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For a long time, bouncing over the waterlogged dirt track to the medical facility, 18-year-old Makka Ibraheem Mohammed held on tight to her seat and concentrated on stopping herself vomiting. She was in labour, in agonizing discomfort after her uterus ruptured, but was now being tossed around in the ambulance that jumped along the dips and bumps of the road through the Chadian desert.

Most of the close to a million Sudanese refugees who have fled to Chad since 2023, surviving precariously in this difficult terrain, are women. They stay in isolated camps in the desert with limited water and food, few job opportunities and with healthcare often a dangerously far away.

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

“I repeatedly suffered from infections during my gestation and I had to go the medical tent multiple occasions – when I was there, the pregnancy started. But I wasn’t able to give birth normally because my uterine muscles failed,” says Mohammed. “I had to remain for 120 minutes for the ambulance but all I can think of the suffering; it was so unbearable I became delirious.”

Her maternal figure, Ashe Khamis Abdullah, 40, feared she would lose both her child and grandchild. But Mohammed was hurried into surgery when she arrived at the hospital and an urgent C-section saved her and her son, Muwais.

Chad was known for the world’s second-highest maternal death rate before the ongoing stream of refugees, but the conditions endured by the Sudanese put even more women in danger.

At the hospital, where they have delivered 824 babies in often critical situations this year, the doctors are able to help plenty, but it is what happens to the women who are cannot access the hospital that worries the staff.

In the 24 months since the civil war in Sudan started, 86% of the people who reached and stayed in Chad are females and minors. In total, about 1.2 million Sudanese are being sheltered in the eastern part of the country, 400,000 of whom escaped the previous conflict in Darfur.

Chad has hosted the bulk of the millions of people who have fled the war in Sudan; some have travelled to South Sudan, Egypt and Ethiopia. A total of almost twelve million Sudanese have been displaced from their homes.

Many males have not left to be in proximity to homes and land; some were killed, captured or made to join the conflict. Those of employable age rapidly leave from Chad’s isolated encampments to seek employment in the capital, N’Djamena, or elsewhere, in nearby Libya.

It results in women are left alone, without the means to feed the children and the elderly left in their responsibility. To prevent congestion near the border, the Chadian government has moved individuals to more compact settlements such as Metche with average populations of about a large community, but in distant locations with few facilities and few opportunities.

Metche has a hospital built by a medical aid organization, which began as a few tents but has grown to feature an surgical room, but not much more. There is no work, families must travel long distances to find fuel, and each person must get by with about a small amount of water a day – far below the advised quantity.

This remoteness means hospitals are admitting women with issues in their pregnancy when it is almost too late. There is only a single ambulance to serve the area between the Metche hospital and the clinic near the settlement of Alacha, where Mohammed is one of nearly 50,000 refugees. The medical team has observed instances where women in severe suffering have had to endure a full night for the ambulance to arrive.

Imagine being expecting a child, in childbirth, and travelling hours on a cart pulled by a donkey to get to a hospital

As well as being rough, the route passes through valleys that flood during the rainy season, completely preventing travel.

A surgeon at the hospital in Metche said all the situations she encounters is an critical situation, with some women having to make challenging travels to the hospital by walking or on a pack animal.

“Imagine being in the late stages of pregnancy, in childbirth, and travelling hours on a animal-drawn vehicle to get to a medical center. The main problem is the wait but having to travel in this state also has an influence on the childbirth,” says the surgeon.

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

Mohammed has stayed at the medical facility in the two months since her C-section. Afflicted by malnutrition, she got sick, while her son has been closely watched. The male guardian has journeyed to other towns in look for employment, so Mohammed is completely reliant on her mother.

The malnutrition ward has grown to six tents and has cases exceeding capacity into other sections. Children are placed under mosquito nets in sweltering heat in almost utter stillness as doctors and nurses work, mixing medications and weighing children on a scale made from a bucket and rope.

In mild cases children get small bags of PlumpyNut, the specially formulated peanut paste, but the worst cases need a regular intake of nutrient-rich liquid. Mohammed’s baby is fed his through a medical device.

Suhayba Abdullah Abubakar’s infant son, Sufian Sulaiman, is being nourished via a nose tube. The baby 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 coming in in this shelter,” she says. “The nutrition we receive is low-quality, there’s insufficient food and it’s lacking in nutrients.

“If we were at home, we could’ve coped better. You can go and grow crops, you can work to earn some money, but here we’re reliant on what we’re distributed.”

And what they are provided is a small amount of grain, edible oil and salt, handed out every couple of months. Such a basic diet lacks nutrition, and the little cash she is given purchases very little in the regular markets, where costs have risen.

Abubakar was transferred to Alacha after arriving from Sudan in 2023, having escaped the paramilitary Rapid Support Forces’ raid on her home city of El Geneina in June that year.

Failing to secure jobs in Chad, her partner has gone to Libya in the hope of raising enough money for them to come later. She lives with his relatives, distributing whatever nourishment they obtain.

Abubakar says she has already seen food distributions being reduced and there are concerns that the abrupt cuts in overseas aid budgets by the US, UK and other European countries, could deteriorate conditions. Despite the war in Sudan having produced the 21st century’s gravest emergency and the {scale of needs|extent