Nearly seven months later, a case for why some healthcare providers in Nigeria are getting nervous.

Rose sits in the waiting room of a Planned Parenthood clinic in Isolo, Lagos, waiting to receive her prescription for oral contraceptives. While her husband supports her decision, her family does not, and she is here despite their insistence on her having more children before trying them, believing that they can take away her fertility. That she’s even able to get these contraceptives would have been unthinkable just a few years ago: Rose has never heard about Roe v. Wade, but she remembers when it was impossible to consider family planning at all, let alone have access to it, and fears returning to those times.

Before organizations like Planned Parenthood Federation Nigeria (PPFN), sexual and reproductive agency were impossible for most women in the country. “Many women who visit Planned Parenthood defy their husbands to get contraceptives, secretly making choices that save their lives despite facing consequences if they are ever found out,” says Zainab Mukhtar, Communications Officer for PPFN. “We advocate method by choice and exercising free will, not only for married women but sexual and reproductive health choices for young people.”

In Nigeria, many women cannot access reproductive health services without spousal permission, and if unmarried, they are shunned for considering it. Even health workers cite God’s omniscience when refusing care: While trying to obtain birth control, one unmarried woman recalls her male doctor condescendingly telling her, “Ah, madam, do you want to test God? Where is your husband? Go and bring [him].” This provider bias, where health workers lead with disapproval when consulted for reproductive and sexual health care, has only made it harder for many women in Nigeria to access the care they need—a bias that becomes far more severe when it comes to abortion.

This bias is likely to only get worse: Sani Mohammed, a sociologist, activist, and the executive director of the Bridge Connect Africa Initiative, says the repeal of Roe v. Wade last summer has had ripple effects beyond the U.S., and creates justification for more limits on women’s rights worldwide, often detering advocacy efforts and slowing momentum behind progressive bills. “It sends a signal to anti-abortion advocates in Nigeria that if the U.S. can do it, why not us?” Mohammed says. “It will take longer for Nigeria to make abortion services open and legal because it sets a precedent and justification, rescinding all the work done today and making it harder to make a case in favor of sexual and reproductive rights.”

Sani was careful in choosing his words, so as not to risk the little progress made, adding that it took a long time to even get this far. Bridge Connect Africa Initiative focuses on women’s rights and reproductive health rights, pushing for policies and campaigns around gender-based violence, and access to education for young girls to help inspire more informed social and reproductive health choices, especially in northern Nigeria. But it’s been an uphill battle.

Except in situations where having the child puts the mother’s life at risk, Nigeria is governed by two laws that criminalize abortion: the penal code in the north and the criminal code in the south. When discussing restrictive sexual and reproductive laws in Nigeria, people often think of the north, associating it with Sharia law and terrorism, but southern Nigeria is predominantly Christian, comprising of Catholics and evangelical Christians, and their stance toward abortion and sexual reproductive rights is similar to hardliners in America. In Enugu State, in southeastern Nigeria, for example, a coalition of civil society organizations claimed that the comprehensive sexuality education (CSE) in the public school curriculum equates to pornography and demanded to stop sex education in schools.

While abortion is a crime in Nigeria, it is also a cause of shame to be pregnant out of wedlock, regardless of the circumstances of the pregnancy. In northern Nigerian culture, a girl is considered old enough to be married and have children at 11 years old, but an 11-year-old girl is not allowed to seek out family planning methods. Young girls who get pregnant from rape still have to carry it to term, and to avoid scorn and ostracism, often find unsafe means to hide their shame. Without legal recourse, these girls either neglect the children after they are born or resort to unsafe abortions, regardless of the risks. Sani recalls witnessing two cases of hysterectomies performed on 14-year-old girls. “It is already difficult to have access to safe abortion, and other reproductive health devices that help girls as young as 12 to 14 stay safe and live healthy lives.”

According to a report by the Population Reference Bureau (PRB), about two million women and girls aged 15 to 45 have abortions in Nigeria every year—a staggeringly high number over three times the estimated number of abortions in the U.S. Of these women and girls, 6,000 die, and 500,000 live with complications from unsafe abortions, despite some doctors risking their licenses to provide off-record/off-book abortion care. It is also the fourth leading cause of death for lower and middle income women, according to the Academy for Health Development (AHEAD), a not-for-profit health research agency in Nigeria.

Organizations like PPFN—which is a member of the International Planned Parenthood Federation (IPPF)—are doing their best to combat this, but similar to America, misconceptions about their services abound. Like in the U.S., the majority of Planned Parenthood Nigeria’s services are preventive, especially against HIV/AIDS, cervical cancer, and malaria. They provide maternal and child care through malaria prevention and treatments, especially intermittent preventive treatment (IPT) for pregnancy malaria, which is a critical public health problem in Nigeria. Also like in the U.S., PPFN provides post-abortion care for women and girls having spontaneous abortions or miscarriages, and those who attempt incomplete abortions using crude objects to remove an unwanted pregnancy “by any means necessary.” Sometimes these objects are found still inside the women.

Would PPFN provide abortions in uncomplicated cases? Zainab, with a careful laugh, says they would, but that it’s “tricky.” They are damned if they do and damned if they don’t. If they don’t help, the patient could seek an unsafe abortion elsewhere that could lead to death; if they do, it could mean breaking the law. Nevertheless, PPFN will not turn away a patient in need, and will perform abortion services within legal exceptions—that is, when the birth of the child directly puts the life of the mother in mortal danger.

Perhaps if Nigerians were more open about abortion, it could inspire a legislative debate similar to the one in Ireland, and allow a platform to discuss the benefits of legalizing abortion, providing safer choices for women and girls through government funding and training for health care providers. But with the Nigerian health sector being one of the most underfunded in the world, it does not leave much hope.

While Zainab believes it is too early to say what the real effects of the overturning of Roe v. Wade will be on Africa, she predicts the heightening of fear and possibilities of regression. “It is difficult to work in this field in Nigeria; these things happening here have existed a long time but signaling from the U.S. can make things worse.” Shortly after the repeal of Roe v. Wade, the Lagos Government proposed new abortion guidelines on the safe termination of pregnancy. They were quickly rejected after the governor, Babajide Sanwo Olu, who is running for re-election, received backlash from Christian and Muslim religious organizations in the state.

But even before the overturning of Roe v. Wade, it’s been an especially difficult time. For more than 50 years, the United States has supported global family planning and reproductive health rights in Nigeria, but when countries like America, which have historically provided aid, start taking them away in their own countries, the idea of choice for women in oppressive societies is erased forever. Most notably, the global gag rule on abortion during the Trump years reduced reproductive health funding and setback the work being done independently on sexual health rights both locally and abroad.

There is progress, however, no matter how slow. Planned Parenthood Nigeria has a more comprehensive curriculum for sexual and reproductive health rights (SRHR) education currently being piloted in private schools, where there is less national control of the curriculum. They also train health workers on sexual and reproductive health rights and how to identify provider bias. Bridge Connect Initiative has been able to get three northern states (Kano, Jigawa, and Bauchi) to recognize the Violence Against Person Prohibition Act (VAPP) and the child protection bill. They also provide psychosocial support to child brides and survivors of gender-based violence while helping many girls complete their education.

The durability of these successes lies in the allyship of progressive nations towards women’s health abroad. This is why the rescinding of Roe v. Wade is so dangerous on a global scale. Women are dying now. Nigerian women are deprived of contraception when they want it or forced by their husbands to take it when they don’t, and even that is considered progressive. What becomes the fate of a woman living in Nigeria when the government takes a more hardline stance on her agency without a powerful ally to help? With the right support from local organizations and international health rights networks, and a renewed interest in Africa from the U.S., hopefully, we never have to find out.