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For hours, travelling roughly on the soggy dirt track to the medical facility, 18-year-old Makka Ibraheem Mohammed clung desperately to her seat and concentrated on stopping herself vomiting. She was in childbirth, in extreme pain after her uterus ruptured, but was now being jostled relentlessly in the ambulance that jumped along the potholes and ridges of the road through the Chadian desert.

Most of the 878,000 Sudanese refugees who have fled to Chad since 2023, barely getting by in this difficult terrain, are women. They reside in secluded encampments in the desert with scarce resources, little employment and with treatment often a dangerously far away.

The hospital Mohammed needed was in Metche, a different settlement more than 120 minutes away.

“I continuously experienced infections during my gestation and I had to go the clinic on numerous visits – when I was there, the delivery commenced. But I could not give birth normally because my uterine muscles failed,” says Mohammed. “I had to wait two hours for the ambulance but all I remember was the pain; it was so intense I became disoriented.”

Her mother, Ashe Khamis Abdullah, 40, feared she would be bereft of her child and grandchild. But Mohammed was rushed straight into surgery when she arrived at the hospital and an emergency caesarean section preserved the lives of her and her son, Muwais.

Chad was known for the world’s second-highest maternal fatality statistic before the current influx of refugees, but the conditions endured by the Sudanese put even more women in peril.

At the hospital, where they have birthed 824 babies in mostly emergency conditions this year, the medical staff are able to help plenty, but it is what happens to the women who are not able to reach the hospital that worries the staff.

In the 24 months since the domestic strife in Sudan began, the vast majority of the refugees who have arrived and stayed in Chad are mothers and kids. In total, about over a million Sudanese are being accommodated in the east of the country, four hundred thousand of whom escaped the previous conflict in Darfur.

Chad has taken the lion’s share of the over four million people who have escaped the war in Sudan; some have travelled to South Sudan, Egypt and Ethiopia. A total of millions of Sudanese have been forced out of their homes.

Many men have not left to be in proximity to homes and land; many were murdered, captured or conscripted. Those of working age move on quickly from Chad’s isolated encampments to find work in the capital, N’Djamena, or elsewhere, in nearby Libya.

It results in women are abandoned, without the resources to provide for 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 usual resident counts of about a large community, but in distant locations with few facilities and minimal chances.

Metche has a hospital set up by a medical aid organization, which began as a few tents but has expanded to include an surgical room, but not much more. There is a lack of jobs, families must journey for extended periods to find fuel, and each person must subsist with about minimal water of water a day – much less than the recommended 20 litres.

This remoteness means hospitals are receiving women with complications in their pregnancy dangerously late. There is only a sole emergency vehicle to serve the area between the Metche hospital and the health post near the camp at Alacha, where Mohammed is one of close to fifty thousand refugees. The medical team has encountered situations where women in extreme agony have had to remain overnight for the ambulance to arrive.

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

As well as being bumpy, the road traverses valleys that flood during the wet period, completely preventing travel.

A surgeon at the hospital in Metche said each patient she treats is an critical situation, with some women having to make long and difficult journeys to the hospital by on foot or on a donkey.

“Imagine being about to give birth, in delivery, and journeying for an extended time on a donkey cart to get to a clinic. The biggest factor is the wait but having to arrive under such circumstances also has an influence on the childbirth,” says the surgeon.

Undernourishment, which is on the rise, also raises the chance of issues in pregnancy, including the uterine splits that medical staff often encounter.

Mohammed has stayed at the medical facility in the couple of months since her C-section. Experiencing malnutrition, she got sick, while her son has been closely watched. The parent has gone to other towns in look for employment, so Mohammed is completely reliant on her mother.

The malnutrition ward has increased to six tents and has patients spilling over into other sections. Children lie under mosquito nets in extreme warmth in almost total quiet as medical staff work, mixing medications and assessing weights on a scale made from a container and string.

In less severe situations children get sachets of PlumpyNut, the uniquely designed peanut paste, but the worst cases need a daily dose of fortified formula. Mohammed’s baby is fed his through a injector.

Suhayba Abdullah Abubakar’s 11-month-old boy, Sufian Sulaiman, is being nourished via a nasal drip. The child has been ill for the past year but Abubakar was consistently offered just painkillers without any medical assessment, until she made the travel from Alacha to Metche.

“Every day, I see further minors joining us in this structure,” she says. “The nutrition we receive is inadequate, there’s too little nourishment and it’s deficient in vitamins.

“If we were at home, we could’ve coped better. You can go and cultivate plants, you can get a job, but here we’re dependent on what we’re distributed.”

And what they are given is a small amount of sorghum, cooking oil and salt, provided every 60 days. Such a basic diet lacks nutrition, and the small amount of money she is given purchases very little in the local bazaars, where prices have become inflated.

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

Unable to get employment in Chad, her husband has gone to Libya in the aspiration to earning sufficient funds for them to come later. She resides with his relatives, sharing out whatever food they can get.

Abubakar says she has already seen food supplies decreasing and there are fears that the sudden reductions in international assistance funds by the US, UK and other European countries, could deteriorate conditions. Despite the war in Sudan having produced the 21st century’s worst humanitarian disaster and the {scale of needs|extent