By the time the woman arrived at the hospital, she had nearly bled to death. She went into labor on a warm September day earlier this year, and made the trek from her rural village in the small West African country of Gambia to a nearby clinic. The baby was delivered successfully, but after the birth, the nurses at the clinic couldn’t stop the mother’s bleeding. She suffered from a complication in which her placenta — which is normally expelled after labor — clung to her uterus, preventing the blood vessels that once nourished her child from closing properly. When she arrived at the bigger hospital across the river, the blood loss had caused the color to drain from her skin. Her organs were close to failing. This story is part of the 2025 Future Perfect 25Every year, the Future Perfect team curates the undersung activists, organizers, and thinkers who are making the world a better place. This year’s honorees are all keeping progress on global health and development alive. Read more about the project here.But the facility’s sole doctor was not there.The Essau District Hospital serves as the primary point of specialized care for over 50,000 people. It is also chronically underfunded, and all the more so since the US curtailed billions in funding for global health earlier this year, forcing similar clinics and hospitals dependent on aid to shutter worldwide. Pregnant people in the hospital’s birthing wing these days sometimes lie two to a hospital bed, and often there aren’t enough medications, blood donations, or trained staff to go around. Retained placentas affect up to one in every 33 births, and in rich countries, they’re relatively easy to treat. In places like the Gambia, however, where the complication is rarer and where giving birth is still very dangerous, about one in 10 people who develop the complication will die. What stands between those people and a safe birth is not advanced treatment or technology. It is not a state-of-the-art hospital or even a specialized doctor. What makes the biggest difference in a country like the Gambia is the presence — or absence — of a skilled birth worker, most often a midwife, who has the training needed to deliver a baby safely and adapt quickly when common complications arise.With no doctor present that day at Essau District Hospital, Jainaba Ceesay, a senior midwife, sprang into action. She pried the placenta out of the woman’s body and swiftly transfused two pints of blood. With some food and antibiotics, the mother made a full recovery. But had Ceesay or a midwife like her not been on the scene, the mother almost certainly would have died.“There are little resources, but we still manage,” Ceesay told Vox by phone a couple of weeks after the delivery. “We make sure all of the available resources are utilized well, and with the knowledge that we have, we use that to help the mothers and their babies.”But there are now fewer midwives like Ceesay around the world than there were just a year ago. The simple tools, tests, and treatments they need to help their patients are in much shorter supply as well. And it’s all because of President Donald Trump’s deep cuts to foreign aid, which — driven partly by America’s ongoing culture wars over abortion — are making pregnancy much more dangerous throughout the global South. Inside this story:What it takes to give birth safelyThe progress we’re about to loseThe midwives who aren’t giving upWe could save so many more livesMaternal death was once far too common around the world, but it is now exceedingly rare in rich countries. We have every tool we need to make it just as rare almost everywhere else, but for that to happen, we need ambulances that can get people to the hospital in time. We need the $5 emergency birthing kits with their gloves, gauze, and antiseptic wipes. “It’s extremely important for all of us that women survive and that they thrive after childbirth,” said Anna af Ugglas, chief executive of the International Confederation of Midwives. “Women dying actually keeps countries and societies in poverty.”In many countries those resources still aren’t in place, which is why midwives around the world have become masters at making do with what they have, often saving lives under impossible conditions and for meager pay. “When a crisis happens, the midwives are there,” said af Ugglas. The question now is whether we will be there for them. Because while restoring some of the funding lost in Trump’s cuts would help, money alone won’t save parents. We need more midwives.What it takes to give birth safelyLet’s start with the good news. Giving birth globally has gotten a lot safer than it used to be. Maternal deaths worldwide plummeted by 40 percent between 2000 and 2023, thanks largely to the marvel of modern contraceptives — which help reduce the number of unwanted or risky, and by extension, deadly, pregnancies — and simple but lifesaving innovations like obstetric drapes and care kits. View LinkThose interventions were only possible because many more people began giving birth at a clinic or hospital instead of at home. Skilled health workers, who include nurses, midwives, and doctors, delivered over 80 percent of babies worldwide in 2019, up from 62 percent in 2000. In the United States, the most dangerous rich country in the world for expectant parents, the lifetime risk of dying from pregnancy or childbirth is roughly 1 in 4,000. And in a much safer country like Japan, it’s roughly 1 in 35,000. Globally almost 700 people die from preventable pregnancy-related causes every single day, over 90 percent of whom live in low and lower-middle-income countries. One simple reason is that people in low-income countries tend to give birth to more children than in rich nations, which compounds their risk. But that’s only part of the story.Another is the lack of medical care. In Nigeria, for instance, where roughly 1 in every 100 births proves deadly, there are less than four obstetricians and gynecologists for every 100,000 people, compared with nearly 14 for every 100,000 people in the US. The majority of skilled birth workers in Nigeria and other low-income countries are instead midwives, who receive specialized training in maternal and newborn care. As a result, they are the lifeblood of maternal health care, combining medical expertise with deep-rooted cultural fluency. And they make a major difference — studies show that the presence of skilled midwives could reduce the risk of a pregnant person dying during birth by more than 65 percent in low- and middle-income countries. “Midwives can change lives. They can change the communities that they live in,” said Jama Egal, the first midwife to earn a PhD in Somaliland, an unrecognized state in the Horn of Africa. She also leads Somaliland’s Nursing and Midwifery Association, which runs midwifery trainings and advocates for public health policies. If the whole world had 3 million midwives, which af Ugglas says would be enough for every pregnant person to have a skilled birth worker by their side, we could avert over 60 percent of all maternal and newborn deaths and stillbirths — amounting to 4.3 million lives saved — by 2035. In the Gambia, Ceesay regularly goes door-to-door in nearby villages, screening expectant parents for sexually transmitted illnesses and educating them about prenatal care. She works hard to build trust so that parents seek out the clinic for help when they’re expecting a new baby. Thanks to that kind of outreach, over 80 percent of people in the Gambia now give birth under the care of a skilled health professional, up from 57 percent in 2013. During that time, the country’s maternal mortality rate dropped by more than 40 percent, from 606 maternal deaths per 100,000 births in 2013 to 354 today.There are just over 2 million midwives in the world today. We’ve got 1 million more to go.The progress we’re about to loseBut instead of moving toward a future where childbirth is safe no matter where it occurs, the world is going in the wrong direction. Researchers at Stanford estimate that up to 64 percent of the progress made against maternal mortality in recent decades could soon be lost as a result of major foreign aid cuts.“When you cut foreign aid to a country, one of the first things that goes is women’s ability to access care when they’re going into labor and the care that they receive after giving birth,” said Ruth Gibson, the study’s lead author and a postdoctoral fellow in Stanford’s department of health policy. “If we don’t start moving on this now, it’s going to be catastrophic.” At a clinic in western Chad, mobile midwife Raouda Hassan remembered the day she learned that the new American president was about to cut her job.“They told us that voilá, America has suspended its aid,” she said in French through a translator from the United Nations Population Fund (UNFPA), the UN’s reproductive health agency. “That’s it. We could no longer work.” Until this year, the US Agency for International Development’s (USAID) Bureau of Humanitarian Assistance funded her job delivering babies in tents across a region terrorized by violence from the extremist group Boko Haram. The country has the world’s second-highest maternal mortality rate, after neighboring Nigeria. Her work also included testing pregnant people for HIV and providing them with the antiretrovirals they need to keep themselves and their future children safe. She has no idea how those people are doing now.The sudden funding freeze forced the mobile clinic to cancel all its previously scheduled appointments, involuntarily abandoning pregnant people in urgent need of their next dose of antiretroviral therapies or other forms of support. And Hassan is struggling too. Since the mobile clinic was cut, she’s found herself “at home, stressed,” she said. Her midwife salary covered “most of the burdens of the house” for herself and her many siblings. But her options are dwindling. Chad is one of the most impoverished countries in the world, with over 60 percent of people living on less than $4.20 per day. Most girls in the country never finish primary school.Even though she’s the only person in her family who had the chance to study, “as a woman, I cannot travel and look for work,” Hassan said, because norms in her community forbid it. Chad is the third-worst country in the world for gender equality, after Sudan and Pakistan, according to the World Economic Forum. Being a midwife was one of the few real employment options available.Around the world, women and girls have been hit disproportionately by foreign aid cuts. In a United Nations survey of women-led and women’s rights organizations that rely on foreign assistance, almost half said that funding cuts would force them to shut down this year, caught in the crosshairs of America’s culture wars. They include midwifery schools, maternal health clinics, and rape crisis centers.One of USAID’s most transformative initiatives was its $9.5 billion Global Health Supply Chain Program, which has streamlined the production and delivery of life-saving medication and health supplies since launching a decade ago. The program procured a full one-third of the world’s contraceptives, which are key to making sure people can choose when and how often they give birth, and make a massive difference in lowering the likelihood that a woman will one day die from maternal complications in resource-starved countries. USAID spent a little over $600 million on family planning services around the world, preventing about 17 million unintended pregnancies, 5.2 million unsafe abortions, and 34,000 maternal deaths each year. Where are many of those condoms and birth control pills now? In a warehouse in Belgium, where a $9.7 million stockpile of birth control pills, implants, and injections is slowly expiring, awaiting incineration by the Trump administration. “It’s unbelievable” that the Trump administration would waste money incinerating contraceptives they already paid for, said af Ugglas, who noted that the US talks a big game about “fiscal responsibility and taxpayer accountability,” but “in fact, that’s not as important as stopping women from being able to make choices about their bodies.”How I reported this storyI knew that if I wanted to get to the heart of this story, I’d need to connect with midwives working in mobile clinics, hospitals, and homes around the world. The problem is that they are extremely busy people. You know, delivering babies and saving lives, often in places with very shoddy cell service.So many of these women jumped through a bunch of hoops just to take my WhatsApp call. Raouda, the midwife from Chad, lives in an area where the government has literally shut down the internet because of military activity, so she traveled more than an hour to the one Starlink connection in her town to take my call. Since I don’t speak French very well, a representative named Joel from her former employer, the United Nations Population Fund, took the time to translate for me. And Jainaba, the midwife who saved a woman’s life in Gambia, spoke to me right from the hospital floor in between taking care of patients. So did several others. But they still took the time out of their busy schedules because they are incredibly passionate about what they do. They’ve already begun to see the impact of foreign aid cuts on rising maternal mortality in their communities. They want the rest of the world to see it, too. It’ll cost taxpayers a total of at least $167,000 to burn the stored contraceptives, which Planned Parenthood International offered to pick up and distribute for free, an offer the administration refused.But that scandal just scratches the surface. An internal memo from USAID leaders in March anticipated that cuts to US programs would affect services for 16.8 million pregnant people every year. If US funding for maternal health doesn’t recover or isn’t replaced over the next five years, one study projects that the cuts will cause 340,000 more women to die during pregnancy and childbirth around the world, which would result in an 18.4 percent increase in maternal mortality.The Trump cuts are the culmination of years of efforts by anti-abortion advocates to defund reproductive health groups in the US and abroad, even when those groups don’t offer abortion services. Since 1977 the Hyde Amendment has banned the use of federal funds for abortions in the United States, and the Trump administration has since reinstated the Mexico City Policy, which bans foreign aid for any organization that promotes or advocates for abortion at all, even if US aid isn’t used for that purpose. In reality, the cuts could actually increase the number of unsafe abortions — because people who can no longer prevent unwanted pregnancies might still seek to end them — by over 12 million. Thomas McHale, public health director at Physicians for Human Rights, has been surveying health workers about the devastation wrought by US aid cuts overseas. In Tanzania, at least one woman living with HIV got an abortion specifically because she feared aid cuts would disrupt the steady supply of antiretrovirals she would need to protect her unborn child from the virus. “You can’t reverse an abortion, you can’t uninfect someone with HIV. You can’t reanimate someone who has died because they’ve lost access to maternal and child health care,” said McHale, who described the cuts as a “slow-moving tsunami of impact” that put “already fragile systems under severe strain.”In some parts of the world, there is no funding for maternal health at all absent foreign aid, because the domestic government is either too poor or lacks the will to pay for it itself. Few countries are feeling that strain as painfully as Afghanistan, where the US clawed back half a billion dollars’ worth of aid earlier this year. One woman dies every two hours from pregnancy-related complications in Afghanistan, making it “one of the most dangerous places in the world to give birth,” said Samira Sayed Rahman, programs and advocacy director of Save the Children in Afghanistan. The country has a severe shortage of midwives, which has only been exacerbated by the Taliban’s decision to ban women from studying nursing and midwifery last year. Even before the Taliban’s takeover in 2021, only about three in five women in Afghanistan gave birth with a skilled health worker present. With the Taliban’s severe curtailing of women’s freedom of movement, it has become exponentially more difficult for Afghan mothers to access care today. But aid cuts have made a dire situation even worse, forcing the closure of over 420 health clinics and reducing care for about 3 million. Save the Children alone lost about one-third of its budget to cuts earlier this year. “It’s an erosion of progress,” said Rahman. “It’s years of investments in health, in education, in community-building that have been undone in the span of a few months, and in some instances, in a few days.”Many of the clinics that closed were sprinkled across remote villages in Afghanistan’s eastern mountains, where an earthquake killed thousands this September and further isolated the region. Some pregnant people have traveled vast distances in recent months, walking hours on foot over rocky terrain, to reach their nearest clinic to access care — only to find the doors shut and the clinic closed.The midwives who aren’t giving upOn the day that earthquake struck, a midwife with Save the Children’s mobile health team in Afghanistan walked for hours over rubble to reach the hardest-hit zone. There, she came across a displaced woman already in labor. She acted quickly. Within the hour, and despite everything — the destruction, the blocked roads, and constant aftershocks from the quake — with only a first aid kit on hand, she delivered a healthy baby under the trees.It just goes to show that “you did not need the fancy hospital,” said Rahman of the midwife. “What you needed was a woman who was trained, who was educated, and who was skilled enough to be able to deliver that baby safely.”Over the course of the war in Gaza, for instance, midwives have been forced to deliver babies with literally nothing on hand, not even gloves, according to the UNFPA. At least one had no help at all when she herself gave birth, cutting her own child’s umbilical cord, according to the UNFPA. Edwina Conteh is a midwife and deputy head of King Harman Maternal and Child Hospital, a specialized facility in Sierra Leone that was founded a few years ago with funding from the United Kingdom and the UNFPA.The UNFPA used to get about $180 million or 7 percent of its annual budget from the US. But the Trump administration defunded the agency, rescinding $335 million in promised grants for future years, citing its supposed complicity in forced sterilizations and abortions in China, a country where the UNFPA barely works. The United Kingdom has been slashing its international aid too, though Conteh says it’s the gutting of USAID and cuts to agencies like the UNFPA that have done the most damage. Even as the country’s “facilities operate with limited staff, irregular electricity, and shortages of essential drugs,” she says her hospital has continued to offer quality care primarily through “low-cost, high-impact interventions.” When a baby is born prematurely, for example, they use “kangaroo mother care,” which involves skin-to-skin contact, and has been shown to reduce infant mortality for babies with low birth weights by 40 percent. It’s simple. It’s life-saving. And it basically costs nothing.Still, other parts of the country have had a harder time adapting to the cuts. She knows many midwives working in rural, hard-to-reach areas, where the service is so spotty that they often have to climb trees to get enough cell reception every time they need to call an ambulance.It’s already extremely difficult to recruit skilled help for that hard work, she said, and it’s become even more challenging now, with much less money to go around.“We are the cornerstone of safe motherhood in Sierra Leone,” said Conteh. “Midwives should be supported. They should be motivated. They should be empowered.”We could save so many more livesEgal, the midwife leader with a PhD, often thinks of a young midwife-in-training she knew at one of the five schools her organization helped run in Somaliland. The student was from a very rural community, but partners like the UNFPA made it possible for her to live and study for free in the capital of Hargeisa.Then, the funding cuts hit. The schools took out loans to keep the lights on, before temporarily closing and laying off staff. When they reopened, they couldn’t afford to be tuition-free anymore. Students had to purchase their own uniforms and gloves. Enrollment plummeted from 55 future midwives to just eight.“They were going to be somebody, they were going to provide livelihood for themselves and for their families,” said Egal, “and all of it was just gone.”Despite the challenges, the student tried to make it work. She moved in with extended family, working as their cleaner, which often made her late to class. Once, she arrived at school with no shoes, and the rest of the student midwives pooled their money to buy her slippers.But eventually, she too dropped out and returned to her village, where Egal fears she’ll soon join the ranks of the so-called “traditional midwives,” who conduct home deliveries that are often very unsafe. Already, around 70 percent of people giving birth in Somaliland lack a skilled birth attendant, Egal said.“The system needed to be scaled up,” Egal said, especially in rural and nomadic areas. “Instead of that, it’s collapsing.”How much would it cost to move the needle? According to Egal, just $200 per year. After three years and $600, you have a fully trained midwife who could go on to save the lives of dozens of parents and children in her lifetime. The numbers are staggering On a global scale, if it were as safe to give birth in every country as it is to give birth in Sweden, for example, then the world could save around 290,000 pregnant people per year, according to an estimate from Our World in Data. That’s life or death for the equivalent of the population of Pittsburgh, each and every year.View LinkWe won’t get there without trained midwives, and we won’t get enough trained midwives without the funding to support them. In Chad, Hassan, who lost her USAID-funded job at the mobile clinic, has been picking up shifts here and there with the few remaining international nonprofits still operating in her region. She’s worried about what the future will hold and thinks often of the pregnant people she was forced to leave behind. Above all, she says, “I truly wish to go back to work.”