the most commonly used form of contraception for women in Africa. Invisible to partners, they reduce the risk of backlash and are easy to use.
Africa already has the lowest percentage of women using birth control, and the highest unmet demand for contraceptives in the world.
And because many African countries rely on US Agency for International Development (USAID) money to fill gaps in women's health services, the Trump funding cuts are hitting women like Dija particularly hard.
Without access to contraception, Dija became pregnant with her third child last October. She went to a backstreet clinic in Kibera and got abortion pills illegally. To pay for the pills, which cost about $10, Dija had to dip into precious savings she had made from her work at a women's group in the slum.
"I couldn't give birth because my husband is not supporting or helping me, so I decided to terminate the pregnancy. I thought that was the best option," she said. When CNN interviewed Dija in her home, she said it had been a month since taking the abortion pills, and she was still bleeding.
Asked what she will do if the bleeding doesn't stop, Dija said: "I hope it will."
Abortion is illegal in Kenya, except for when the life or health of the mother is at risk, but it is on the rise in Kibera, where most residents live in extreme poverty -- earning less than $1 per day.
Wilson Bunde, who works with FHOK, said women like Dija, who were coming to the Kibera clinic for free contraceptives, are returning to be treated for botched abortions instead.
Organizations like Bunde's are supported by the International Planned Parenthood Federation (IPPF), a global provider of sexual and reproductive health services, which stands to lose up to $100 million in USAID after refusing to sign up to the terms of Trump's policy. The cuts meant FHOK stopped offering subsidized contraception in Kibera, closed a clinic and cut a community outreach program.
Without access to that program, Bunde estimated, 36,000 women went without family planning last year.
In February 2018, the US State Department released an initial review of Trump's expanded policy, rebranded Protecting Life in Global Health Assistance (PLGHA). The State Department said it was still "too early to assess the full range of benefits and challenges of the PLGHA policy." But it did include one comment of support from the United States Conference of Catholic Bishops, which praised PLGHA as "one of the most significant policy initiatives on abortion ever taken by the United States in an area of foreign assistance."
It's not the first time that a US president has imposed changes to USAID for organizations administering family planning in the world's least developed countries.
First introduced by President Ronald Reagan in 1984, the global gag rule was rescinded by Democrats and then reinstated by Republicans (under George W. Bush), but never before to this extent.
Trump's policy slashes an estimated $8.8 billion in US global health assistance -- funding that applies not only to family planning, as it has previously, but extends to prevention and treatment of HIV/AIDS, tuberculosis, malaria, infectious diseases, and even hygiene programs.
In 2001, the Bush administration cut about $600 million in foreign aid. One year later, induced abortions spiked.
The correlation was identified in a 2011 Stanford University study, which analyzed abortion rates in 20 sub-Saharan African countries receiving USAID for family planning and women's health over 14 years. The researchers found that when the Mexico City policy was in place, women were up to 2.73 times more likely to get abortions than women in countries where the policy was not applied.
In Kibera, women are turning to untrained abortion providers as a last resort. One practitioner, who asked that CNN not use her real name due to fear of prosecution, said she often treats women who are between six and seven months pregnant.
She performs the procedure with a knitting needle, puncturing the pregnant woman's amniotic sac, which forces the fetus out of the uterus.
The practitioner, who told CNN that she was a trained midwife, said she sees mostly young schoolgirls and unmarried women. She carries out the abortions in her small home. On a twin bed covered by a thin clear plastic sheet, sat a bag with surgical gloves, a jar of petroleum jelly, cotton wool, some pain killers and the needle, attached to a long, thin tube, which is used to drain the fluid into a bucket on the floor.
Botched abortions cost Kenya about $6.3 million in 2016, according to a recent report published by Africa Health Population Research in partnership with Kenya's Ministry Of Health. And experts say that number is expected to rise in the wake of Trump's cuts.
Kibera health worker Elizabeth Wanjiru, says that when she first became involved in family planning outreach programs she had hoped it would bring an end to the backstreet abortions.
When she saw the fetus in the ditch in Kibera, she said: "It touched me, and it made me remember what I did."
Wanjiru once had a backstreet abortion herself, and she doesn't want women to have to go through what she experienced.
But she says that it's become much more difficult to stop women from turning to backstreet abortions, now that contraceptives are unaffordable for most. "This is why you will find babies aborted, due to lack of access to family planning."
- Florence Obondo contributed to this report from Nairobi.
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