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For hours, bouncing over the waterlogged dirt track to the medical facility, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and tried hard stopping herself being sick. She was in delivery, in extreme pain after her uterus ruptured, but was now being shaken violently in the ambulance that bumped over the uneven terrain of the road through the Chadian desert.

Most of the hundreds of thousands of Sudanese people who ran to Chad since 2023, surviving precariously in this harsh landscape, are women. They stay in secluded encampments in the desert with scarce resources, few job opportunities and with medical help often a life-threateningly long distance away.

The hospital Mohammed needed was in Metche, another refugee camp more than a considerable journey away.

“I kept getting infections during my term and I had to go the medical tent on numerous visits – when I was there, the labour began. But I wasn’t able to give birth naturally because my uterine muscles failed,” says Mohammed. “I had to remain for 120 minutes for the ambulance but all I recall is the suffering; it was so unbearable I became confused.”

Her parent, Ashe Khamis Abdullah, 40, worried she would suffer the death of her child and grandchild. But Mohammed was hurried into surgery when she reached the hospital and an emergency caesarean section preserved the lives of her and her son, Muwais.

Chad already had the world’s second most severe maternal fatality statistic before the ongoing stream of refugees, but the circumstances suffered by the Sudanese put even more women in risk.

At the hospital, where they have delivered 824 babies in mostly emergency conditions this year, the medical staff are able to save many, but it is what happens to the women who are not able to reach the hospital that concerns them.

In the couple of years since the internal conflict in Sudan erupted, the vast majority of the displaced persons who came and settled in Chad are women and children. In total, about 1.2 million Sudanese are being hosted in the east of the country, 400,000 of whom ran from the past violence in Darfur.

Chad has hosted the bulk of the over four 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 men have not left to be close to homes and land; many were murdered, taken hostage or made to join the conflict. Those of employable age rapidly leave from Chad’s desolate refugee camps to look for jobs in the main city, N’Djamena, or further, in neighbouring Libya.

It results in women are abandoned, without the resources to provide for the children and the elderly left in their care. To avoid overcrowding near the border, the Chadian government has moved individuals to smaller camps such as Metche with usual resident counts of about a large community, but in isolated regions with few facilities and few opportunities.

Metche has a hospital set up by a medical aid organization, which started off as a few tents but has developed to contain an operating theatre, but not much more. There is no work, families must journey for extended periods to find fuel, and each person must survive on about nine litres of water a day – well under the suggested amount.

This isolation means hospitals are treating women with complications in their pregnancy at a critical stage. There is only a one medical transport to serve the area between the Metche hospital and the health post near the camp at Alacha, where Mohammed is one of nearly 50,000 refugees. The medical team has seen cases where women in desperate pain have had to remain overnight for the ambulance to reach them.

Imagine being nine months pregnant, in labour, and journeying for a long time on a cart pulled by a donkey to get to a hospital

As well as being uneven, the route passes through valleys that become inundated during the monsoon, completely blocking 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 mule.

“Imagine being in the late stages of pregnancy, in childbirth, and making a long trip on a donkey cart to get to a medical center. The primary issue is the lag but having to arrive under such circumstances also has an influence on the birth,” says the surgeon.

Malnutrition, which is growing, also elevates the likelihood of complications in pregnancy, including the womb tears that medical staff often encounter.

Mohammed has stayed at the medical facility in the two months since her C-section. Suffering from malnutrition, she contracted an illness, while her son has been carefully monitored. The male guardian has journeyed to other towns in search of work, so Mohammed is totally dependent on her mother.

The nutritional care section has increased to six tents and has patients spilling over into other sections. Children rest beneath mosquito nets in sweltering heat in almost total quiet as medical staff work, mixing medications and assessing weights on a device constructed from a bucket and rope.

In less severe situations children get small bags of PlumpyNut, the specifically created peanut paste, but the critical situations need a daily dose of nutrient-rich liquid. Mohammed’s baby is given his nourishment through a medical device.

Suhayba Abdullah Abubakar’s 11-month-old boy, Sufian Sulaiman, is being given nutrition by a nasogastric tube. The infant has been unwell for the past year but Abubakar was repeatedly given only painkillers without any medical assessment, until she made the journey from Alacha to Metche.

“Every day, I see more children arriving in this structure,” she says. “The meals we consume is low-quality, there’s too little nourishment and it’s not nutritious.

“If we were at home, we could’ve adapted ourselves. You can go and grow crops, you can get a job, but here we’re relying on what we’re given.”

And what they are provided is a small amount of cereal, cooking oil and salt, distributed every two months. Such a minimal nutrition offers little sustenance, and the small amount of money she is given acquires minimal items in the weekly food markets, where costs have risen.

Abubakar was moved to Alacha after coming from Sudan in 2023, having escaped the militia Rapid Support Forces’ attack on her native town of El Geneina in June that year.

Finding no work in Chad, her husband has left for Libya in the desire to earning sufficient funds for them to join him. She resides with his family members, dividing up whatever meals they acquire.

Abubakar says she has already observed food distributions being reduced and there are fears that the abrupt cuts in international assistance funds by the US, UK and other European countries, could make things worse. Despite the war in Sudan having created the 21st century’s gravest emergency and the {scale of needs|extent