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For hours, jolting along the waterlogged dirt track to the medical facility, 18-year-old Makka Ibraheem Mohammed held on tight to her seat and tried hard stopping herself being sick. She was in delivery, in extreme pain after her womb tore, but was now being jostled relentlessly in the ambulance that jumped along the uneven terrain of the road through the Chadian desert.

Most of the 878,000 Sudanese refugees who have fled to Chad since 2023, surviving precariously in this difficult terrain, are females. They live in secluded encampments in the desert with scarce resources, no work and with treatment often a perilously remote away.

The clinic Mohammed needed was in Metche, a different settlement more than two hours away.

“I kept getting infections during my pregnancy and I had to go the medical tent multiple occasions – when I was there, the pregnancy started. But I found it impossible to give birth without intervention because my uterus had collapsed,” says Mohammed. “I had to remain for 120 minutes for the ambulance but all I remember was the agony; it was so bad I became delirious.”

Her maternal figure, Ashe Khamis Abdullah, 40, was terrified she would suffer the death of her offspring and descendant. But Mohammed was hurried into surgery when she reached the hospital and an urgent C-section rescued her and her son, Muwais.

Chad already had the world’s second-highest maternal fatality statistic before the recent arrival of refugees, but the circumstances suffered by the Sudanese place additional women in peril.

At the hospital, where they have birthed 824 babies in frequently urgent circumstances this year, the medics are able to help plenty, but it is what affects the women who are not able to reach the hospital that concerns them.

In the two years since the civil war in Sudan started, over four-fifths of the displaced persons who came and settled in Chad are mothers and kids. In total, about one point two million Sudanese are being sheltered in the east of the country, 400,000 of whom ran from the earlier war in Darfur.

Chad has hosted the bulk of the 4.1 million people who have fled the war in Sudan; others have gone to South Sudan, Egypt and Ethiopia. A total of almost twelve million Sudanese have been forced out of their homes.

Many males have not left to be near homes and land; some were killed, abducted or conscripted. Those of adult age soon depart from Chad’s barren settlements to find work in the main city, N’Djamena, or beyond, in neighbouring Libya.

It means women are stranded, without the resources to sustain the young and old left in their care. To prevent congestion near the border, the Chadian government has transferred refugees to less crowded encampments such as Metche with usual resident counts of about fifty thousand, but in distant locations with limited infrastructure and scarce prospects.

Metche has a hospital set up by a medical aid organization, which started off as a few tents but has grown to feature an operating theatre, but few additional amenities. There is a lack of jobs, families must walk hours to find fuel, and each person must get by with about a small amount of water a day – far below the suggested amount.

This remoteness means hospitals are treating women with problems in their pregnancy when it is almost too late. There is only a sole emergency vehicle to travel the path between the Metche hospital and the health post near the Alacha encampment, where Mohammed is one of close to fifty thousand refugees. The medical team has observed instances where women in severe suffering have had to wait an entire night for the ambulance to arrive.

Imagine being expecting a child, in labour, and journeying for a long time on a animal-drawn transport to get to a hospital

As well as being bumpy, the road traverses valleys that flood during the monsoon, completely cutting off travel.

A surgeon at the hospital in Metche said every case she sees is an emergency, with some women having to make long and difficult journeys to the hospital by foot or on a donkey.

“Imagine being about to give birth, in delivery, and travelling hours on a cart pulled by a donkey to get to a clinic. The main problem is the lag but having to arrive under such circumstances also has an impact on the birth,” says the surgeon.

Poor nutrition, which is on the rise, also increases the risk of issues in pregnancy, including the womb tears that medical staff frequently observe.

Mohammed has continued under care in the couple of months since her caesarean. Experiencing malnutrition, she developed an infection, while her son has been closely watched. The male guardian has travelled to other towns in search of work, so Mohammed is completely reliant on her mother.

The undernourishment unit has expanded to six tents and has individuals overflowing into other sections. Children rest beneath mosquito nets in sweltering heat in almost total quiet as health workers work, creating remedies and assessing weights on a scale made from a bucket and rope.

In moderate instances children get packets of PlumpyNut, the uniquely designed peanut paste, but the most severe instances need a daily dose of enriched milk. Mohammed’s baby is administered his nutrition through a injector.

Suhayba Abdullah Abubakar’s infant son, Sufian Sulaiman, is being fed through a nasogastric tube. The child has been ill for the past year but Abubakar was only provided with painkillers without any identification, until she made the trip from Alacha to Metche.

“Every day, I see further minors joining us in this structure,” she says. “The meals we consume is low-quality, there’s insufficient food and it’s lacking in nutrients.

“If we were at home, we could’ve adjusted our lives. You can go and grow crops, you can find employment, but here we’re reliant on what we’re given.”

And what they are provided is a meager portion of sorghum, edible oil and salt, distributed every couple of months. Such a simple food offers little sustenance, and the little cash she is given purchases very little in the weekly food markets, where values have increased.

Abubakar was moved to Alacha after arriving from Sudan in 2023, having escaped the armed group Rapid Support Forces’ attack on her birthplace of El Geneina in June that year.

Failing to secure jobs in Chad, her husband has gone to Libya in the hope of earning sufficient funds for them to join him. She lives with his kin, distributing whatever nourishment they obtain.

Abubakar says she has already seen food distributions being reduced and there are concerns that the sudden reductions in international assistance funds by the US, UK and other European countries, could make things worse. Despite the war in Sudan having produced the 21st century’s worst humanitarian disaster and the {scale of needs|extent