The midwife pulled on her latex gloves and flattened her measuring tape against the young pregnant woman’s exposed belly. It was measuring large for 36 weeks.
“Maybe it’s a big baby,” said the midwife, a redoubtable woman in pink scrubs named Nancy Symgambaye. “Maybe there’s too much fluid. Or it could be twins.” All were risky scenarios for any pregnant woman, let alone Taiba Baraka, a 26-year-old Sudanese refugee.
Ms. Baraka looked nervously from the bed as Ms. Symgambaye continued to examine her. It was mid-August, and the ward she had come to for her last prenatal appointment before giving birth was a run-down tent in Aboutengué camp, an isolated refugee station in Chad housing more than 50,000 people, most of them women and children fleeing the civil war in neighboring Sudan.
Pieces of thin floral cloth were strung up to serve as interior walls.
Chad, a sparsely populated Central African country of rugged desert and rippling savanna, has the world’s second highest rate of maternal mortality and is one of its poorest countries. Still, it has taken in 900,000 people fleeing a humanitarian catastrophe of giant proportions in Sudan, where famine, cholera and unfathomable trauma have been among the devastating effects of more than two years of civil war.
Medical workers like Ms. Symgambaye have until recently provided a modicum of care to these refugees, relying partly on funds from the United States. But when the Trump administration announced this year that it would eliminate U.S. foreign assistance worldwide, those workers began to lose their jobs.
For decades, American officials argued that aid was beneficial to U.S. interests, saving lives and helping spread American influence abroad. The Trump administration has departed from that argument, pulling government spending and targeting agencies like the United States Agency for International Development, calling it wasteful, fraudulent and run by “radical lunatics.”
But the cuts were so swift and so unclear that relief workers were unable to manage the fallout. Now more lives are at risk and more people are dying, experts say. The consequences of the cuts are unfolding most clearly in places like Aboutengué’s maternity unit in Chad, where until this year the United States was by far the biggest donor.
Two of the eight midwives at Aboutengué (pronounced Ah-boo-TEN-gay) were laid off in February, just after President Trump signed an executive order halting all foreign aid. Another three will be gone in December, said a senior official with the International Rescue Committee, the organization paying their modest salaries with American funds.
The maternity ward would be expected to operate with just three midwives, often treating women who have endured unimaginable sexual violence. Many of the tens of thousands of expecting mothers fleeing Sudan are not pregnant by choice, but are rape survivors in what the United Nations has called a war on women in Sudan.
Sexual violence is so widespread in Darfur — the region in western Sudan where most of the refugees in Chad come from — that many describe it as unavoidable. Women are attacked in their homes, while working in the fields and as they flee. The International Criminal Court has said rape is being used as a weapon of war in the region.
And more women are getting pregnant than ever before, the International Rescue Committee’s supervising doctor in the area, Dr. Raick Bell, said. Dr. Bell said part of the problem was the major disruption to birth control supply chains after the Trump administration decided to stop funding family-planning programs in developing countries.
“We will find ourselves with numerous pregnancies — women who don’t have enough time to be able to recover afterward,” Dr. Bell said in a corner of the maternity ward as Ms. Symgambaye and her colleagues tried to get through the backlog of waiting women sitting on a plastic mat at the entrance to the sweltering tent.
Evelyne Ndjepa, the midwife in charge of the maternity unit, limped by on a bandaged ankle. She was injured when part of her roof was destroyed in a storm the previous day. Still, there was no question of taking time off, with the unit already operating with so few staff. She quizzed a woman about several missed periods, and sent her off for a pregnancy test.
Before the aid cuts, Ms. Ndjepa said in an interview, there were always two midwives on duty at night, when many women tend to arrive to give birth. But since the cuts, a single midwife had to manage night shifts alone.
“We can’t cope,” she said.
She cast a worried glance at the month’s handwritten schedule, a sheet of paper stuck to sagging tarpaulin. She knew the aid cuts would lead to further reductions of her exhausted staff, she said, but she had no idea how they would continue to operate.
Another pregnant woman arrived, supported by her teenage daughter, and collapsed. The woman, Nafissa Adam, 38, was weak with hunger after a week with almost nothing to eat, having given the little food she had to her children. Three people had to hold her up as she got on the scale. She was then carried to a bed, where she cried quietly as a nurse set her up with an IV.
Along with most people in Aboutengué, Ms. Adam had lost everything in her flight from Sudan.
The civil war that began in 2023 between Sudan’s military and its paramilitary rivals, the Rapid Support Forces, has ravaged one of Africa’s biggest countries. Meddlesome foreign powers have picked sides. The United Arab Emirates has used a field hospital it built in eastern Chad, purportedly for delivering aid to Sudanese refugees, as a cover to smuggle weapons over the border to the R.S.F., a New York Times investigation revealed last year. The United Arab Emirates has denied the report.
Like many of the camps dotted around Chad’s rural east, Aboutengué is hard to reach. War refugees must travel down miles of potholed road lined with herds of cows, a few chomping camels and the occasional equestrian, elegant in a towering turban.
For much of the year, the camp is a parched, shadeless landscape where survival is a feat. Then August brings torrential rains, and the dust becomes a thick mud, turning the camp into a swamp and trapping people in their tiny shelters.
Many of the families in the camp lived comfortable lives before war took everything from them. They desperately want to support themselves again by finding work, or at least supplement their meager U.N. food rations. But the only opportunities to earn income in Aboutengué — such as support from aid organizations to start small businesses — dried up quickly after the cuts were announced.
Ms. Baraka, the young pregnant woman at the maternity ward, pulled her orange wrap around her bulging waist and over her head. Over on the mat full of waiting women, her 2-year-old daughter lay asleep in her best dress, legs and arms akimbo. The daughter was Ms. Baraka’s second child; her first had died a day after being born five years before.
The same little girl had been asleep beside Ms. Baraka one morning in May 2023 as she made breakfast in Misterei, her hometown in the Darfur region of Sudan. Five Rapid Support Forces fighters suddenly jumped her fence and burned her house, she said. She grabbed her daughter and ran.
After escaping the R.S.F. fighters, she and her baby made it to Chad. They arrived with nothing, and now live with a handful of family members who also escaped the war in Sudan.
Ms. Baraka waddled over to Ms. Symgambaye’s desk and sat down on a plastic chair. She had trouble understanding the midwife’s questions because they spoke different dialects of Arabic. The ward’s designated interpreter, a Sudanese refugee working as an assistant to the midwives, was flitting around, trying to translate several conversations simultaneously.
Ms. Symgambaye told Ms. Baraka that it looked as if she would have a difficult delivery, and beseeched her to come back to the clinic the moment she had contractions. “If you stay home, nobody can help you,” she said. “Please, please come here to deliver.”
Part of the midwives’ work is to encourage women to come to the clinic for proper medical care. Many women at the camp choose to deliver at home, at great risk to themselves and the child. But as the maternity ward loses its staff, such outreach in the camp is fading.
Ms. Baraka heaved herself up from the plastic chair and wandered through the busy tent toward her sleeping daughter. She slipped off her sandals and tucked them under the mat, nodded to her aunt, who had accompanied her to the hospital, and sank down beside her toddler.
She wished she had grabbed her smartphone the day she fled Sudan, she said. She wished she had grabbed the $90 in cash she had saved up. “I wish many things,” Ms. Baraka said. “But I can’t go back.”
She stroked her toddler’s leg gently, waking her up. They had to get back to their shelter before the rain started.
Zainab Ali Abdallah contributed reporting.
Ruth Maclean is the West Africa bureau chief for The Times, covering 25 countries including Nigeria, Congo, the countries in the Sahel region as well as Central Africa.
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